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Expert Q&A

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How do you fight depression after injury, job loss?

Asked by Jeff, Nashville, Tennessee

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I suffered a career-ending injury in the past and now have further health issues related to that incident. How do you keep from going into a deep depression when you lost your job, have undergone 12 surgical procedures and almost three years of rehab since 2002? I have battled depression, lack of self-worth and confidence.

I have a decent job now, but have been off work because of back problems. My previous injury keeps me from squatting, bending or kneeling and now even though my job is sedentary I can't sit upright for more than 10 to 15 minutes because of pain and stiffness. I go to rehab and pain management, but it seems that I just can't win.

I have dealt with daily pain for years, but am reaching my wits end. Where else can I turn?

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Mental Health Expert Dr. Charles Raison Psychiatrist,
Emory University Medical School

Expert answer

Dear Jeff,

It is not much help for me to tell you that the combination of emotional stress and physical pain is probably the world's most potent brew for causing depression, but it is important to recognize the seriousness of what you are up against. Unfortunately, adding insult to injury is the fact that depression and pain both cause and worsen each other. So, for example, we know that people who have depression are much more likely to subsequently develop chronic pain, and people with chronic pain are at incredibly high risk of later developing depression.

From your question I'm not able to tell how much treatment you've gotten for either your depression or chronic pain. Let me make it easy on myself and assume two things: 1) that you would meet criteria for major depression were I to clinically evaluate you; and 2) that you have not had any treatment for your depression and have received only painkillers for your back pain. I realize that this may be far from the truth, but it's a good way to start about your options.

Let's start with medication approaches. As a general principle you want to get on a regimen that is likely to be maximally effective against both your emotional and physical pain. The cornerstone of any such regimen is usually an antidepressant. It turns out that not all antidepressants are equally effective for chronic pain. Although most people being treated in the United States start out with one or the other of the selective serotonin reuptake inhibitors (e.g. fluoxetine, paroxetine, sertraline, citalopram or escitalopram) many studies suggest that antidepressants that affect both serotonin and the related neurotransmitter norepinephrine have more pain efficacy. Currently in the United States, three have FDA approval: EffexorXR, Cymbalta, and Pristiq. If you have not had a trial of one of these antidepressants this would be a very reasonable first action.

There is another medication called Lyrica, which has a very different mechanism of action from the other antidepressants I've mentioned. This medicine has also been approved for pain states such as fibromyalgia and might help your condition. You might also think about taking some formulation of omega-3 fatty acids, which are available without a prescription, and which have anti-inflammatory properties that might be of benefit.

There are a number of other ways that you might be able to help your symptoms, although they require real commitment and discipline. Many studies show that exercise helps pain and depression. But you'll need to be careful and not overdo it. You would need to start with something low-impact like walking. Try walking 15 minutes a day at the start -- preferably in the morning. See if you can get permission from your job to take 10 minute walk breaks every couple of hours to help with the stiffness and pain.

You didn't comment on your sleep. Pain often disrupts sleep. On the other hand, not sleeping can make people feel pain. Exercising and getting sunlight early in the day helps improve sleep at night. You might also talk to your doctor about getting a mild sleeping pill such as Ambien or Lunesta. It is amazing how much difference a good night's sleep makes for both pain and depression.

Finally, explore ways that you might be able to develop the most positive state of mind you can manage. Many studies show that if you are feeling depressed or anxious this actually makes the brain perceive pain as worse than it is. There are many ways to work on developing a positive state of mind -- and no words left in this short blog to go into them!

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