Often people who are going through depression experience unexplained physical symptoms such as back pain or headaches that can weigh them down. Similarly, going through chronic pain can be so overwhelming that sufferers sometimes go into depression, creating a vicious cycle in which pain worsens symptoms of depression and depression worsens the feeling of pain.
Researchers at the University of Cape Town say the link between these two conditions should not be overlooked and clinicians should treat them both holistically.
In a new study done in a Cape Town pain management clinic at Groote Schuur Hospital they found that almost a third of about 620 patients, or 32% who presented with chronic pain, had a history of depression. This is three times higher than the national lifetime prevalence of depression of about 10% in the country.
Researchers analysed patient records over a seven-year period between 2010 and 2017. Women were found to be most at risk of depression, accounting for 77% of cases compared to 23% of male patients. Despite evidence of depression, the majority of patients were not adequately treated for the illness, but were given pain medication to help them sleep better and manage their pain.
Fifty-one percent were put on a low-cost and common antidepressant, amitriptyline, to manage nerve pain and at higher doses for the treatment of depression.
In a paper published in the SA Journal of Psychiatry, researchers said the high prevalence of a history of depression in patients presenting with chronic pain “emphasises the importance of looking for and understanding the interrelation of the physiological, psychiatric, psychological and socioeconomic factors that are common to both depression and chronic pain”.
“Pain relief alone is insufficient to ensure optimal rehabilitation of these patients and integrating the management of their depression should improve patient outcomes and overall wellbeing,” wrote lead research Joseph van Vreede, an anaesthetics registrar at Groote Schuur Hospital.
Van Vreede and colleagues said the latest statistics of depression among women are not surprising, with a 2017 global burden of disease study having found an annual prevalence of major depression to be higher in women at 4.1% compared with 2.7% in men, representing a 1.5-fold greater incidence in women.
Women are particularly at high risk of depression when their hormones fluctuate, such as during puberty, pregnancy, postpartum and perimenopause. In SA, one in three women during or after childbirth experience a mental health disorder, mainly depression. This figure is threefold higher than the World Health Organisation global prevalence.
Combined therapy focusing on both depression and chronic pain may yield superior outcomes than managing either condition in isolation
— UCT researchers
Apart from hormonal fluctuations, researchers argue that women in SA tend to be more vulnerable to domestic abuse, both physical and emotional, and may be victims of sexual or racial discrimination on a social level, affecting their self-esteem and contributing to their vulnerability to depression.
Poverty also increases their susceptibility to depression, with people with lower levels of income and education said to be at increased risk of both pain and depression due to poor access to health care, which in turn delays appropriate referrals.
Van Vreede said the role of depression in chronic pain syndromes has been in the spotlight and it has been acknowledged “that chronic pain and depression share neurobiology and neuroanatomy”.
“Our study provides essential insight into the importance of psychiatric and psychological management as an integral part of an effective pain management strategy and the need for an interdisciplinary team approach in chronic pain management. Our findings emphasise the importance of the interrelation of the physiological, psychiatric, psychological and socioeconomic factors that link depression and chronic pain,” the researchers noted.
“Current literature suggests that when pharmacotherapy is considered in the management of this cohort, that combined therapy focusing on both their depression and chronic pain may yield superior outcomes than managing either condition in isolation.”
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