Depression: A Risk Factor for Chronic Back Pain?
While not all chronic pain cases will have psychogenic origins, virtually all pain conditions can be influenced by psychological factors.
LAS VEGAS — Psychological and behavioral interventions are an essential part of an interdisciplinary chronic pain treatment plan and should not be overlooked, according to a presentation Ravi Prasad, PhD, clinical associate professor of anesthesiology, perioperative, and pain medicine, at Stanford University in California, gave at PAINWeek 2017, held September 5-9.1
“Because psychological factors can influence the onset, maintenance, and exacerbation of chronic pain conditions, inclusion of psychological and behavioral interventions as a part of an interdisciplinary treatment plan can help minimize suffering by enabling patients to improve their quality of life and functioning,” Dr Prasad told Clinical Pain Advisor.
Chronic pain affects approximately 100 million American adults, costing $500 to $600 billion annually in medical treatment and lost productivity, indicating a dire need for better pain management approaches.2 In 2015, a National Institutes of Health panel called for “evidence-based, multidisciplinary approaches to pain treatment that incorporate patients' perspectives and desired outcomes while also avoiding potential harms.”3 According to the panel, to successfully implement such approaches, the emotional aspects of pain need to be addressed, including patients' perceptions of suffering.3
Because chronic pain can have numerous etiological pathways, including biomedical, physical, and psychological components, the first step in tailoring treatment is determining the underlying factors causing or contributing to pain in each individual patient. Two such major psychological factors include depression and a history of adverse childhood experiences (eg, physical, emotional, or sexual abuse; household substance abuse; only one or no parents).1
As demonstrated during the presentation, numerous studies have shown strong connections between psychological factors and chronic pain. In one study, depressed individuals were 3 times more likely than their nondepressed counterparts to develop chronic back pain, showing depression to be a potentially modifiable risk factor in the development of chronic back pain.4 Another study found a significant association between sexual abuse and a lifetime diagnosis of nonspecific chronic pain, chronic pelvic pain, and other painful conditions, indicating the importance of obtaining a thorough patient history.5
While not all chronic pain cases will have psychogenic origins, virtually all pain conditions can be influenced by psychological factors, Dr Prasad noted, making a patient's emotional state a critical factor in establishing more effective pain control, regardless of the etiology of the pain. As with other chronic health conditions lacking a cure, the emphasis should be placed on measures that improve quality of life and functioning, he noted.
“Breathing/relaxation exercises, cognitive restructuring, and pacing of activities are 3 important tools for patients to learn, and helping them master these can have a significant positive effect on overall outcomes,” he said. Dr Prasad sees these strategies as working synergistically to address various factors that contribute to pain levels and perception.
Breathing and relaxation exercises activate the parasympathetic nervous system, which can help the body return to a calmer state — decreasing heart rate, blood pressure, and muscle tension — while stopping the release of stress hormones. At the same time, negative cognitive processes such as catastrophization need to be addressed to empower patients to put their situation in perspective and find solutions to the challenges they face. Cognitive restructuring enables patients to modify their thought processes to be more accurate and helpful. For example, instead of thinking “there is nothing I can do to control this,” patients can modify their internal dialogue to “I can practice self-management skills.”1 By refocusing their thought process, damaging emotions such as sadness, anxiety, and anger can be decreased. Finally, pacing of activities prevents pain exacerbations by navigating the fine line between overactivity and inactivity. With this approach, patients may find that they can perform certain activities with slight modifications rather than having to foreclose on them altogether, thereby improving their quality of life.
Even after patients are taught these strategies, reinforcement is necessary to optimize outcomes. “Knowing and doing are two different things. Just because patients comprehend the role of psychological and behavioral interventions in the management of their pain does not mean they are applying these skills and techniques with any consistency,” said Dr Prasad. “Clinicians are pain educators for patients but need to take the extra step to ensure that patients are maximizing their use of their newly acquired knowledge.”
Read more of Clinical Pain Advisor's coverage of PAINWeek 2017 by visiting the conference page.
- Prasad R. Nonpharmacologic management of pain: essential tools for frontline clinicians. Presented at: PainWeek 2017. Las Vegas, Nevada; September 5-9, 2017.
- Institute of Medicine (US) Committee on Advancing Pain Research, Care, and Education. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington DC: National Academies Press (US); 2011. www.nationalacademies.org/hmd/%20~/media/Files/Report%20Files/2011/Relieving-Pain-in-America-A-Blueprint-for-Transforming-Prevention-Care-Education-Research/Pain%20Research%202011%20Report%20Brief.pdf. Accessed September 1, 2017.
- Indiana University. 100 million Americans live with chronic pain, but treatment research is insufficient. www.sciencedaily.com/releases/2015/01/150113121206.htm. Published January 13, 2015. Accessed August 29, 2017.
- Currie SR, Wang J. More data on major depression as an antecedent risk factor for first onset of chronic back pain. Psychol Med. 2005;35(9):1275-1282.
- Paras ML, Murad MH, Chen LP, et al. Sexual abuse and lifetime diagnosis of somatic disorders: a systematic review and meta-analysis. JAMA. 2009;302(5):550-561.