Pain and Depression: Looking Beyond the Disease

I think the essence of how to move forward in treating these comorbid conditions is to become more specific in how we define depression. It’s a word that is general, has a lot of different meanings, and when you think about it from a clinical perspective, there really are many different types of disorders that might fall under that umbrella. So we really want to try and get to the specific type of depression so that then we can design a tailored treatment plan. When healthcare practitioners encounter someone who uses the word depression, or who appears to be emotionally distressed, one of the things to think about is that this is a temperamentally vulnerable patient who is being stressed in some way. For example, the person that we typically think of as neurotic is easily overwhelmed in situations that may be provocative in a distressing sort of way, being told you have an illness; they don’t necessarily react in a predictable way. So they become somewhat catastrophic, somewhat unpredictable, and the healthcare practitioner finds them hard to interact with. Another temperamental trait is the introversion/extroversion spectrum. Introverts tend to worry, they tend to be punishment averse, they tend to think about the future and the past, and they’re slower to engage with situations. They need time and detail to process something. Whereas the extrovert is more likely to live in the moment, more likely to engage with an unfamiliar setting more easily, more likely to be driven by the promise of rewards rather than the threat of a bad outcome.

Catastrophizing really is an example of a coping style, where patients feel helpless and overwhelmed, and as if they have no opportunity to make a difference and so will present in a way that feels as if they’re spiraling out of control. It can be very stressful for a healthcare practitioner because it can feel as if there’s nothing you can do to calm them down and to keep them on track. However, there’s a lot of evidence that shows that working with patients who are catastrophizers in very simple ways will greatly reduce their tendency to do that. So, providing them with education, talking to them about their illness and how you’re going to manage it, trying to get them to think about improved support systems, will all be effective and help to reduce that going forward. Grief too is an everyday experience for people. We’ve all suffered losses of one kind or another, and every healthcare practitioner is going to have to think about how the person who has a chronic illness is grieving the loss of their health and all that comes from losing that. So they don’t feel as well, they don’t do the same things that they used to do when they were younger, everything becomes a bit more of a chore. But yet it’s a meaningful event for them, and as long as something is meaningful, there’s the opportunity to change someone’s interpretation of it. Working with grief really is about helping people to see that it’s really not a disaster, it’s not a failure, that there’s still an opportunity to have a satisfying life and to experience some type of good going forward. The primary care physician, or any healthcare practitioner, should be thinking about themselves more as a coach than a dictator. They cannot make the patient do things. They can only try to present information in such a way that the patient recognizes that it would be worth making a change. And then they have to help the patient make that change and feel empowered to do so. So it’s about listening to patients, and asking if they couldn’t see a better way, a better outcome for themselves, and then asking them to just be willing to try things that can be refined over time.