Chronic Pain and Mental Health: A Two-Way Street

Chronic pain is a complex issue affecting different parts of the body, such as the head, back, neck, spine, and joints, and is associated with conditions like migraines, fibromyalgia, and IBS. It’s closely tied to mental health, contributing to problems like anxiety, depression, and sleep issues, which can worsen the pain. There are shared biological mechanisms between mental health conditions and chronic pain that impact pain sensitivity. For instance, depressive symptoms can heighten the perception of pain.

These strategies can involve lifestyle changes, therapy, and medication. Taking an integrated approach is essential to managing chronic pain and its impact on mental well-being. It means addressing both the physical and mental aspects to improve overall outcomes. These strategies can involve lifestyle changes, therapy, and medication.

Chronic Pain’s Impact on Mental Health

Chronic pain can significantly impact mental health; it can disrupt sleep patterns, and raise stress levels, leading to depression. According to the Anxiety and Depression Association of America (ADAA), people with anxiety disorders, particularly generalized anxiety disorder, may experience acute pain as a common symptom ¹.

Chronic pain frequently coexists with mood disorders like anxiety, depression, and other related issues caused by conditions such as fibromyalgia, back problems, migraines, and arthritis. Pain and mental health issues often happen together. Research shows they can worsen each other, creating a challenging cycle ¹.

Chronic Pain and Brain Chemistry

Chronic pain significantly shapes brain chemistry, primarily through neuroplasticity(the brain’s ability to adapt and make structural and functional changes in response to learning, experiences, and challenges). This mechanism, integral to the brain’s ability to adapt to prolonged pain signals, involves alterations in neurotransmitters like serotonin, norepinephrine, glutamate, and dopamine—crucial players in mood regulation ¹⁰.

These alterations impact how nerve connections function, contributing to the complex link between chronic pain and mental health ¹⁰. Living with major chronic pain conditions can profoundly influence mental health, elevating the risk of depression, anxiety, and other mental health disorders ⁴.

Understanding Chronic Pain

Chronic pain impacts about 20% of the global population and 15% to 20% of doctor visits ¹³. It’s not a fleeting warning but a lasting condition affecting the central and peripheral nervous systems, involving structural and functional changes in the brain and body ¹⁵.

The transmission of pain involves a complex process through nerves, neurotransmitters, and the spinal cord, where central sensitization plays a crucial role. Neurotransmitters and substances like glutamate, GABA, nitric oxide, opioids, and endocannabinoids contribute to modulating pain signals, influencing the development and persistence of chronic pain ¹⁵.

Chronic pain induces lasting changes in the corticolimbic system, impacting decision-making, emotion regulation, and memory-related areas. Several regions of the brain, including the somatosensory cortex and amygdala, play roles in processing pain and affecting emotional responses ¹⁵.

Chronic Pain Conditions and Mental Health

Living with chronic pain significantly impacts mental health, leading to conditions such as major depression, anxiety, chronic stress, and substance use disorders. Various chronic pain conditions, including fibromyalgia, arthritis, migraines, and irritable bowel syndrome (IBS), are associated with mental health problems, creating a challenging cycle.

Studies show that depression and anxiety disorders can make a person more sensitive to pain ³. The complex connection between chronic pain and mental health is evident, with depression surging to 30%-45% among those dealing with chronic pain. This bidirectional relationship emphasizes the need for holistic approaches, where positive factors like hope and optimism play a vital role in adapting to persistent pain, serving as protective factors ¹⁴.

Fibromyalgia

Fibromyalgia significantly impacts mental health, leading to heightened sensitivity, sleep disturbances, and cognitive challenges. Chronic fatigue and sleep problems contribute to a cycle of intensifying mental health issues, resulting in higher rates of depression and chronic anxiety ³.

IBS and Rheumatoid Arthritis

Conditions like IBS, marked by abdominal pain and irregular bowel patterns, significantly affect mental health. The enduring pain influences brain chemistry, potentially leading to symptoms of anxiety and depression ¹². Depression is twice as prevalent among Rheumatoid Arthritis (RA) patients compared to the general population, with chronic inflammation exacerbating mental health disorders ⁶.

Headache, Back and Neck Pain

Chronic pain isn’t just physical; it’s a companion to sleep disruption, heightened stress, and, often, depression. Conditions like headaches, neck pain, and back pain amplify the cycle of chronic pain, leading to higher rates of depression and chronic anxiety ⁸. Recognizing the specific impact of these conditions on mental health is crucial for developing tailored strategies.

Researchers identified shared biological mechanisms between mental health disorders and chronic pain, influencing headaches, neck pain, and back pain. During periods of depression, individuals become more sensitive to pain, intensifying the physical experience of discomfort ¹. This heightened sensitivity contributes to the intricate relationship between mental health and various forms of chronic pain.

Headaches, neck pain, and back pain significantly impact mental health, amplifying the cycle of chronic pain and leading to higher rates of depression and chronic anxiety ⁸. Acknowledging the specific impact of these conditions on mental health is crucial for developing tailored strategies.

Lupus

Systemic Lupus Erythematosus (SLE) presents unique challenges in the chronic pain-mental health relationship. Up to 90% of lupus patients experience persistent pain, primarily from inflammation affecting joints and muscles. The unpredictable nature of lupus flares intensifies psychological distress, with depression rates reaching 40% among patients – significantly higher than the general population. Lupus patients often face a complex interplay between pain, fatigue, and cognitive difficulties (known as “lupus fog”), which can exacerbate anxiety and depression. The overlap between lupus and fibromyalgia, occurring in many patients, creates an additional layer of chronic pain management challenges. This combination of symptoms particularly impacts sleep quality and daily functioning, contributing to the cycle of chronic pain and mental health challenges.

Treatment Options

People dealing with chronic pain and associated mental health issues often require a combination of medical and psychological treatments to cope effectively. Treatments may include the use of medication, transcranial magnetic stimulation (TMS), psychotherapy, holistic and lifestyle methods, as well as alternative therapies.

Medications

Psychiatric medications demonstrate notable efficacy in alleviating physical pain associated with several chronic conditions, including arthritis, tension headaches, migraines, low back pain⁷, IBS¹¹, and fibromyalgia ³. They are also helpful due to their mood-improving properties, enabling them to treat pain and mental health conditions ¹¹.

Antidepressants

Antidepressants are believed to reduce pain signals by enhancing neurotransmitters in the spinal cord. However, their effects are not immediate, and it may take several weeks to experience maximum relief. While some users report moderate pain alleviation within a week of starting antidepressant therapy, the precise pain-relieving mechanism is not fully understood ⁷.

If antidepressants don’t provide sufficient relief from physical symptoms, healthcare providers may prescribe medications from other classes in combination with antidepressants ⁷. There are several categories of antidepressants that are effective for pain relief, they include tricyclic antidepressants, SNRIs, and SSRIs.

Tricyclic Antidepressants

Tricyclic antidepressants stand out as the most prevalent type of antidepressant employed in pain management. Some Tricyclic antidepressants include Amitriptyline, Nortriptyline (Pamelor), Doxepin (Silenor), Imipramine (Tofranil), Clomipramine (Anafranil), and Desipramine (Norpramin). The big hurdle with tricyclic antidepressants is the difficulty in combating them with other medication. Caution is advised due to the risk of unintentionally enhancing the levels of tricyclic antidepressants in the bloodstream ⁷.

SNRIs

This antidepressant class has fewer side effects and has gained popularity for chronic pain relief. Serotonin and norepinephrine reuptake inhibitors (SNRIs) such as, venlafaxine (Effexor XR), duloxetine (Cymbalta), milnacipran (Savella), and desvenlafaxine (Pristiq) offer an advantage by addressing depression and anxiety at dosages effective for pain. However, there are side effects such as drowsiness, insomnia, nausea, among others ⁷.

SSRIs

Selective serotonin reuptake inhibitors (SSRIs) such as paroxetine (Paxil) and fluoxetine (Prozac) fall into this category ⁷. While SSRIs may help relieve certain pain types, evidence regarding their efficacy in alleviating nerve pain is less compared to SNRIs and tricyclics.

Antidepressants carry a slight risk of adverse side effects such as increased suicidal thoughts or actions. If experiencing such feelings, seek prompt consultation with a doctor or counselor.

Spravato (esketamine)

Spravato, or esketamine, approved by the FDA for major depressive disorder, is administered as a nasal spray, working on the glutamate system in the brain. Different from traditional antidepressants, it offers a faster improvement in symptoms, making it an option for those unresponsive to standard treatments. Not suitable for everyone, including those with a history of substance misuse or specific health conditions.

Transcranial Magnetic Stimulation (TMS)

TMS is a treatment that uses magnetic pulses to address severe depression and other mood-related issues. It is a safe and noninvasive procedure that helps to reset the brain, leading to an improvement in mood, a reduction in anxiety and depression, and an increase in energy levels.

Transcranial magnetic stimulation (TMS) has been studied for its potential to manage chronic pain and associated mental health conditions ⁵. Although studies are limited, some suggest that TMS may be a promising noninvasive alternative for managing chronic pain, such as lower back pain ⁹. However, more rigorous and standardized research is needed to establish it as a standard treatment option.

Psychological Treatments

Beyond medications, non-pharmacological interventions are crucial. Psychotherapy, such as cognitive-behavioral therapy, addresses psychological distress and other psychosocial factors contributing to chronic pain-induced depression ¹⁰. Psychologists develop personalized treatment plans, helping individuals challenge negative thoughts, make lifestyle adjustments, and manage anxiety or depression related to their condition.

Lifestyle Changes

Lifestyle modifications, including regular exercise, proper nutrition, and sufficient sleep, are integral to holistic symptom management. These changes enhance physical health and positively impact mental well-being, providing a comprehensive approach to managing chronic pain. The American Psychiatric Association (APA) offers the following tips for coping with chronic pain ².

Tips for Coping with Chronic Pain

• Stay active: Despite the pain, maintaining activity is crucial, preventing it from dominating one’s life.
• Know your limits: Acknowledge physical limitations and plan activities accordingly.
• Exercise: Incorporate low-impact exercises like stretching, yoga, walking, or swimming to promote overall health.
• Make social connections: Foster relationships to enhance resilience, reducing depression and anxiety.
• Distract yourself: Engage in enjoyable activities to divert attention during pain flares.
• Don’t lose hope: With appropriate psychological treatments, individuals can learn to manage pain differently.
• Follow prescriptions carefully: Adherence to prescribed medications is essential, and psychologists assist in developing routines for treatment adherence.

Break Free From the Grip of Mental Health Challenges

When you’re in the midst of a condition like chronic pain, depression, or anxiety, finding relief may seem impossible. In reality, there are so many ways to start healing. If you or a loved one is struggling, contact Neuro Wellness Spa to learn more about our in-person or online psychiatry services for psychiatric medication management to help with mental health symptoms as well as chronic pain and alternative treatments like TMS therapy. Your path to a healthier, happier life begins with a simple step. Take that step now – get in touch.

References

1. American Psychiatric Association (2020, November 13). Chronic Pain and Mental Health Often Interconnected. https://www.psychiatry.org/news-room/apa-blogs/chronic-pain-and-mental-health-interconnected

2. American Psychological Association. (2013, December 15). Managing chronic pain: How psychologists can help with pain management. https://www.apa.org/topics/pain/management

3. Arthritis Foundation (n.d.). Arthritis and Mental Health. https://www.arthritis.org/health-wellness/healthy-living/emotional-well-being/anxiety-depression/arthritis-and-mental-health

4. Crofford L. J. (2015). Chronic Pain: Where the Body Meets the Brain. Transactions of the American Clinical and Climatological Association, 126, 167–183.

5. Hamid, P., Malik, B. H., & Hussain, M. L. (2019). Noninvasive Transcranial Magnetic Stimulation (TMS) in Chronic Refractory Pain: A Systematic Review. Cureus, 11(10), e6019. https://doi.org/10.7759/cureus.6019

6. Lwin, M. N., Serhal, L., Holroyd, C., & Edwards, C. J. (2020). Rheumatoid Arthritis: The Impact of Mental Health on Disease: A Narrative Review. Rheumatology and therapy, 7(3), 457–471. https://doi.org/10.1007/s40744-020-00217-4

7. Mayo Clinic (n.d.). Antidepressants: Another weapon against chronic pain. https://www.mayoclinic.org/pain-medications/art-20045647

8. Mental Health America. Early, Equitable, and Trauma Responsive Care for Chronic Pain and Mental Health 2020. https://www.mhanational.org/sites/default/files/Early%2C%20Equitable%20and%20Trauma%20Responsive%20Care%20for%20Chronic%20Pain%20and%20Mental%20Health.pdf

9. Olechowski, C., Gener, M., Aiyer, R., & Mischel, N. (2023). Transcranial magnetic stimulation for treating chronic low back pain: a narrative review. Frontiers in pain research (Lausanne, Switzerland), 4, 1092158. https://doi.org/10.3389/fpain.2023.1092158

10. Sheng, J., Liu, S., Wang, Y., Cui, R., & Zhang, X. (2017). The Link between Depression and Chronic Pain: Neural Mechanisms in the Brain. Neural plasticity, 2017, 9724371. https://doi.org/10.1155/2017/9724371

11. Sinagra, E., Romano, C., & Cottone, M. (2012). Psychopharmacological treatment and psychological interventions in irritable bowel syndrome. Gastroenterology research and practice, 2012, 486067. https://doi.org/10.1155/2012/486067

12. Staudacher, H. M., Black, C. J., Teasdale, S. B., Mikocka-Walus, A., & Keefer, L. (2023). Irritable bowel syndrome and mental health comorbidity – approach to multidisciplinary management. Nature reviews. Gastroenterology & hepatology, 20(9), 582–596. https://doi.org/10.1038/s41575-023-00794-z

13. Treede, R. D., Rief, W., Barke, A., Aziz, Q., Bennett, M. I., Benoliel, R., Cohen, M., Evers, S., Finnerup, N. B., First, M. B., Giamberardino, M. A., Kaasa, S., Kosek, E., Lavand’homme, P., Nicholas, M., Perrot, S., Scholz, J., Schug, S., Smith, B. H., Svensson, P., … Wang, S. J. (2015). A classification of chronic pain for ICD-11. Pain, 156(6), 1003–1007. https://doi.org/10.1097/j.pain.0000000000000160

14. Vadivelu, N., Kai, A. M., Kodumudi, G., Babayan, K., Fontes, M., & Burg, M. M. (2017). Pain and Psychology Reciprocal Relationship. Ochsner journal, 17(2), 173–180.

15. Yang, S., & Chang, M. C. (2019). Chronic Pain: Structural and Functional Changes in Brain Structures and Associated Negative Affective States. International journal of molecular sciences, 20(13), 3130. https://doi.org/10.3390/ijms20133130