It must be one of the worst combinations – to have both chronic pain and depression. It makes treatment much harder to stay with, it means much more effort on behalf of the therapist and the patient, and progress can be very very slow.
Most of the people attending tertiary care for chronic pain will have low mood – whether it is a depression that will respond to medication is arguable, and sometimes the word ‘demoralisation’ is perhaps a better description of what is going on. The difference between demoralisation and depression is probably also arguable, but my rule of thumb is that people with treatable depression will usually have vegetative signs such as slowed movements, flat affect, loss of appetite and weight, poor sleep (but that happens for most people with chronic pain!), and poor concentration and slowed speech. Demoralisation is much more like ‘I don’t think anything is going to make a difference, so I’ve just given up.’
The good news is that there has been a study on a stepped care approach for people with both depression and chronic pain – and this very good review of it is available through Medscape. It’s a description of a study by Kroenke, Bair, and Damush, published in the JAMA, looking at whether optimised treatment for depression, combined with self management for chronic pain, might have an effect on both problems. I won’t describe the study itself, but just want to draw your attention to a couple of things.
Firstly, this review has some good points to make about optimising antidepressant therapy to the type of pain – they actually say ‘source’ of pain, but I think that’s probably not exactly certain. It may take several trials to find an antidepressant medication that is both tolerated and effective – and each trial needs to be of good duration. This process can be really difficult for people (I know, I’ve been through it myself!), and it’s important to ensure adequate support is available throughout. CBT is one way to provide this support, but simply listening and encouraging both a structure to the day with pleasurable activities and simple self care may be enough.
Secondly, although the study itself has some problems because of the population it was drawing on, the conclusions were that people involved in a self management programme alongside antidepressant therapy made greater gains and sustained these for longer – including adhering to use of the medication! This is good news, because many people are prescribed medications but actually don’t use them either for long enough, or in the right way for them to be effective.
A double whammy of both depression and chronic pain can be one of the most challenging problems for us as clinicians. This study shows that there is some hope that common treatments available already can help – maybe it’s time to target some community-based programmes to carry this sort of thing out.
Kroenke K, Bair MJ, Damush TM, et al. Optimized antidepressant therapy and pain self-management in primary care patients with depression and musculoskeletal pain. JAMA. 2009;301:2099-2110.