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Pain and Depression: How the Two are Linked

Published June 9, 2020
| Written By SpineNation Editorial Staff   | Medically Reviewed by Ginger Houghton, LMSW/CAADC
Major depression affects an estimated 17.3 million Americans each year making it one of the most commonly diagnosed mental health conditions. Women more often than men (8.7% compared to 5.3% in men) deal with the adverse effects of depression.
According to the American Pain Foundation, approximately 65% of people reporting depression also complained of living with pain that affected their quality of life. When pain and depression intersect, a downward spiral of adverse health conditions surface creating additional problems.

“Chronic pain can trigger depression and anxiety. Think of being in pain day in and day out and having no way of making the pain go away. It creates a sense of helplessness and hopelessness which transitions into depression,” says Rachel Freedland, LMSW from Bright Spot Counseling in Farmington Hills, Michigan.

“Not knowing what the next day will be like and ‘waiting for the other shoe to drop’ and make things worse, is a hallmark of anxiety. The awareness of the loss of control over our own body makes us grieve what we were like setting off both depression and anxiety.”


The Definition of Chronic Pain

In order to decode the correlation between chronic pain and depression, we have to begin by defining what chronic pain is and what its common causes are. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V), chronic pain is defined as severe pain unresponsive to treatment that lasts longer than six months. When pain enters this phase, it poses consequences such as “psychological distress, job loss, social isolation, and, not surprisingly, it is highly comorbid with depression and anxiety.” Invariably, those with chronic pain spend more on health care attempting to manage their declining health caused by the persistence of their physical ailments.

Chronic back pain is characterized by, but not limited to, the following symptoms:

  • dull to sharp pain in the lower back
  • muscle aches and/or spasms
  • pain-related fatigue
  • difficulty sleeping
  • stiffness when in one position for a prolonged amount of time (i.e., sitting)
  • lost flexibility
  • moodiness, depression, irritability, social isolation

Common back conditions attributing to chronic pain include:

  • Osteoarthritis. A condition where the cartilage between the bones in the spine wears thin causing the bones to rub.
  • Rheumatoid arthritis. An autoimmune disease marked by joint inflammation in the spine.
  • Fibromyalgia. A neurological condition with an unknown cause that triggers debilitating pain to radiate throughout the body.
  • Degenerative disc disease. A condition when the intervertebral discs wear out, rupture, or herniate causing pain.
  • Spinal stenosis. This occurs when the spinal canal narrows causing compression on the spinal cord and nerves.

In some cases, treatment relieves chronic low back pain, but in other cases surgery is required.


How Chronic Back Pain Causes Depression

Pain creates an emotional response within the body. When someone has chronic pain, that emotional response triggers a higher stress response as the person feels their outlook for getting relief diminishes with each failed treatment.

Among the challenges of living with chronic pain, the inability to enjoy regular activities, loss of function in the affected area, and dependency on others to meet basic needs add to feelings of hopelessness. Anxiety, depression, insomnia or hypersomnia, and anger are also prevalent in some people who struggle with managing pain and coping with a change in lifestyle. This can lead to the development of a depressive disorder.

When a person with chronic pain becomes severely depressed, these are some of the external problems that can ensue:

  • Family caretaking and management concerns
  • Job security fears
  • Financial difficulty from missed work
  • Legal issues brought upon by lack of money
  • Social isolation and rejecting help from friends and family for fear of burdening them

If these are present in you or someone you know, it's best to encourage the person to seek professional help through a qualified therapist trained to help people with chronic pain. In some cases, since chronic pain and depression are linked through a common neuro-chemical pathway, they can be treated simultaneously in order to remedy both conditions.

“When a person starts feeling stuck in a state of chronic pain, disappointed on one after another trial of solutions that don't work, it is time to get help from a therapist,” says Freeland. “The therapist can help the client explore and develop strategies that work for them, to deal with the pain and to move it from ‘stage center.’ The client learns how to control the pain experience instead of being a slave to it.”


How the Neuro-Chemical Link Works

The brain neurotransmitters responsible for affecting pain and mood are serotonin and norepinephrine.

Serotonin, nicknamed the happy chemical, plays a role in mood regulation, among other functions. When serotonin is normal or elevated, a person feels good or elated. It’s one of the reasons why recreational stimulants, like cocaine or LSD, cause people to feel good.

On the other side of the coin, it’s unclear whether low serotonin levels can trigger depression, or if depression can decrease serotonin levels, but a study conducted by Harvard Medical School suggests that a low serotonin byproduct has led some depressed people to commit suicide.

Norepinephrine is the body’s stress response hormone. When released into the blood stream, the brain reacts by preparing the body to engage with stress. It sends signals to increase heart rate, release of glucose, pump more blood into the muscles, and boosts alertness and reaction time. In the case of chronic pain, norepinephrine can trigger anxiety as a reaction to pain.

It comes as no surprise that when depression from chronic pain sets in, the chemical reaction between serotonin and norepinephrine can exasperate the symptoms. Changes in serotonin triggered by changes in sleep, mood, and digestion coupled with released norepinephrine lead to depression and anxiety in people with chronic pain. Treat the mind, and the body can begin to heal.


Treating Chronic Pain with Selective Serotonin Reuptake Inhibitors (SSRIs)

Selective Serotonin Reuptake Inhibitors (SSRIs) have been used for decades by psychiatrists to help patients with depression and anxiety. The goal of SSRIs is to create increased neuroplasticity of the brain by enabling it to adapt to new levels of serotonin. This elevates mood and alleviates depression. Successful treatment ends with the patients tapering off of antidepressants. Common SSRIs include:

  • Zoloft
  • Prozac
  • Celexa
  • Lexapro
  • Paxil

Given that people with chronic pain are 2 to 5 times more likely to develop depression, SSRIs given at lower doses have proven to be effective in treating chronic pain. Properly matched to a person’s pain profile, antidepressants have been instrumental in chronic pain relief in conditions like osteoarthritis and fibromyalgia.

As with any medication, a conversation with a physician can help to determine which antidepressant is right for your specific chronic pain condition and to determine the pros and cons of being treated with SSRIs — including possible side effects.

“Psychotropic medication including SSRIs have proven to be helpful as part of the treatment of depression. However, it is rarely a stand-alone approach. Improvement of symptoms has been seen from diet, exercise, social interactions and of course therapeutic interventions,” Freeland says.


Psychotherapy for Chronic Pain

Before antidepressants can be prescribed, physicians may refer patients to psychotherapists who can create treatment options to address the underlying mental health aspect of chronic pain.

During one of the first therapy visits, a patient is required to undergo a detailed psychiatric evaluation to understand the cause of the underlying pain and the depth of the patient’s depression. Using techniques within cognitive behavioral therapy, psychotherapists can be more vigilant in treating depression and pain. This therapy requires patients to address their issues within therapy sessions, as well engaging in homework between sessions designed to help the patient focus on participating in their own recovery.

While CBT focuses on helping a patient accept and understand their pain position, heal from within mentally, and begin to take steps to live normally with their pain, psychotherapy alone will not decrease pain, only enable you to better manage it.

To gain a deeper understanding of how cognitive behavioral therapy is used to treat chronic pain, download this free guide.


Conclusion

Given that chronic pain creates additional stress, anxiety, and depression, it’s important for anyone dealing with it to understand the mental health ramifications of chronic pain. People with prolonged depressive feelings should consult with a psychotherapist to begin treatment before the symptoms create the aforementioned external problems from above — financial distress, job insecurity, social isolation, etc. Treating chronic pain through a mental health approach can go a long way to understanding the role of your pain in your life and how you can live with it should it be recurring throughout your life.

“Most people who decides to take a sustained, comprehensive approach to their chronic pain and depression see significant gains. There are many approaches available to help the interested individual significantly modify the pain and depression circle and live a satisfying life” says Freeland.
Updated: June 9, 2020

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Contributors and Experts

Ginger Houghton, LMSW/CAADC, has specialized training in depression, anxiety, substance use, insomnia and chronic pain.
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