‘Find the broken part and fix it’: Treating depression can improve chronic pain
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SAN DIEGO — Improving depressive symptoms can reduce patients’ chronic pain, according to a presenter at the 2024 Congress of Clinical Rheumatology West.
“I want to take you through the practical aspects of managing patients with pain and depression,” Michael R. Clark, MD, MPH, MBA, chair of psychiatry in the Inova Health System, in Virginia, and a faculty member at the Johns Hopkins University School of Medicine, in Baltimore, told attendees. “They go hand in hand a lot of time but they are not always the same thing.”
Despite the focus on mental health, Clark assured the rheumatologists in attendance that it is not necessary to be a psychiatrist to care for patients with depression.
“You have plenty of tools in your toolbox to manage these patients,” he said.
To illustrate his point, Clark described the case of a woman aged 53 years with chronic back pain and depression, who had run the gamut of interventions and providers. A surgeon recommended another surgery, an anesthesiologist recommended further injections, primary care recommended SSRIs and muscle relaxers, a physical therapist recommended a gym membership, a psychiatrist suggested learning better coping skills, and emergency medicine chastised her opioid use.
“An attorney suggested she apply for disability and consider suing the surgeon,” Clark said. “And the internet is not helpful.”
Such a patient is often seeking a “holy grail” treatment, according to Clark.
“She is in the vicious cycle that I am sure you have seen a million times — of thinking that there must be a single answer for all of my issues,” he said.
Many patients seen by rheumatology providers experience this overlap of neurobiology and pain — central sensitization with major depression, according to Clark.
“What you see is that individuals with chronic pain are vulnerable to a reactive demoralization,” he said. “In the patient’s mind, they think, ‘Of course I am depressed. Why wouldn’t I be depressed? If you just take care of my pain, the depression will go away.’”
However, Clark argued that treating the depression may actually improve the chronic pain.
“Studies show that after 8 years, depression becomes the best predictor of whether chronic pain will persist,” he said.
Rather than trying to find that one “holy grail” treatment, rheumatologists should consider the disease processes that patients are experiencing, along with the problematic behaviors like lack of activity or medication use, plus the stressors in their lives, and treat them accordingly.
“Find the broken part and fix it,” Clark said.
He additionally suggested taking patients off of ineffective medications or reducing their opioid use if needed.
“Try to help people organize themselves,” Clark said. “Be willing to talk about what they have tried, and what went well and what did not. Find out what succeeded. Try to praise and reward those things dramatically.
“Form better relationships with patients,” he added. “What you are trying to do is instill a readiness to change. Get them to imagine themselves doing something.”
Regardless of the strategies used or the individual challenges faced by each patient, the overall goal should remain the same, according to Clark.
“No matter what medications you use, the best thing you can do is put that depression into remission,” he said.
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Clark MR. Pain and Depression. Presented at The Congress of Clinical Rheumatology West; Sept. 26-29, 2024. (hybrid meeting).
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