Features December 2009 Issue

Easing the Double Whammy of Depression and Arthritis

Treating one of these troubling conditions can help the other, but it’s best to treat both.

Anecdotal evidence as well as scien-tific research support the notion that pain and depression interact synergistically: The deeper your depression, the worse your pain. And when your pain is caused by arthritis, the "double whammy" can be especially debilitating, says psychologist Michael McKee, Ph.D., former vice chairman of Cleveland Clinic’s

Department of Psychiatry and Psychology.

On the anecdotal side, Dr. McKee recalls two patients whose stories exemplify the connection between depression and arthritis, and the benefits of treating the two conditions. A 50-year-old woman with controlled rheumatoid arthritis had a full social life and enjoyed her volunteer work until her husband filed for divorce. "Her pain complaints got worse and worse, starting a vicious circle," Dr. McKee recounts. "The pain started robbing her of sleep. She stopped socializing and volunteering, became more sedentary, and constantly complained to her daughters. They were afraid she was turning into an invalid."

Treating the woman’s arthritis pain directly wasn’t enough, Dr. McKee says. "I talked her into joining an outpatient group for women with depression. The women who had been in the program a long time and gotten better served as role models. They managed to convince my patient to resume her social life and volunteering. In the group, she also learned to stop her pain behavior—complaining to her daughters, canceling activities—and take simple steps like going for a walk instead of sitting and watching television, relaxing and refocusing instead of giving into the pain." Eventually, the woman developed new friendships and started dating, all the while continuing to participate in the group.

Another patient, a man about the same age, had osteoarthritis in his knees and back. He had few pain complaints until he lost his job. "He took it very hard, and the job loss spurred a kind of avalanche of other losses—loss of sleep, loss of self-respect, loss of structure and routine, and loss of identity, because his identity was so closely linked to his job," Dr. McKee explains. The man’s depression escalated exponentially, as did his pain complaints, until he began treatment for both.

Convincing Evidence

Dr. McKee’s experience is not unique. He pointed to recent reseaarch in The Journal of the American Medical Association, the latest in a number of studies demonstrating a connection between depression and pain. In this study, researchers found that closely monitoring antidepressant therapy and appropriately adjusting dosages, coupled with pain self-management techniques, led to substantial improvement in both conditions.

The study’s 250 participants had lower-back, hip, or knee pain and at least moderate depression. They were randomized into two groups: The control group received usual care from their primary-care physicians for both depression and pain. The other group received monitoring of the medications prescribed for their depression plus 12 weeks of pain self-management training (muscle relaxation, deep-breathing exercises, coping techniques, and other strategies).

Those whose depression medications were closely monitored and who were trained in pain self-management were two to three times more likely to have decreased depression compared with the control group. Pain severity and disability also lessened.


The Connection

What links pain and depression? "Some people say, ‘If you have a painful condition, that alone is depressing’—but that’s not universally true," Dr. McKee says. "Others say that depression inevitably makes pain worse because you sit and focus on what’s wrong with you instead of what’s right. That may be true, but again, that’s not the case for many people."

Although researchers still don’t know precisely how the two are connected, they do appear to share common pathways and neurotransmitters. "And while it’s true that we don’t know for sure yet, the ‘gate control’ theory has guided research and is consistent with treatment programs that seem to work," Dr. McKee says.

"Gate control" postulates the presence of a mechanism in the spinal cord that acts like a gate. Feelings and thoughts that open the gate—letting in more pain signals from damaged tissue—include depression, anxiety, and the memory of pain, Dr. McKee explains. By contrast, pain medications, antidepressants, biofeedback, meditation, and similar techniques tend to close the gate. "Combined programs that treat depression with cognitive behavior therapy and medication, and treating pain behavior, beliefs, and emotions related to chronic pain, seem to be most effective." Without such programs, says Dr. McKee, "people end up taking far more pain medication than they might otherwise need."


Take Action

If someone is in pain and depressed, doing the very things needed to relieve the conditions may often seem impossible. Therefore, if you’re close to someone who is in such a state, try to help them take action. "Tell them you’re worried and concerned about them, and you know they have plenty of reasons to be depressed, including pain and illness, but that everything you understand suggests that pain-related depression is treatable. Offer to schedule a consultation with a health-care provider and, if possible, accompany them to the appointment," Dr. McKee advises.

If you’re the one who’s in distress, "remember that depression is treatable, and if you haven’t been able to overcome it on your own, at least talk to someone. Depression makes you feel helpless, but you don’t have to be," Dr. McKee says. "The first step may be making a call to see your doctor or another health-care provider who understands and treats depression."