pain, whether pain by itself can cause depression, or whether there is a common risk factor, such as genetics, for both pain and depression (Sheng, et al., 2017).The two conditions are likely bidirectional and inseparable. From a clinical perspective, it is more important to understand risk factors for depression in chronic pain and to treat both conditions simultaneously and effectively. An overview of the scientific literature identifies risk factors for depression in persons with chronic pain (National Institute of Mental Health, 2018; Schaakxs, et al., 2017; Martins et al., 2017; Dagnino, et al., 2020; Shadrina , et al., 2018). These risk factors include: ● Genetic factors : ○ Family history of depression. ○ One or both parents depressed. ● Disease factors : ○ Higher pain severity. ○ Greater physical disability. ○ Physical deformities associated with the painful condition. ● Demographic factors : ○ Being female. ○ Younger age at disease onset. ● Psychosocial factors : ○ Low self-esteem (especially feeling “like a burden” because of pain). ○ Previous history of depression. ○ History of trauma or abuse. ○ Passive coping (helplessness, reliance on others, avoidance, self-pity). ○ Poor body image. ○ Social isolation. Anger, often expressed as frustration or irritability, has been studied in people with chronic pain as far back as the 1970s (Pilowsky & Spence, 1976). It is estimated that among the 100 million people afflicted with chronic pain 27% meet the crireia for depression; 35% for anxiety and 61% for substance abuse disorder (Patel, 2019). Considering the sleep deprivation and painful sensations alone, it is easy to understand why people with chronic pain might be ill tempered in their interactions with others or struggle with anger management. The development of communication skills among patients with chronic pain can reduce the negative emotions associated with their condition and can allow them to vent their pain-related anger and frustration in a manner that is not disparaging to others (London Pain Clinic, 2017). Emotions such as fear, anger, anxiety, guilt, grief and the feeling of helplessness can exacerbate the symptoms of chronic pain so it is essential that these patients can communicate their feelings to their family and healthcare providers and in turn receive empathetic support (Dawson, 2020).Unfortunately, this intentional suppression of anger comes at a high price: It is associated with greater levels of muscle tension and subsequent pain (Black, 2020; Cosio, 2019a).The person with chronic pain may face a dilemma in terms of managing anger – either express it and risk alienating friends and family or bottle it up and deal with more pain and frustration as a result. This kind of problem around emotional awareness and expression is the target of a number of psychotherapy approaches to chronic pain, including acceptance and commitment therapy, cognitive behavioral therapy (CBT) and Chronic pain can be disruptive to a person’s social network. Again, not all individuals with chronic pain will suffer all the potential negative consequences, and it is important to remember that many individuals with chronic pain do not experience changes in their relationships as a result. However, those who do may experience significant problems. As described above, chronic Compassion Cultivation Training (Black, 2020). Disruption of family and social support pain is often associated with anger and irritability, which can either drive loved ones away or draw them into a position of tolerating formerly unacceptable behavior. Because chronic pain is associated with depression, it often results in disengagement from pleasurable activities, including those involving family and friends.
also feeds into sleep problems, especially by contributing to obstructive sleep apnea, the occurrence of which patients with chronic pain are at an increased risk (Tentindo, et al. 2018). Unfortunately, sleep deprivation actually makes nerves more sensitive to painful stimuli (Nijs, et al., 2018). Pain and sleep problems are cyclical. Studies have shown that a night of poor sleep is followed by increased pain the next day and that this increase in pain is associated with worse sleep the next night (Moawad, 2020). Sleep deprivation due to chronic pain can have adverse physical, emotional and behavioral ramifications (Moawad, 2020). This fatigue means that people with chronic pain are less physically active than those people without sleep disturbances initiated by chronic pain (Husak and Bair, 2020). Now, coming full circle, the lack of physical activity is also associated with more pain-related disability (Husak and Bair, 2020). Depression and irritability Depression and chronic pain co-occur so frequently, and have such overlapping symptoms, they have become a kind of “chicken and egg” story in pain research. Text Box 4 provides a clinical description of major depression. On the one hand, it is easy to see how chronic pain could lead to depression, since it disrupts sleep, limits an individual’s ability to engage in valued activities such as socializing, and in many cases creates significant financial limitations by limiting work. On the other hand, people who are depressed might be more likely to suffer from physical symptoms Major depression is a clinical term used by physicians and mental health providers, and is different from normative low mood or occasional sadness. To be diagnosed with major depression, an individual must report that for at least the past two weeks, more days than not, he or she experienced: (a) feeling either depressed or a loss of interest/pleasure in nearly all activities; and (b) at least four additional symptoms drawn from a list that includes changes in appetite or weight; changes in sleep and psychomotor activity; decreased energy; feelings of worthlessness or guilt; difficulty thinking, concentrating, or making decisions; or recurrent thoughts of death or suicidal ideation (Coryell, 2020). The yearly prevalence of depression among those afflicted with chronic pain approximates 23% (Orhurhu, et al., 2019) compared to a prevalence of 7.1% among the general population (The National Institute of Mental Health, 2019). In fact, if a person has chronic pain, his or her lifetime risk of developing major depression is three times greater than if he or she does not have chronic pain. It can be difficult to determine if the chronic pain caused the depression or the depression was a factor in the development of the chronic pain (Smith, 2021). as a part of their depression. Box 4: What Is Depression It is also true, however, that people who are depressed are more likely to report pain problems. Low back pain is reported twice as frequently by individuals who are depressed as by those who are not, and depressive symptoms are predictive of future episodes of musculoskeletal pain (Ciccone, 2016). People who are prone to depression are often prone to catastrophic thinking, which has been shown to increase the functional and emotional impact of pain (Craner et al., 2016). So, which is the chicken, and which is the egg? Some studies have looked at the relationship between pain and depression over time. The relationship typically progresses as follows: Pain → Fatigue and Disability → Depression However, depression often feeds back into, and further exacerbates, fatigue (Aiken, 2019). There is also a school of thought that believes that pain may in itself be a physical symptom of depression (National Institute of Mental Health, 2018) although this hypothesis has not been scientifically evaluated. It may never be known for certain whether depression exacerbates
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