How is chronic pain with co morbid depression treated
What are the treatment strategies for chronic pain with co-morbid depression and/or anxiety?
Mindfulness-based stress reduction (MBSR) is a structured training program that aims to provide adaptive coping, focused attention, and cognitive restructuring skills to distressed populations. These programs have been shown to have positive outcomes in patients with chronic pain, especially chronic back pain. It has been suggested that an abbreviated 4-week MBSR program (as opposed to the traditional 8-week program) may be an effective complementary intervention for back pain patients. However, there appears to be a dose-response relationship among pain, depression, anxiety, and MBSR; therefore, a course that is at least 8 weeks provides a more solid foundation and likely leads to more enduring positive cognitive and emotional changes. On fMRI, patients who have gone through both abbreviated and full MBSR courses show increased frontal lobe hemodynamic activity, which is thought to be associated with gains in awareness of their emotional state.
Intensity of pain correlates with intensity of psychological symptoms, including depression, anxiety, and worry. Active pain coping strategies such as striving to function in spite of pain and distracting oneself from pain are adaptive strategies. Passive strategies that involve withdrawal or relinquishing control are maladaptive strategies that are related to greater pain and depression.
Cognitive-behavioral methods (CBT) of pain treatment in the domains of pain experience, cognitive coping, and appraisal are effective in reducing pain. Multifaceted cognitive behavioral treatment regimens need further study—more specifically, they need to be compared to placebo. Recently, web-based CBT has been proposed as a potentially cost- and time-effective treatment strategy. It is important to take into account comorbidities when developing the CBT plan. For example, it has been shown that children with chronic pain and anxiety are more likely to initiate and complete CBT than those that have chronic pain without anxiety, but still have poorer outcomes. One proposed strategy to address this is to identify these individuals with anxiety prior to CBT and initiate tailored behavioral interventions.
Managing expectations prior to an event that may be uncomfortable or painful (giving information regarding procedural and objective aspects as well as information about the specific sensations that the patient may experience during the event) may alter patients’ cognitive appraisal of an event, which may result in shorter subjective pain duration and intensity. Combining the provision of this preparatory information with information/training regarding coping skills and reduction of stress and anxiety reactions appears to be more effective than providing preparatory information alone.
Stress-inoculation training is a CBT intervention that has three phases. It takes into account the multidimensional nature of differences between individuals’ reactions to pain and provides multiple options for coping skills. There is an educational phase, a rehearsal phase, and an application phase. The effectiveness of this method is unclear.
Yoga has been shown to be an effective complementary component of comprehensive chronic pain management programs, especially for individuals with anxiety, depression, and chronic low back pain.