Evidence-Based Reviews

Chronic pain and depression: Treatment of 2 culprits in common

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Catastrophizing also has been implicated in mediating the relationship between pain and sleep disturbance. Not surprisingly, a randomized controlled study demonstrated the benefit of 8-week, Internet-delivered CBT in patients suffering from comorbid chronic pain, depression, and anxiety. Treatment significantly diminished pain catastrophizing, depression, and anxiety; maintenance of improvement was demonstrated after 1 year of follow-up. 31

Other behavioral and psychological approaches. Biofeedback, mindfulness-based stress reduction, relaxation training and diaphragmatic breathing, guided imagery, hypnosis, and supportive groups might play an important role as components of an integrated mind−body approach to chronic pain, 28,32,33 while also providing mood benefits.

Exercise. The role of exercise as a primary treatment of MDD continues to be controversial, but its benefits as an add-on intervention are indisputable. Exercise not only complements pharmacotherapy to produce greater reduction in depressive scores and improvement in quality of life, it might aid in reestablishing social contacts when conducted in a group setting—an effect that can be of great value in both MDD and chronic pain. 34

Exercise and restorative therapies provide several benefits for chronic pain patients, including:

  • improved pain control, cognition, and mood
  • greater strength and endurance
  • cardiovascular and metabolic benefits
  • improved bone health and functionality. 26,28,32,33,35

To achieve optimal benefit, an exercise program must be customized to fit the patient’s physical condition, level of fitness, and specific type of pain. 35 Preliminary evidence suggests that, beyond improvement in pain and functionality, exercise might reduce depressive symptoms in chronic pain patients. 36

Bottom Line
Because pain and depression share common neurobiological pathways and clinical manifestations, similar strategies and agents are used to treat these conditions, including when they are comorbid. Use of antidepressants for treatment of chronic pain is a common practice. Long-term benefit of opioids is limited, although the risk of these drugs is high. Gabapentin and pregabalin decrease pain intensity and improve quality of life and function neuropathic pain. Non-drug approaches can be used as stand-alone, but are more commonly incorporated into a multimodal treatment plan or applied as an adjunct.

Related Resources
  • Maletic V, DeMuri B. Chronic pain and depression: Understanding 2 culprits in common. Current Psychiatry. 2013;15(2):40-44,52.
  • Fava M. Depression with physical symptoms: treating to remission. J Clin Psychiatry. 2003;64(suppl 7):24-28.

Drug Brand Names
Amitriptyline • Elavil
Bupropion • Wellbutrin
Citalopram • Celexa
Desipramine • Norpramin
Duloxetine • Cymbalta
Fluoxetine • Prozac
Fluvoxamine • Luvox
Gabapentin • Neurontin, Gralise
Milnacipran • Savella
Modafinil • Provigil
Nortriptyline • Aventyl, Pamelor
Pregabalin • Lyrica
Tramadol • Ultram
Venlafaxine • Effexor
Vortioxetine • Brintellix Gralise

Dr. Maletic has served as a consultant to FORUM Pharmaceuticals; Eli Lilly and Company; Lundbeck; Merck & Co.; Otsuka; Pamlab, Inc.; Sunovion Pharmaceuticals; Takeda Pharmaceuticals; and Teva Pharmaceuticals. He has served on the promotional speakers’ bureau of Eli Lilly and Company; Lundbeck; Merck & Co.; Sunovion Pharmaceuticals; Otsuka; Pamlab, Inc.; Takeda Pharmaceuticals; and Teva Pharmaceuticals.

Dr. DeMuri reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

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