Managing Stress, Depression and Chronic Back Pain

William Deardorff, PhD

Grant Cooper, MD

Spine-health.com expert featured on Back Pain Radio

What many patients don’t realize is that stress, chronic pain and depression are interrelated and need to be treated simultaneously by a multi-disciplinary team of health professionals. Read what William Deardorff, Ph.D., a clinical health psychologist in California and contributing author for Spine-health.com, and Grant Cooper, M.D., host of Back Pain Radio, had to say as they discussed how to identify the warnings signs of depression and properly manage chronic pain and depression.

Transcript of Back Pain Radio show on chronic back pain and depression

Below is the transcript summary from the Depression, Stress and Chronic Back Pain show on Back Pain Radio on April 11, 2005.

Dr. Cooper: What is the relationship between stress, depression and chronic back pain?

Dr. Deardorff: Well, it can go both ways (pain causing depression and stress, or depression and/or stress causing pain).The most common way is that a chronic pain problem develops, and then in response to that, a patient will show signs of depression, increased stress and physical concomitants of the depression and stress. So, as that happens, then the chronic pain syndrome, of course, gets worse.

Dr. Cooper: There’s a wonderful quote, I think it was Maudsley who said "the sorrow which has no vent in tears may make other organs weep." Do you see that reciprocal relationship where, sometimes, depression can lead to the pain?

Dr. Deardorff: Yes. Occasionally, and there’s been some recent research on this, people who are more prone to depression or have a history of clinical depression may be vulnerable to developing a chronic pain problem. Especially in response to, let’s say, an initial back injury which most people might recover from, the person who has a history of clinical depression might, again, be more vulnerable to developing a chronic pain problem that doesn’t remit.

Dr. Cooper: What kinds of things can people do to try and help to avoid that? Suppose it is someone who has depression, and they have this injury that might not cause chronic pain in somebody who wasn’t otherwise depressed. Are there steps that they can take to minimize their chances of developing chronic pain?

Dr. Deardorff: Well, I think one of the most important things is while in the acute pain phase, when they’re being evaluated by their doctor for the back pain, they should be sure to inform their doctor that they do have a history of clinical depression, and maybe inform their doctor that they’re familiar with the research that this could put them at risk for chronic pain problems, because a lot of internal medicine or family practice doctors may not be aware of that. I think initially, and usually appropriately so, when the patient first comes in with the acute back pain problem, of course, all of the medical attention is on that, and then some of the emotional responses get ignored and then the diagnosis of depression is missed. So, if the patient can be a little proactive, tell the doctor, ‘you know, I’ve had this back pain problem, this acute problem, but I also have this history of depression and I’d like for us to monitor both of these things simultaneously’.

Dr. Cooper: And how can the doctor help to monitor the depression? The patient comes in and they, in a sense, educate the doctor and say, ‘this is something that we’re both going to need to look out for’ – what can each party do to help stop it from becoming a problem before it is one?

Dr. Deardorff: Well, I think most family practice doctors and internal medicine doctors are going to be familiar with some basic screening questions for depression. On the website - www.spine-health.com - I wrote an article that has an actual screening questionnaire for depression, where a patient can go on there and actually rate themselves and sort of help keep track of their depression levels. Those sorts of things, I think, are going to help keep track of it. And then the patient, and the doctor, should always be aware that occasionally, patients will express increased pain as an expression of depression rather than actual increased pain – sort of a cry for help, or like you were saying, almost a symptom substitution type of thing. I think both parties need to be aware that that may occur and keep in mind when that might be happening.

Dr. Cooper: And if that occurs, what kinds of things should they be thinking to do? Is this something that they should talk about and are medications indicated?

Dr. Deardorff: Anytime, whether depression preceded the pain or is in response to the pain, you need a good evaluation, either with a psychologist or with a psychiatrist as indicated. Then, multi-disciplinary treatment should occur, where the pain problem is getting treated appropriately and the depression is getting treated appropriately, and the physicians or physician and psychologist working with the patient are in good communication about what they’re doing. Some of the things a physician might do, such as prescribe opioid medications and some of these other medicines, might actually make the depression worse. And then the mental health professional needs to know about that so that they can take appropriate steps.

Dr. Cooper: Right. And also, I would imagine that when a patient is also seeing a psychiatrist, some of the medications can interact.

Dr. Deardorff: Right, exactly.

Dr. Cooper: Anyone who has pain is going to feel at least a little bit angry or depressed, at some point, most likely. What are some of the warning signs – you mentioned the survey that you have online at Spine-health.com. Can you mention some of the symptoms that people should be on the lookout for?

Dr. Deardorff: Usually what we see is, in the acute pain phase like with a back injury, before three months, the patient is going to feel more anxious and worried about the symptoms, and then at about six months, that’s when the depression starts to emerge more. Everybody, like you said, is going to be upset about having a chronic pain problem and the things that go with it, like not being able to do their favorite activities, relationship problems, financial, problems with sexual functioning, that sort of thing.

When you start to see a worsening depression, you’ll see what we call neurovegetative signs, and those are things like changes in appetite, disrupted sleep, again, feeling agitated or depressed, crying spells, loss of interest in things that they used to enjoy. For instance, maybe they used to have hobbies and different activities, and they just don’t feel like doing them anymore; decreased sex drive, feelings of guilt, and then in more severe cases, you’ll get some thoughts of suicide and social withdrawal and that sort of thing.

Dr. Cooper: And of course anybody with thoughts of suicide should immediately seek medical attention. What about somebody who notices some of these other symptoms coming on. Who is the most appropriate person to reach out to?

Dr. Deardorff: It depends. If they’re working with a physician that works with a lot of chronic pain patients, such as a physiatrist or physical medicine specialist, that doctor may be comfortable with evaluating them for some of the anti-depressant medications and then referring them to a psychologist familiar with chronic pain management. So, that’s actually a pretty common team of professionals. It is important to get to someone who can help psychologically treat the depressive symptoms.

Dr. Cooper: There are a lot of medicines for depression, there are a lot of medicines for chronic pain and there are some that are designed for a mix of the two. Do you have favorite medicines that you like to see your patients on?

Dr. Deardorff: Really, it depends on a good evaluation in terms of these neurovegetative signs. Some of the tricyclic anti-depressants are good not only to help with sleep (you take them at night), they are also generally fairly sedating and non-addictive. You use them in fairly low doses for chronic pain to help with sleep. One of the things we do initially is to try to get that sleep disruption under control, because that’s such a big variable in making the depression and the chronic pain worse. And then, if there’s a fairly significant clinical depression along with the chronic pain problem, we may move toward what are called SSRI groups of medications (such as the newer Lexapro).

Dr. Cooper: These are newer versions of Prozac.

Dr. Deardorff: Or Paxil, or that group. And, then, a lot of times, a Wellbutrin might be good, that doesn’t have the sexual side effects that some of the SSRIs do. If it gets to that level, you really need to see someone for an evaluation who really knows their anti-depressant medications.

Dr. Cooper: If someone has back pain and then they get depressed and then their back pain is healed, does the depression go away also or might the depression stay longer?

Dr. Deardorff: I see a lot of cases where the depression can linger. I see a lot of patients come in with a chronic back pain problem, and they’ll say, which kind of makes common sense at first, ‘once I get this back pain problem fixed, my depression, anxiety and all these other things are going to go away.’ In a lot of cases I see that the depression can take on a life of its own, because there have been so many losses (we call them secondary losses) due to the chronic pain. By the time the pain gets fixed, all those other factors are still there, so they still need to be addressed – like disrupted family relationships, financial stress, loss of job – all that stuff hasn’t gone away just because the back pain has been fixed.

Dr. Cooper: Do people typically come to see you early in the course of their pain, or later?

Dr. Deardorff: I’d like to see them earlier, but unfortunately that’s not usually the case. I tend to get them when it’s more chronic, let’s say, a year or two years out.

Dr. Cooper: There are so many doctors who, I’m sure, would share your frustration there.

Dr. Deardorff: Always the earlier the better – if you get in, there are fewer problems and you can be more aggressive with your treatment, but usually it’s not the case.

Dr. Cooper: What advice might you give to someone who might have a friend or a loved one who they fear might be having some of these signs or symptoms, because of chronic pain or another reason? What kinds of things can they do to help out?

Dr. Deardorff: Well, I think probably one of the biggest things is to help them realize that the depression and the emotional reaction to the chronic pain problem is perfectly understandable, it happens all the time, it’s not a matter of being weak-willed, it’s part of the chronic pain syndrome. So, you give them a little insight into the problem, and then help them get to the appropriate providers. I’m a big fan of multi-disciplinary intervention, and that means more than a bunch of different disciplines of doctors helping that aren’t talking to one another. The ideal situation is different disciplines working with the patient, and the doctors are in close communication about what everybody’s doing.

Dr. Cooper: Coordinating efforts.

Dr. Deardorff: Exactly.

Dr. Cooper: We just have a minute left. I’d like to ask you – we’ve all felt stressed at some time, and we’ve felt that stress show up as a little bit of ache or pain in our back or somewhere else – do you have any simple relaxation or other techniques that might help us so that we don’t manifest our emotions into physical complaints?

Dr. Deardorff: Deep breathing techniques work great. Breathe in through your nose and out through your mouth on a ten count. Keep a stress diary to try and look for triggers for stress. When you have a bout of back pain, stop, and instead of focusing just on the back pain, ask yourself what kind of stress might be going on in your life that’s triggering this back pain, and then go ahead and attack the stress, rather than completely focusing on the back pain as its own issue.

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