Patient with pain and depression – practical therapeutic implications

Abstract

Depression and pain are often coexisting phenomena, and the relationship between both phenomena is two-way – the occurrence of depression increases the risk of pain, and both acute and chronic pain increase the risk of depression. Pain may be part of the clinical picture of depression, be a result of comorbid psychiatric disorders, be associated with comorbidities, be a chronic pain syndrome, or be a complication of pharmacotherapy. The comorbidity of pain and depression is associated with a worse prognosis, lower therapeutic response, lower quality of life, impaired functioning, and a greater risk of relapse and suicide. There are indications that the same structures and neurotransmitters are involved in the pathophysiology of pain and depression, which may explain the coanalgesic effect of some antidepressants. The drugs with the best proven effectiveness are serotonin and noradrenaline reuptake inhibitors (especially duloxetine) and amitriptyline. Other drugs that may be of use in the treatment of pain are mirtazapine, mianserin, trazodone, agolemelatine, bupropion, and moclobemide. Selective serotonin reuptake inhibitors are used primarily in the treatment of depression symptomatic pain, but there is little evidence that they are effective in other types of pain. The use of certain psychotropic drugs, incl. SSRIs, clomipramine, benzodiazepines, Z drugs, and anticholinergics may be associated with increased pain. Caution is required when using polypharmacy in the form of a combination of an antidepressant and an analgesic because of the risk of worsening side effects or loss of treatment effectiveness. In the case of opioid drugs, in particular tramadol, the combination with drugs with a serotonergic effect may be associated with the risk of serotonin syndrome.