Ms. A, age 44, fell from a 3-foot stool while reaching for a high kitchen shelf and suffered severe neck flexion. Her initial pain persisted for weeks and then months, resulting in chronic neck pain aggravated by movement.
Over the past year, her doctor has prescribed numerous analgesics and muscle relaxants, including tramadol, hydrocodone, oxycodone, tizanidine, and nonsteroidal anti-inflammatory drugs (NSAIDs). Treatments at a pain clinic have included triggerpoint injections, cervical epidural corticosteroid injection, left-sided cervical medial branch blocks, transcutaneous electrical nerve stimulation, and physical therapy. None provided sustained relief.
During a pain clinic visit, Ms. A wept and said she was tired of living with pain. She acknowledged depression and agreed to psychiatric consultation.
As in Ms. A’s case, physicians often refer patients with chronic pain and affective symptoms for psychiatric evaluation. These patients are often fearful, angry, and suspicious of any suggestion that their physical discomfort has a psychiatric component. They typically believe their pain had a clear onset and therefore should have an end point. Many have experienced unproductive specialty evaluations and failed treatments.
To help you overcome these obstacles when treating patients with chronic pain and depression, we discuss:
- strategies to gain patients’ trust and build a therapeutic alliance
- how to assess their pain, depression, and suicide risk
- the role of psychotherapy in treating chronic pain
- and evidence for choosing effective, nonaddicting medications.
Psychiatric evaluation
Depression and pain are linked psychologically and biochemically, sharing neurotransmitters involved in both nociceptive pathways and mood, especially serotonin and norepinephrine.1,2 One-third to one-half of patients with chronic pain report comorbid depression,3 and more than one-half of depressed patients presenting to primary care physicians report only somatic symptoms—various pain complaints among the most common.4,5
Primary care doctors tend to refer chronic pain and depression cases to psychiatrists when:
- patients are preoccupied with medication, have not followed treatment recommendations, or do not respond to treatment as expected
- extensive medical evaluations reveal few or equivocal findings
- somatic complaints are vague and diffuse, or there is marked disparity between pain complaints/disability and objective findings.6,7
Assessing pain. In the initial assessment, validate the patient’s pain experience by asking about the location, quality, and severity of pain. The visual analogue scale (VAS) is commonly used to measure pain severity. The patient marks a spot on a line from “no pain” to “worst possible pain,” or—on a numbered VAS—from 0 (no pain) to 10 (extreme pain). The least and most severe pain over the preceding month can be ranked as baseline values.8
Be sensitive to the patient’s fear that you will attribute the pain to psychosocial issues or imply that “the pain is in your head.” Emphasize that you intend to evaluate the “whole person,” not just the part that hurts. Focus on how the pain affects the patient’s lifestyle—rather than its cause—and explore medication use patterns.
Assessing depression. The word “depression” is emotionally charged for chronic pain patients, who view affective symptoms—if they acknowledge them at all—as secondary to pain. They may strongly resist treatment for anything but pain. One way to defuse this defensiveness is to avoid attributing the pain to stress or depression.
Begin by assessing vegetative symptoms, which overlap in chronic pain and depression. The Beck Depression Inventory-II (Beck-II) may be a useful screening tool in a busy practice; the short form (13 questions) takes about 5 minutes to complete.9
Explore cognitive and behavioral symptoms such as concentration, pleasure and interest level, activity, and self-esteem. Review the chronology of pain onset, mood changes, and stressors (proximate, remote, and cumulative).
Seek clues to endogenous factors by asking about past affective episodes, response to antidepressants, and family history of psychopathology. Substances that may induce depression include reserpine, interferon, and antiparkinsonian agents. Screen for potential organic mood disorders, such as depression secondary to hypothyroidism, corticosteroid use, Parkinson’s disease, lupus, HIV infection, or cerebrovascular disease. Where appropriate, obtain collateral information from family or friends.
Assessing suicide risk. Chronic pain patients may be at greater risk of suicide than the general population. Besides pain, other risk factors for suicide—such as major depression, anxiety disorders, alcohol/substance abuse, sleep disturbances, male gender, diminished social support, and recent loss—are common among these patients.10,11
Screen chronic pain patients with suicidal ideation for these risk factors. Interventions include:
- aggressively treat associated depression, anxiety, or insomnia
- elicit support from family or other caregivers
- pay close attention to talk about suicide
- hospitalize when necessary
- and, of course, treat pain.
Case continued: No stranger to depression
Ms. A’s psychiatric assessments revealed a pain severity ranking of 9 on a 1-to-10 scale, frequent crying, hopelessness, disrupted sleep, low energy, limited ability to concentrate, and fleeting suicidal thoughts. Her history included counseling during her first marriage and severe depression after separation from her second husband 3 years ago. An 8-week trial of fluoxetine, 20 mg/d, did not improve her depression then.