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MENTAL HEALTH
CHALLENGES

depression, the associated fatigue and insomnia were attributed to was significantly relieved also had a significant resolution of their
the pain originating from the organic disease process. Unrecognized depressive symptoms.
depression even in the presence of organic disease increases the
pain severity and duration and inadequate pain relief. More opioids Effect of depression on pain treatment outcome
were prescribed than antidepressants in patients with pain and de- Preexisting depression is associated with increased postsurgical
pression. This further leads to polypharmacy, substance abuse (opi- pain and longer hospital stays. Most of the studies found that co-
oids and benzodiazepines). Unrecognized depression can result in morbid pain with depression was associated with poor outcomes
failure to control the pain even with invasive procedures leading to with pharmacological and interventional procedures, more severe
further complications. Patients are also reluctant to accept that de- pain intensity, increased disability, lower quality of life, higher un-
pression could be contributing to their pain experience or treatment employment, more investigations and treatments, and higher cost.
failures because of the social stigma attached to the diagnosis of High copays and inadequate insurance coverage discourage depres-
depression. The patient may say, “pain is in my back, not in my sion treatment.
head.” In such instances, patients go doctor shopping in search of
a “real doctor or an expert or magical cure.” After the delayed recog- Overlapping neurobiology, neurochemistry and
nition of depression physicians also feel absolved of the responsi- related treatment options
bility for the treatment failure. Early recognition of depression and Pain sensory input reaching the somatosensory cortex via the lat-
concurrent management of both depression and pain is likely to re- eral thalamus helps with the assessment location and intensity. The
sult in better outcome. In a busy primary care practice, it is difficult sensory input reaching the limbic system via the medial thalamus
to identify mild to moderate depression. results in affective-emotional response such as suffering and hurting.
This area of input into the limbic system including prefrontal, an-
The increasing use of patient health terior cingulate insular cortex and amygdala overlaps the areas in-
questionnaire (PHQ-9) increases the recognition volved in depressive mood. The processing of both mood and pain
of depression and suicidal ideation are controlled by the same neurotransmitters, serotonin, norepi-
Explaining the following facts to the patient is likely to increase nephrine, and glutamate. Pharmacological treatments affecting these
patient acceptance and referral to a mental health professional. neurotransmitters are likely to reduce both pain and depression. De-
1. Chronic pain and decreased ability to participate in pleasurable scending pain inhibitory systems activate pathways to reduce pain
activities can lead to depression. impulse transmission from the dorsal gray matter of the spinal cord.
2. The treatment of depression, with certain kinds of anti-depres- These pathways are activated by serotonin, norepinephrine and en-
sants, may significantly decrease pain. dogenous opioids. Optimizing the treatment with antidepressants
3. Concurrent management of both pain and depression is likely reduces both pain and depression. The addition of patient self-man-
to result in better outcome. agement cognitive behavior therapy (CBT) and brief intense psy-
chotherapy result in further outcome improvements. A few studies
Influence of pain on depression treatment report SSRIs (sertraline and paroxetine) were effective in reducing
outcome both pain and depression. Majority of the studies confirm better

Many studies assess the incidence of pain with depression or the success with TCAs (amitriptyline, nortriptyline and imipramine) and
influence of depression on the pain treatment outcome and not the SNRIs (venlafaxine, duloxetine and milnacipran) in reducing the co-
outcome of the treatment of depression. Some studies indicate that morbid pain in depressed patients. SNRIs and TCAs act on both
Pain in multiple sites, increasing severity and greater than 6 months the serotonin and norepinephrine receptors, unlike SSRIs which act
duration were associated with poor outcome including increased only on serotonin receptors. Duloxetine is better tolerated than the
depression. Pain related decreased ability to participate in activities other drugs even in the elderly. TCAs have the worst side effect pro-
results in increased doctors’ visits, multiple pain medications includ- file especially in the elderly (a common cause of fall and fractured
ing opioids, unemployment, all of which can lead to more depres- hip). The pain reduction starts earlier (one week) than the reduction
sion and poor depression treatment outcome. Continuing pain of depression (two weeks). Duloxetine is approved for use in pa-
increases treatment failure and relapse rate of depression. Presence tients with fibromyalgia and diabetic neuropathy. These drugs can
of pain also increased the cost of medical care. Patients whose pain precipitate a manic episode in patients with bipolar depression.
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