Depression is common in chronic pain patients. This study states that “up to 85% of patients with chronic pain are affected by severe depression”. Which came first is like the analogy of the chicken and the egg. Regardless of which health condition was present in an individual first, they can both influence one another and often become a vicious cycle.
What is depression?
Depression is a mental illness which causes a persistent, all-encompassing feeling of sadness and despair. For some people, depression can last weeks or months, while for others it can go on for years. Depression can come and go over time. While depression has some commonly shared symptoms, it can be experienced differently depending on the individual. Depression is not just ‘feeling a bit sad’ and isn’t something you can just snap out of. It can be extremely debilitating.
- Feelings of extreme sadness and low mood
- Low self esteem
- Fatigue and lethargy
- Feeling your limbs are heavy and movement takes a lot of energy
- Having low or no motivation
- Losing interest in things which previously brought you joy
- Feeling irritable or angry with others
- Feeling hopeless
- Feeling tearful
- Problems sleeping
- Decrease or increase in appetite
- Low sex drive
- Aches and pains
- Social withdrawal
- Having thoughts or actions of harming yourself and/or suicide
I live with bipolar disorder, which means that my moods move on a sliding scale between severe depression and hypomania (elevated mood). While my experience of bipolar depression differs slightly from unipolar depression (depression in someone without bipolar), many of the symptoms are the same. I know from personal experience how devastating, and frankly terrifying, depression can be, not just for the individual but for their loved ones. The good news is, as scary as this may sound, depression is something that you can recover from.
How can chronic pain impact depression?
- Being in long term pain
Living in pain can be difficult, both physically and emotionally. For many people, chronic pain is widespread and often constant. The experience of being in pain is draining. It can make you angry, sad, frustrated, tearful and more. Understandably, living in pain and knowing that it’s long-term, that it isn’t going to go away anytime soon, can cause a drop in mood.
- Loss of functioning
For many people, their chronic pain, fatigue and associated symptoms reduce their level of functioning, especially when they are not receiving treatment. This means that they might not be able to do the things they used to and may struggle to keep up with the day-to-day tasks. Loss of daily functioning can feel devastating and can take its toll on your mood.
- Needing to ask for help
When you struggle with day to day tasks, this often results in needing to ask loved ones for help. This can feel embarrassing and frustrating. It’s bad enough accepting within yourself that you can’t do all the activities you used to do, but allowing other people to see that and asking them to help you makes it all the more real. There can be a sense of losing your independence which comes with a whole range of emotions, contributing to depression.
- Social isolation
Low levels of functioning and often fear avoidance (avoiding activity because patients fear it might worsen their pain), can lead to your social life declining. You may not feel able to keep up with the social activities your friends are engaging in, and so may decline invitations.
Chronic pain is often highly unpredictable; even when you do make plans, you may have to cancel at the last moment if you have a flare in symptoms. Loved ones can find this frustrating, especially if it happens often and they don’t understand your condition. This can lead to a lack of invitations in the future.
As humans, we need those social connections to thrive and to be happy. Without them, our mood naturally drops. We become lonely. We feel guilty for ‘letting down’ the people we care about most or not being able to keep up with them. Without someone we trust to talk about our thoughts and problems with, they can build up and start to feel insurmountable. All these negative feelings can contribute to depression.
- Being unable to work
With low levels of functioning, many people living with chronic pain are unable to work. This can not only be worrisome financially but also cause an individual’s confidence to take a hit. Not being able to work can add to feelings of helplessness, guilt and worthlessness.
- Financial worries
As well as the financial pressures of being out-of-work, for many people medical bills can be a big concern. In many countries, people must pay for medical expenses out of pocket. Even with medical insurance, it doesn’t always cover every aspect of medical care.
Even in the UK, where we have the National Health Service (NHS), they don’t cover more complex mobility aids or all medical treatments. Many may need to seek treatments privately which they fund themselves. These medical bills can pile up and result in the patient’s being in debt. Understandably this can contribute to stress, worry and depression.
- Low self esteem
Many of the aspects we have discussed can also mean that an individual’s confidence levels can take a hit. You can start to feel useless because you can’t function in the way that you used to. It can be all too easy to be hard on yourself. Low esteem can contribute to depression.
- Confused sense of self
When your daily life looks so vastly different, it can seem like you are a different person than you were before you became chronically ill. It can be confusing, and many people start to doubt who they are as a person. This study refers to this, discussing, “the powerful ways in which chronic pain has negative impact on patients’ self and identity.”
- Uncertainty about the future
For many people, they may feel that they are going to be stuck in this situation forever. A lot of the time we are not made aware by medical professionals that recovery from chronic illness is possible; symptoms can be reduced, and functioning can be regained. Some people can even become completely pain-free!
Without this knowledge and hope for the future, it can feel as though you are not going to be able to follow your dreams and be able to live a happy life. Many people worry about what their life will look like going forward, and whether their symptoms might even get worse. This can be an extremely daunting prospect.
- Tense connections with loved ones
Chronic pain doesn’t just affect the individual; it can also be very tough for their loved ones. When loved ones don’t fully understand an illness which is often invisible, this can lead to frustration on their part. This frustration can increase the person in pain’s sense of being a burden and often make them feel invalidated.
Dynamics can often change within connections, particularly if loved ones take on a caring role. These changes can often lead to tension and stress on both sides. It can be frightening to see someone you care about in pain, and perhaps to feel unsure of how to help.
With all these emotions running high, often connections can become tense. Both parties can become irritable and communication can break down. This can contribute to a feeling of isolation on the person in pain’s part and contribute to stress and depression.
How can depression impact chronic pain?
- Withdrawal from activity
With the lack of motivation, fatigue and difficulty engaging in daily activities that often comes with depression, it can mean that patients become inactive. Inactivity can result in deconditioning, meaning that muscles weaken because they aren’t being used. This can actually worsen chronic pain as explained here.
- Stress levels
Depression means that you are experiencing low mood and negative emotions in the extreme; this can result in high stress levels. It can feel overwhelming to try and fight depression, to attempt to function despite it. The entire experience is emotionally draining.
The body is not designed to be in a prolonged state of stress. Being stuck in a ‘fight or flight’ response for a long period of time takes its toll on the body and mind. Tight muscles increase pain. High levels of cortisol (known as the stress hormone) increase inflammation, pain and fatigue. Fundamentally, stress actually causes and perpetuates chronic pain, causing a cycle of stress causing pain and pain causing stress.
- Less motivation for self-management
With low motivation and low energy, depressed patients are less likely to follow through with treatment plans for their chronic pain. They’re less likely to attend appointments, to seek help and to commit to talking therapies as this article explains.
Self-care is a big part of chronic pain management. Healthy coping behaviours like regular exercise, eating well and keeping a good sleep routine are vital. When a patient is depressed, they are far less likely to actively practice these adaptive (helpful) coping behaviours at home.
- Sharing neural pathways
Depression and chronic pain share the same neural pathways within the brain, meaning that they influence one another directly. Our brains are neuroplastic, simply meaning that they change as they learn from our environment and the experiences we go through. Many of the same neuroplastic changes seen in depressed patients are also seen in chronic pain patients.
This study states that “pathways of body pains have been shown to share the same brain regions involved in mood management, including the insular cortex, prefrontal cortex, anterior cingulate, thalamus, hippocampus, and amygdala, which form a histological structural foundation for the coexistence of pain and depression”.
If you’re experiencing symptoms of depression, you should see your doctor. Depression can be recovered from with the right treatment.
Your doctor may prescribe you some antidepressants, which can help to lift and stabilize your mood. Some antidepressants can also aid with chronic pain, although more research needs to be done into this. Antidepressants can have side effects. Ensure you do your research and ask any questions you have before you start taking any medication.
There are a wide variety of antidepressants which may be prescribed. It can be a trial and error process to figure out which ones work for you and cause you the least side effects. Antidepressants can take a good few weeks to start having an effect and for side effects to settle down. If after this time has passed you feel they aren’t working for you, don’t lose hope. You can go back to your doctor and discuss trying another type.
Many of the same psychological therapies which are used to treat chronic pain, can also be applied to depression. When you are experiencing both, you can use therapy sessions to address both problems at the same time. Some therapies are aimed at mental health solely, however, by dealing with your depression, you can actively improve your chronic pain.
- Cognitive Behaviour Therapy (CBT)
CBT is a form of talking therapy which is based on the fact that our thoughts influence our behaviours. CBT helps you to replace negative thoughts and the behaviours which follow them, with positive thoughts and behaviours. It is proven to be very effective in both depression and chronic pain.
You can be referred to CBT through your doctor. From there you will see a CBT therapist usually weekly, for between 5 and 20 sessions depending on your progress and what is needed. Alternatively, you can find a CBT therapist privately or access CBT online, for example for chronic pain you can access CBT through our pain relief app (update Aug 2023: Pathways is now a web app! Start our program here).
Guided mindfulness is about learning to be present in the moment, not to worry about the past or the future. It can allow you to gain greater control over your emotions and can aid with relaxation. Mindfulness can help with depression as well as chronic pain.
Guided mindfulness meditations are often used during sessions, as well as breathing exercises, slow flowing mindful movements and visualisation. Often mindfulness techniques are combined with other types of therapy, such as CBT.
You may be referred for mindfulness through your doctor, you may find local mindfulness classes and courses, or you can find plenty of mindfulness resources online such as videos and mindfulness apps.
Psychotherapy is a talking therapy to treat depression among other mental health problems. This type of therapy which tries to get to the root of your deepest feelings. Rather than trying to change your thoughts, psychotherapy helps you to recognise negative thoughts and talk about them. Often psychotherapists will direct you towards figuring out solutions to problems yourself.
Psychotherapy is usually done in a face to face setting. It may be done individually or can be practised in a group setting. When engaging in group therapy, group members often offer advice and support to their peers. You can access psychotherapy through a referral from your doctor or privately. Some psychotherapists may offer their services online through video chat, or over the phone.
- Interpersonal therapy (IPT)
IPT is a talking therapy to help you build stronger connections with those in your life. You may address problems within specific relationships and figure out solutions with the help of your therapist. IPT teaches you the communication skills to express your feelings constructively without allowing emotions to escalate.
When you visit your doctor to discuss feeling depressed, often you will be referred for counselling. These are simply talking sessions with a qualified counsellor in a face to face setting. Rather than give you guidance or try to change your thoughts, counselling is more so about you talking through your problems and getting things off your chest. Counsellors may gently guide you towards solutions and better coping strategies by asking questions to encourage you to come up with the answers yourself.
As well as through your doctor, you can access counselling privately, through mental health charities, and online through counselling apps. Be sure to do your research and ensure that you are talking to a qualified, registered counsellor if you are seeking treatment online.
As well as seeking professional help for your depression, it’s important that you utilize active self-management strategies. This is often difficult to do when you’re depressed, but small steps towards healthy behaviours can be really helpful. Remember if you’re struggling to keep up with your self-management, you could ask a loved one to encourage you and help you along.
- Talking to someone you trust
Sometimes talking through your emotions with someone you really trust can feel as though a weight has been lifted. It can make you feel less alone and more supported.
- Finding support from others who understand
It’s common to feel alone when you are depressed, but this is far from the case. You can find support from others who understand what you’re going through online through social media, or by joining local support groups.
- Practising daily mindfulness
As well as guided mindfulness, you can also integrate mindfulness into your day to day life with tasks like taking a bath or washing the dishes. This can really help you to feel grounded in the present and reduce your stress levels.
- Regular exercise
Even though it can feel like the absolute last thing that you want to do, exercise truly can boost your mood. It’s a great way to tackle depression. Asking a loved one to go with you, even for a short walk outdoors, can make a big impact.
- Eating a healthy diet
Giving your body the fuel it needs to fight your depression and your chronic illness is really important. You could ask family members to help you prepare healthy meals in advance which you can later just heat up if you are feeling fatigued.
- Taking prescribed medicines regularly
It’s so important that you take antidepressants regularly. Missing a dose can cause withdrawal symptoms as explained here.
- Praising yourself
Little tasks feel like you are climbing a mountain when you are depressed. Praise yourself when you get to the top of that mountain!
- Treating your chronic pain
As we discussed, chronic pain influences and worsens your depression. Treating your chronic pain can help you to tackle your depression.
- Staying safe
If you are feeling at risk of harming yourself or are feeling suicidal, please reach out for help. Talk to a friend, call a hotline (you can find an international list of hotlines here) or call your doctor. If you’re in immediate danger, please go to the hospital or call the emergency services.
Remember that even though both depression and chronic pain can feel impossible to deal with at times, they don’t have to be forever. You can recover and regain your quality of life. There is help out there. Please don’t give up hope!
- Journal of Health and Social Behaviour, Erin York Cornwell, Linda J. Waite, (2009), “Social Disconnectedness, Perceived Isolation, and Health among Older Adults”
- Psychology & Health, Volume 22, Issue 5, Dr Jonathan A. Smith, Mike Osborn, (2007), “Pain as an assault on the self: An interpretative phenomenological analysis of the psychological impact of chronic benign low back pain”
- Medicine (Baltimore), Jae-A Lim, MA, Soo-Hee Choi, MD, PhD,Won Joon Lee, MD, et al, (2018), “Cognitive-behavioral therapy for patients with chronic pain”
- NHS, (2018), “Antidepressants”
- NHS, (2019), “Clinical depression”
- International Bipolar Foundation: “List of international suicide hotlines”
Please note: This article is made available for educational purposes only, not to provide personal medical advice.