Depression and chronic back pain

Clinical depression and back pain
Depression is by far the most common emotion associated with chronic back pain. The type of depression that often accompanies chronic pain is referred to as major depression 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 (DSM-IV, 1994):

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 problem 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

Chronic pain and depression are two of the most common health problems that health professionals encounter, yet only a handful of studies have investigated the relationship between these conditions in the general population (Currie and Wang, 2004).

Major depression is thought to be four times greater in people with chronic back pain than in the general population (Sullivan, Reesor, Mikail & Fisher, 1992). In research studies on depression in chronic low back pain patients seeking treatment at pain clinics, prevalence rates are even higher. 32 to 82 percent of patients show some type of depression or depressive problem, with an average of 62 percent (Sinel, Deardorff & Goldstein, 1996). In a recent study it was found that the rate of major depression increased in a linear fashion with greater pain severity (Currie and Wang, 2004). It was also found that the combination of chronic back pain and depression was associated with greater disability than either depression or chronic back pain alone.

Depression is common for those with chronic back pain
Depression is more commonly seen in patients with chronic back pain problems than in patients with pain that is of an acute, short-term nature. How does depression develop in these cases? This can be understood by looking at the host of symptoms often experienced by the person with chronic back pain or other spine-related pain.

The pain often makes it difficult to sleep, leading to fatigue and irritability during the day.
Then, during the day, because patients with back pain have difficulty with most movement they often move slowly and carefully, spending most of their time at home away from others. This leads to social isolation and a lack of enjoyable activities.
Due to the inability to work, there may also be financial difficulties that begin to impact the entire family.
Beyond the pain itself, there may be gastrointestinal distress caused by anti-inflammatory medication and a general feeling of mental dullness from the pain medications.
The pain is distracting, leading to memory and concentration difficulties.
Sexual activity is often the last thing on the person’s mind and this causes more stress in the patient’s relationships.

Understandably, these symptoms accompanying chronic back pain or neck pain may lead to feelings of despair, hopelessness and other symptoms of a major depression or clinical depression.

A recent study by Strunin and Boden (2004) investigated the family consequences of chronic back pain. Patients reported a wide range of limitations on family and social roles including: physical limitation that hampered patients’ ability to do household chores, take care of the children, and engage in leisure activities with their spouses. Spouses and children often took over family responsibilities once carried out by the individual with back pain. These changes in the family often led to depression and anger among the back pain patients and to stress and strain in family relationships.

Psychological theories about depression
Several psychological theories about the development of depression in chronic back pain patients focus on the issue of control. As discussed previously, chronic back pain can lead to a diminished ability to engage in a variety of activities such as work, recreational pursuits, and interaction with family members and friends. This situation leads to a downward physical and emotional spiral that has been termed "physical and mental deconditioning" (See Gatchel and Turk, 1999). As the spiral continues, the person with chronic back pain feels more and more loss of control over his or her life. The individual ultimately feels totally controlled by the pain, leading to major depression. Once in this depressed state, the person is generally unable to change the situation even if possible solutions to the situation exist.