Depression and Pain: Two Sides of the Same Coin?
May 10, 2020Each patient at Specialists In Pain Care gets screened for depression throughout the course of their treatment, and we use the PHQ-9 screening tool, which is likely familiar to most primary care providers. The PHQ-9 is a multipurpose instrument for screening, diagnosing, monitoring and measuring the severity of depression.
Why do we do this? The symptoms of pain and depression often present concomitantly. More specifically, depression is comorbid with chronic pain in 60% of patients. Moderate pain that impairs function or is refractory to treatment is associated with more depressive symptoms and worse depression outcomes such as a lower quality of life and increased healthcare utilization. Conversely, depression in patients with pain is associated with more physical pain complaints and greater impairment. In depression, we often emphasize the emotional and vegative symptoms, but many depressive states can be associated with painful physical symptoms such as headache, joint pain, limb pain, back pain, gastrointestinal problems, and fatigue. Stressing this close association between pain and depression, studies have shown that physical symptom improvement was correlated with the improvement of other depression symptoms, which suggests that the patient’s ability to achieve depression remission may be directly related to the reduction of painful physical symptoms. In short, treatment regimens must address both the physical and emotional components of depression.
Why this link is so “tight” is unclear, but it may be secondary to the fact that depression and pain share biological pathways and neurotransmitters. This has implications for treatment as we will find ourselves utilizing medications in the pain setting such as SNRIs and TCAs. Cymbalta (duloxetine) is a serotonin and norepinephrine reuptake inhibitor familiar to most that has antidepressant and pain-relieving properties, and this agent may be an excellent first-line treatment in depressed patients who present with predominantly physical symptoms as opposed to emotional symptoms.
What about the role of opioids? Research has shown that patients with depression are more likely to receive opioids, to use higher doses and to misuse opioids. Conversely, there is mounting evidence that chronic opioid use for non-cancer pain more than doubles the risk for new onset depression. What about the patient with a prior depressive episode who initiates opioid pain medication and ends up being a chronic user? This individual is at risk for recurrence of depression. Taken together, these retrospective cohort studies provide compelling evidence of a potential depressogenic impact of opioid use. It can be a vicious cycle that is reinforced through a feedback loop. Depression leads to more opioid use and more opioid use leads to new onset or worsening depression and worsens the prognosis for pain.
Like yourselves, we don’t have a “magic bullet”, but we do view ourselves as your partner in helping our patients to lead a more productive life. Therefore, the PHQ 9 questionnaire is the tool we use to screen for the presence and severity of depression. We do not use it to diagnose depression, but it is a place to start a discussion with the patient. Abnormal PHQ-9 screens will generate an alert to the patient’s primary care provider. That is, we will notify you that our patient/ your patient needs your help. At Specialists in Pain Care, we see ourselves as part of the patient’s treatment team, and we believe in always communicating with the primary care team. Referrals are not just a one-way street especially when it comes to depression and pain.
