Depression may be diagnosed if an individual experiences extreme sadness or despair that lasts for more than several days. Continuous, severe pain from degenerative disc disease and depression are closely linked in two ways:
- Severe pain from lumbar degenerative disc disease may understandably lead to depression
- Psychological distress, such as depression, is the second most significant risk factor for disability,1 and may lead to pain or worsen existing pain
Close to half of all patients whose pain was severe enough to warrant spinal surgery also have depression, and the depression usually persists after surgery as well.2 When both chronic pain and depression are present, it is essential to treat both the depression and the pain rather than just one or the other, as they are compounding conditions.
Antidepressant medications also seem to have an anti-pain quality.3 Specific classes of antidepressants used for chronic pain include:
- Tricyclic antidepressants (TCAs), such as imipramine (Tofranil)
- Serotonin and norepinephrine reuptake inhibitors (SNRIs), such as duloxetine (Cymbalta)
- Atypical antidepressants, such as bupropion (Wellbutrin)
These medications work by targeting and lowering the central sensitization of chronic lower back pain.4 One pronounced side effect of antidepressants is an initial "hangover" effect (headaches, dizziness, or grogginess), but the effect tends to recede over time.
These medications may be used to treat only pain, or both pain and depression. In low doses, antidepressants may have a pain-relieving effect without altering the mood. In higher doses, antidepressants may help treat pain and depression.
Active Physical Therapy and Exercise
Engaging in an exercise routine elevates the heart rate and may alleviate depression as well as chronic low back pain. Active exercise also releases endorphins, the body’s natural pain-relieving and “feel good” chemical, which helps with mood and pain reduction. Physical therapy is superior to exercises performed at home. The success of completing an exercise directed by a physical therapist, physiatrist, or other qualified health professional tends to reduce fear and provide confidence, and when correctly done an exercise program may significantly reduce pain.
Psychological therapy is usually a core component of treatment for depression. Therapeutic approaches often have a neuroscientific or clinical basis. Examples include cognitive behavioral therapy, which may help treat the 90% of low back pain cases that do not have a clearly identifiable cause,5 and biofeedback, which may train the mind to influence the level of pain. This form of treatment can be individualized, altering the patient’s experience of pain using modifiable factors such as the coping response or the environmental triggers.
With depression and chronic pain, sleep problems may complicate matters and make it more difficult for the patient to heal. If patients are not sleeping regularly, it makes it much more difficult to cope with the stress that chronic pain creates, which in turn may lead to more depression.
A number of older-generation antidepressants (such as amitriptyline, nortriptyline, or imipramine) are used to treat sleep disorders and chronic pain. These drugs are usually:
- Well tolerated when used at night
- Prescribed in doses that are a fraction of the dose for treating depression
- Not addictive
The drugs are designed to restore sleep without changing the sleep cycle.
Other antidepressant medications may also be prescribed to help with sleep. For example, trazodone is commonly prescribed to help with sleep as it does not disturb the quality of sleep, is not considered addictive, and may help with mood and energy, as well as sleep.
Cannabis is a treatment option for chronic pain, and cannabis happens to have properties that improve disturbed sleep. The use of this drug as a medical treatment for sleep disorders6 and for chronic pain has been proven beneficial, but frequent use may develop drug tolerance and lead to increased difficulty falling and staying asleep.7-9
Some studies have shown that higher doses of medical cannabis over several years may have the added benefit of helping to stop or reduce opioid use.10,11 Discontinuation of opioid use may alleviate sleep issues and depression because opioids tend to exacerbate depression12 and sleep apnea or sleep-related breathing disorders. 13