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Can physical injury cause depression?

Asked by John H., Georgia

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I suffered a pretty serious compound fracture to my ankle last year, followed by an infection, five surgeries, three rounds of IV treatment with PICC lines, hyperbaric oxygen treatment, and now physical therapy and oral antibiotics. I feel like I've let my family, my company and myself down. I find it hard to concentrate and my limited mobility makes everything worse. I am in constant pain (bone-on-bone in the ankle) and even though the infection is finally gone, I find that an alarming amount of my thoughts are related to doing away with myself. When I was really hurt, I had getting better to look forward to. Now that I am there (sort of) it isn't that much better. Right now my life seems pretty joyless. Is this typical for a Type A after an injury? Should I be (even more) worried?

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

Expert answer

Dear John,

I am really sorry to hear of your difficulties. I've recently had a close family member undergo a prolonged period of chronic pain, so I am especially sensitive to your situation. Until one has experienced the horror of prolonged physical pain, its endless, grinding hours and sense of hopeless eternity, one cannot understand how easy it is to become clinically depressed.

I am very concerned about your suicidal thoughts, but know also that these types of thoughts are very common at the bad crossroads where physical and emotional pain meet.

Let me make some practical recommendations aimed at improving your situation. First, it is absolutely imperative that you get treatment for your depression ASAP. In addition to the grave danger posed by suicidal thoughts, emotional pain has been shown in study after study to worsen the perception of physical pain.

Scientists have shown that the brain uses the same areas to register both types of pain -- essentially treating them as being to a large degree equivalent -- which may explain why physical pain so often produces depression and why depression worsens physical pain.

One particular class of antidepressant, called serotonin-norepinephrine reuptake inhibitors, or SNRIs, has been shown to help reduce several types of physical pain in addition to treating depression. Although your type of post-fracture-related pain has not been studied, you might still receive some relief from your physical pain in addition to the depression with this type of antidepressant.

Your pain might also benefit from treating with either gabapentin or pregabalin, both of which affect a type of calcium channel. In the case of my family member who has recently struggled with chronic pain, use of one of these calcium channel agents and an antidepressant has significantly improved her situation both physically and emotionally.

Just as treating your depression will help with the physical pain, continuing to do all you can to improve the physical pain will help greatly with your depression. One word of caution here, however, is that standard "pain pills" (officially known as opiates), while providing short-term benefit, may actually make pain worse over the long term and can also worsen depression.

For this reason, I strongly recommend trying very hard to avoid a taking an opiate on a regular basis if possible. If you are already taking opiates regularly, I recommend talking with your doctor about any potential behavioral/physical therapy type interventions that might help you reduce your need for these medications.

Finally, it is probably harder for Type A (that is driven, focused) individuals to cope with the way bad pain brings life to a crashing halt. The trick, and it's not an easy one, is to use your Type A nature to your benefit by exploring ways you can optimally re-engage with your life despite your pain.

Not only will this give you at least a portion of your life back, but studies have shown that not focusing on pain actually reduces its intensity.

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