Dr. Gallagher is editor-in-chief of www.nationalpainfoundation.org and a member of the NPF Board of Directors and Clinical Directors. He is Director of Pain Management at the Philadelphia Veterans Medical Center and a professor in the Departments of Psychiatry and Anesthesiology at the University of Pennsylvania School of Medicine. Dr. Gallagher has served as editor-in-chief of the Clinical Journal of Pain, and currently is editor-in-chief of Pain Medicine, the official journal of the American Academy of Pain Medicine, where he serves on the board of directors and as chair of the Scientific Advisory Committee. He is current president of the American Board of Pain Medicine. Dr. Gallagher's career background includes family practice, psychiatry, epidemiology and numerous teaching and training positions. He publishes and speaks regularly at national and international symposia on topics ranging from evidence-based pain medicine, organizational models of pain management, pharmacologic and biopsychosocial pain treatment, pain and depression, and workers' compensation. He received his undergraduate degree from Harvard College, his medical degree from Boston University, and his M.P.H. from Columbia University.

JL is Jennifer Lobb
RG is Rollin Gallagher

JL: How common is depression in persons with pain?

RG: Anybody who has pain for any period of time is going to get distressed by it simply because of the relationships between the pain centers and stress centers in the brain. Pain — particularly acute pain — automatically activates stress in the brain, which creates secondary consequences in the body, such as muscles tightening, heart rate accelerating, and other things that involve the activation of the sympathetic nervous system. This is a natural reaction to acute pain.

Chronic pain is, naturally, chronically stressful. Chronic pain is a burden that actually interferes with concentration and function — it interferes with your ability to carry on with the things you need to do and the things you like to do. You don't get much pleasure out of life because you can't do the things that are normally fun, like interacting with your kids, playing sports, making love to your spouse, having a party, or going out to dinner. Those of us who don't have chronic or severe persistent pain often take these activities for granted, and yet surprisingly, others around the person with pain, such as family members or co-workers, often fail to recognize and acknowledge the serious impact of pain. There are several reasons for this failure. First, pain-related impairments in a person cause role changes in the family or at work. Others have to pick up the slack or new tasks formerly performed by the person with pain, causing resentment and anger. Second, when a person with chronic pain cannot participate in activities that are important to family members and friends, these relationships may suffer, and both may experience a sense of loss and frustration. Third, when pain persists to the point where it causes inability to work, financial losses and stress will affect family relationships.

You can imagine that even the most stress hardy person — even someone who's especially resilient and optimistic — can get worn down by pain. Some well-designed studies of persons with chronic facial pain and with chronic low back pain demonstrate clearly that the risk for having severe clinical depression increases the longer a person is afflicted by chronic pain.

JL: What's the relationship between mood and pain?

RG: Pain and mood is a very close relationship that's best explained through an example. Say you have a chronic pain problem or an episodic pain problem—something that comes and goes. For example, you injured your back at work and have pain that radiates down your leg. You're going about your normal activities and, all of a sudden, pain crops up while you're doing something important. The pain gets worse while you're sitting in your chair trying to meet a deadline or trying to drive somewhere for work. You fall behind because you can't concentrate or can't drive. This becomes a problem for you as your co-workers become upset because you can't get your work done or your boss is coming down on you because you're not as productive. I think a lot of people fail to recognize that even low levels of pain can actually interfere with one's functioning on a day-to-day basis in ways that can be very distressing.

Take that kind of day-to-day pain and add to that a bad mood, where you're thinking negative thoughts or you're upset about something. Psychological distress acts like a rheostat on your pain, amplifying its intensity. When you turn up a rheostat to control your kitchen light, the light gets brighter and brighter. Well, that's what happens with your pain level when stress, bad mood, sadness, or depression occurs at the same time as pain. Thus, a low level pain signal — say from a chronic back condition — a level that normally you might be able to cope with—all of sudden starts bothering you much more because the pain signal is amplified.

The strong relationship between mood and pain is established in the medical literature by the research and through patients' own experiences. Think about how grouchy you get when you're in pain and you can't do things. When someone has chronic pain that impairs functioning, which it usually does, the rates of clinical depression are from 30% to 80%, depending on which group of patients and what types of pain. If you have chronic low back pain and are unable to work, the rate of comorbid depression goes way over 50%. If you happen to have a family history of depression or you yourself have had depression in the past, the stress of pain may be the trigger for a new bout of depression. Therefore those who are more vulnerable to depression (ie, had a prior episode of depression, or have a family history of depression) need to be careful when they develop persistent pain and make sure they seek treatment at the first signs of depression.

JL: Are there pain conditions or other factors that predict, so to speak, depression?

RG: The impairments and disability associated with the pain increase the incidence of depression. In addition to this factor, if you've had depression before or a family history of depression, you may be more likely to respond to chronic pain with a depression. So, as I mentioned before, you have to keep an eye out if you're more vulnerable.

There are plenty of people in this country and the world who have a family history of depression. You're not alone—10% to 20% of people are at risk for a clinical depression in their lifetime. It's a common illness. Right now, depression is the number two highest public health problem for women in the United States in terms of disease burden. It's a big problem. Women historically have had higher rates of depression than men in the large studies that have been done. We're not exactly sure why that is, frankly, and we're not sure those rates hold up in today's world. At any rate, depression affects the sexes in the same ways. The same neurotransmitters are affected. We don't know if one drug is better for women and another is better for men—we don't have that degree of specificity in the treatment of depression.

JL: How can a person tell the difference between feeling "blue" and clinical depression?

RG: When you're in a clinical depression, you just can't get out of the blues. You may be able to temporarily feel good when you see someone you've missed or you go to a funny movie, but what happens is the feeling of enjoyment or optimism doesn't persist. When the enjoyment of a brief interlude doesn't persist, that can be a mild depression. Say you're normally a person who likes to be active and socialize and you feel like you've lost that desire or verve for life; you're more fatigued; and the blues just don't go away. There's a cognitive aspect to depression—you're seeing life through dark glasses or as a glass half empty. Your mind negatively interprets things or puts a negative slant on things when, frankly, you could see things in a much more optimistic light. Depression can sneak up on you that way.

There are other symptoms of depression that are not related to mood. For example, you may not have energy. You may not be sleeping well. People with depression often have a problem staying asleep—they may fall asleep easily but will wake up several times during the night and early in the morning and have trouble falling back asleep because their minds may be worrying about something. People's sexual desire may decrease during a depression. You may lose your appetite and not enjoy food as much. Or you may find yourself gobbling or eating in spurts and gaining weight, so weight changes are a symptom of depression. Of course, when depression is more severe, people may start thinking, "Well, maybe life isn't worth going on," and may have a very negative interpretation of events, a sense of hopelessness about the present and future. Suicidal thoughts should be taken seriously, and you should seek treatment right away.

As I said before, pain is one of the most common symptoms that people present with when they have depression. Aches and pains that normally wouldn't bother you will start bothering you more. Pain may actually be the reason you seek treatment, but the real problem may be depression causing your aches and pains to get a lot worse. The important thing is if these symptoms persist, you need to recognize that it's something chemical and something you can't control or make better without help.

JL: How can persons in pain help mitigate their depression, if they have one?

RG: First of all, if you have pain, make sure you get good treatment for your pain. You also have to make sure that you accept what you have. I think one of the hardest transitions for people is to accept the fact that they have pain and it isn't going to be cured. It's going to be something they have to learn to manage with the help of a multidisciplinary team of health care providers. Sometimes that in and of itself can be very depressing—people get depressed by the fact that they're not cured.

Once you have chronic pain, it's very hard to cure it, but you can manage it and have a good life. With pain, you have to accept the realistic limitations you have and do your best to work around them, and try not to get discouraged when you can't. Accept the realities of your limitations and then find others ways to reward yourself and feel fulfilled.

For example, a middle-aged man who has a back injury will tell me, "I'm a terrible father. I can't go out and play ball with my son." I'll ask, "Well, what do you think is really important in terms of who your son will be, what kind of person he will become? Do you think playing catch with him will make a difference as to whether he'll be a Mickey Mantle? Or a good husband and father? Or a college graduate and successful in a career? Think about the things you do with and for your son that will really make a difference in the long run. Are you able to talk to your son about how to cope with the difficulties or challenges of daily life, for example friendships, homework, playing on a team? Will he come to you for advice? You being a successful father has a lot more to do with these kinds of skills than being able to play catch, even though that's disappointing for you."

So you try to help people learn to accept the losses that they have, but also see that they have other opportunities now to do other things and to develop other skills or participate in other activities that will be rewarding for them and for those around them.

Learning to accept your limitations and learning to manage your day-to-day life so that you're not activating the pain are important concepts. You also need to do some things that are fulfilling and enjoyable. Those are general, overall strategies to manage pain and depression.

Specifically, learning effective time management, learning how to pace your activities so you don't over do things and activate the pain is critical. I know a lot of people who start to feel a little bit better, for example, after they begin a medication that is starting to control their pain. Then they think they have to make up for the last three months of not cleaning the house perfectly. They'll go on a two-day binge of cleaning or they'll go back to work and try and catch up with the work they missed as well as doing today's work. They simply over do it. Then they have a flare-up and become impaired again.

Learn how to pace your activities, be realistic about what you can do, don't get overly stressed by what you can't do and learn how to manage your stress because stress is inevitable. Learn how to not react to stress with negative thinking or a sense of desperation. Learn how to stay calm—learning some relaxation techniques and good coping skills can help a lot.

JL: What kinds of treatments are available for depression?

RG: In the old days, and I mean 30 or 40 years ago, we didn't have too many treatment choices for depression. Prior to the late 1950s, there were no medical treatments for depression except electroconvulsive therapy, which was used for severe cases. There was talking therapy, which could help for some patients with mild depression, but not for those with moderate or severe depression. In the 1960s and 1970s, the tricyclic antidepressants (TCAs) emerged as an effective treatment for depression followed by a class called monoamine oxidase inhibitors (MAOIs). Both classes of medication, particularly the MAOIs, had safety problems and the tricyclics often caused unpleasant side effects.

In the 1980s, with the advent of fluoxetine hydrochloride (Prozac), a new class of drugs called the SSRIs (selective serotonin reuptake inhibitors) emerged — this class also includes sertraline hydrochloride (Zoloft), paroxetine (Paxil), and citalopram (Celexa). These drugs actually work well for depression and don't have the side-effect burden and safety burden that some of the older drugs do. As a result, doctors have a much lower threshold for making a decision to treat depression because we now know that depression — even a mild depression — can have a major impact on a person's ability to function with pain. In other words, it doesn't take much depression to impair you when you have a pain problem. And to reiterate, doctors tend to be much less reluctant to prescribe the newer drugs because they're safer and have fewer side effects. It's important to recognize that even low levels of depression over time can really interfere with functioning, joy of life and the ability to get things done at one's work or with the family, so you don't want to let depression go on and on, even if it's just at a mild level. For example, consider how you're functioning at work. Normally you are an A or A- worker and you've gone down to a B- or a C—you're getting by, but you're not doing your best. Depression, even mild depression, can have that kind of effect.

So doctors will use the SSRIs and newer antidepressants, called the selective serotonin norepinephrine reuptake inhibitors (SSNRIs), which are have more specific effects on the brain chemistry systems that affect mood and pain, but don't affect other areas of the brain so they're better tolerated and cause less side effects. In contrast to 30 years ago, there's a long list of medications that can be effective for depression.

In addition to that, counseling can be very useful, and research has shown that two specific types of counseling are effective in depression. One type, called cognitive therapy, helps you learn to reframe the way you think about things. So if you have a tendency to see events through dark glasses, making a negative interpretation of events on a regular basis, the therapist works with you to help you change that. This helps you identify how you're making your thoughts negative and how your negative thoughts are then leading to behaviors that maintain the depression.

The other kind of therapy that's been shown to be effective is called interpersonal therapy. That's when you work with a therapist to evaluate the relationships you have in your life and how the depression is affecting those relationships. Then you begin working on restoring healthy relationships. That's important because relationships are necessary for our well being. We need love and affection and have a need to interact in a positive way with people. That's just part of our biology, our nature. We need to restore helpful relationships, and for that matter, relinquish or avoid unhealthful or stressful relationships to the degree we can. For example, if you have a problem with your boss or with a coworker, working on that relationship is going to be an important part of getting better in terms of the depression. Similarly, if the depression is better, it's easier to work with these sometimes challenging relationships.

A lot of doctors will advocate getting some regular exercise, good nutrition and other things you can do for yourself, like good time management so you don't feel like you're always behind or good stress management — these things can be quite useful in treating depression.

JL: What type of physicians should persons in pain see with regard to depression?

RG: The pain medicine doctor, depending on his or her background or experience, can treat uncomplicated depression in the context of pain. It's important for persons who are suffering from chronic or episodic pain to realize that pain can really start depression or make it worse, so you have to get your pain treated too. But you don't want to undergo back surgery if you have depression, unless of course it's an emergency, for example you're losing bowel or bladder function or muscle function because of a herniated disc. You want to get yourself in good emotional shape before you make any big decisions about surgeries that are elective in nature.

You want to treat both together — both the pain and the depression. The pain clinic can do that, depending on their personnel and the background and training of the pain physicians, but also, there may be a practitioner working with the physician who has training in psychology or psychiatry or other counseling types of skills so that you can actually get psychotherapy treatment for the depression as well. Obviously it takes a physician or a nurse practitioner to manage the medications.

The key thing to remember is if treatment is not working, it's not your fault. It's not the doctor's fault if he or she is doing a good job prescribing the right amounts of medications. It just may be that you have a more complicated problem that requires a specialist. In that case, it would be wise to seek a psychiatrist for consultation — someone who specializes in what we call the psychopharmacology of depressive illness. It also may be wise to have more intensive specialized psychotherapy with a psychologist, psychiatrist or counselor who knows how to do the very specialized counseling treatments I mentioned above — cognitive therapy and interpersonal therapy. Irrespective of that, you don't want to delay getting treatment, because delay of treatment for depression — just like a delay in treatment for pain—can cause many bad consequences. You may become more dysfunctional at work or home, make some life changes, or have physical complications. You want to get right on top of depression. If treatment's not working where you are, talk it over frankly with your physician and get a referral to someone who's an expert in that particular area, someone who specializes in more complex depressions. This doesn't mean that you can't treat depression adequately in your primary care office or your pain center, it just means that if it's not working, don't accept that and make sure you get treatment that works for you. Don't accept a marginal response or marginal outcome.

JL: What other things can persons in pain do?