Mood disorders and medical illnessPersistent pain and depression: a biopsychosocial perspective
Introduction
Persons who experience both persistent pain and depression suffer inordinately. The physical, psychological, social, and financial costs associated with experiencing persistent pain and depression can be enormous. Over the past 20 years, there has been growing interest in the relationship between persistent pain and depression. The literature on this topic has been reviewed in a comprehensive fashion by several authors (e.g., Banks and Kerns, 1996, Fishbain et al., 1997, Pincus and Williams, 1999. Banks and Kerns (1996) found that depression prevalence rates in patients with persistent pain ranged from 30% to 54% in those studies in which the most rigorous criteria for diagnosing depression were used. These prevalence rates seem to be higher than in the general population, both among persons reporting persistent pain (16%) and persons not reporting persistent pain (6%) (Magni et al 1993). Depression among chronic pain patients also seems to be more common than among other chronic illness populations, including patients with cardiac disease, cancer, diabetes, and neurologic disorders Anderson et al., 2001, Banks and Kerns, 1996. Based on systematic reviews (e.g., Fishbain et al 1997), there is an emerging consensus that persistent pain is more likely to lead to depression than vice versa and that patients with more severe, frequent, and enduring pain are at risk for more severe depression. Finally, severe pain has also been associated with significantly higher levels of suicidal ideation, suicidal gestures, and completed suicide (Fishbein et al 1997).
The purpose of the present article is to highlight recent research findings on biopsychosocial factors linking pain and depression, and to discuss the implications of these findings for future research in persons who suffer from both pain and depression.
This review is divided into four sections. First, we briefly discuss the evolution of theories of pain and highlight newer theories that underscore the important role that depression can play in the pain experience. Second, we review biological and psychosocial mechanisms that have been used to explain the link between pain and depression. Third, we discuss treatment approaches for managing comorbid pain and depression. We conclude by highlighting important future directions for research in this area.
Section snippets
Evolution of pain theories: implications for understanding depression–pain relationships
Early conceptualizations of pain were consistent with specificity theory. Specificity theory implies that there is a simple, fixed relationship between tissue damage and pain perception. This theory also maintains that pain is determined solely by characteristics of noxious stimuli and that the nociceptive system functions as a passive relay system (International Association for the Study of Pain 1997). This theory of pain was problematic in that it was unidimensional and failed to explain the
Biological mechanisms underlying pain and depression
Recognition of the overlap between persistent pain and depression has led to increased interest in the biological mechanisms linking pain and depression. Persistent pain conditions and depression, however, are heterogeneous (Clauw and Chrousos 1997). In certain pain conditions (e.g., osteoarthritis and rheumatoid arthritis), persistent pain is believed to be more strongly linked to peripheral factors (e.g., cartilage damage, inflammation), psychosocial factors are considered to be less
Psychosocial mechanisms underlying pain and depression
Empirical studies support the role of a number of psychological factors in the chronic pain experience. Pain that lasts for months and years can produce a number of maladaptive coping responses that can influence pain severity. Examples of maladaptive responses to pain include catastrophizing (i.e., overly negative thinking about pain), perceived helplessness, and low self-efficacy (i.e., lack of confidence in one's ability to manage pain). Patients who report high pain catastrophizing and
Treatment approaches for managing depression in the context of persistent pain
The treatment approaches for managing persistent pain and depression can be grouped into two major categories: pharmacologic and psychosocial/combined treatments.
Future research directions
Our overview of persistent pain and depression from a biopsychosocial perspective suggests a number of important directions for future research. In this section, we will highlight future research directions related to screening and diagnosis, treatment of pain and depression, and individual and subgroup differences.
Acknowledgements
Preparation of this article was supported by National Institute of Mental Health Grant #MH63429 to FJK and Department of Army Grant DAMD 17–00–2-0018 to DJC.
Aspects of this work were presented at the conference, “The Diagnosis and Treatment of Mood Disorders in the Medically Ill,” November 12–13, 2002 in Washington, DC. The conference was sponsored by the Depression and Bipolar Support Alliance through unrestricted educational grants provided by Abbott Laboratories, Bristol-Myers Squibb
References (100)
- et al.
Psychotherapy and combined psychotherapy/pharmacotherapy for late life depression
Biol Psychiatry
(2002) - et al.
Self-efficacy as a mediator of the relationship between pain intensity, disability, and depression in chronic pain patients
Pain
(1999) - et al.
A placebo-controlled randomized clinical trial of nortriptyline for chronic low back pain
Pain
(1998) - et al.
Effects of noradrenergic and serontonergic antidepressants on chronic low back pain intensity
Pain
(1999) - et al.
Current advances and trends in the treatment of depression
Trends Pharmacol Sci
(1994) - et al.
Disease activity and severity in patients with rheumatoid arthritisRelations to socioeconomic inequality
Soc Sci Med
(1999) - et al.
The relationship of pain and depression to cognitive function in rheumatoid arthritis patients
Pain
(2002) - et al.
Chronic widespread pain and fibromyalgiaWhat we know, and what we need to know
Best Pract Res Clin Rheumatol
(2003) - et al.
Analyzing chronic low back painThe relative contribution of pain coping strategies
Pain
(1990) - et al.
Understanding the adoption of arthritis self-managementStages of change profiles among arthritis patients
Pain
(2000)
Readiness to adopt a self-management approach to chronic painThe Pain Stages of Change Questionnaire (PSOCQ)
Pain
The relationship of arthritis self-efficacy to daily pain, daily mood, and daily pain coping
Pain
Chronic musculoskeletal pain and depressive symptoms in the National Health and Nutrition Examination IEpidemiologic follow-up study
Pain
Predicting complaints of impaired cognitive functioning in patients with chronic pain
J Pain Symptom Manage
From the gate to the neuromatrix
Pain
Motivational interviewingResearch, practice, and puzzles
Addictive Behaviors
Systemic review and meta-analysis of randomized controlled trials of cognitive behavior therapy and behavior therapy for chronic pain in adults, excluding headache
Pain
Cognitive distortions of somatic experiencesRevision and validation of a measure
J Psychosom Res
A review of the efficacy of serotonergic and noradrenergic reuptake inhibitors for treatment of major depression
Biol Psychiatry
Out-patient cognitive-behavioral therapy with amitriptyline for chronic non-malignant painA comparative study with 6-month follow-up
Pain
Models and measurement of depression in chronic pain
J Psychosom Res
The neuropharmacology of centrally acting analgesic medications in fibromyalgia
Rheum Dis Clin North Am
Efficacy of pharmacological treatments of neuropathic painAn update and effect related to mechanism of drug action
Pain
The treatment of depression in chronic low back painReview and recommendations
Pain
Comparison of desipramine and cognitive/behavioral therapy in the treatment of elderly outpatients with mild-to-moderate depression
Am J Geriatr Psychiatry
Analgesia produced by injection of lidocaine into the anterior cingulum bundle of the rat
Pain
Alternative diagnostic criteria for major depressive disorder in patients with chronic pain
Pain
The prevalence of comorbid depression in adults with diabetesA meta-analysis
Diabetes Care
Explaining high rates of depression in chronic painA diathesis-stress framework
Psychol Bull
Cognitive Therapy of Depression
Cognitive and physical capacity process variables predict long-term outcome after treatment of chronic pain
J Consult Clin Psychol
Do changes in cognitive factors influence outcome following multidisciplinary treatment for chronic pain? A cross-lagged panel analysis
J Consult Clin Psychol
Measures of activity and damage in rheumatoid arthritisDepiction of changes and prediction of mortality over five years
Arth Care Res
Antidepressants in pain management
Curr Opin Invest Drugs
Chronic pain and fatigue syndromesOverlapping clinical and neuroendocrine features and potential pathogenic mechanisms
Neuroimmunomodulation
Ilness self-schemas in depressed and nondepressed rheumatoid arthritis patients
J Behav Med
The role of passive coping and helplessness in rheumatoid arthritis depression and pain
J App Health Beh
Abnormalities of serotonin metabolism and nonpsychotic psychiatric disorders
Ann Clin Psychiatry
DepressionThe case for a monoamine deficiency
J Clin Psychiatry
Irritable bowel syndromeNew agents targeting serotonin receptor subtypes
Drugs
Prevalence of psychiatric disorders in patients with chronic work-related musculoskeletal disorders
J Occup Environ Med
Substance PA new era, a new role
Pharmacotherapy
A pilot study of interpersonal psychotherapy by telephone with cancer patients and their partners
Psychooncology
Enhanced responses of spinothalamic tract neurons to excitatory amino acids accompany capsaicin-induced sensitization in the monkey
J Neuroscience
Gender and psychological well-being of persons with rheumatoid arthritis
Arth Care Res
Assessment of depression in chronic musculoskeletal pain patients
Clin J Pain
Central nervous system mechanisms of pain modulation
Evidence-based data on pain relief with antidepressants
Ann Med
Chronic pain-associated depressionAntecedent or consequence of chronic pain? A review
Clin J Pain
Behavioral Methods for Chronic Pain and Illness
Cited by (281)
Altered physical pain processing in different psychiatric conditions
2022, Neuroscience and Biobehavioral ReviewsCitation Excerpt :Decreased sensitivity to experimental pain has been posited to be caused by an overall reduced perceptual unresponsiveness (HALL and STRIDE, 1954), however, this view is not supported by studies examining pain tolerance and those using ischemic painful stimuli. Overall, individuals with depression tend to report physical pain more frequently (Strigo et al., 2008b) and to experience pain as more distressful than the general population, but have a dampened sensory response to pain in experimental studies (Bair et al., 2003; Campbell et al., 2003). This apparent contradiction has been explained by a differential role of attention in pain processing.
Pelvic Pain and Sexual Function in Primiparous Pregnant Women with and without High/Severe Fear of Childbirth
2024, Sexuality Research and Social PolicyThe soluble epoxide hydrolase inhibitor TPPU improves comorbidity of chronic pain and depression via the AHR and TSPO signaling
2023, Journal of Translational Medicine