Chronic Pain and Mental Health

At some time in our lives we will all experience pain—physical and/or emotional discomfort caused by illness, injury, or an upsetting event. Though most of us would rather avoid it, pain does serve an actual purpose that is good and seen as “protective.” For example, when you experience pain your brain signals you to stop doing whatever is causing the pain, preventing further harm to your body.

Pain, however, is not meant to last for a long time. Pain that typically lasts less than 3 to 6 months is called acute pain, which is the form of pain most of us experience. For some people, pain can be ongoing or go away and then come back, lasting beyond the usual course of 3 to 6 months and negatively affecting a person’s well-being. This is called chronic pain or persistent pain. Put simply, chronic or persistent pain is pain that continues when it should not.

Chronic pain is often associated with other health conditions such as anxiety and depression, resulting in a low health‐related quality of life. [1]  

Living with daily pain is physically and emotionally stressful. Chronic stress is known to change the levels of stress hormones and neurochemicals found within your brain and nervous system; these can affect your mood, thinking and behavior. Disrupting your body’s balance of these chemicals can bring on depression in some people.

There are several ways chronic pain associated with these conditions can interfere with your everyday life. It can affect your ability to function at home and work. You may find it difficult to participate in social activities and hobbies, which could lead to decreased self-esteem. It is also common for people with chronic pain to have sleep disturbances, fatigue, trouble concentrating, decreased appetite, and mood changes. These negative changes in your lifestyle can increase your pain and dampen your overall mood; the frustration of dealing with this can result in depression and anxiety.

Prevalence of mental health conditions in those with chronic pain

Chronic pain, one of the most common reasons adults seek medical care, has been linked to activity limitations, dependence on opioids, anxiety and depression, and reduced quality of life. [2] 

Research shows that those with chronic pain are four times more likely to have depression or anxiety than those who are pain-free. [3]

In 2016, approximately 20 percent of U.S. adults had chronic pain (approximately 50 million), and eight percent of U.S. adults (approximately 20 million) had high-impact chronic pain. [4] 

High-impact chronic pain is pain that has lasted three months or longer and is accompanied by at least one major activity restriction, such as being unable to work outside the home, go to school, or do household chores. These people report more severe pain, more mental health problems and cognitive impairments, more difficulty taking care of themselves, and higher health care use than those who have chronic pain without these activity restrictions. [5] 

Common chronic pain conditions and their association with mental health

Arthritis: Arthritis is inflammation of one or more of your joints, which can cause disabling pain. There are more than 100 different forms of arthritis. The most common types include:

• Osteoarthritis (OA): protective cartilage inside the joint breaks down, making movement more difficult and painful - throughout time, bones of the joint may rub directly together, causing severe pain.
• Rheumatoid arthritis (RA): joints and organs are attacked by the body’s own immune system; ongoing inflammation breaks down the joints and damages it permanently.
• Psoriatic arthritis (PsA): the immune system attacks the body, causing inflammation and pain; joints, connective tissue, and the skin are all affected by PsA.

Osteoarthritis is the most common type of arthritis which typically affects the hands, knees, hip, and spine. Osteoarthritis, however, has the ability to affect any joint and cause joint deformity and chronic disability.

Specific mood and anxiety disorders occur at higher rates among those with arthritis than those without arthritis. [6]

Due to pain, limitation of movement, and impairment of the joints, osteoarthritis may reduce a person’s ability to complete daily activities and can sometimes keep people from participating in social activities. The frustration with the inability to meet life’s demands and isolation from not being able to participate in social activities may lead to development of mental health conditions like depression, which can happen at any age. [7] 

Fibromyalgia: Fibromyalgia (FM) is a chronic multi-symptom disease where the brain and spinal cord process pain signals differently. If you have FM, a touch or movement that doesn’t cause pain for others may feel painful to you or something that is mildly painful for a person without FM may be more intense for you. FM is associated with widespread pain in the muscles and bones, areas of tenderness and general fatigue. FM affects approximately 2-3 percent of the general population (more than 90 percent of the patients are female), and pain probably is its most important symptom. [8]

FM typically affects your mental health, social functioning, energy, and overall general health. It was found that the risk of anxiety disorders (particularly obsessive-compulsive disorder) seemed to be approximately five times higher in women with FM than in the general population. [9] 

Multiple Sclerosis: Multiple sclerosis (MS) is nerve damage that disrupts communication between the brain and the body. It is the most common chronic disabling central nervous system (CNS) disease in young adults, affecting 1 in 1,000 people in Western countries. [10] 

The three common mental health concerns when dealing with MS include depression, anxiety and pseudobulbar affect. When you have MS and suffer from depression, you can experience disruption of your social support and family systems. Depression also adversely affects functional status, such as increased time lost from work.

People with MS are nearly twice as likely as those without it to experience Major Depressive Disorder (MDD) over the course of a year. [11]

Generalized anxiety disorder appears to be the most common anxiety disorder among persons with MS. Panic disorder and obsessive compulsive disorder (OCD) may also be much more common among MS patients than among the general population. Studies have found that at some point in a person’s life, 36 percent of those with MS will experience some form of anxiety compared to only 25 percent for those without MS. [12] 

In addition to mood disorders, some people with MS may experience the phenomenon referred to as “pathological laughing and crying,” or pseudobulbar affect (PBA). This happens when a person laughs or cries excessively either in reaction to a feeling or in inappropriate situations. For example, you might laugh or cry in situations that others don't see as funny or sad. PBA occurs in approximately 10 percent of people with MS. [13]

Back/Neck Pain: The back/neck pain most are familiar with is a mild ache that can occur from muscle strain, sleeping in an uncomfortable position, dealing with heavy objects, trauma and/or stress. While not common, back/neck pain can also be a signal of a serious underlying medical issue, such as meningitis, or cancer.

Some symptoms associated with this type of pain could indicate the health of a nerve root or the spinal cord is at risk. These symptoms can include radiating pain, tingling, numbness, or weakness into the shoulders, arm, or hands; neurological problems with balance, walking, coordination, or bladder and bowel control; fever or chills; and other troublesome symptoms. However, these symptoms are also common signs of other serious health conditions, such as heart attack in women, therefore, it always best to consult with your doctor first about any symptoms you may be experiencing.

Mental health conditions were more common among persons with back/neck pain than among persons without. [14] 

In a study of adults with depression and chronic pain, those with backaches and headaches had the highest odds of having major depression. It was also noted that having a chronic painful condition made depressive symptoms last longer compared to those without painful conditions. [15] 

Chronic Migraines: Migraines that last for 15 or more days a month for more than three months are known as chronic migraines. Chronic migraines frequently occur simultaneously with mental health conditions; there is an increased prevalence of major depressive disorder and anxiety disorder in those with migraines compared to those without migraines. [16]

Increasing evidence also suggests that having migraines along with a mental health condition is associated with poorer health-related outcomes such as disability, restriction of activities, and more utilization of mental health care services. [17]

Treatment/Therapies for chronic pain and mental health

Sometimes diagnosing and treating pain can be a tricky process because pain is a subjective experience and there is no test to measure and locate it precisely. Often times chronic pain is treated with medications that can be taken orally, applied directly to the skin (creams and patches), or through injections. If you are taking opioids (painkillers) or talking with your doctor about this treatment option, make sure to plan for safe use of these medications as they are highly addictive. As always, it is very important to remember to continuously work with your doctor to identify the proper treatment options suitable for you.

Although treating pain and mental health conditions sometimes uses separate therapies for each condition, there are some methods that can help alleviate both at the same time.

Ways to help

• Antidepressant medications may relieve both pain and depression because of shared chemical messengers in the brain.
• Talk therapy, also called psychological counseling (psychotherapy), can be effective in treating both conditions.
• Stress-reduction techniques, physical activity, exercise, meditation, journaling, learning coping skills and other strategies also may help.
• Pain rehabilitation programs, typically provide a team approach to treatment, including medical and psychiatric aspects.

Treatment is most effective when using a combination of these therapies.

Mental health screening can help

Effective chronic pain treatment relies on regular screening and includes proper referrals to mental health treatment. Screening provides a quick and easy way to spot the first signs of serious illnesses and initiates the connection to care during the early stages. Take a screen at https://screening.mentalhealthamerica.net/

If you or a loved one is in a mental health crisis, please either visit your local Emergency Room, call 911, reach out to The National Suicide Prevention Lifeline's 24-hour toll-free crisis hotline, 1.800.273.TALK (1.800.273.8255), or text "MHA" to 741741 to receive text-based crisis help.

Sources

Gormsen, L. , Rosenberg, R. , Bach, F. W. and Jensen, T. S. (2010), Depression, anxiety, health‐related quality of life and pain in patients with chronic fibromyalgia and neuropathic pain. European Journal of Pain, 14: 127.e1-127.e8. doi:10.1016/j.ejpain.2009.03.010

Dahlhamer J, Lucas J, Zelaya, C, et al. Prevalence of Chronic Pain and High-Impact Chronic Pain Among Adults — United States, 2016. MMWR Morb Mortal Wkly Rep 2018;67:1001–1006. DOI: http://dx.doi.org/10.15585/mmwr.mm6736a2

Kleiber, B., Jain, S., & Trivedi, M. H. (2005). Depression and pain: implications for symptomatic presentation and pharmacological treatments. Psychiatry (Edgmont (Pa. : Township)), 2(5), 12–18.

U.S. Department of Health and Human Services, National Institutes of Health (2018). Prevalence and profile of High Impact Chronic Pain. Retrieved from https://nccih.nih.gov/research/results/spotlight/Prevalence-Profile-High-Impact-Chronic-Pain

He, Y., Zhang, M., Lin, E., Bruffaerts, R., Posada-Villa, J., Angermeyer, M., . . . Kessler, R. (2008). Mental disorders among persons with arthritis: Results from the World Mental Health Surveys. Psychological Medicine, 38(11), 1639-1650. doi:10.1017/S0033291707002474

Nazarinasab, M., Motamedfar, A., & Moqadam, A. E. (2017). Investigating mental health in patients with osteoarthritis and its relationship with some clinical and demographic factors. Reumatologia, 55(4), 183–188. doi:10.5114/reum.2017.69778

Salaffi, F., Sarzi-Puttini, P., Girolimetti, R., Atzeni, F., Gasparini, S., Grassi, W. (2009). Health-related quality of life in fibromyalgia patients: a comparison with rheumatoid arthritis patients and the general population using the SF-36 health survey. Clinical and Experimental Rheumatology, 56(5), 67-74.

Chwastiak, L. A., & Ehde, D. M. (2007). Psychiatric issues in multiple sclerosis. The Psychiatric clinics of North America, 30(4), 803–817. doi:10.1016/j.psc.2007.07.003

Demyttenaere, K., Bruffaerts, R., Lee, S., Posada-Villa, J., Kovess, V., Angermeyer, M.C., Levinson, D., de Girolamo, G., Nakane, H., Mneimneh, Z., Lara, C., de Graaf, R., Scott, K.M., Gureje, O., Stein, D.J., Haro, J.M., Bromet, E.J., Kessler, R.C., Alonso, J., Von Korff, M. (2007) Mental disorders among persons with chronic back or neck pain. World mental health surveys. 129, 332-342.

Kleiber, B., Jain, S., & Trivedi, M. H. (2005). Depression and pain: implications for symptomatic presentation and pharmacological treatments. Psychiatry (Edgmont (Pa. : Township)), 2(5), 12–18.

Antonaci, F., Nappi, G., Galli, F., Manzoni, G. C., Calabresi, P., & Costa, A. (2011). Migraine and psychiatric comorbidity: a review of clinical findings. The journal of headache and pain, 12(2), 115–125. doi:10.1007/s10194-010-0282-4