Strategies for Treating Depression Associated With Chronic Pain Part 1: Psychotherapy

In last month’s Pain Perspectives, I discussed the importance of assessing patients with chronic pain for depression — as it is extremely prevalent in this population and has been found to interfere with physical treatment. This month, we will begin to look at what the primary care physician can do to ensure that their patients with chronic pain have their depression addressed adequately.

Family physicians are aware that there are evidence-based psychological treatments for mental health issues (1). In looking at the research on depression among patients with pain, psychotherapy has been found to be an effective treatment — with systematic reviews and meta-analyses indicating that cognitive behavior therapy (CBT) is effective not only in reducing depression, but pain severity and related dysfunction as well! (2,3).

While other psychotherapies for chronic pain have been studied, they have not produced outcomes as favorable as those demonstrated among patient receiving CBT (4). If your practice has access to a pain psychologist, such a referral is optimal. However, fellowship-trained pain psychologists outside of academic research settings have become a rare breed, and are typically not available.

Accordingly, a primary care physician should seek out a generalist mental health provider specializing in CBT, which should be much easier to find. Although many physicians continue to complain that their patients do not have insurance coverage for mental health treatment, the enactment of the Mental Health Parity and Addiction Equity Act of 2008 requires insurers to generally cover psychological treatment to the same extent that they cover medical treatment (5).

Some patients with pain, however, may not be as open to psychological treatment as others. Factors such as social stigma (6), socioeconomic status (7), gender (8), and race (9) have been found to influence individuals’ willingness to seek mental health treatment. Often, such patients are more open to psychopharmacologic intervention, which has also been empirically established as effective for treating depression in patients with chronic pain (10).

Although CBT with a qualified psychologist is ideal, patients with pain living in underserved areas may not have access it. However, approaches such as telephonic (11) and internet-based (12) CBT are beginning to gain some empirical support. I have had considerable success blending such approaches with occasional in vivo sessions working with depressed patients with chronic pain in my practice.

Primary care physicians can facilitate their chronic pain patients’ recoveries by underscoring to them the value of psychological counseling. Although such an approach can be seen as overly paternalistic, it is appropriate to tell patients with chronic pain and comorbid depression that they are less likely to experience restoration of their quality of lives if they do not participate in psychological counseling. Clearly, the data support such an assertion (13,14).

Next month’s Pain Perspectives will consider options for psychopharmacological intervention in addressing the depression that is so prevalent in patients experiencing chronic pain. In the meantime, keep in mind that there is little in primary care medicine more rewarding than seeing a patient with chronic pain regain control of his or her life.

References

1) Grenier J, Chomienne MH, Gaboury I, Ritchie P, Hogg W. Collaboration between family physicians and psychologists: what do family physicians know about psychologists' work? Can Fam Physician 2008;54:232-233.

2) Hofmann SG, Asnaani A, Vonk IJ, Sawyer AT, Fang A. The efficacy of cognitive behavioral therapy: a review of meta-analyses. Cognit Ther Res. 2012;36:427—440.

3) Day MA, Thorn BE, Burns JW. The continuing evolution of biopsychosocial interventions for chronic pain. J Cogn Psychother. 2012;26:114—129.

4) Williams AC, Eccleston C, Morley S. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database Syst Rev. 2012;11:CD007407.

5) Andrews M. Mental health parity rule clarifies standards for treatment limits. Kaiser Health News, December 3, 2013. Available at: http://kaiserhealthnews.org/news/michelle-andrews-expert-answers-mental-health-parity/. Accessed on April 3, 2015.

6) Mackenzie CS, Erickson J, Deane FP, Wright M. Changes in attitudes toward seeking mental health services: a 40-year cross-temporal meta-analysis. Clin Psychol Rev. 2014;34:99-106.

7) Kazdin AE, Stolar MJ, Marciano PL. Risk factors for dropping out of treatment among White and Black families. J Fam Psychiatry 1995;9:402—417.

8) Mori L, Panova A, Keo ZS. Perceptions of mental illness and psychotherapy in a sample of Asian, Hispanic, and White American college students. J Psychiatry Psychol Ment Health 2007;1:1-13.

9) Cooper LA, Gonzales JJ, Gallo JJ, et al. The acceptability of treatment for depression among African-American, Hispanic, and white primary care patients. Med Care 2003;41:479-489.

10) Müller N, Schennach R, Riedel M, Möller HJ. Duloxetine in the treatment of major psychiatric and neuropathic disorders. Expert Rev Neurother. 2008;8:527-536.

11) Mohr DC, Vella L, Hart S, Heckman T, Simon G. The effect of telephone-administered psychotherapy on symptoms of depression and attrition: a meta-analysis. Clin Psychol. 2008;15:243-253.

12) Månsson KN, Skagius Ruiz E, Gervind E, Dahlin M, Andersson G. Development and initial evaluation of an Internet-based support system for face-to-face cognitive behavior therapy: a proof of concept study. J Med Internet Res. 2013;15:e280.

13) Bair MJ, Robinson RL, Katon W, Kroenke K. Depression and pain comorbidity: a literature review. Arch Intern Med. 2003;163:2433—2445.

14) Kroenke K, Wu J, Bair MJ, Krebs EE, Damush TM, Tu W. Reciprocal relationship between pain and depression: a 12-month longitudinal analysis in primary care. J Pain 2011;12:964-973.