Treating chronic pain and depression from degenerative disc disease

Chronic pain most often takes a psychological toll on patients. There can be a reinforcing cycle—chronic pain commonly leads to depression, and patients who are depressed often have chronic pain. Therefore, both the depression and the chronic pain need to be treated before any significant progress with treatment is achieved.

Medications for depression
The depression can be treated with medication, and there are several very effective antidepressants that can be useful. The newer antidepressant medications do not have as many side effects as many of the older antidepressants. As with everything else, exercise also can also help relieve some symptoms of depression.

Depression medications and sleeping
With depression and chronic pain, difficulty sleeping can complicate matters. If patients are not sleeping regularly, it makes it much more difficult to cope with the stress that chronic pain can create.

Patients did not tolerate some of the older antidepressants (e.g. Amytriptiline) in doses prescribed for depression because the medication made patients so sleepy. However, these classes of anti-depressants are useful to treat sleep disorders, and when used at night in doses that are a fraction of what they were needed for treating depression, they are well tolerated by patients. These anti-depressants are not addictive and do not change a patient’s sleep cycles. The most pronounced side effect is that many patients report an initial "hangover" effect that tends to recede over time. The anti-depressant medications also seem to have an anti-pain quality to them and many patients report a reduction in pain with these medications. They seem to be especially good for reducing nerve root pain (e.g. radiculopathy or neuropathy).

Disability from chronic pain can be affected by depression
The amount of disability a patient experiences is not always directly proportional to the amount of pain or pathology present. Other factors in our lives can significantly impact our level of disability. Patients who are most likely to have a great deal of difficulty returning to work are especially those who have lower than average socioeconomic status, heavy laborers, and patients with a low level of education, or who do not enjoy their work place. Patients may be scared to return to work since this is most likely where they were injured in the first place.

Treating depression comprehensively
It often takes a very comprehensive approach to assist patients in returning to their former level of functioning, with a team that consists of a rehabilitation specialist (physiatrist), physical therapist, psychologist, occupational therapist, and a nurse case manager who helps coordinate the care needed to treat depression and chronic pain.

By: Peter F. Ullrich, Jr., MD
June 7, 2000