Depression plays a significant role in chronic pain—taking just a few steps to get ahead of it can help patients appreciably by giving them more control over their personal situation.

For some people, the stress and depression resulting from chronic pain can become consuming and have the potential to significantly worsen and prolong the pain. Increased pain can, in turn, lead to increased stress and depression, creating a cycle of depression and pain that can be difficult to break.

Chronic Pain is Unique

Chronic pain is generally defined as any pain that continues more than 3 to 6 months. Please note that this discussion is specifically focused on chronic pain that is not due to cancer or other disease process. This type of pain is also termed “chronic non-cancer pain” or chronic benign pain.

Back pain and neck pain can become chronic in a few ways, for example:

  • Some chronic pain may be due to a diagnosable anatomical problem, such as degenerative disc disease or spinal stenosis, that can cause continual pain despite attempts at treatment.
  • Prolonged pain appears to set up a pathway in the nervous system that sends pain signals to the brain, even in the absence of an underlying anatomical problem in the spine. In such cases, the pain is itself the disease.
  • After spine surgery, it is possible for the patient's pain to either continue or to become worse. When this occurs, it is broadly referred to as failed back surgery syndrome.

In any type of chronic back or neck pain, it is essential to be aware of the potential development of depression, as depression can prolong and/or worsen the pain.

Often, health professionals will refer to a patient’s “suffering” which is the pain plus its emotional component (e.g. depression). As such, one can have a great deal of chronic pain with little suffering or minimal pain with great suffering


4 Steps to Proactively Address Depression

Following are several steps to help proactively prevent or manage both the chronic pain and associated depression that may develop:

  1. Early diagnosis of depression associated with pain.
    Many physicians are not necessarily trained to assess for depression during the course of treating pain. Talking to a physician about symptoms of depression, while still in the acute pain phase of pain, can alert a physician to the need to consider treatment of both conditions.

    While one patient may demonstrate a full recovery from the initial episode of pain, a patient who is more prone to or shows signs of depression and stress, or who has a history of clinical depression may be more vulnerable to developing a chronic pain problem that persists beyond the initial acute pain complaint.

    See When Acute Pain Becomes Chronic Pain

    An informed physician can suggest a treatment plan early on that treats the patient’s depression as well as their physical pain, giving the patient the best chance at a positive outcome. It is advisable to talk to a doctor if any of the following common symptoms of depression are experienced:

    It is advisable for patients to talk with their doctors if they experience any of the following common symptoms of depression:

    • A sad or anxious mood
    • Difficulty with falling asleep and/or staying asleep
    • Feeling of hopeless or lack of interest in previously enjoyable activities
    • An increase or decrease in appetite
    • Low energy or a lack of motivation

    Similarly, people should talk with their doctors if they believe they exhibit symptoms characteristic of stress-related back pain, which are similar to those of fibromyalgia:

    • Back pain and/or neck pain
    • Diffuse muscle aches
    • Muscle tender points
    • Sleep disturbance and fatigue

    In many stress-related back pain cases, patients complain of the pain "moving around" or becoming noticeably worse either just before, during, or just after a stressful event or experience.

    Chronic pain can also be exacerbated by things such as physical de-conditioning due to lack of exercise and a person’s thoughts about the pain. An appropriate exercise program and practicing distraction, guided imagery, and other cognitive techniques, are all effective coping techniques that can help prevent the pain from worsening.

  2. Identify stress triggers that can increase chronic pain.
    Identifying stress triggers or emotional triggers that affect the pain is the first step in helping manage pain—at least in part—by avoiding or eliminating specific stress triggers. For example:


    • A person does not plan ahead for appointments causing s/he to be habitually late due to traffic and other unforeseen problems. This “stress” results in increased pain. Developing a behavioral strategy for being early to appointments, and relaxing beforehand once there, can go a long way toward resolving this stress and the pain exacerbation. This is effective time and pain management.
    • A couple develops a pattern of bringing up, and discussing, stressful issues just before bed. The individual with chronic pain gets “stressed,” sleep poorly, and wakes up in increased pain. A simply behavioral prescription of prohibiting these types of discussion in the evening (e.g. the finances), could help avoid this trigger.

    Patients can monitor how their own stress and anxiety affects their back pain by keeping a diary of when their back pain changes and what kinds of stress could be triggering the pain. This exercise can provide and identification of the elements in one's life that affects the pain.

    Recognizing how stress affects pain provides the ability to lessen pain without pain medications some level of empowerment over chronic pain.

  3. Communicate about depression.

    Depression and an emotional reaction to chronic pain are to be expected; they are understandable.

    Many patients do not speak to their physicians about their depression because they believe that once the initial pain problem is resolved, the depression, anxiety, and stress they are feeling will go away. However, secondary losses from a chronic pain problem, such as the loss of the ability to do favorite activities, disrupted family relationships, financial stress, or the loss of a job, can continue to contribute to feelings of hopelessness and depression even beyond the resolution of the pain problem.

    Talking to a physician about feelings of depression will keep the physician better informed and better able to provide appropriate care.

    Depression can affect the frequency and intensity of pain symptoms, and the healing rate. Getting simultaneous back pain and depression treatment will give the patient a better chance of a full recovery.


  4. Seek multi-disciplinary care for pain and depression.

    A multi-disciplinary course of treatment that involves involving both a physician and a mental health professional can often provide the best outcomes.

    With a team approach, both the pain problem and the depression are monitored simultaneously, and both doctors can communicate about how each area affects the other.

    It’s important for physicians to understand that changes in the physical symptoms of pain can also be related to changes in a patient’s mental state.


In addition, it's important to note that some common treatments for pain (e.g. opioid pain medication, activity restriction, bed rest), can actually make depression worse. This worsening depression can then affect the physical presentation of the pain.

If both physical and mental well-being are being monitored closely by medical experts, treatment and medication recommendations, including antidepressants, can be made that take both the physical pain and the emotional health of the patient into account.

Dr. William Deardorff is a clinical health psychologist and specializes in providing psychological services to patients with chronic pain and spinal conditions. He has led a private practice for more than 30 years.