Treating Chronic Pain and Depression

There is a high rate of depression in patients with chronic pain — a rate of more than 50 percent in those with terminal illness and pain.¹

Of course, physicians and care providers know that depression and pain often co-exist, and that one sometimes masks the other. Also, sometimes one condition is treated while the other is missed or under-treated. Patients in severe pain may attribute their depression symptoms to the pain itself and, therefore, under-report it.

It is important to assume chronic pain patients are depressed and rule it out through direct questioning using a modified depression rating scale.² Many depressed patients with somatic complaints perceive their conditions as more problematic than their non-depressed peers with similar somatic illness. Treating depression effectively often results in less pain medication or other somatic interventions.

Chronic, unremitting pain correlates highly with suicidal thoughts and risk.

In particular, men with chronic, unremitting pain are at highest risk for suicide.  For example, one study found men with carcinoma of the pancreas, known for its association with depression as well as chronic pain, to have an 11-fold increased risk for suicide over their non-afflicted peers.

Among terminally ill patients, the wish to die fluctuates over time and is often correlated with levels of depression, anxiety, and pain.³ Furthermore, 8.5 percent of terminally ill patients, often those with unremitting pain, have sustained and pervasive wishes for an early death. Psychiatric palliative care measures diminish these requests substantially.

In addition, hidden substance abuse can be a complicating factor for chronic pain and depression and increases suicide risk.

Treating pain and depressive symptoms appropriately may significantly reduce the desire for death and abuse of alcohol or drugs. Health care providers often fail or are circumspect about asking patients or their family members about substance abuse concerns. Unidentified or unverified substance abuse undermines most treatment efforts for pain or depression.

Please remind the physicians and other caregivers in your practice or facility to:

• Be alert to depression or substance abuse in patients with chronic, unremitting pain.
• Treat depression aggressively with medication, with referral for specialized psychotherapy, or psychiatric consultation, if warranted.
• Ask both patients and family members about substance abuse.
• Try antidepressants that are FDA-approved for both pain control and depression for patients suffering from both conditions.