PA_MaryAnne: Good evening everyone and welcome to our Online Chat with Brenda Murdough MSN, RN-C, Military/Veterans Initiative Coordinator, American Pain Foundation. We’re glad you could join us! The topic for this evening will be "Pain and Depression: It’s Not All in Your Head." Ms. Murdough will explore the relationship between chronic pain and depression this evening.

Brenda currently serves as the American Pain Foundation Coordinator of the Military/Veterans Initiative where she advocates for the pain management needs of veterans, military and their caregivers. In this position she provides information, education, resources and support to members of the military and veterans’ community that are affected by pain, doing outreach and collaboration with other organizations, and developing and supervising staff to assist with this work.

Brenda is also a pain management nurse specialist at the Cheshire Medical Center in Keene, N.H., where her duties include all aspects of patient care in the peri-anesthesia/pain management care setting including assessment, intervention, education and support of patients and families regarding Pain management, and peri-anesthesia procedures.

A member of the American Society for Pain Management Nursing, Brenda earned her nursing diploma from the Albert Einstein School of Nursing in Philadelphia, Pa., a Bachelor of Science, Management degree from Keene State College in Keene, N.H. and a Master of Science, Nursing Education degree from Rivier College in Nashua, N.H.
Ms. Murdough will be giving a short presentation followed by a question and answer period. Please remember that this is a protocol chat. In order to give everyone a turn, anyone with a question or a comment will just type a "?" for question or a "!" for a comment and wait to be called upon. One of the PA’s (PainAid chat moderator) will then call on each person in turn. When you complete your questions, type either /ga (for go ahead) or /end to indicate that you are finished with your question and our speaker will respond and conclude in kind. The PainAid moderator will then call upon the next person for their question or comment. Participants are asked to ask one question at a time to allow others an opportunity. We also ask that you have your question prepared in advance so that when we call on you, you will be prepared to post your question.

The PainAid staff will periodically list the order for upcoming questions so that participants can see where they are in line. These procedures help us to answer as many questions as possible during our allotted time. Now, I’d like to hand over the chat to Brenda for her presentation! GA, Brenda.


BMurdough: Hi everyone and thanks for joining me for a discussion about pain and depression and how the two diagnoses are interrelated. As many of you already know, pain and depression can many times go hand-in-hand almost joined like Siamese twins. I’ll talk a bit about what depression is and isn’t.

Also, I’m sure many of you have heard the expression, “it’s all in your head.” Well actually, depression and pain both have to do with chemistry in your brain - sometimes creating a vicious cycle - so we can talk about what part actually is in your head.

Depression can also be affected by psychosocial factors like stress, family relationships, friends, and community support - just as pain can be affected by these.

We’ll talk about how to recognize signs and symptoms of depression, some options for treatment of pain and depression and a few tips that might be helpful in decreasing depressive symptoms associated with chronic pain. And then we’ll have some questions but, please remember, I cannot give individual medical advice or treatment plans as part of this discussion.

So how do we know if we have depression?

I’m guessing that some of you out there who have experienced what is often called “the pit” or “black hole” that is Depression, can recognize it. But many times it is a family member or caregiver that notices something is different; and as many as 50 % of those who have depression do not recognize it.

Veterans responding to the American Pain Foundation’s Online Veterans Survey have depression with chronic pain almost 95 % of the time.

Caregivers or family members will often use these phrases to describe Depression:

“They don’t have any energy,” “My mom used to be so active - she loved to walk outside and now she sleeps,” “I try to talk to him, but he isn’t paying any attention,” “She seems irritable, sad - just wants to be left alone.” Maybe you’ve heard these statements or thought them yourself.

Let’s define what depression is -

It may be called Major Depressive Disorder or Clinical Depression or just plain Depression and it is a serious, but treatable illness that requires professional diagnosis and treatment. It is also very common - as many as 40-60% of persons with chronic pain also have Depression.

Now there are many forms of Depression - Seasonal Affective Disorder, Post- Partum Depression, Mood disorders, Anxiety Disorders and others. And there are degrees of depression from mild to severe. Like pain, Depression is experienced individually, and may be different in each person. We’ve all had the “blues” and days when we just didn’t feel like getting out of bed. And, of course there are normal periods of sadness or grief after a loss or death, change in health or family situation, or other stressful event. These feelings are generally short-lived and most times self-resolving.

Matt Bair MD, MS describes pain and depression as a “Reciprocal relationship” (APF Pain Community News, Winter 2008, pg.3.) Research has shown that persons who suffer from depression often develop chronic pain and persons who suffer with chronic pain often develop depression

Why is the relationship so strong? This is the part that is all in your head or better put, all in your brain.

Research shows that how individuals experience pain, and emotion or depression are both located in the same area of the brain and are both influenced by chemicals in the brain - serotonin, norepinephrine and dopamine. When pain is increased or decreased, depression can be increased or decreased as well. Treating both conditions at the same time can sometime be the most effective way to decrease pain and depressive symptoms and improve function and quality of life.

This is why many time Providers will prescribe anti-depressants to help in the management of pain and its related symptoms. It is also why pain patients think that they are being told “it’s all in your head,” or that the Provider doesn’t believe they really have pain - they’re just depressed right now. But really, the combination of anti-depressants with other medications and other options for pain treatment may be very helpful for many individuals who have chronic pain.

So how do we recognize depression either in our self or a loved one who is experiencing chronic pain? Well, that’s not always easy, but here are a few signs and symptoms to look for:

Difficulty sleeping, change in mood with increases in sadness, irritability or anxiety and worry, problems at work or school, loss of interest in activities that were once enjoyable including family relationships, and decreased self esteem .

Also, changes in appetite, energy level, and ability to concentrate, and decreased participation in social activities may be present. Loss of hope, anger, and inability to make decisions can also be present.

When depression is more severe, symptoms may include isolation, substance abuse, immobility and indecision to the point of not being able to function and thoughts of suicide. This can be a medical emergency and requires professional intervention to treat appropriately and effectively.

We know that depression, like pain is often undiagnosed, untreated and under treated and the consequences contribute to decreased ability to function and increased suffering, and affect the individual and their family and caregivers, as well.

So what are some treatment options for depression?

Similar to pain, treatment for Depression is often a multidisciplined approach that works best to improve function and decrease symptoms of depression.

First, a complete evaluation should be performed by a trained professional who you are comfortable with, to evaluate Depression - a thorough history and physical exam, and there are several questionnaires that are used to measure depression and pain, together. Then a plan of care can be discussed and agreed upon with the individual and the provider.

You might find it helpful to document your symptoms in a diary similar to one you might use for pain - paying attention to how your feelings or your mood have impacted your daily activities with special attention to any of the symptoms we talked about before.

The Target Pain Notebook and other resources can be downloaded from the APF website at http://www.painfoundation.org/page.asp?file=Publications/Index.htm

Treatment options might include Counseling either individually or family, Behavioral Therapy, Relaxation Techniques and Stress Reduction, Medications, Bio- feedback, Meditation, Physical Therapy with stretching and massage.

And we hear it all the time - Exercise.

Even a small amount of physical activity such as walking, aquatic exercise if you have joint pain, gentle stretching and strengthening for myofascial pain or fibromyalgia, or other activity can be helpful to keep the chemistry in your brain in balance and help decrease depressive symptoms and also decrease pain.

We all have days when we feel “down” or “blue.” Here are a few tips that might help you turn a bad day into a better one. These are not meant to be treatment options for Depression, which again, requires professional collaboration and a plan of care agreed upon by the individual and the provider. But it might help you turn your day around.

1. Think positively and surround yourself with others who think this way.

2. Be kind to yourself and set small, attainable goals.

3. Get plenty of sleep.

4. Eat a balanced diet with lots of fruits, veggies, whole grains and lean protein.

5. Relax with soothing music, meditation, scented candles, slow deep breathing or outside in a quiet setting.

6. Talk things out with a friend or family member so small things don’t become big things.

7. And, did I mention Exercise? – Yes, exercise - even small increases in activity can be helpful.

8. Remember, it’s ok to cry.

9. And it’s equally as important to laugh - so look for the humor and make time to have fun.

For additional information, education, support and resources to manage pain, be sure to visit our website at www.painfoundation.org.

I hope this has been informative and now I’ll turn it over to our moderators for the question and answer period.

JudiBFL: The MMPI – How much credibility does that test really carry?

BMurdough: The MMPI is an inventory or questionnaire used to help determine personality traits. As far as determining depression, we need to keep in mind that it’s only one tool and one piece of information. A complete history and physical exam need to be part of any determination regarding depression.

SpiderMeema: I am living proof that controlled pain can change everything. For more than 8 years, I suffered, having procedure after procedure done. I tried it all – hypnotherapy, PT, acupuncture, changed my diet…on and on… Finally, after 26, yeah count ‘em, 26 doctors, I found one that prescribed a regimen of opioids. It took some tweaking, and I no longer have anxiety attacks, no longer require antidepressants. I’d have to say 75% of the pain is under control for me now. I look at journals prior to adequate pain control and I don’t recognize that person. I feel so much better now.

BMurdough: What a great story to share about how finding the right provider can be so important. Thank you.

Jane28: Have you ever heard of severe urinary retention issues when using either pain meds and/or antidepressants. And, if so, what can one do about it or get more info on it?

BMurdough: I have heard that some individuals can suffer from side effects like urinary retention. I think that this is a discussion that needs to be addressed with your prescriber. There may be other options that work without side effects. Just like pain medications, not everyone does well with the same medications. As far as specific interventions, I really can’t recommend. Thanks for the question.

JudiBFL: Is depression with chronic pain a lifelong problem and/or can it be cured?

BMurdough: Well, it depends upon what you mean by cure. I believe the goals of any treatment plan for pain and depression are to decrease symptoms and improve quality of life.

JudiBFL: Does it require ongoing counseling meds?

BMurdough: Not necessarily – when you reach the goals that you and your provider have set and you’re satisfied with your progress – either from the standpoint of decreased symptoms or improved qualify of life, then changes can be made to the treatment plan. But, certainly this is a collaborative effort with you and your provider.

MsDenisee: I have RSD and pain and depression go hand in hand for me. And now I have seizures. It doesn’t seem like much research is going on for this disease. What do you think?

BMurdough: I agree that we need more research into the causes and certainly treatment options for RSD. It is definitely one of the more difficult pain conditions to diagnose and treat. Try checking out the National Institute of Health for Research or the National RSD Association.

Mquacken: Has anyone ever had the following symptoms: not being able to express yourself, not understanding what someone wants you to do, not being able to choose what to wear, or not being able to answer the Alzheimer’s questions the doctor asked?

BMurdough: I can’t speak for everyone, but the symptoms you are describing should certainly be discussed with your provider. Also, you might want to keep a diary like I suggested to document how often this is happening and take it with you to your next appointment so that you can talk with them about this.

Gootes: I seem to cycle. At times I’m good for months and then, wham, depression will hit me again. I recognize that at times it’s “situational” circumstances and these are the times that I prefer not to being medication again – in hopes that whatever the situation is will resolve itself or I’ll work through it the best way I know how. Does this seem reasonable? My last doctor wanted to medicate me at every turn, every chance due to history…

BMurdough: I think that what you’re describing often happens – the cycling part and doing well for a period of time and then not. I think that if you feel that you’re managing ok and the symptoms are mild, short-lived and resolve within a few days or a week – discuss it with your provider – but also share the fact that you don’t feel that you need medication at this time. The plan of care should be agreed upon by both of you and there may be some additional options they might suggest.

JudiBFL: My RSD has developed into Autonomic dysfunction, peripheral neuropathies and dysautonomia. Sometimes, it takes a village of doctors, but if you can find someone who specializes in these areas I think you will find help. Check Dysautonomia Foundation – seizures and many other anomalies from RSD may appear there.

Dino6543: I have constant joint pain and wish that I could find something for pain besides the morphine that the VA has put me on. Any suggestions? I have just been told that I have lupus.

BMurdough: While I can’t give personal medical advice, I can suggest that you take a look at APF’s Treatment Options located on our website under Publications at www.painfoundation.org and discuss this with your provider. Lupus, like other chronic pain conditions, can often require a multi-modal approach to pain management to really improve quality of life and decrease pain. Again, please talk to your provider about this. Also, maybe use our Target Pain Notebook to bring with you to your next appointment so that you have a clear documentation of pain and how it is impacting your daily life. Again, this can be found at the APF website.

Jane28: I am looking for a good on-line support group for chronic back pain without depression. Do you have any suggestions?

Gootes: You could join us on the Discussion board here at PainAid. The link is on the APF homepage.

BMurdough: How about PainAid. You’re already signed up, so log on and join in. Thanks, gootes.

Gootes: PainAid is an awesome place to ask and get answers to your questions. We love it here.

Jane28: Thanks! I’ll certainly log on.

Dino6543: Is lupus hereditary? My mother had lupus and it attacker her kidneys

BMurdough: It does run in families. As for whether there is a genetic link for this, I don’t know. But, like many autoimmune conditions, a family predisposition does exist. Try the Arthritis Foundation website, maybe, for more information about lupus.

PA_MaryAnne: We would like to invite everyone to take advantage of the wonderful resources here at the American Pain Foundation. The chat room you are in tonight is part of our PainAid Online Community. We have daily chats, Monday-Friday at 11:00am EST, as well as evening chats Mondays at 9:00pm EST and Wednesday at 7:00pm EST. The PainAid discussion boards are also available to you 24/7 for support from your fellow pain patients, caregivers and medical professionals.

Our home page (www.painfoundation.org) has numerous resources, publications, opportunities for advocacy and a great pain information library.

Thank you, Brenda, for sharing such an informative and inspirational chat this evening. Thank you all for coming this evening. We will be posting a transcript of this chat on our home page and on the PainAid discussion boards for your convenience.

You are all welcome to stick around and chat amongst yourselves. Good night, everyone!