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There are many challenging issues presented to a clinician when dealing with persons who have a primary report of chronic pain but who also present with depression and other comorbidities (see Table 17-1; Box 17-1). In this chapter we present an overview of epidemiology of pain and depression, discuss the biological basis for depression and pain, review commonly used assessment measures for depression in persons with chronic pain, and present treatment strategies for depression and chronic pain, including psychopharmacology and psychotherapy. We also include a brief discussion of somatization and suicidal ideation associated with pain and depression. Finally, we discuss future issues related to this topic.
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BOX 17-1 CASE HISTORY
Mr. Jones is a 49-year-old disabled construction worker with a 4-year history of chronic back and left lower extremity pain. He was involved in an incident at work when he fell from a ladder and injured his back. He was seen by a number of providers and, despite receiving nerve blocks, physical therapy and many medications, still reported significant back and leg pain. He had evidence of a herniated disk in his lumbar spine and had back surgery. The surgery was unsuccessful and his symptoms worsened following the surgery. Over time his back and leg pain increased and he was prescribed oxycodone by his primary care physician. He became less inclined to leave his house and spent most of his days sitting on the couch watching television. He often became tearful when discussing his situation with others and was increasingly irritable with those around him. He preferred being by himself and became more socially isolated. He was angry that his coworkers no longer contacted him and he felt abandoned by his employer and friends. He had recurrent thoughts that life would not be worth living if he had to continue suffering in pain.
Eventually he was referred to a psychiatrist for an evaluation after reporting to his wife that he no longer wanted to live because of his pain. During the initial interview he described his back pain as very intense (8 to 10 on a 0–10 scale) and stated that the pain was burning, aching, pulling and sharp in nature and became much worse with any activity such as standing, walking, lifting, bending, or sitting for long periods. He ...