Dr. William Deardorff is a clinical health psychologist who specializes in evaluating and treating patients with chronic pain.
For part 1 of this series, we spoke with him about the relationship between chronic pain and depression, particularly chronic pain caused by arthritis conditions. Part 2 addresses treatment options for depression in arthritic patients.
What’s the difference between depression and feeling blue?
Depression is by far the most common emotion associated with chronic pain, including that caused by arthritis. The type of depression that often accompanies chronic pain is referred to as major or clinical depression.
This type of depression goes beyond what would be considered normal sadness or “feeling down” for a few days. The symptoms of a major depression occur daily for at least two weeks and include at least 5 of the following:
- 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 problems of either too much (hypersomnia) or too little (hyposomnia) 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
If you think you may be depressed, you can take this Depression Questionnaire to see if you should consult your doctor for a diagnosis and treatment.
Why is depression more likely to occur in those with chronic pain?
Chronic pain and depression are two of the most common health problems that health professionals encounter. Major depression is estimated to be at least four times greater in people with chronic pain than in the general population. People with rheumatoid arthritis (RA) are about twice as likely to be depressed as people without RA.
How does depression develop in these cases? This can be understood by looking at the host of symptoms often experienced by a person with chronic pain. The pain often makes it difficult to sleep, leading to fatigue and irritability during the day. Then, during the day, the need for people with chronic pain to move slowly and carefully can lead to them spending most of their time at home, away from others. This leads to social isolation and a lack of enjoyable activities. If someone with chronic pain is unable to work, there may be financial difficulties that begin to impact the entire family.
In addition to these psychological triggers, there are physical and medical triggers that raise risks too. There may be gastrointestinal distress caused by anti-inflammatory medication and/or a general feeling of mental dullness from the pain medications. Chronic pain is distracting, leading to memory and concentration difficulties. When dealing with chronic pain, sexual activity is often the last thing on someone’s mind, and this can cause stress in the relationships. Understandably, these factors may lead to feelings of despair, hopelessness, and other symptoms of a major depression.
Several psychological theories about the development of depression in chronic pain focus on the issue of control. When chronic pain causes a diminished ability to engage in a variety of activities such as work, recreational pursuits, and interaction with family members and friends, this can lead to a downward physical and emotional spiral that has been called “physical and mental deconditioning.”
As the spiral continues, someone with chronic pain can feel more and more loss of control over his or her life. The individual ultimately feels totally controlled by the pain, leading to a major depression. Once in this depressed state, they are generally unable to change the situation even if possible solutions to the situation exist.
How does arthritis in particular affect someone’s risk for depression?
When someone has arthritis, the relationship between the chronic pain and depression may be more complex than a straightforward psychological mechanism. In fact, recent research suggests that the inflammation itself may play a role in causing or contributing to the depression. For instance, high levels of tumor necrosis factor-alpha (TNF-a) in the blood have been associated with a greater risk of depression in patients with rheumatoid arthritis (RA).
So, it is possible that the inflammation causing the RA also causes depression. Interestingly, TNF blockers, which are widely used to treat RA, may also help with some symptoms of depression.
Watch for part 2 coming soon, in which Dr. Deardorff will discuss the ways depression can be treated for those with arthritis and chronic pain.