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How to treat these conditions when they occur together.

Pain is something that everyone experiences, but for people suffering from anxiety and depression, the pain can be particularly severe and difficult to treat. People with depression, for instance, are more likely to suffer from severe pain and long-lasting discomfort.

The overlap between anxiety and depression is especially evident in chronic pain syndromes that can be disabling, such as Fibromyalgia and irritable bowel symptoms. Other pain syndromes include low back pain and headaches. About two-thirds (or more) of patients with irritable bowel syndrome who receive follow-up treatment have psychological distress symptoms, most commonly anxiety. Around 65% of those seeking treatment for depression report experiencing at least one pain symptom. Psychological disorders can increase pain and disability.

Researchers used to believe that the relationship between anxiety and depression, pain, and their reciprocal relation was primarily due to psychological factors rather than biological ones. Major depression can also be physically painful. Chronic pain can be depressing. Researchers have found that anxiety and depression share some biological mechanisms.

Some of the interplays are due to shared anatomy. The somatosensory cortex (the part that interprets touch and other sensations) interacts with the amygdala and anterior cingulate cortex (areas of the brain that regulate emotions and stress responses) to produce the mental and physical experience of pain. These same areas also contribute to depression and anxiety.

Two neurotransmitters, serotonin (and norepinephrine) — also contribute to the pain signaling of the nervous system and brain. Both anxiety and depression are also implicated.

When pain is accompanied by anxiety or depression, treatment can be difficult. The focus on pain may mask the fact that there is also a mental disorder. This can be true for both clinicians and patients. It can be challenging to treat both problems, even when they are diagnosed correctly. A review of available treatment options for pain that occurs with anxiety or depression was conducted.

Key Points

  • The best-studied psychotherapy to treat pain is cognitive behavioral therapy (CBT).
  • Exercise, relaxation training, and hypnosis may also be helpful.
  • Antidepressants and anticonvulsants can treat a psychiatric condition while reducing pain. However, you should be aware of possible drug interactions.

Double-duty Psychotherapy

Psychotherapies are effective in treating pain for patients suffering from depression or anxiety. They can also be used as an adjunct to drug therapy.

Cognitive behavioral therapy. The pain is both demoralizing and hurtful. CBT is the most researched psychotherapy to treat pain. It is an established treatment for anxiety and depression. CBT is based on the idea that thoughts, emotions, and sensations connect. Therapists use CBT to teach patients coping skills to help them manage their pain instead of being victimized. Patients might, for example, try to engage in certain activities to distract them from the pain and improve their function.

Relaxation Training. Different techniques can help relax people and reduce stress, which increases pain and anxiety symptoms. The techniques include progressive muscle relaxation, mindfulness training, and yoga.

Exercise. Research shows that physical activity can improve mood and reduce anxiety. However, there is less evidence to support its effects on pain.

The Cochrane Collaboration reviewed 34 studies that compared different exercise interventions to various control conditions for the treatment of Fibromyalgia. The reviewers concluded that aerobic exercise performed at an intensity recommended to maintain heart and respiratory fitness improved physical function and overall well-being in patients with Fibromyalgia and may alleviate pain. Limited evidence suggests weight lifting and other exercises to increase muscle strength can also help with pain, mood, and overall functioning.

Avoiding drug interactions

There are potential drug interactions with many psychiatric and pain medications. Here are some common examples.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) can relieve short- and long-term pain. They also reduce inflammation. Combined use of SSRIs and NSAIDs can increase the risk of gastrointestinal bleeding. NSAIDs may cause kidney failure in people with reduced renal function. NSAIDs combined with lithium can cause toxic levels of lithium to build up in the bloodstream.

Acetaminophen is a pain reliever that does not cause bleeding. Acetaminophen, however, is metabolized by the liver using the same enzymes as many SSRIs. The liver function of any patient taking acetaminophen and psychiatric medication for a prolonged period should be monitored. Acetaminophen should be used cautiously by patients with liver damage due to hepatitis C, alcoholism, or other causes.

Opioid Analgesics treat moderate to severe levels of pain. Clinicians and patients need to be aware of potential interactions in addition to the usual precautions, such as dependency risk. Tramadol (Ultram), an opioid, can interact with SSRIs, increasing the risk of seizures in patients taking both drugs simultaneously. Opioids can also cause respiratory problems when taken with benzodiazepines. Patients taking benzodiazepines should begin an opioid slowly and increase the dose. When taken with certain psychiatric drugs that compete for liver enzymes (such as bupropion [Wellbutrin], paroxetine, and duloxetine), codeine and hydrocodone can be less effective.

Double-duty medication

Some psychiatric drugs also relieve pain to solve two problems simultaneously. It is important to ensure that any medication used “off-label” (not FDA-approved) has been supported by evidence.

Some patients prefer to take medication for the pain, and others for the psychiatric condition. Avoiding drug interactions, which can cause side effects or decrease medication effectiveness, is crucial.

Antidepressants. A wide variety of anxiolytics is prescribed to treat both depression and anxiety. Some of these drugs also relieve chronic pain and nerve pain. Research strongly supports the dual-purpose use of tricyclic antidepressants or serotonin reuptake inhibitors (TCAs), which can treat psychiatric conditions and pain. Findings regarding the effectiveness of selective serotonin reuptake inhibitors (SSRIs) are mixed.

Duloxetine, an SNRI (Cymbalta), can be used for pain caused by diabetic neuropathy and Fibromyalgia. Venlafaxine, or Effexor, treats headaches, Fibromyalgia, and nerve pain. Mirtazapine, also known as Remeron, may prevent chronic tension headaches.

In a randomized controlled study, bupropion, which affects norepinephrine and dopamine, helped alleviate chronic nerve pain but not low-back pain unrelated to nerve damage. Patients with nerve pain and depression may find this option helpful. Bupropion can cause insomnia and anxiety in some patients.

TCAs such as amitriptyline, nortriptyline, and desipramine are prescribe for chronic headaches and nerve pain. TCAs used for pain are prescribe at lower doses than those used to treat depression.

All drugs can cause side effects. SSRIs may, for instance, increase the risk of gastrointestinal hemorrhaging. TCAs may cause dizziness and constipation. They can also blur vision and make it difficult to urinate. Overdoses can cause fatal heart rhythm disruption, so the danger must carefully weighed against any possible benefits for patients at high risk of suicide.

Anticonvulsants can also used to stabilize the mood. These medications reduce abnormal electrical activity in the brain and hyperresponsiveness, which can lead to seizures. Some of these medications can provide relief for chronic pain, which is characterize by nerve hypersensitivity. Pregabalin, or Lyrica, is FDA-approve for treating diabetic neuropathy and postherpetic nerve pain.

Psychotherapy and drugs combined

Psychotherapy and medication can provide the best relief for patients with anxiety or depression. A randomized controlled study called the Stepped Care for Affective Disorders & Musculoskeletal Pain (SCAMP) suggests that a combination of psychotherapy and medication may also be effective for those who suffer from both pain and a psychiatric condition.

The trial included 250 patients with chronic lower back, hip, or knee pain. The participants also had moderate depression as measured by standard clinical instruments. The first group received 12 weeks of antidepressant treatment, followed by a 12-week intervention in pain management based on CBT principles. The “usual care group,” a control group, informed participants that they had depression and should seek treatment or advice. Participants were consider to have achieved significant results if they reported a reduction of at least 50% in the severity of depression and at least 30% in pain. After 12 months, depression and pain had significantly reduced for 32 out of 123 patients who received the intervention (roughly 1 in 4), compared to 10 out of 127 participants receiving usual care (about 1 in 12).

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