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Pain, Anxiety, and Depression INSIDE Why These Conditions Often Occur Together and How to Treat Them When They Do

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Pain, Anxiety, and Depression INSIDE Why These Conditions Often Occur Together and How to Treat Them When They Do VOLUME 26 • NUMBER 11 May 2010 Pain, anxiety, and depression INSIDE Why these conditions often occur together and how to treat them when they do. Cultivating a “winner’s brain” veryone experiences pain at some works, and how the nervous system inter- Strategies for dealing point, but in people with depression acts with other parts of the body, they have with stress and achieving or anxiety, pain can become particu- discovered that pain shares some biological success . .4 Elarly intense and hard to treat. People suf- mechanisms with anxiety and depression. fering from depression, for example, tend Shared anatomy contributes to some of Preventing depression to experience more severe and long-lasting this interplay. The somatosensory cortex in adolescents Interventions are most pain than other people. (the part of the brain that interprets sen- effective when targeted to The overlap of anxiety, depression, and sations such as touch) interacts with the those at risk . .6 pain is particularly evident in chronic and amygdala, the hypothalamus, and the an- sometimes disabling pain syndromes such terior cingulate gyrus (areas that regulate In brief as fibromyalgia, irritable bowel syndrome, emotions and the stress response) to gen- Preventing relapse in low back pain, headaches, and nerve pain. erate the mental and physical experience of bipolar disorder . .7 For example, about two-thirds of patients pain. These same regions also contribute to The quirky brain with irritable bowel syndrome who are re- anxiety and depression. Why songs get “stuck” in ferred for follow-up care have symptoms In addition, two neurotransmitters—se- people’s heads . .7 of psychological distress, most often anxi- rotonin and norepinephrine—contribute to ety. About 65% of patients seeking help for pain signaling in the brain and nervous sys- Ask the doctor depression also report at least one type of tem. They also are implicated in both anxi- How does someone overcome pain symptom. Psychiatric disorders not ety and depression. fear of dogs? Why are patients with body dysmorphic disorder only contribute to pain intensity but also to Treatment is challenging when pain over- so self-critical? . .8 increased risk of disability. laps with anxiety or depression. Focus on Researchers once thought the reciprocal pain can mask both the clinician’s and pa- relationship between pain, anxiety, and de- tient’s awareness that a psychiatric disor- pression resulted mainly from psychological der is also present. Even when both types of rather than biological factors. Chronic pain problems are correctly diagnosed, they can is depressing, and likewise major depression be difficult to treat. A recent review identi- may feel physically painful. But as research- fied a number of treatment options available ers have learned more about how the brain when pain occurs in conjunction with anxi- What’s new ety or depression. KEY Points Women’s Health After 50 Special Health Report • Cognitive behavioral therapy (CBT) is not Double-duty psychotherapy from Harvard Medical School only an established treatment for anxiety Various psychotherapies can be used on their To order, call 877-649-9457 and depression, it is also the best studied own to treat pain in patients with depression (toll-free) or visit us online at www .health .harvard .edu . psychotherapy for treating pain. or anxiety, or as adjuncts to drug treatment. • Relaxation training, hypnosis, and exercise Cognitive behavioral therapy. Pain is Contact us may also help. demoralizing as well as hurtful. Cognitive Write to us at mental_letter@hms harvard. edu. behavioral therapy (CBT) is not only an • Some antidepressants or anticonvulsants may For customer service, write us at alleviate pain while treating a psychiatric established treatment for anxiety and de- harvardMH@strategicfulfillment com. disorder, but be aware of potential drug pression, it is also the best studied psycho- Visit us online at interactions. therapy for treating pain. CBT is based on www .health .harvard .edu/mental the premise that thoughts, feelings, and sen- Pain, anxiety, and depression continued sations are all related. Therapists use CBT pharmaceutical companies have a finan- to help patients learn coping skills so that cial interest in promoting as many uses Editor in Chief Michael Craig Miller, MD they can manage, rather than be victim- as possible for their products—so it is Editor Ann MacDonald Founding Editor Lester Grinspoon, MD ized by, their pain. For example, patients wise to check that evidence exists to sup- Editorial Board Jonathan F. Borus, MD might attempt to participate in activities port any “off label” (not FDA approved) Christopher B. Daly Sandra DeJong, MD in order to improve function and distract uses for medications. Frank W. Drislane, MD themselves from focusing on the pain. Other patients may prefer to take one Anne K. Fishel, PhD Donald C. Goff, MD Relaxation training. Various tech- medication for the psychiatric disorder Stuart Goldman, MD Alan I. Green, MD niques can help people to relax and re- and another for pain. In this case, it’s im- Shelly Greenfield, MD, MPH duce the stress response, which tends to portant to avoid drug interactions that Thomas G. Gutheil, MD Michael Hirsch, MD exacerbate pain as well as symptoms of can increase side effects or reduce medi- Matcheri S. Keshavan, MD anxiety and depression. Techniques in- cation efficacy (see sidebar, page 3). Kimberlyn Leary, PhD, ABPP Robert W. McCarley, MD clude progressive muscle relaxation, yoga, Antidepressants. A variety of antide- Michael J. Mufson, MD and mindfulness training. pressants are prescribed for both anxiety Andrew A. Nierenberg, MD Scott L. Rauch, MD, PhD Hypnosis. During this therapy, a cli- and depression. Some of these also help Nadja Lopez Reilly, PhD Hester H. Schnipper, LICSW, BCD nician helps a patient achieve a trance- alleviate nerve pain. (The evidence is less Janna M. Smith, LICSW, BCD like state and then provides positive convincing about their ability to treat other Caroline L. Watts, EdD Barbara Wolfe, PhD, RN suggestions—for instance, that pain will types of pain, such as backaches, which Editorial Board members are associated with improve. Some patients can also learn are usually of muscle rather than nerve or- Harvard Medical School and affiliated institutions. They review all published articles. self-hypnosis. igin.) The research most strongly supports In one study, investigators asked 204 the use of serotonin and norepinephrine Art Director Heather Derocher Production Editor Nicole Wall patients with irritable bowel syndrome to reuptake inhibitors (SNRIs) or tricyclic Customer Service complete self-assessment questionnaires antidepressants (TCAs) as double-duty Phone 877-649-9457 (toll-free) before, immediately after, and up to six drugs that can treat both psychiatric dis- E-mail [email protected] Online www.health.harvard.edu/customer_service years following hypnosis training. They orders and pain. The findings are more Letters Harvard Mental Health Letter P.O. Box 9308, Big Sandy, TX 75755-9308 found that 71% of participants reported mixed about the ability of selective sero- Subscriptions $72 per year (U.S.) the technique reduced both gastrointes- tonin reuptake inhibitors (SSRIs) to al- Bulk Subscriptions tinal distress and levels of depression and leviate pain. StayWell Consumer Health Publishing 1 Atlantic St., Suite 604, Stamford, CT 06901 anxiety. The SNRI duloxetine (Cymbalta), for 888-456-1222, ext. 31106 (toll-free) 203-653-6266 Exercise. There’s an abundance of example, can also be used to treat the [email protected] research that regular physical activity pain from diabetic neuropathy or fibro- Corporate Sales and Licensing StayWell Consumer Health Publishing boosts mood and alleviates anxiety, but myalgia. Venlafaxine (Effexor) is also 1 Atlantic St., Suite 604, Stamford, CT 06901 [email protected] less evidence about its impact on pain. used for nerve pain, fibromyalgia, and Editorial Correspondence The Cochrane Collaboration reviewed headaches. Likewise, mirtazapine (Re- E-mail [email protected] 34 studies that compared exercise inter- meron) may help prevent chronic ten- Letters Harvard Mental Health Letter 10 Shattuck St., 2nd Floor, Boston, MA 02115 ventions with various control conditions sion headaches. Permissions in the treatment of fibromyalgia. The re- One randomized controlled trial found Copyright Clearance Center, Inc. viewers concluded that aerobic exercise, that bupropion (Wellbutrin), which af- Online www.copyright.com performed at the intensity recommended fects dopamine and norepinephrine, was Published by Harvard Health Publications, a division of Harvard Medical School for maintaining heart and respiratory fit- helpful at alleviating chronic nerve pain, Editor in Chief Anthony L. Komaroff, MD ness, improved overall well-being and but not chronic low back pain unrelated Publishing Director Edward Coburn physical function in patients with fibro- to nerve damage. This may be an option © 2010 Harvard University (ISSN 0884 -3783) Proceeds support the research efforts of Harvard Medical School. myalgia, and might alleviate pain. More for patients suffering nerve pain and de- Harvard Health Publications limited evidence suggests that exercises pression. Be aware, however, that in some 10 Shattuck St., 2nd Floor, Boston, MA 02115 The goal of the Harvard Mental Health Letter is to interpret timely designed to build muscle strength, such patients, bupropion may increase
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