Chronic Pain and Depression, Anxiety, and Mental Health

What Is Depression?

Depression is a common mental health condition involving symptoms that affect a person’s mood, energy, motivation, and many other aspects of life. People with depression may vary greatly from each other as depression symptoms can range from mild to quite severe. Although depression can create debilitating effects, with quick and effective treatment, symptoms can be managed.

What Causes Chronic Pain?

Causes for chronic pain may include a physical injury, like a pulled muscle, strained back, or whiplash. Diseases like cancer, multiple sclerosis, or fibromyalgia can cause chronic pain as well. It can also be caused by underlying health conditions, such as endometriosis, inflammatory bowel disease, or neuropathic conditions that involve nerve damage in key systems that transmit pain information.

Chronic Pain Symptoms

The symptoms of chronic pain vary from person to person and can occur in various parts of the body. In addition to the wide variability of the type, duration, and intensity of pain, people also differ in terms of the levels of pain interference they experience in their lives and if it leads to permanent disability.

Typical chronic pain symptoms can include:

• Lower back pain
• Knee pain
• Stomach pain
• Nerve pain
• Migraines

Chronic Pain & Mental Health

Chronic pain can take a significant toll on your mental health and quality of life. The emotional difficulties associated with chronic pain include distress from the pain itself, as well as secondary emotional distress caused by the impact of chronic pain. This might involve frustration related to frequent medical contact, isolation resulting from limited engagement in social/recreational activities, worries about what comes next, or hopelessness related to your condition.

This combination of feelings can cause a person to feel overwhelmed and experience burnout. As a result, those who experience chronic pain are also more likely to experience other mental health symptoms and conditions, especially depression and anxiety.^1,2,3

Depression & Chronic Pain

The relationship between depression and chronic pain may actually be bidirectional, as depression has also been identified as a risk factor in the transition from acute to chronic pain.⁴ This can be similar to chronic illness, such as for those living with multiple sclerosis, rheumatoid arthritis, or heart disease.

Some recent research has found that the absence of cheerfulness and laughter that occurs with depression had the strongest association with pain interference ratings.³ People experiencing chronic pain are also more likely to experience insomnia and fatigue, engage in problematic medication use, and report lower overall quality of life.

Regarding chronic pain, the primary psychological mechanisms that seem to lead to worse mental health outcomes are:

• Pain catastrophizing: Focusing on (and thus magnifying) the negative effects of pain and feeling helpless to cope with it
• Fear of pain: Fears surrounding the pain or the condition worsening typically lead to more activity avoidance

Chronic Pain & Suicide

The most pressing concern in regards to chronic pain and mental health is the fact that people who experience chronic pain are at increased risk for suicide. Specifically, research has found that those with chronic pain are at least twice as likely to report suicide ideation or to complete suicide.⁵

The factors that seem to contribute to increased suicide risk for people living with chronic pain include:

• Mental defeat
• Pain catastrophizing
• Hopelessness
• Perception of being a burden
• Feeling that you don’t belong

How Psychotherapy Fits Into Chronic Pain Management

Here are several ways that therapy can help someone manage their chronic pain:

Changing Your Thought Patterns

The ways you think about and manage your pain can impact whether or not you will also experience associated depression and anxiety. For instance, focusing on and magnifying the negative aspects of your pain (termed “pain catastrophizing”) typically makes you feel worse. A therapist can help you learn to catch these thought patterns so you can replace them with more balanced and helpful thoughts. Acknowledging the pain without judgment, reducing maladaptive ways of avoiding the pain (such as overusing pain medication), and learning to live a full life despite the pain can change someone’s relationship with their pain.

Education

Psychotherapy can also teach you things about pain that will help you learn to manage it more effectively. For instance, you might learn about how pain information gets to your brain, so you can learn how to use things like distraction to reduce pain. You will also learn tools for coping with pain, such as relaxation techniques and activity pacing.

Tools for Utilizing Your Support System

Many people with chronic diseases already struggle with feeling like a “burden” to their friends and family, so therapy can provide you with a space where it is okay to talk about difficult emotions. A therapist can also help you learn how to get the most from your existing support system or may encourage you to begin to develop one.

Determining Your Values

Finally, working with a therapist can help you clarify and work toward what is important to you in life, so your values can define how you live instead of your pain. The wide-scale adoption of online or video therapy has made accessing quality psychotherapy much easier, especially for those living with chronic illness.

Therapy for Chronic Pain

There are many styles of therapy available to those suffering from chronic pain including cognitive behavioral therapy, mindfulness-based stress reduction (MBSR), acceptance and commitment therapy (ACT), and psychoeducational interventions.

Cognitive Behavioral Therapy (CBT) For Chronic Pain

CBT for chronic pain is often considered the gold standard because a significant body of research has demonstrated its effectiveness for a wide range of pain populations.⁶ CBT targets the unhelpful thoughts and behaviors that people have in response to their pain in order to improve their overall mental health and ideally, also lower their levels of pain sensation or at least interference.

CBT often begins with an exploration of your thoughts, behaviors, and emotions. In other words, along with your therapist, you become a detective about your life and pain. By examining your thoughts about pain, you can identify any patterns that aren’t helpful for you in order to shift towards more helpful ways of thinking. This often includes identifying and modifying instances of pain catastrophizing.

Your CBT therapist will also help you figure out how to continue to do the things you enjoy, despite your pain. Because depression risk dramatically increases when you stop engaging in recreational, social, and work activities.

You will also learn other behavioral tools for managing your pain, including activity pacing (during which you learn the optimal window to take breaks in order to reduce pain flare ups), and relaxation techniques. A typical course of CBT therapy for chronic pain is about 10-20 sessions, with follow-up as needed.

Mindfulness-Based Stress Reduction (MBSR) For Chronic Pain

Mindfulness-based stress reduction (MBSR) and other mindfulness therapy techniques have also been used to treat chronic pain.^7,8 Mindfulness techniques all involve developing a present awareness of thought and sensation, without judgment or attachment.

Eventually, this practice can help you separate the pain sensation from your emotional and cognitive responses to it. Specifically, MBSR is thought to desensitize individuals to pain and to increase their comfort with difficult emotions thereby reducing maladaptive responses to pain, such as overusing prescription medication or avoiding activities.

Acceptance & Commitment Therapy (ACT) For Chronic Pain

Acceptance and commitment therapy (ACT) is a newer therapeutic modality that is also showing promise for managing chronic pain and improving quality of life.⁹ Rather than focusing on changing the way you think about pain, an ACT therapist would help you shift your behavior to be consistent with your goals and values.

Similarly, instead of focusing on reducing pain, ACT works to increase your acceptance of pain sensations, which has been shown to be predict better pain treatment outcomes, reduce depression, and decrease prescription opioid use.^9,10

Psychoeducational Interventions For Chronic Pain

There are also effective psychoeducational interventions for chronic pain that typically occur in multidisciplinary medical settings.¹¹ The delivery formats for these interventions vary, but common methods include informational support groups, individual sessions, online tutorials or phone sessions.

These interventions typically include education regarding various pain management techniques, and some include components of cognitive behavioral therapy, such as learning about pain catastrophizing. Psychoeducational groups are typically low commitment and show benefit after even a couple sessions.

Where to Find a Therapist Who Is Familiar With Chronic Pain

If you are already working with a medical professional for your chronic pain (or for the condition your pain is secondary to), you can start by asking them about resources for your pain-related mental health. Many primary care settings or pain clinics offer pain support groups or psychoeducation groups.

Even if your doctor or medical center does not offer pain-related mental health support onsite, they can likely refer you to a therapist that specializes in pain management. It can be very helpful to have interdisciplinary teams work collaboratively on treating chronic pain. Therefore, you may want to consider signing a release of information to allow communication between the various professionals you are working with.

If you’re searching for a therapist on your own, using “chronic pain” as a search term on an online therapist directory site will help you find someone with this subspeciality. You can also search for chronic pain support and therapy groups on the same site. Alternately, because CBT and ACT are therapeutic modalities that have both been shown effective in treating chronic pain.

Cost & Insurance

Out of pocket, traditional therapy typically costs $100-200 per session. Depending on your insurance, you may be able to receive therapy at free or low cost with an in-network provider or receive partial reimbursement for out-of-network care.

Unfortunately, if your insurance carrier requires a diagnosable mental health condition for treatment coverage, your therapy may only be covered if you develop secondary anxiety or depression (or other mental health condition). Group therapy options are typically cheaper, ranging from about $15-50 per session, and support and education groups are often free.

Is Therapy Effective For Treating Chronic Pain?

Cognitive behavioral therapy (CBT) has demonstrated small-to-medium effect sizes on pain-associated anxiety and depression and has even shown effects on pain and functioning that are comparable to medical care.^8,12 CBT-related changes in helplessness and catastrophizing seem to be a particularly important component to long lasting change in overall functioning.

The benefits of CBT have been demonstrated in a range of pain populations, including cancer, lower back pain, multiple sclerosis, and nonspecific musculoskeletal pain.

Mindfulness-based stress reduction has shown long lasting reductions in the severity of pain intensity and has shown small-to-medium effects on pain-related anxiety and depression.^7,8 It has also been studied with diverse pain samples, including cancer-related pain, fibromyalgia, and chronic migraine. Finally, MBSR has been found to enhance treatment outcomes when combined in interdisciplinary treatment.

Acceptance and commitment therapy (ACT) is a newer therapeutic modality, so it has not been studied as extensively as CBT has, but it is also showing promise in treating pain-related mental health and functioning.^8,9

Some studies have found medium-to-large effect sizes in treating pain-related anxiety, disability, number of medical visits, and work status. Lower effect sizes have been found for depression and actual pain. ACT has also demonstrated effectiveness with multiple pain populations, including musculoskeletal pain and whiplash associated disorders.

Another important benefit of therapy is that it is extremely low risk, especially when compared to some other pain treatment options, such as opioid medication or surgery. Research has also demonstrated the importance of receiving psychosocial interventions as early as possible.

For example, one study conducted a cost benefit analysis of 1,000 participants with low back pain and found that the participants who received early psychosocial intervention reported fewer health-care visits and missed workdays.¹³

Combining Psychotherapy With Medication

Psychotherapy is a great way to address the symptoms of various mental health concerns, but at times, it is not enough to achieve the wanted level of benefit. At times like this, a mental health prescriber may offer a medication or a combination of medications to improve symptoms. Adding medication can enhance the benefit of psychotherapy and provide a more positive reaction. For many, combining psychotherapy with medication tends to create a better outcome than either alone.

The Importance of Avoiding Drug Reactions

Any time a medication is recommended, the patient and the prescriber should thoroughly review all medications, over-the-counter drugs, and other substances consumed to check for possible drug reactions. Drug reactions range in intensity with death being the most serious effect. To be safe, people should always keep a complete list of all medications, doses, and frequencies, and contact their doctor before making any changes.

Psychiatric Medication As Pain Relievers: Dual Function

At times, people with depression, anxiety, and other mental health conditions can experience pain as a symptom. With mental illness causing or increasing the impact of pain, addressing the psychological concerns can have a very positive impact on pain. In this case, therapy and medication can potentially reduce pain and improve health.

Living With Chronic Pain: Coping & Managing Symptoms

Living with chronic pain will naturally impact your mental health and quality of life, but there’s a lot you can do to manage your symptoms and cope with difficult emotions. Some of the major takeaways from the research on what works in therapy for chronic pain involves not exaggerating or focusing on the negative aspects of your pain or worrying about what else could go wrong with your condition.

Instead, try to stay in the present moment, do what you can to manage your pain, but accept that some pain sensation may be inevitable. Focus your attention on what you want from life and figure out a way to take your pain along for the ride.

Here are additional ways to cope:

• Practice active stress management: the muscle tension associated with stress can make chronic pain worse. Watch your stress levels and use relaxation tools, like deep breathing, to help you relax.
• Track your pain: keeping some sort of record of your pain levels can help you learn more about what helps with your pain and what doesn’t. For example, if you notice you barely slept the night before a hard pain day, it is a clue that good sleep is essential to managing your pain.
• Take breaks and modify: rather than not doing what you love, try to figure out a way to modify your favorite activity and/or take regular breaks. If possible, try to take breaks before your pain flares.

Final Thoughts on Chronic Pain & Depression

Chronic pain and depression have a bidirectional relationship, with each being impacted by the other. When these two conditions exist concurrently, the best path is targeting them both in a concerted effort. With evidence-based treatment from a team of physical and mental health experts, pain management is possible.