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June 1, 2010

Pain, anxiety, and depression

Everyone experiences pain at some point, but in people with depression or anxiety, pain can become particularly intense and hard to treat.

The overlap of anxiety, depression, and pain is particularly evident in chronic and sometimes disabling pain syndromes such as fibromyalgia, irritable bowel syndrome, low back pain, headaches, and nerve pain. For example, about two-thirds of patients with irritable bowel syndrome who are referred for follow-up care have symptoms of psychological distress, most often anxiety.

Researchers once thought the reciprocal relationship between pain, anxiety, and depression resulted mainly from psychological rather than biological factors. Chronic pain is depressing, and likewise major depression may feel physically painful. But as researchers have learned more about how the brain works, and how the nervous system interacts with other parts of the body, they have discovered that pain shares some biological mechanisms with anxiety and depression.

Shared anatomy contributes to some of this interplay. The part of the brain that interprets sensations such as touch interacts with the areas that regulate emotions and the stress response to generate the mental and physical experience of pain. These same regions also contribute to anxiety and depression.

In addition, two neurotransmitters — serotonin and norepinephrine — contribute to pain signaling in the brain and nervous system. They also are implicated in both anxiety and depression.

Treatment is challenging when pain overlaps with anxiety or depression. Focus on pain can mask both the clinician’s and patient’s awareness that a psychiatric disorder is also present. Even when both types of problems are correctly diagnosed, they can be difficult to treat. A review identified a number of treatment options available when pain occurs in conjunction with anxiety or depression.

Double-duty psychotherapy

Various psychotherapies can be used on their own to treat pain in patients with depression or anxiety, or as adjuncts to drug treatment.

Cognitive behavioral therapy. Cognitive behavioral therapy (CBT) is not only an established treatment for anxiety and depression, it is also the best studied form of psychotherapy for treating pain. Therapists use CBT to help patients learn coping skills so that they can manage, rather than be victimized by, their pain.

Relaxation training. Various techniques can help people to relax and reduce the stress response, which tends to exacerbate pain as well as symptoms of anxiety and depression. Techniques include progressive muscle relaxation, yoga, and mindfulness training.

Hypnosis. During this therapy, a clinician helps a patient achieve a trance-like state and then provides positive suggestions — for instance, that pain will improve.

Exercise. There’s an abundance of research that regular physical activity boosts mood and alleviates anxiety, but less evidence about its impact on pain.

Double-duty medications

Some psychiatric medications also work as pain relievers, thereby alleviating two problems at once.

Antidepressants. A variety of antidepressants are prescribed for both anxiety and depression. Some of these also help alleviate nerve pain. The research most strongly supports the use of serotonin and norepinephrine reuptake inhibitors (SNRIs) or tricyclic antidepressants (TCAs) as double-duty drugs that can treat both psychiatric disorders and pain. TCAs are usually prescribed at a lower dose than when they are used to treat depression.

Mood stabilizers. These medications exert their effects by constraining aberrant electrical activity and hyper-responsiveness in the brain, which contributes to seizures. Because chronic pain in particular involves nerve hypersensitivity, some of these medications may provide relief.

Combining psychotherapy and drugs

Patients with anxiety or depression sometimes find that combining psychotherapy with medication offers the most complete relief.

June 2010 update


Understanding Depression

Sadness touches all of our lives at different times, but depression can have enormous depth and staying power. It can leave you feeling continuously burdened and can sap the joy out of once pleasurable activities. This report provides in-depth information on treatment options, including medication, therapy, exercise, and new approaches. You’ll also learn about the biology of depression and bipolar disorder. Learn more »