Recently, with the flurry of sports interest generated by the Olympics, The New York Times ran an article about how many injured athletes suffer from depression. The full focus of their lives which revolved around their physical ability to perform was suddenly taken away from them. In the place of their former physical prowess they find pain, incapacitation, and depression. The Times went on about how little acknowledged this serious problem is. Only 2% of sports injury facilities have psychological treatment available for the athletes.
The Times may have been surprised but I’m sure it comes as no surprise to any of you who have dealt with intractable pain. Chronic pain and depression go hand in hand. The questions arise of why is this so and what can be done about it.

Take a look first at what depression is. A simple dictionary definition is that depression is a mood or affect that involves subjective feelings, thoughts, fantasies or wishes. A clinician will look for specific symptoms. You need to have quite a few of these to be considered clinically depressed. And keep in mind that there are many degrees of depression. Here are the symptoms:

1. feeling sad most of the day, nearly every day
2. insomnia or hypersomnia (all you want to do is sleep)
3. low energy or chronic fatigue
4. increase or decrease in appetite nearly every day
5. decreased effectiveness or productivity
6. decreased attention, concentration or ability to think clearly
7. social withdrawal, irritability
8. loss of interest in or enjoyment of sex
9. restriction of involvement in activities that were previously pleasurable
10. feeling slowed down
11. less talkative than usual
12. pessimistic attitude toward the future (hopelessness) or brooding about the past
13. open tearfulness or crying
14. recurrent thoughts of death or wanting to end your life.

You may read this list and think, "Wow, I must be depressed." Or you may recognize many of these symptoms in yourself but not think you are depressed. There is a tremendous overlap between the symptoms of depression and the symptoms that accompany chronic pain or chronic illness. And, yes, many times it is depression but you are chalking it up to pain.

One theory of depression that I like because it explains why pain and depression so often go together suggests that depression is part of a continuum. At one end is stress where we do the best we can to handle the demands that life throws at us. As these demands increase we become increasingly overwhelmed leading to a state of feeling anxious all the time. Anxiety is fear without a source. You feel like you are afraid but don’t know what you’re afraid of. As stressors become increasingly unpredictable and uncontrollable, you begin to feel helpless. There seems no way to cope with what is happening. Helplessness is a key element in the development of depression.

Often we don’t think of it this way, but pain is a stressor. Pain is your body shouting a demand at you. Usually there isn’t much you can do about that demand. Not only is pain a stressor, but the fact that pain requires almost every thing in your life to be done differently is also a major stressor. In addition, all the other normal stressors don’t go away just because you are in pain and incapacitated. They’re still there and may take 10 times as long to do or may be impossible now. It is very stressful to not recognize who you have become in your present condition. With some chronic pain or illness it is actually normal to feel helpless. Unfortunately, feeling hopeless often comes with prolonged helplessness.

Once hopelessness begins to pervade your thoughts, it seems to change the chemistry of the brain. Not only do you not feel joy or pleasure, you lose the ability to do so because of decreased serotonin, a neurotransmitter. Another factor that links these three factors - depression, pain and decreased serotonin levels - is poor sleep. Chronic lack of sleep has major mental and physical consequences.

There are other causes for depression and other theories. For instance, some people seem to inherit a genetic predisposition toward becoming depressed. Others may become predisposed to depression through developmental events such as losing a significant person early in life or being faced repeatedly with being made to feel helpless. Of course, major losses at any time in life can precipitate grief and serious depression.

Pain sufferers may have all of these things working against them or just some. Even without any predisposition, pain usually brings several losses: loss of physical capacity, loss of sense of self, perhaps loss of income, lifestyle, etc. Each individual can do their own inventory, and, as you do, try to assess which losses are permanent or temporary, and how much change we must adapt to.

Here we get to the question of what to do about depression resulting from pain. With severe depression, the new generation of anti-depressant medication is pretty effective. These meds can take the dark gloomy edge off most depression and give you back some energy and motivation. Then you need to take over the job for yourself, as those with less severe depression must do. Here are some tips:

1. Begin to clarify boundaries between yourself and the people you need.
Pain often bring a loss of independence. You may need far more assistance from those around them. This changes your view of yourself and your view of those who are helping. One patient of mine said she began to see anyone entering the room as a pair of hands who could perform some task she couldn’t. Of course, the helpers may come to resent and avoid this kind of desperate need. Boundaries can be made clear through improved communication. Learn to express your needs in a non emotional way, and encourage others to express theirs. Be careful not to evoke pity or guilt in your expression. Your capacity is different at this moment but you still have needs. Express them clearly.

2. Look for ways you can be an active participant in your own gratification.
Even with pain and a changed capacity, you still have things you can do. You’re still alive and conscious. Anything you do that will give you a sense of accomplishment will help to jump start the pleasure centers of your brain. Do not compare your achievements with what you may have been able to do at some other time. If you must compare, judge your feat next to doing nothing. Each positive action is a step out of depression. If you have been avoiding social interaction, a simple phone call to a friend can be a big achievement.

3. Generate alternative views to the negative ones you keep dwelling on.
This is not the same as saying think positively. Depressed thinking is negative and pessimistic. Not only do bad things happen, everything is bad, and its always bad, and it always happens to me. Coming up with alternatives means first recognizing your negative depressing thoughts, realizing that they are not cut in stone, and looking for alternatives. For instance, the following thought won’t make you feel very good: "Every time I try to do something for myself, this blasted pain stops me in my tracks and destroys my life." This thought makes the pain even worse and adds to your depression. Is it true? Every time? Your whole life destroyed? Try this instead: "Well, at least, I did try to do something for myself, and it did increase my pain. Maybe I did too much. No point beating myself up any more than the pain already is." Changing thinking patterns takes consistent attention and effort because you’re dealing with habits of thinking plus altered brain chemistry. This is the realm of cognitive therapy and a therapist with training in this can help a great deal.

4. Pay attention to your self and your situation on a moment to moment basis.
One of the few things of which we can be certain is that things will change. Your pain, your physical capacity, your thoughts, your emotions, your loved ones, your resources - all of these keep changing. Usually we act and think as if this were not the case. We create expectations based on some old situation or idea and then become frustrated, angry and depressed when events don’t match our expectations. You can let go of expectations by keeping track of your current condition and accepting it as what you’ve got to work with. Also with any chronic condition, pacing is important. Pacing requires accurate assessment of your mental, physical and emotional capacities. Even the capacity of your support system needs to be monitored. Training in mindfulness meditation is the best way I know to accomplish this one.

5. Develop your stress management skills.
Remember the theory that depression results from stress that has gotten out of hand. You can learn to manage your stress and never reach the overwhelmed or helpless levels. Good stress management has three strategies of attack.

First, learn to counter the mental and physical effects of stress by developing the ability to relax deeply. There are many techniques to achieve this and you should master several of them. I dealt with relaxation techniques at an earlier chat that should be available in the archives. Not only is relaxation the primary self-help technique for managing stress, it is fundamental in psychologically-based pain management. Remove tension and you reduce pain.

Second, learn to deal more effectively with your stressors. Everyone has a different set of stressful events, but, in that we are all human, there are many common elements. Most of our stress involves other people and one way to reduce people stress is to examine your patterns of communication and work to improve them. Learning how to better express you needs, emotions and thoughts without putting anyone on the defensive is a good start. Half of communication is learning to be a better listener. Two skills here are to stop yourself from jumping to conclusions, and ask for clarification when your understanding is incomplete. Some other general stress skills are learning to manage your time, pacing your resources (which means learning when to say "no"), and taking control of your finances. We could (and may) spend a whole chat on each of these.

The third attack on stress is to catch stress at its true source - your own mind. There is nothing that is inherently stressful. Our interpretation and appraisal of events makes them something we end up wearing in our body. The way we look at something and the importance we impart to it give it the power to make us sick with stress. Start by making yourself more aware of the thoughts you are having in stressful situations. You’ll probably have to start after the situation is over and then think back. As you begin to locate the specific thoughts that always raise your stress level, ask yourself, "Is this the only interpretation?" and try to generate other ways of looking at it. Notice how other perspectives change your emotional reactions. It takes practice, but gradually you recognize that you always have a choice in how you look at things, and that choice will change your experience. One great technique for practicing this is mindfulness meditation. The increased sense of control from this goes a long way toward fending off depression.

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