Diagnosis of depression
and chronic back pain
Depression is a commonly missed diagnosis
One
of the biggest problems in treating major depression
for the patient with chronic back pain is missing the
diagnosis. This occurs for two reasons: the chronic
back pain patients often do not realize they are also
suffering from a major depression, and the doctor is
not looking for depression.
Chronic back pain patients will often define their
problem as strictly medical and related to the pain. This
is supported by a recent study which found that individuals
with chronic pain and depression went to their physicians
20% more often than a comparison group of non-depressed
medical patients. In addition, depressed chronic
back pain patients were 20% less likely to see a mental
health specialist than medical patients without a pain
problem (Bao, Sturm, & Croghan, 2003).
The depressive symptoms may be downplayed by the chronic
back pain patient who believes that, “just get
rid of this pain and I won’t feel depressed” or
that acknowledging depression is a sign of weakness
in dealing with the pain. When the diagnosis
of major depression in the chronic back pain patient
is missed or ignored, treatments strictly directed
at the pain are much more likely to fail. As
concluded by Ohayon and Schatzberg (2003), the presence
of a chronic pain physical condition increases the
duration of depressive mood, and chronic pain patients
seeking medical consultation should be routinely screened
for a major depression.
Simultaneous treatment for depression and chronic
back pain
Treatment of depression associated with
chronic back pain requires a specialized approach. It is generally
accepted that the pain and the depression should be
treated simultaneously in a multidisciplinary fashion. The
treatment of clinical depression most often includes
psychological interventions (e.g. counseling, relaxation
training, etc) and anti-depressant medication.
In a recent review of the research from 1980 though
2000 that looks at treatment of depression, it was
found that the combined treatment approach of medication
and psychotherapy yielded better outcomes than either
of the interventions alone (Pampallona et al., 2004). Simultaneous
treatment directed at the chronic back pain is critical. It
has been found that chronic pain may interfere with
depression improvement.
Treatment for the chronic pain might include such
things as physical rehabilitation aimed at restoration
of function, trying to “normalize” one’s
life as much as possible even with the pain, appropriate
medication management, among other things. Multidisciplinary
treatment of the chronic back pain and major depression
will ultimately give the patient more of a sense of
control over the pain and start a “positive spiral” toward
physical and mental re-conditioning.
Assessing depression
The Depression Questionnaire
is a self-administered test that patients can take
to gauge the severity of their depression. If the score is in the moderate
to severe range, the patient should discuss the results
with his or her doctor or back specialist. It
may find be helpful to print up this page to take the
depression questionnaire and record the answers and
final score.
The Depression Questionnaire
It may be helpful for patients to print this page
to more easily record their answers and score.
Using the following scale for each of the listed symptoms,
the patient should circle the number that best indicates
how much of this type of feeling has been experienced
over the past one to two weeks. Make sure that
all the questions are answered. If it is difficult
to answer any of the questions, a best guess should
suffice.
The scale is as follows:
0 = Not at all
1 = Somewhat
2 = Moderately
3 = A lot
| Symptoms |
Not at all |
Somewhat |
Moderate |
A lot |
Do you feel sad, low, blue,
or unhappy? |
0 |
1 |
2 |
3 |
Do you feel hopeless or discouraged
about the future? |
0 |
1 |
2 |
3 |
Do you feel useless or believe
yourself to be a failure? |
0 |
1 |
2 |
3 |
Do you feel inadequate or inferior
to others? |
0 |
1 |
2 |
3 |
Do you feel guilty or blame
yourself for everything? |
0 |
1 |
2 |
3 |
Do you find it difficult to
make decisions? |
0 |
1 |
2 |
3 |
Do you feel frustrated and irritable? |
0 |
1 |
2 |
3 |
Have you lost interest in other
people or your usual activities? |
0 |
1 |
2 |
3 |
Do you feel unmotivated and
find it difficult to do things? |
0 |
1 |
2 |
3 |
Do you think you’re looking
old, unattractive or ugly? |
0 |
1 |
2 |
3 |
Have you lost your appetite
or had a change in weight not due to dieting? |
0 |
1 |
2 |
3 |
Do you have trouble falling
asleep, or do you wake up during the night,
earlier than you would like? |
0 |
1 |
2 |
3 |
Do you feel tired much of the
time? |
0 |
1 |
2 |
3 |
Have you had crying spells or
felt like crying but couldn’t? |
0 |
1 |
2 |
3 |
Have you lost your interest
in sex? |
0 |
1 |
2 |
3 |
Do you worry often about your
general health even beyond the upcoming surgery? |
0 |
1 |
2 |
3 |
Do you have thoughts about killing
yourself or do you think you might be better
off dead?* |
0 |
1 |
2 |
3 |
|
Add up your total score for the 17 symptoms and record
it for scoring.
The total score will be somewhere between 0 (answering “Not
at all” to each item) and 51 (answering “A
lot” for each item). Use the following key to
interpret your score:
| Total
Score |
Degree
of Depression |
0-4 |
Minimal or no depression |
6-11 |
Borderline depression |
12-21 |
Mild depression |
22-31 |
Moderate depression |
32-51 |
Severe depression |
*If you have had thoughts about killing yourself or
scored in the severe range of depression, you should
consult a qualified mental health professional.
By: William
W. Deardorff, PhD, ABPP
October 15, 2004
|
