Depression is a very common emotion associated with chronic back pain. The symptoms of depression include:
- A predominant mood that is depressed, sad, blue, hopeless, low or irritable, which may include periodic crying spells
- Poor appetite or significant weight loss or increased appetite or weight gain
- Sleep problem – too little sleep
- Feeling agitated (restless) or sluggish (low energy or fatigue)
- Loss of interest or pleasure in usual activities
- Decreased sex drive
- Feeling of worthlessness and / or guilt
- Problems with concentration or memory
- Thoughts of death, suicide or wishing to be dead
Major depression is thought to be four times greater in people with chronic back pain than in the general population.
Depression is common for those with chronic back pain
Depression is more commonly seen in patients with chronic back pain problems, this is due to a number of factors:
- The pain often makes it difficult to sleep, leading to fatigue and irritability during the day.
- Then, during the day, because patients with back pain have difficulty with most movement they often move slowly and carefully, spending most of their time at home away from others. This leads to social isolation and a lack of enjoyable activities.
- Due to the inability to work, there may also be financial difficulties that begin to impact the entire family.
- Beyond the pain itself, there may be gastrointestinal distress caused by anti-inflammatory medication and a general feeling of mental dullness from the pain medications.
- The pain is distracting, leading to memory and concentration difficulties.
- Sexual activity is often the last thing on the person’s mind and this causes more stress in the patient’s relationships.
These symptoms accompanying chronic back pain or neck pain may lead to feelings of despair, hopelessness, inability to enjoy anything and other symptoms of a depression.
Anxiety and Back Pain
Patients with back pain, can also present with anxiety. This may be caused by a worry about their pain, its cause, the treatment, and the future. Understanding all the facts is important, in reducing these fears.
For example – patients often ask if they can end up in a wheelchair either without or with treatment. The chances of this are extremely small!
Some patients who suffer from anxiety and worry in their lives anyway, suffer more with these symptoms when they get back pain. It is also widely recognised that patients with anxiety or depression experience more pain than those who do not.
This is because even though pain is generated in the spine, its is processed in the pain centre in the brain. Each part of the brain affects other parts – so if one is depressed one can experience more pain, and pain in turn can cause people to feel depressed.
Psychological theories about depression
Chronic back pain can lead to a diminished ability to engage in a variety of day to day activities.
This situation leads to a downward physical and emotional spiral. As this continues, the person with chronic back pain feels more and more loss of control over his or her life, leading to major depression. Once in this depressed state, the person is feels unable to change the situation and stuck in a rut.
Depression is a commonly missed diagnosis
One of the biggest problems in treating major depression for the patient with chronic back pain is missing the diagnosis.
This occurs for two reasons: the chronic back pain patients often do not realize they are also suffering from a major depression, and the doctor is not looking for depression.
The depressive symptoms may be downplayed by the chronic back pain patient who believes that, “just get rid of this pain and I won’t feel depressed” or that acknowledging depression is a sign of weakness in dealing with the pain. When the diagnosis of major depression in the chronic back pain patient is missed or ignored, treatments strictly directed at the pain are much more likely to fail.
Simultaneous treatment for depression and chronic back pain
Pain and the depression should be treated simultaneously in a multi-disciplinary fashion. The treatment of clinical depression most often includes psychological interventions (e.g. counseling, relaxation training etc), exercise and anti-depressant medication.
Treatment for the chronic pain might include such things as physical rehabilitation aimed at restoration of function, trying to “normalize” one’s life as much as possible even with the pain, appropriate medication management, among other things.
Multi-disciplinary treatment of the chronic back pain and major depression will ultimately give the patient more of a sense of control over the pain and start a springboard toward physical and mental re-conditioning.
Cognitive behavioural therapy is a well recognised treatment for depression linked to back pain.
I use a variety of means of assessing for depression in all of back pain patients. Depression questionnaires can alert us to the presence and severity of their depression.
If diagnosed it can be treated using a multi-disciplinary approach in addition to treatment of backpain, resulting in a better outcome for the patient.