"We know that in some patients, depression follows the pain," says Russell K. Portenoy, MD, chairman of the Department of Pain Medicine and Palliative Care at the Beth Israel Medical Center in New York City, "And in some patients, depression seems to precede or drive the pain."
And yet there are patients who feel that because it's pain that they suffernot a life-threatening diseasethey have no right to depression. This can lead to what Lynne Nelson, 56, from Nashua, N.H., calls "a mess of thoughts."
"I feel pretty crummy," says Amanda, 39, of Manchester, N.H., who suffers from debilitating migraines. "A lot of times with the migraines, I find I'll have a lot of anxiety, depression. And after I'm two or three days into it, that of course is intensified."
Antidepressants can help two ways
Antidepressant medications are used for their direct pain-relief effect.
"Antidepressant medications can treat pain in people who are not depressed," says Dr. Portenoy. "Some of them are in fact painkillers. There have been many studies to show that antidepressants can be used to treat headache, lower back pain, fibromyalgia, and nerve pain."
But these meds do "double duty" by attacking depression itself, says Steven Feinberg, MD, a past president of the American Academy of Pain Medicine.
"If a person has depression and pain, then the antidepressants should be considered first-line drugs," adds Dr. Portenoy.
Whether the medication is for pain or depression relief, some patients resist it, because of the stigma associated with antidepressantsor because they're resistant to having to take one more pill.
Lynne Nelson says she "fought it and fought it."
"My primary care doctor and my neurologist had been telling me for over a year that I need to be on an antidepressant. Finally my primary care doctor said 'Look, do you want to get in your car every day after work and cry all the way home? That's what you do every day. That's depression. People who are in chronic pain are depressed, and you don't need to be depressed.'"
Nelson went on Effexor and within three months, she "felt like a cloud had lifted. It was very subtle and it's a very low dose," she says. "But I was depressed and I didn't want to believe that. So I am much happier now."
The benefits of talk therapy
For others, counseling or therapy is effective. Sandy Frandsen was finally able to regain an active life with family and friends after doing a eight-week, multidisciplinary course that worked on breathing techniques, stretching and physical activity, and methods for helping to manage the way she viewed her pain.
Beverly Thorn, PhD, a psychology professor at the University of Alabama in Tuscaloosa conducts cognitive-behavioral therapy sessions with chronic pain patients and asks them at the end of their therapy, "What has changed since the treatment? The things they say are 'I still have the pain, but the pain doesn't have me anymore. I'm able to take back my life.'"
Frandsen was able to see this change during an exercise in which she expressed her emotions in a collage. "When I started I was just doing layers of different colors. And they were all dark colors, black, purple, red, the gloomy colors, they were grey, you know, it was just because that was the place I was in." she says. "And at the end of the course, the last thing I did was just a big yellow happy face."