Depression: The Physical Pain and Symptoms
Sidney Kirchheimer, writing for WebMD, took up a problem that gets overlooked in a lot of exam rooms: medication often fails the people who show up with both depression and chronic pain. His point is that depression gets diagnosed by the signs clinicians expect to see, the fatigue, the sluggishness, the broken sleep. But it can arrive as something that looks strictly bodily instead. Chest pain with no cardiac cause. Aching muscles. Trembling, hot flashes, pains that no test can pin down.
That mismatch is where people fall through the cracks. According to Kirchheimer, patients who present mainly with physical complaints tend not to respond to the usual drugs, and researchers have been trying to work out the mechanism behind it. He cites a study in the Journal of General Internal Medicine that followed 200 patients who were eventually diagnosed with depression. Early on, doctors frequently missed the call, chalking up the vague physical symptoms to almost anything other than a mood disorder. So the treatment those patients needed never got offered.
Even once the diagnosis landed, there was a second wall. Keeley's work, referenced by Kirchheimer, found that patients carrying these physical symptoms pushed back against the standard prescription, antidepressant medication, mostly because they did not see themselves as depressed in the first place.
There is a human logic to that resistance. If your body hurts, a bodily explanation feels more plausible than a psychiatric one, and it carries less baggage. Some of the reluctance comes from the stigma still hanging around mental illness. Some of it is simpler: people want the fast fix. We live in a world where you can swallow a tablet for most aches, so of course someone would rather their trouble be physical, with a physical remedy, than something messier to name.
The numbers back up how fragile the treatment can be. Kirchheimer reports that patients diagnosed through psychological symptoms were four times as likely to still be taking their antidepressants six months later than those put on the drugs for physical complaints. When surveyed, the group with both depression and physical ailments often said they were unhappy with how treatment went. In the study he describes, close to eight in ten depressed patients left with a prescription, and nearly all of them filled it. Within three months, a large share had quit. Many clinicians will tell you that six to nine months of treatment, sometimes more, is what it takes to keep depression from coming back.
Since the 1990s, the evidence has pointed one direction: patients do better when the treatment matches what they actually want. Kirchheimer notes Keeley's view that people whose physical symptoms have no clear cause tend to favor counseling over a pill.
The June issue of the British Journal of Psychiatry adds weight to this. Dutch researchers found that at least one in six depressed patients seen in primary care had no medical explanation for their physical complaints. In the Netherlands, general practitioners were looking at symptoms with no diagnosable condition behind them and no obvious tie to depression, so the diagnosis slipped past.
The takeaway for anyone in pain is worth sitting with. Unexplained physical symptoms can be depression wearing a disguise. A good doctor should be asking about mood alongside the chronic complaints, and paying attention to sudden shifts in sleep or weight. Pain deserves a wide search for causes, mental health included. Some physicians will reach for antidepressants; others will suggest counseling, or both together, and plenty of studies have shown that pairing the two works well.
Depression is not abstract for the people living it. If you or someone close to you is dealing with these symptoms, getting a real evaluation from a therapist or psychiatrist is where to start. They can tell you whether the criteria are met and point you toward treatment and support that actually lowers the symptoms. (Kim B.)
A reader's account, shared here, fills in what the research describes from the inside. He writes that he has been in chronic pain for over a decade, after a serious back injury on the job that led to surgery and months of physical therapy. He is not a man who goes to the doctor willingly; by his own telling, it usually takes being near death or being hauled in by his wife. He will happily push her to go for routine checkups while resisting his own at every turn.
He draws a line between being hurt and being injured. Hurt is a twisted ankle you walk off, a slip that leaves you sore the next morning but still at work. Injury is different. Injury is the broken leg that keeps you off work for weeks, the kind of blow that benches an athlete for a season or ends a career outright. That, he says, is what people should watch for.
His own injury frightened him, and not because of the accident itself but because of what the pain did afterward. He could barely walk. He could not drive. His wife had to help him dress and tie his shoes. Being unable to look after himself cut against who he understood himself to be, and handing that care over to someone else was its own kind of fear.
She insisted he get treated, and he went along with it. The doctor sent him for more testing, then to a surgeon who operated and put him on home restrictions before therapy started. Six months of physical therapy ended with the news that he would never be fully whole again, that he could no longer do the work he had built his life around. He lost his job to the injury.
Then came the depression. He could not keep his family's sleep schedule, often could not even share the bed with his wife through the night, and he was irritable and hurting almost all the time. What pulled him back, slowly, was work. As his movement returned, he took on whatever small tasks he could manage, and those tasks gave him something to aim at. Contributing again shrank both the pain and the low mood. He still has setbacks, still has days when he has to stop and start over, and the depression still surfaces now and then. He keeps going anyway, and the strength and the sense of purpose keep coming back.
Source: "Body Aches May Signal Depression," Sid Kirchheimer, WebMD Health News, July 20, 2004.