Depressive symptoms

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Depression is probably the most common psychological disturbance in chronic pain. Various studies show that 30-80% of patients at a pain clinic have some depressive symptoms, and up to 20% meet the criteria for a major depressive disorder (Sullivan et al 1992, Banks & Kerns 1996). Although pain clinic patients are not representative, most patients with chronic back pain probably have some lesser degree of depression (von Korff et al 1993, Croft et al 1995, Ohayon & Schatzbrg 2003).

However, we need to be clear what we mean by depression. In ordinary speech, we use the word depression for anything from a minor emotional reaction such as feeling fed-up to a crippling psychiatric illness or even suicide. It is important to distinguish depressed mood from actual depressive illness. Patients with chronic pain often have depressed mood and describe depressive symptoms, but this is seldom severe enough to meet the criteria for a depressive illness. It is important to identify those patients who are psychiatrically ill, and to refer them for appropriate treatment

Please describe how you have felt during the PAST WEEK by making a check mark (.) in the appropriate box. Please answer all questions. Do not think too long before answering.

Not at all

A little/slightly

A great deal/ quite a lot

Extremely/could not have been worse

Heart rate increasing

Feeling hot all over"

0

1

2

3

Sweating all over*

0

1

2

3

Sweating in a particular part of the body

Pulse in neck

Pounding in head

Dizziness"

0

1

2

3

Blurring of vision"

0

1

2

3

Feeling faint*

0

1

2

3

Everything appearing unreal

Nausea'

0

1

2

3

Butterflies in stomach

Pain or ache in stomach"

0

1

2

3

Stomach churning'

0

1

2

3

Desire to pass water

Mouth becoming dry"

0

1

2

3

Difficulty swallowing

Muscles in neck aching*

0

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2

3

Legs feeling weak"

0

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2

3

Muscles twitching or jumping*

0

1

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3

Tense feeling across forehead"

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3

Tense feeling in jaw muscles

The questionnaire as given to patients does not include the scoring.

Only those items marked with an asterik (*) are scored and added to give a total score.

Figure 11.1 Modified Somatic Perception Questionnaire (MSPQ). From Main (1983), with permission.

(Rush et al 2000). For most patients with back pain, however, depressed mood is simply one more facet of their chronic pain. We must not ignore depression just because it is associated with chronic pain, but the best treatment is usually to help them cope with their pain.

Depression involves negative beliefs, lowered mood, and clinical symptoms. Different patients show different patterns. The key feature of depression is a negative view of oneself, of the world, and of the future. There is loss of interest and energy and slowing of mental function. Mental symptoms include a sense of loss, sadness, hopelessness, and pessimism about the future. There may be disturbances of appetite, sleep, and sexual function. Physical symptoms such as headache, constipation, weakness, aches, and pain are also common. Simon et al (1999) found that about 50% of patients with major depression have multiple unexplained bodily symptoms. Many of them present with somatic symptoms but acknowledge psychological symptoms when asked about them. Eleven percent deny any psychological symptoms, even on direct questioning. In patients with chronic low back pain, the most common depressive symptoms include sleep disturbance, loss of energy, chronic fatigue, and persistent worrisome thoughts (Rush et al 2000). (See Main & Spanswick 2000 p 203 for the ICD-10 and DSM-IV diagnostic criteria for depression and other psychiatric conditions.)

The above description of depression is true, as far as it goes. However, recent research suggests that the relationship between depression and pain is more complex than this (Averill et al 1996, Banks & Kerns 1996, Wilson et al 2001, Clyde & Williams

2002). Part of the difficulty is that many of the bodily symptoms of chronic pain are very similar to those of depression. So chronic pain itself may meet some of the usual diagnostic criteria for depression, and we need to be more careful how we diagnose depression in these patients (Robinson & Riley 1999, Wilson et al 2001, Slesinger et al 2002). Pain and depression are often associated with each other, but the link can work in various ways. Patients who are depressed report more pain, and some pain may be a symptom of depression. Depression may aggravate pain of physical origin. And, not surprisingly, chronic pain and failed treatment may cause depression. So it can be a vicious circle. Most research shows that in chronic pain patients, depression develops secondary to the pain (Magni et al 1994, Rush et al 2000, Ohayon & Schatzbrg

2003). So we need to interpret these symptoms in the context of chronic pain. Perhaps we can describe it best as learned helplessness in the face of severe and chronic pain, which the patient cannot control, and which impacts on the patient's whole life.

Once again, we must set priorities for treatment (Rush et al 2000). A few patients need to be referred for specialized help. For most patients, the best way to relieve pain-associated depression is to help them regain some measure of control over their pain and disability.

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