BRITISH JOURNAL OF PSYCHIATRY (2006), 188, 202^203 EDITORIAL

Painful symptoms in depression: under-recognised symptoms. This is four times higher than the incidence of such symptoms in individuals without depression. Pain and under-treated? was reported by 54% of psychiatric in-patients in a Swedish study (Von ROBERT PEVELER, CORNELIUS KATONA, SIMON WESSELY KnorringKnorring et aletal, 1984).,1984). and CHRISTOPHER DOWRICK (c)(c)DepressionDepression and pain may share common pathogenic pathways, possibly involving serotonin (Blier & Abbott, 2001). They are associated with the same range of predisposing environ- mental factors and early childhood Summary Current diagnostic systems A clear example is seen in the classifica- experiences, and may be perpetuated by similar cognitive processes (Gilmer maintain an artificial division between tion of depressive disorders. There is an intimate relationship between experiences & McKinney, 2003). ‘physical’and‘psychological’disorders.This that are conventionally regarded as ‘psy- (d)(d)TheThe presence of pain may be associated is exemplified by the way in which pain chological’ symptoms of depressive illness, with a poor response to treatment for symptoms are dealt with in the context of and other subjective experiences, such as depression, and with greater costs of depressiveillness.The consequencesofthis pain or fatigue, which are regarded as poss- care (Greenberg et aletal, 2003).,2003). ible symptoms of physical illness. Some are discussed, and ways to enhance the (e)(e)TheThe presence of residual symptoms, would even attempt to divide pain and clinical care of patients with depression including pain, is a strong predictor of fatigue symptoms themselves into mental early relapse in patients with major and pain are suggested. and physical subtypes. depression.depression. ICD and DSM do partly acknowledge Declaration of interest All of thetheAll (f)(f)DoctorsDoctors may contribute to increased the problem. In the chapter on mood use of resources by pursuing unneces- authors were involved in the development disorders in ICD–10 it is stated that: sary investigations into the cause of of a review on depression and pain which The relationship between aetiology, symptoms, depression-related pain. was funded by Eli Lilly and Boehringer underlying biochemical processes, response to treatment and outcome of mood disorders is (g)(g)TricyclicTricyclic antidepressants such as Ingelheim. However, the supporting not yet sufficiently well understood to allow amitriptyline are effective, and prob- companies were not represented at their classification in a way that is likely to meet ably more so than selective serotonin with universal approval. meetings and played no partin selecting reuptake inhibitors (SSRIs), in the treat- However, it is then stated that ‘the funda- the participants or preparing the report ment of pain. Serotonin and noradrena- mental disturbance is a change in mood or line reuptake inhibitors (SNRIs) such as or this editorial.R.P.and C.K. have affect’ and that ‘most other symptoms are venlafaxine and duloxetine may also be received speaker fees, hospitalityhospitalityor or either secondary to or easily understood in more effective than SSRIs in reducing consultancy fees from Eli Lilly,Wyeth, the context of such changes’. What is notnot pain symptoms in patients with depression (Bair et aletal, 2004).,2004). Lundbeck,NovoNordiskandBristolLundbeck,Novo Nordisk and Bristol stated is that this is a matter of convention rather than of fact. Similarly, DSM–IV Myers Squibb.S.W.hasSquibb.S.W. has received support acknowledges that physical symptoms are TERMINOLOGY for conference attendance from Eli Lilly. reported by patients, but again such symp- AND CLASSIFICATION toms are excluded from the list of diag- Psychiatric training is based on the tacit nostic features. This is surprising, as the assumption that the clinical focus of psy- Pain in patients with depressive disorders is evidence for the association of depression chiatry is on ‘mental’ disorder. To that frequently regarded as ‘medically unex- and pain symptoms is overwhelming. This end, diagnostic practice has been guided plained’. A joint report from the Royal evidence comes mainly from epidemio- by the development of ICD–10 (World College of Physicians & Royal College of logical studies, but recent developments in Health Organization, 1992) and DSM–IV Psychiatrists (2003) notes that the manage- neuroscience are also beginning to highlight (American Psychiatric Association, 1994). ment of patients with such symptoms is common mechanisms underlying pain and It is therefore not surprising that many psy- often inadequate. The report also states depression (Von Knorring & Ekselius, chiatrists are only dimly aware of the deep that it is unhelpful to think of these 1994).1994). Cartesian dualism inherent in this symptoms in either purely physical or A recent review of published literature approach, and of its potential adverse purely psychiatric terms, and points out on pain and depression (Katona et al,etal, consequences for patients. In reality, the that the phrase ‘medically unexplained’ 2005) highlights these shortcomings and subjective experience of illness is not easily may be unhelpful and resented by patients. draws the following conclusions. carved into separate ‘mental’ and ‘physical’ The traditional classification of diagnoses domains, and diagnostic practice that is (a)(a)InterpretationInterpretation of research on pain and as either organic or psychological, and the based upon such dualism cannot do justice depression is hampered by a lack of use of terms such as ‘functional’, ‘un- to the complexity of the individual experi- clear terminology. explained’ and ‘psychosomatic’ to describe ence of what is conventionally regarded as (b)(b)BetweenBetween two-fifths and two-thirds of painful symptoms, are also unhelpful. For mental illness. patients with depression have painful most pain sufferers, such terms generate

202

Downloaded from https://www.cambridge.org/core. 29 Sep 2021 at 19:41:36, subject to the Cambridge Core terms of use. PAINFUL SYMPTOMS IN DEPRESSION

frustration and distress and offer few ROBERT PEVELER, DPhil, FRCPsych, Mental Health Group,University of Southampton, Southampton; pointers towards treatment, evidence-based CORNELIUS KATONA, MD,FRCPsych,Kent Institute of Medicine and Health Sciences,University of Kent, or otherwise (Feinmann & Newton-John, Canterbury; SIMON WESSELY,MD,FRCPsych, Department of Psychological Medicine,King’s College Hospital, 2004).2004). London; CHRISTOPHER DOWRICK, MD,MD,FRCGP,Department FRCGP,Department of Primary Medical Care,University of Liverpool, Liverpool, UK CLINICAL ASSESSMENT Correspondence: Professor Robert Peveler,Mental Health Group,University of Southampton, Royal South Hants Hospital, Southampton SO14 0YG,UK.Tel: +44 (0) 2380 825533; fax: +44 (0) 2380 234243; As many patients with depression suffer e-mail:e-mail:R.C.Peveler R.C.Peveler@@soton.ac.uksoton.ac.uk from pain of some kind, and in the light of the extensive evidence that such painful (First received 5 May 2005, final revision 24 August 2005, accepted 30 September 2005) symptoms have an adverse effect on clinical outcome, psychiatrists should enquire about and pay attention to pain symptoms (d)(d)negotiatingnegotiating treatment (exploring ACKNOWLEDGEMENTS in patients who are diagnosed with concerns about treatment, including depression. It is important to remember any side-effects that might be We thank Charlotte Feinmann, Linda Gask, Huw that chronic pain is an important indepen- experienced). Lloyd, Amanda C. de C.Williams and Liz Wager for dent risk factor for self-harm and suicide their contributions to the review on depression and (Fishbain, 1999). We should also take into pain and the subsequent discussions which provided account any change in pain symptoms the stimulus for this editorial. Patients who are referred to specialist (and their impact) when assessing patients’ pain clinics are likely to receive multi- progress.progress. REFERENCES modal, multidisciplinary interventions of demonstrated efficacy. Patients with American Psychiatric Association(19 (1994) 94) Diagnostic PRINCIPLES depressive disorders who are referred for and Statistical Manual of Mental Disorders (4th edn) (DSM^IV).Washington, DC: APA. OF MANAGEMENT psychiatric treatment are, in contrast, much less likely to be managed by an integrated Bair, M. J., Robinson, R. L., Eckert, G. J., et aletal (2004)(2004) Patients with complex problems often Impact of pain on depression treatment response in biopsychosocial approach. Indeed their struggle to convey the reality of their symp- primary care. Psychosomatic Medicine,, 6666,17^22.,17^22. pain symptoms may even be ignored, on toms. Psychiatrists may consider that they Blier, P. & Abbott, F.V.(2001) Putative mechanisms of the basis that they will disappear if only action of antidepressant drugs in affective and anxiety lack the specialist knowledge and skills the ‘underlying’ depression can be treated disorders and pain. Journal of Psychiatry and necessary to treat patients with depression effectively. Although it remains difficult so Neuroscience,, 26, 37^43.,37^43. and pain. Taking patients’ pain seriously long as psychiatric services are deeply sepa- Feinmann, C. & Newton-John, T. (2004)(2004) PsychiatricPsychiatric may therefore be therapeutic in its own and related management considerations associated with rated from mainstream medical and surgi- right. The unstated assumption that nerve damage and neuropathic trigeminal pain. Journal of cal services, more joint work in this area Orofacial Pain,, 1818,360^365., 360^365. physical symptoms are secondary to is clearly needed. depression may hamper efforts both to Fishbain, D. A.(1999) The association of chronic pain and suicide.suicide.and Seminars in Clinical Neuropsychiatry,, 44,, engage the patient and to make reciprocal 221^227. links between physical and psychological Gilmer,W.Gilmer,W.& & McKinney,W.T. (2003)(2003) Early experience factors (as opposed to the unidirectional and depressive disorders: human and non-human links that psychiatrists may prefer). CONCLUSIONS primate studies. Journal of Affective Disorders,, 7575,97^113. Techniques that have proved effective Greenberg, P.E., Leong, S. A., Birnbaum, H. G., et aletal in the ‘neutral’ space of primary care can Pain in patients with depressive disorders (2003)(2003) The economic burden of depression with painful be grouped under the following four has received inadequate attention in terms symptoms. Journal of Clinical Psychiatry,, 6464,17^23. headings:headings: of both research and treatment. This topic Katona, C., Peveler, R., Dowrick, C., et aletal (2005)(2005) Pain represents an important gap in psychiatric symptoms in depression: definitiondef inition and clinical (a)(a)helpinghelping the patient to feel understood training. Many psychiatrists feel poorly significance. Clinical Medicine,, 55, 390^395.,390^395. (listening, taking physical complaints equipped to manage patients with complex Royal College of Physicians & Royal College of seriously, picking up cues of emotional presentations such as depression and pain, Psychiatrists(2003) The Psychological Care of Medical Patients. A Practical Guide. London: Royal College of distress, and exploring the patient’s and may look to colleagues in the specialty Physicians/Royal College of Psychiatrists. http:// concerns about their illness) of liaison psychiatry for assistance. www.rcpsych.ac.uk/publications/cr/council/cr108.pdf Although such specialists may have a role Von Knorring, L. & Ekselius, L.(19 (1994) 94) Idiopathic pain (b)(b)broadeningbroadening the agenda (opening up the in education and training, depression with and depression. Quality of Life Research,, 33, S57^S68.,S57^S68. consultation to a discussion of both pain occurs too frequently for it to be Von Knorring, L., Perris, C., Oreland, L., et aletal (1984)(19 8 4) physical and psychosocial issues) exclusively their domain. Twenty-first- Pain as a symptom in depressive disorders and its relationship to platelet monoamine oxidase activity. (c)(c)makingmaking links (providing explanatory century psychiatrists must move away from Journal of Neural Transmission,, 6060,1^9.,1^9. models of the ways in which physical the dualism that currently besets Western WorldHealthOrganization(1992)WorldHealthOrganization(19 92) The ICD ^10 and psychosocial problems may be medical practice if their patients are to Classification of Mental and Behavioural Disorders: Clinical linked)linked) receive optimal care. Descriptions and Diagnostic Guidelines..Geneva:WHO. Geneva: WHO.

203

Downloaded from https://www.cambridge.org/core. 29 Sep 2021 at 19:41:36, subject to the Cambridge Core terms of use.