| One-Minute Clinician

Comorbid Chronic Pain and Depression: Taking a Fresh Approach

If we look at pain and we look at depression, pain is costing us about 600 billion dollars a year.  Depression alone is costing us about 100 billion dollars a year.  The comorbidity of these problems is extremely high--about 50 to 65 percent.  With regard to treating people who are suffering with chronic pain and chronic depression, our success rate is around 9 percent.  Absolutely abysmal.  The heart of the problem is that we’re thinking about these conditions incorrectly.  They’re not diseases unto themselves, but rather symptoms of a brain on fire--a brain that’s inflamed---the consequences of which are depression, sleep disturbances, gastrointestinal problems, such as irritable bowel syndrome, problems with focus and concentration, problems with fatigue. So there’s a wide range of symptoms that result from this chronic inflammation of the central nervous system; pain and depression foremost among them.

So, if we begin to think about these conditions as manifestations and symptoms of neuroinflammatory disease, the next question becomes what is it that creates inflammation? Well, in the brain, inflammation is primarily mediated by neuro-immune cells called the microglia.  And so, if microglia are causing the inflammation of the brain, what causes microglia to become activated? The answer to that is a wide range of things. Hypoxia, such as we see in sleep apnea, problems with ischemia. With ischemia we think about loss of blood supply in terms of strokes, certainly an issue but more commonly in POTS (postural orthostatic tachycardia syndrome).  These people lose blood supply to their brain frequently throughout the day. Other problems include traumas, which come in the form of physical traumas such as concussions, and problems such as psychological traumas.  We know that long-term stress results in degeneration of the central nervous system. There may be toxicity issues such as exposure to heavy metals, or exposure to mold toxins. When we think about pain, we don’t necessarily think about celiac disease. The fact is, fully 15 percent of people with celiac disease will present with only neurologic symptoms and not gastrointestinal symptoms.

So there’s a wide range of things, and if we understand what’s creating the problems in terms of causing the inflammatory factors to be tripped off in the central nervous system that changes our history taking and assessment. We need to be asking questions about their diet.  We need to be asking questions about gastrointestinal function.  We need to be asking questions about sleep, and it’s all coming together in one picture because it’s all one unified physiology.  So we’ve spent way too much time focused on thinking about chronic pain and depression and not enough time thinking about the underlying physiology, which is a neuroinflammatory disease

The keys to successful treatment are many, but the first is history, history, history.  We have to get a very clear understanding of what an individual has gone through and what are the potentially accumulative things that have occurred that have led them to the point of seeing us. You’re going to need to spend a little bit more time with these people.  You’re going to need to spend at least 45 minutes, sitting down and getting an idea of what their sleep looks like, what their diet looks like, any stressors that are going on in their lives. Expanding our history to a more complete review of what’s going on with people is all well within the preview of family physicians.  I’m a family physician originally by training, and I think actually family docs are among the best suited to be able to treat pain in a truly comprehensive manner.

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