124- Chronic Pain and Depression: Breaking the Cycle with Mental Health Care
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Jennifer Steiner, PhD, ABPP: Chronic pain is a significant risk factor for both depression and suicide. The most comprehensive literature review on this was done.

Just a few years ago, it showed that people who have chronic pain are twice as likely to report suicidal behaviors or to complete suicide compared with people who do not have chronic pain. And that in this group of people, who have chronic pain, suicidality is actually more related to psychosocial factors, like the impact on mental health, the impact on finances and family and social and stigma and all, everything we've been talking about.

It's more related to dealing with that than the pain itself, which I think is a real important takeaway because I think most people can think about it as, yeah, if you're in excruciating pain, why would you want to continue to put up with that? But it's not just that. It's really more everything

else.

Regina Koepp: Today's guest expert is Dr. Jennifer Steiner. I. Dr. Steiner is a board certified clinical health psychologist and founder of Beyond the Body Health Psychology Services.

It's a private practice in Atlanta that focuses on chronic pain and illness. She also serves as co-director of the Center for Mental Health and Aging's Continuing Education Program and as adjunct professor at Emory School of Medicine. Part of her service includes being a board member of the Georgia Psychological Association Board of Directors, and in a couple of other capacities with the Georgia Psychological Association.

Dr. Steiner is an expert in the field of pain psychology. She has worked with patients with chronic pain for over 10 years and has published multiple scholarly articles on psychological correlates and interventions for chronic pain. I'm delighted that Dr. Steiner is here imparting her knowledge to all of us for and working with a population that is larger than you might imagine.

So thank you so much for being here, Dr. Steiner. Let's talk about chronic pain and depression. So how are they connected and related? What's the overlap there?

Jennifer Steiner, PhD, ABPP: Yeah, so it's actually pretty interesting. So I think, we've been talking about other ways that pain can affect your life, and so it's not, I think, a hard leap to get to yeah, that could make you depressed, but it also works the other way around, and I don't think people really realize that.

Our brains and our body are unbelievably interconnected, and we are hardwired, or, biologically programmed if you will. So that when we're experiencing any kind of strong or uncomfortable emotion, like depression, like anxiety, like intense stress, it causes a chemical reaction in the brain, which then causes several neurochemicals to be released.

And I think most people have heard of the fight or flight response or the fight, flight freeze response. And that's the idea that when we're faced with any kind of danger or even a perceived danger, like a strong uncomfortable emotion or depression, it can cause the body to react in physical ways.

And so what happens is that when our brain picks up on that potential danger or that uncomfortable emotion, the brain activates your stress response. And that usually starts in the hypothalamus. And then that message gets sent to two other parts of the brain. One is the pituitary gland, which releases the stress hormone cortisol, and the other is the adrenal medulla that releases epinephrine or adrenaline. And what happens then is that causes your heart rate to speed up. It causes your muscle tension to increase, which as you can imagine, more muscle tension for somebody with chronic pain, not a good thing. And it can also suppress the immune system. And while those changes can help you deal with whatever the stress or the threat is in the short term, in the long run, it actually amplifies the effects of chronic pain.

And that's just from having some type of threat, which could be the emotion, it could be the stress. But it's also worth noting that just being in physical pain can actually set off that cascade associated with a stress response because your brain is designed to interpret a pain signal as dangerous.

That's why we have pain. It's our, it's our alarm system. So just having that daily experience can set off that process. And when chronic pain causes that stress response to happen over and over again, it causes dysfunction. In part of our system that we often call our HPA system, and that causes, I weakened immune functioning.

It causes chronic muscle tension and it, in some cases it actually increases pain sensitivity. And so that's all just from having pain and potentially having chronic stress or some depression. So that's that piece of the link. It actually gets a little bit more complicated because in addition to having a stress response when we have pain, another part of the brain actually also takes that pain message and is supposed to help us inhibit it.

But what happens when you have chronic pain and chronic stress and nothing else is working [00:05:00] right? Over time that system breaks down. And so instead of inhibiting the pain messages, it actually causes another cascade of chemicals and the system loses its ability to do that properly. And so you've got your stress response amplifying everything up.

You've got chronic pain, basically making it so that your nervous system doesn't actually process pain the way it should. And it just becomes this really nasty, vicious cycle for people.

And I think, if we were to put it in a what would that actually look like, type of way, you may have somebody it's not uncommon to think of, okay, you're having several bad pain days in a row.

You might start feeling a little down about that. Start worrying about, when am I gonna get back to. My day to day, is this gonna affect my job? What have you? And your brain is gonna interpret those thoughts as potentially a perceived threat to life as you know it, or to your job or your sense of self.

And then that would trigger your stress response, causing the person to have increased muscle tension which would [00:06:00] amplify the pain they were already having. So now they've got pain on top of pain, and then they may even feel more depressed and hopeless because now they're hurting even worse. And so because it's chronic pain and it's been happening for a long time, it would not be unlikely for the brain and the nervous system to have dysfunction in its ability to calm that pain down or stop the pain from amping up.

And so that's how that amplification process happens. And at that point the pain and the depression just start feeding each other and it becomes pretty cyclical in nature.

Regina Koepp: What percentage of people living with chronic pain have depression, would meet criteria for clinic clinical depression?

Jennifer Steiner, PhD, ABPP: There is some research that suggests that just having pain increases the risk for depression, like basically doubles it. So that might give you some thoughts about the prevalence of that. Yeah.

So now, which comes first? I know

Regina Koepp: you were saying like that [00:07:00] there's this bidirectional relationship and there's this loop. So does pain lead to depression or depression lead to pain?

Jennifer Steiner, PhD, ABPP: That's such a good question. The short answer is it's complicated and I'm gonna give you the long answer.

As we were just talking about, because of all of those physiological changes it can be hard to tell. And honestly, I think to some degree it does depend on the individual. And if you can do a good clinical interview with somebody, sometimes you can get the, which came first. But the research is actually a little bit unclear.

There's research to support either way. So there's been some work that shows, that seems to support the idea that the depression comes first. So Williams and colleagues looked at the general population and found that among those people who were depressed, pain was common in 65% of them. And they took that to mean that pain is a symptom of depression, so the depression must come first.

And we also know that depression exacerbates pain. And so some people have taken that to mean that depression at least has a contributing role, if not potentially a causal role. Of course, we know that correlation doesn't imply causation and it's hard to do these studies, so we're not really sure.

But there are arguments for that side. There are other studies that seem to really point to this idea that the pain comes first. And so there was a good, a study that gets cited a lot that was done in 2010 that shows that for people who have chronic pain, the most common course of events is first pain and then the depression naturally follows.

And it was found that the depression is usually associated with the pain, lack of sleep, which may be secondary to the pain and changes in day-to-day life that are secondary to the pain. So that there was some pretty clear research to suggest that at least in that population and in my clinical practice, that's actually what I see the most.

Somebody, sometimes somebody may have had some stressors prior to the onset of pain, but generally they may have been handling those stressors pretty well. And it wasn't until the pain started really getting to the point where it affected many different areas of their life negatively.

That clinical kind of diagnosable major depressive disorder set in. And then you get that cycle or that bidirectional relationship where everything just feeds itself.

Regina Koepp: Your mention of sleep is so essential too. I'm thinking, reflecting on my clients who are living with chronic pain and have other mental health or mild cognitive impairment.

I have one person has mild cognitive impairment and a sleep issue, but the sleep issue is related to chronic pain. And it makes the cognitive issues worse. Pain does, and then so does lack of sleep.

Jennifer Steiner, PhD, ABPP: Yes. I often refer to that as like the trifecta, because they all fuel one another.

Pain actually can affect cognitive functioning too. It's not uncommon to have a little bit of what I affectionately call brain fog associated with the pain and pain medication can cause some of that as well. And so between the pain and the lack of sleep and the not being able to concentrate or recall things the [00:10:00] way one would like, it's just which it can be frustrating and make the pain worse.

Regina Koepp: And then the lack of sleep also lowers our tolerance for distress.

Jennifer Steiner, PhD, ABPP: Yeah. And actually there've been some studies, they're a little old now, but that show that when you don't have sleep, at least in the appropriate. Component, so your sleep architecture's messed up. It can actually lead to chronic pain syndromes, like diffuse syndromes, such as fibromyalgia-like symptoms.

We don't think that's what fibromyalgia is, but it can recreate the symptoms just from lack of sleep.

Regina Koepp: Sleep is such a big deal. There are professionals who can help people with both pain. Physical pain management, the physical, chronic pain management, and also all of the mental health and psychosocial factors.

Yes. Can you say a little bit about that?

Jennifer Steiner, PhD, ABPP: I, first of all, I wanna say that I actually think this is one of the big challenges for people when it comes to accessing mental health.

There are lots and lots of really well-trained mental health providers who have good experience and depression and anxiety and stress and trauma and all of these other areas that are important. But that doesn't necessarily mean that they have training in working with people who have chronic pain or that complex relationship between the physical and emotional pain.

And I find for people who are really caught up in this pain cycle that I keep referring to, they really need somebody who can speak to both in an intelligent and informed way. They need somebody who can help to educate them on how the physical pain and the emotional experience fuels one another.

Because a lot of people don't recognize that in their own experience. And you really need to understand that in order to help break that cycle and do things a little bit differently so you can cope better. You need somebody who has the knowledge of the medical treatments or the common experiences that go along with chronic pain.

And not everybody has that. So health psychologists or pain psychologists in particular are pretty uniquely suited to help people who [00:12:00] have chronic pain because they have received specialized training. Typically these are psychologists who've studied with the intention of working with people who also have either chronic pain or some type of medical condition.

And they have training in anatomy and medical terminology and how to read a medical chart and the psychological interventions that work for people who have chronic pain because those interventions are not just about, okay, you have depression that came after your pain. It's about how do we come up with some strategies that will help you manage your pain triggers?

How do we help you do more with your pain without landing you in bed for the next three days? And how do we help you deal with any kind of depression or anxiety or stress or relationship issues that are stemming from all of this? These challenges in your life. And so they're not treating the pain per se, but they definitely can help to manage triggers and teach you some techniques to reduce the pain or better manage contributing factors.

And I, I think that's why it's important to find somebody that really does have that background.