The Mirror Has 2 Faces

Author: Michael R. Clark

The association between chronic pain and depression is well accepted but remains poorly understood. In the general population, the prevalence of depression is approximately 6% for those without chronic pain, compared to 16% of those with chronic pain. These rates increase significantly in clinical samples and, using rigorous psychiatric diagnostic criteria, reach approximately a third to one-half of patients seeking care for chronic pain. Patients with chronic pain who also complain of depression experience greater pain intensity, use more passive coping skills, feel their lives are more out of control, report greater interference in activities due to pain, exhibit more pain related behaviors, have poorer outcomes from surgery, utilize more healthcare services, and retire from work earlier.

On its face, patients with chronic pain would certainly be depressed. The argument makes intuitive, if not common, sense. Over time, the interactions between chronic pain and depression are supported by evidence of shared neurobiology and treatments for one condition often improving the other. Somatic symptoms occur in the majority of patients with depression, and individuals with documented affective (mood) disorders are at increased risk for developing chronic pain syndromes over a decade into the future.

As we delve deeper into the phenomenology of patients' experiences, we begin to see differences that distinguish them from one another. These variations play important roles in formulating an individual patient's case with direct ramifications for their treatment. In this article, an approach to patients will be illustrated using cases that appear identical on first presentation but evolve with closer inspection such that unique plans of care are required.

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