The Link Between Chronic Pain and Depression: What to Know

The Relationship Between Pain and Depression

Although studies have examined the relationship between chronic pain and depression, it’s still unclear whether or how one causes the other.

“There is likely a bidirectional relationship between depression and many chronic diseases, with biological changes in the brain and body leading to increased rates of clinical depression, and depression leading to worsening outcomes with many chronic diseases,” says Robert W. Charlson, M.D., a board-certified psychiatrist at NYU Langone’s Multiple Sclerosis Comprehensive Care Center, in New York City, and an expert on how depression affects people with neurodegenerative diseases.

People who live with chronic pain are more likely to have depression than those who don’t have pain, but people living with depression may also develop physical pain, including chronic joint, limb, or back pain, because of the mental health condition.

It can also be difficult to separate pain and depression because there is significant overlap between the symptoms of these conditions. “For example,” Charlson says, “some of the key symptoms of depression—cognitive changes, fatigue, sleep disruptions—can also be seen in patients with chronic conditions.”

Investigators are still looking into the underlying reasons for these connections. The exhaustion and emotional toll of living with chronic pain can certainly play a role in the development of depression, but often, structural and functional brain changes related to pain may contribute, as well.

Charlson notes that in certain neurologic diseases, such as multiple sclerosis, “there may be links between areas of damage in the nervous system, chronic pain, and depression.” The areas of the brain that are involved in feeling and experiencing physical pain—including the brainstem, frontal cortex, limbic system, and other areas—may also have direct links to areas of the brain implicated in depression, he explains.

So, depression can increase the risk for development or exacerbation of chronic pain, and chronic pain can be a risk factor for depression.

But the good news is that treating depression can significantly improve pain, and vice versa, says Abbey Hughes, Ph.D., a rehabilitation psychologist at Johns Hopkins Medicine, in Baltimore. “This is why people who participate in cognitive behavioral therapy for depression often report improved pain, and also why some antidepressant medications have also been shown to improve chronic pain.”

How to Cope with Chronic Pain and Depression

If you have chronic pain and depression, take comfort in the fact that several approaches may help alleviate your symptoms. Here are some ways to feel better physically as well as emotionally.

Talk It Out

“The first thing I encourage patients to do is to start to talk about their symptoms,” says Charlson, “and to explain how the chronic pain is impacting them, where it is located, and how severe it's been. This also includes talking about their moods and how they are functioning at home and work.” Start the discussion with your doctor, but also try confiding in a friend or family member and discussing your symptoms with members of a support group for people with your condition.

Consider Psychotherapy

“We know from many studies in depression and chronic pain that some forms of psychotherapy can benefit both conditions,” Charlson says.

For example, cognitive behavioral therapy (CBT) may decrease depressive symptoms and have a positive impact on pain. Dialectical behavior therapy (DBT) or acceptance and commitment therapy (ACT), two other psychological treatments that teach mindfulness and emotion regulation, may also be helpful.

Hughes adds that it’s important to note that the goal of these therapies is not to eliminate sadness, but to “reduce the severity of sadness and other symptoms so that they don't interfere so significantly in daily life.”

Prioritize Diet and Nutrition

When it comes to managing depression and chronic pain, the importance of a healthy diet cannot be overstated. A diet full of green leafy vegetables, fruits, nuts, fatty fish, olive oil, and tomatoes can help reduce inflammation, which often contributes to chronic pain. Conversely, a diet high in sugar, saturated fats, and processed foods can exacerbate both depression and pain, research suggests.

While no one eating plan is right for everyone, it’s generally recommended to eat plenty of fruits and vegetables, lean protein, and healthy fats. If you’re having difficulty figuring out which specific foods you need (or should avoid), talk to your doctor or consult with a registered dietitian.

Exercise

Research suggests that exercise can help alleviate symptoms of depression and improve the physical health of people with depression. In his work with people living with MS, Charlson says that exercise and physical therapy have a powerful effect both on depression and chronic pain and that, in his practice, “getting people moving both at home and with physical therapists is absolutely critical.”

Get Better Sleep

People who have chronic pain and depression often have problems falling and staying asleep. Lack of restorative rest can adversely affect your health and well‑being and can greatly exacerbate both physical and mental pain. It’s important to break this vicious cycle, so try the following:

• Get plenty of natural sunlight during the day, which can help you feel more alert and awake.
• To wake yourself up and hopefully help you feel more tired at night, exercise early in the day when possible.
• Before bed, wind down with relaxation techniques, such as deep breathing, mindfulness techniques, meditation, or guided imagery.

If these strategies don’t help, talk to your doctor or therapist, or see a sleep specialist for other treatment options.

Ask About Medication

Antidepressants are designed to lift mood, but many of these drugs may also help alleviate chronic pain, perhaps by working on the shared mechanisms between pain and depression in the body. In this way, antidepressants may serve a dual purpose of helping you to manage both conditions.

Many antidepressants are available, although some research suggests that tricyclic antidepressants may be more effective in addressing chronic pain. You can talk to your doctor about whether they recommend this approach and what other medication options may be best for you.

Assemble a Coordinated Care Team

It’s important that the members of your care team (which may include a primary care physician, specialist, psychiatrist, physical therapist, pain management specialist, or others) understand your physical and mental health conditions and how they affect one another.

Your team should work together to develop a comprehensive care plan for you. Communication between members of your care team is crucial. For instance, your primary care doctor and psychiatrist should be aware of which medications the other is prescribing, since there may be drug interactions. If they’re part of the same clinic or health system, communication may be seamless, but if not, you’ll likely need to show each of them your records and prescriptions so they’re up to speed.

“Tailored, individualized approaches are best,” Charlson says. “Each patient is different and needs a care team to address their unique challenges.”

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