National Chronic Pain Outreach Association Lifeline Winter 1996
Managing Depression:
While Chronic Pain and Depression Can Go Hand in Hand, They Don’t Have To
- by Kathleen Crowley
Years ago, during an initial interview after a lengthy screening process for admittance to the U.C.L.A. Pain Clinic, I was told that while the pain clinic may be unable to reduce the level of pain I was experiencing, they felt reasonably certain they could teach me to reduce the bothersomeness. I thought they were nuts! They had suggested I was experiencing pain comparable to that of someone with terminal cancer, likened to a war veteran with a bullet lodged in his spine. Not reduce the pain but the bothersomeness? Hard to believe. But during the previous two and a quarter years I’d exhausted all other options that I (and the dozens of other doctors I had seen) could think of. And so I was unwilling to dismiss what sounded a lot like hokey pokey to me. Surprisingly and what struck me as magically I did, despite the inability to reduce my level of pain, learn to reduce the bothersomeness—a fact which many individuals now find equally hopeful and hard to believe.
And in that same context, I am now frequently met with equal surprise when I tell of managing depression without anti-depressants. A depression that was first treated in 1984 by three months in a locked psychiatric ward, a slew of anti-depressants and years of hell. While anti-depressants are now the most popular choice for managing depression, and while there is a definite role for them, the real choice in managing depression should be whether to take an anti-depressant, not which one. Harper’s Magazine in the January 1996 issue quotes an amazing statistic, that in 1995 there was an increase in prescriptions for anti-depressants at HMO’s of more than 34,000 per day. While some of this increase is likely due to the overall growth of HMO’s in general, this is nonetheless incredible evidence of the dominant and growing role of anti-depressants. Some of the reasons for this are:
1. The very nature of depression is at odds with the treatment of it. Severe depression can be defined in one word—hopelessness. A severely depressed person has no hope for the future and no memory of things ever having been any different. Showing a severely depressed person a laughing photo of them taken during a previously happy time can be much like showing someone that has never skydived a photo of themselves in the air with a parachute. There is an immediate recognition but no memory of the event, and their reaction is one of shock, because surely, they reason, that is an event they would remember. Swallowing a pill may be the only action a severely depressed individual is initially capable of.
2. Insurance coverage is generally superior for medications and the associated doctor visits than other possible treatments, including therapy (which is becoming increasingly unavailable given the cost-cutting pressures on, and growth of, managed care organizations).
3. There is substantial clinical research on anti-depressants, largely because of the dominating effect of pharmaceutical company funding on U.S. medical research. And treating professionals have neither the resources nor the legal protection to prescribe treatment alternatives which have not been heavily researched.
4. There is a growing onslaught of popular literature chronicling the path to recovery from depression beginning with meds, leading patients to believe medications are a quick and painless fix.
There are three primary classes of anti-depressants—monoamine oxidase inhibitors (MAOIs), tricyclics and heterocyclics, and selective serotonin reuptake inhibitors (SSRIs). Certain tricyclics, particularly amitriptyline (Elavil) and nortriptyline (Pamelor), are not only anti-depressants but are frequently prescribed in low dosages for certain neurological pain relief. SSRIs such as fluoxetine (Prozac) and paroxetine (Paxil) have fewer side effects but the research is still ongoing as to any possible pain relief features. The process of “stabilizing on an anti-depressant” can be lengthy, as different medications will react differently for different people, and will be altogether unsuccessful for some individuals. When considering anti-depressants, three of the questions a chronic pain patient and his treating professional should consider are:
1. Will this medication help attain health, or merely adjust to sickness? What is the exit strategy for the medication—in other words, is this medication likely to clear up the depression, or intended to manage it on a permanent basis? This question has particular importance for chronic pain sufferers, who have to chronically deal with the possibility of depression.
2. What are the side effects and interactions? This is also particularly important for chronic pain patients, whose physical symptoms (and possible pain medications) may conflict with anti-depressants. A number of deaths have been caused by giving the pain medication Demerol to patients taking MAOIs. Frequently the side effects of anti-depressants and pain medications will be additive when they are taken together, particularly in such areas as sedation, constipation or nausea, and decreased blood pressure. Alcohol, and some antihistamines, can further increase some of these effects. SSRIs, while they have fewer side effects than tricyclics, do have side effects and can interfere with the metabolism of many other common medications. Patients should keep a list of any medications they are taking or take on occasion (including over the counter remedies), and make sure any treating physician is aware of them. The medication pyramid—taking medications to take care of the symptoms of medications—is all too common. These concerns become even more critical if the anti-depressant is proposed for a long-term treatment plan. Dr. Eric Braverman, director of Princeton Associates for Total Health, suggested in Health News and Review that anti-depressants should be prescribed only “when their value clearly exceeds their danger.”
3. What options are available other than anti-depressants? This is the question that just isn’t getting asked. It only seems logical that if millions of Americans suffer each year from depression, there are many paths to wellness. Depressions vary, individuals vary, and therefore treatment plans should vary. Anti-depressants can play a significant role, but they should be seen as the emergency medicine of mental illness, not necessarily the primary tool for a long term treatment plan.
In fact, some of the many other possible treatment options are listed below.
· Therapy: A November 1995 Consumer Reports survey (not specifically limited to depression) provided what they believe is “convincing evidence that therapy alone can make an important difference.” I was initially resistant to therapy at U.C.L.A., reasoning that no real benefit could come from me sitting around talking about things (i.e., chronic pain) that I couldn’t do anything about. But depression is the knife turned inward, all of the anger, and guilt, and fear that goes unexpressed. Therapy is a spillage of the anger and guilt and frustration holding the knife. In fact, it is amazing how much therapy can help, specifically in cases such as chronic pain where there is such an inherent build-up of guilt and frustration in daily life.
· Dl-phenylalanine (also called D.L.P.A.) is an amino acid generally available from health food stores. It is remarkably effective for both pain and depression and is relatively inexpensive. You should not take this if you are pregnant, breast-feeding, have high blood pressure, are taking MAOIs, or have diabetes or phenylketonuria. (It is best to keep your doctor advised of any supplements you are considering, in the event there is a medical reason you should not take them.) This amino acid has proved to be a lifesaver for me, and I cannot recommend it highly enough.
· St. John’s Wort (Hypericum perforatum, also sometimes listed under its active ingredient, Hypericin) is an herbal treatment for depression. It improves mood and sleep quality for depressed persons, and is available in capsule form from health food stores.[1]
· Aerobic exercise: While chronic pain may be an obstacle to aerobic activity, if at all possible it can be the best anti-depressant of all.
· Sleep: The irony is that in dealing with chronic pain, you may need more sleep than ever, but have less of an ability to get it. Michael Norden, M.D., author of Beyond Prozac, notes that, “Depression is strongly tied to inadequate sleep.” So while ideally, in managing depression, an individual would both get sufficient sleep and sleep on a schedule, this may not be realistic. A person in chronic pain should at least rest whenever possible, not feeling guilty but recognizing this as a necessary part of a defensive strategy against depression.
· Lighting: While natural outdoor sunlight is best and full spectrum artificial lighting can be a close second, in truth any increase can be a huge factor in dealing with depression. Halogen lighting, which is a clean white light, can work exceptionally well. I have begun thinking of storing light in the pineal gland (a pine-cone shaped gland located in the middle of the brain which among many other things affects mood and sleeping) as like putting money in the bank.
· Hope: And most of all find ways to build and maintain hope. As William Styron said, “It is hopelessness, even more than pain, that crushes the soul.” Positive emotions create positive reactions in the body, and negative emotions create negative reactions. While the biology of this is in dispute, the fact of it is not; hope is an enormous factor in healing. The power of hope is the basis for why placeboes often work. If I thought about growing old with chronic pain, it would be very easy for me to become depressed. And so when I find myself thinking about this possibility, I instead focus on various treatments that are now being explored. One can always find reason to hope for circumstances to improve. And the fact is that miracles—which are simply events we cannot explain and we cannot duplicate on demand—do take place, both created by and creating hope.
Conclusion
Chronic pain sufferers can be particularly susceptible to undertreatment because they don’t often seek treatment, assuming depression is part and parcel of chronic pain; and because it is often not recognized by their treating physicians. When someone is suffering from chronic pain, they no longer look like they are in acute pain, a diagnosis physicians are both trained to look for and to treat. In this same way, an individual suffering from chronic pain with the added complication of depression may go undiagnosed, the depressive symptoms commingling with the pain symptoms and complicating diagnosis. Yet much of the lifestyle of an individual in chronic pain can cause depression. If chronic pain patients and their treating professionals can recognize the early onset of depression, they can cut it off at the pass.
If anti-depressants are to be taken, it is critical to be aware of the choices and to treat depression in conjunction, and in harmony with chronic pain. It is important to remember that the choice is not just which anti-depressant to take, but whether to take one at all. Depressions vary; individuals vary. And therefore treatment plans should vary.
Depression can loom so deadening, so debilitating, so destructive that we assume it requires something strong, powerful and exceptional to beat it. Some of the ideas for treatments in this article such as light, exercise and DLPA may seem too “anecdotal,” too incidental to treat something as serious as depression. But in fact, they make use of the strongest medicine of all— the active participation of the patient. The cycle of sickness (where sickness breeds stress which breeds sickness) can be beaten by the cycle of health (where hope generates health which generates hope) every time.
Editor’s Note: Ms. Crowley is the author of The Day Room, A Memoir of Madness and Mending, reviewed in this issue.
© Kathleen Crowley, National Chronic Pain Outreach Association 1996
* Reprinted courtesy of the National Chronic Pain Outreach Association
Managing Depression:
While Chronic Pain and Depression Can Go Hand in Hand, They Don’t Have To
- by Kathleen Crowley
Years ago, during an initial interview after a lengthy screening process for admittance to the U.C.L.A. Pain Clinic, I was told that while the pain clinic may be unable to reduce the level of pain I was experiencing, they felt reasonably certain they could teach me to reduce the bothersomeness. I thought they were nuts! They had suggested I was experiencing pain comparable to that of someone with terminal cancer, likened to a war veteran with a bullet lodged in his spine. Not reduce the pain but the bothersomeness? Hard to believe. But during the previous two and a quarter years I’d exhausted all other options that I (and the dozens of other doctors I had seen) could think of. And so I was unwilling to dismiss what sounded a lot like hokey pokey to me. Surprisingly and what struck me as magically I did, despite the inability to reduce my level of pain, learn to reduce the bothersomeness—a fact which many individuals now find equally hopeful and hard to believe.
And in that same context, I am now frequently met with equal surprise when I tell of managing depression without anti-depressants. A depression that was first treated in 1984 by three months in a locked psychiatric ward, a slew of anti-depressants and years of hell. While anti-depressants are now the most popular choice for managing depression, and while there is a definite role for them, the real choice in managing depression should be whether to take an anti-depressant, not which one. Harper’s Magazine in the January 1996 issue quotes an amazing statistic, that in 1995 there was an increase in prescriptions for anti-depressants at HMO’s of more than 34,000 per day. While some of this increase is likely due to the overall growth of HMO’s in general, this is nonetheless incredible evidence of the dominant and growing role of anti-depressants. Some of the reasons for this are:
1. The very nature of depression is at odds with the treatment of it. Severe depression can be defined in one word—hopelessness. A severely depressed person has no hope for the future and no memory of things ever having been any different. Showing a severely depressed person a laughing photo of them taken during a previously happy time can be much like showing someone that has never skydived a photo of themselves in the air with a parachute. There is an immediate recognition but no memory of the event, and their reaction is one of shock, because surely, they reason, that is an event they would remember. Swallowing a pill may be the only action a severely depressed individual is initially capable of.
2. Insurance coverage is generally superior for medications and the associated doctor visits than other possible treatments, including therapy (which is becoming increasingly unavailable given the cost-cutting pressures on, and growth of, managed care organizations).
3. There is substantial clinical research on anti-depressants, largely because of the dominating effect of pharmaceutical company funding on U.S. medical research. And treating professionals have neither the resources nor the legal protection to prescribe treatment alternatives which have not been heavily researched.
4. There is a growing onslaught of popular literature chronicling the path to recovery from depression beginning with meds, leading patients to believe medications are a quick and painless fix.
There are three primary classes of anti-depressants—monoamine oxidase inhibitors (MAOIs), tricyclics and heterocyclics, and selective serotonin reuptake inhibitors (SSRIs). Certain tricyclics, particularly amitriptyline (Elavil) and nortriptyline (Pamelor), are not only anti-depressants but are frequently prescribed in low dosages for certain neurological pain relief. SSRIs such as fluoxetine (Prozac) and paroxetine (Paxil) have fewer side effects but the research is still ongoing as to any possible pain relief features. The process of “stabilizing on an anti-depressant” can be lengthy, as different medications will react differently for different people, and will be altogether unsuccessful for some individuals. When considering anti-depressants, three of the questions a chronic pain patient and his treating professional should consider are:
1. Will this medication help attain health, or merely adjust to sickness? What is the exit strategy for the medication—in other words, is this medication likely to clear up the depression, or intended to manage it on a permanent basis? This question has particular importance for chronic pain sufferers, who have to chronically deal with the possibility of depression.
2. What are the side effects and interactions? This is also particularly important for chronic pain patients, whose physical symptoms (and possible pain medications) may conflict with anti-depressants. A number of deaths have been caused by giving the pain medication Demerol to patients taking MAOIs. Frequently the side effects of anti-depressants and pain medications will be additive when they are taken together, particularly in such areas as sedation, constipation or nausea, and decreased blood pressure. Alcohol, and some antihistamines, can further increase some of these effects. SSRIs, while they have fewer side effects than tricyclics, do have side effects and can interfere with the metabolism of many other common medications. Patients should keep a list of any medications they are taking or take on occasion (including over the counter remedies), and make sure any treating physician is aware of them. The medication pyramid—taking medications to take care of the symptoms of medications—is all too common. These concerns become even more critical if the anti-depressant is proposed for a long-term treatment plan. Dr. Eric Braverman, director of Princeton Associates for Total Health, suggested in Health News and Review that anti-depressants should be prescribed only “when their value clearly exceeds their danger.”
3. What options are available other than anti-depressants? This is the question that just isn’t getting asked. It only seems logical that if millions of Americans suffer each year from depression, there are many paths to wellness. Depressions vary, individuals vary, and therefore treatment plans should vary. Anti-depressants can play a significant role, but they should be seen as the emergency medicine of mental illness, not necessarily the primary tool for a long term treatment plan.
In fact, some of the many other possible treatment options are listed below.
· Therapy: A November 1995 Consumer Reports survey (not specifically limited to depression) provided what they believe is “convincing evidence that therapy alone can make an important difference.” I was initially resistant to therapy at U.C.L.A., reasoning that no real benefit could come from me sitting around talking about things (i.e., chronic pain) that I couldn’t do anything about. But depression is the knife turned inward, all of the anger, and guilt, and fear that goes unexpressed. Therapy is a spillage of the anger and guilt and frustration holding the knife. In fact, it is amazing how much therapy can help, specifically in cases such as chronic pain where there is such an inherent build-up of guilt and frustration in daily life.
· Dl-phenylalanine (also called D.L.P.A.) is an amino acid generally available from health food stores. It is remarkably effective for both pain and depression and is relatively inexpensive. You should not take this if you are pregnant, breast-feeding, have high blood pressure, are taking MAOIs, or have diabetes or phenylketonuria. (It is best to keep your doctor advised of any supplements you are considering, in the event there is a medical reason you should not take them.) This amino acid has proved to be a lifesaver for me, and I cannot recommend it highly enough.
· St. John’s Wort (Hypericum perforatum, also sometimes listed under its active ingredient, Hypericin) is an herbal treatment for depression. It improves mood and sleep quality for depressed persons, and is available in capsule form from health food stores.[1]
· Aerobic exercise: While chronic pain may be an obstacle to aerobic activity, if at all possible it can be the best anti-depressant of all.
· Sleep: The irony is that in dealing with chronic pain, you may need more sleep than ever, but have less of an ability to get it. Michael Norden, M.D., author of Beyond Prozac, notes that, “Depression is strongly tied to inadequate sleep.” So while ideally, in managing depression, an individual would both get sufficient sleep and sleep on a schedule, this may not be realistic. A person in chronic pain should at least rest whenever possible, not feeling guilty but recognizing this as a necessary part of a defensive strategy against depression.
· Lighting: While natural outdoor sunlight is best and full spectrum artificial lighting can be a close second, in truth any increase can be a huge factor in dealing with depression. Halogen lighting, which is a clean white light, can work exceptionally well. I have begun thinking of storing light in the pineal gland (a pine-cone shaped gland located in the middle of the brain which among many other things affects mood and sleeping) as like putting money in the bank.
· Hope: And most of all find ways to build and maintain hope. As William Styron said, “It is hopelessness, even more than pain, that crushes the soul.” Positive emotions create positive reactions in the body, and negative emotions create negative reactions. While the biology of this is in dispute, the fact of it is not; hope is an enormous factor in healing. The power of hope is the basis for why placeboes often work. If I thought about growing old with chronic pain, it would be very easy for me to become depressed. And so when I find myself thinking about this possibility, I instead focus on various treatments that are now being explored. One can always find reason to hope for circumstances to improve. And the fact is that miracles—which are simply events we cannot explain and we cannot duplicate on demand—do take place, both created by and creating hope.
Conclusion
Chronic pain sufferers can be particularly susceptible to undertreatment because they don’t often seek treatment, assuming depression is part and parcel of chronic pain; and because it is often not recognized by their treating physicians. When someone is suffering from chronic pain, they no longer look like they are in acute pain, a diagnosis physicians are both trained to look for and to treat. In this same way, an individual suffering from chronic pain with the added complication of depression may go undiagnosed, the depressive symptoms commingling with the pain symptoms and complicating diagnosis. Yet much of the lifestyle of an individual in chronic pain can cause depression. If chronic pain patients and their treating professionals can recognize the early onset of depression, they can cut it off at the pass.
If anti-depressants are to be taken, it is critical to be aware of the choices and to treat depression in conjunction, and in harmony with chronic pain. It is important to remember that the choice is not just which anti-depressant to take, but whether to take one at all. Depressions vary; individuals vary. And therefore treatment plans should vary.
Depression can loom so deadening, so debilitating, so destructive that we assume it requires something strong, powerful and exceptional to beat it. Some of the ideas for treatments in this article such as light, exercise and DLPA may seem too “anecdotal,” too incidental to treat something as serious as depression. But in fact, they make use of the strongest medicine of all— the active participation of the patient. The cycle of sickness (where sickness breeds stress which breeds sickness) can be beaten by the cycle of health (where hope generates health which generates hope) every time.
Editor’s Note: Ms. Crowley is the author of The Day Room, A Memoir of Madness and Mending, reviewed in this issue.
© Kathleen Crowley, National Chronic Pain Outreach Association 1996
* Reprinted courtesy of the National Chronic Pain Outreach Association