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
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