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Question
Posted by: Very concerned friend | 2011/01/12

Depression and chronic pain - way forward?

Hi CS

My apologies in advance for the long question!

I have had a friend from the States staying with us over the festive season. He is a 49 year-old AK amputee and has suffered (particularly in the last 11 years from major depression and chronic pain). He has been to numerous counsellors (as apposed to psychologists) over the years - to no avail. He saw a psychiatrist/psychologist recently but the therapy came to a disasterous end due to a misunderstanding which involved very questionable behaviour on the part of the professional involved - he became particularly suicidal at this point. He is now still on his meds - Trazadone, Ambien and Efexor (initially prescribed by a psychiatrist) but is currently not being monitored by any health professional (neither a psychiatrist or psychologist).

What concerns me is that he is still very down and seems to have “ up”  periods when he manages (but still has some pain) but then other times when he just ‘ crashes”  and sleeps for most of the day. When he crashes he becomes very depressed and black, speaks of everything being hopeless, feels the pain (particularly in his back) very acutely and has problems concentrating and often forgets things that he said during this period.

He has discovered that when he takes less Trazadone at night - he feels less hungover during the day. When he takes the recommended dose he often finds that he sleeps most of the day and then ends up being up most of the night –  he says he is most productive at night! Obviously this is seriously effecting his sleep-wake cycle and I am worried that he fiddles with the dose without being overseen by a psychiatrist. So my questions are:

1. Surely he needs both a psychiatric help as well as psychotherapy?
2. How much of the chronic pain in such patients is usually psychological and how much physical?
3. His sense of helplessness and hopelessness is quite profound at times and he seems unable to take any life changing decisions even though he is conversant and generally subsistent (he has been on work disability due to the severity of the depression)–  is learned helplessness more prevalent in chronic pain patients (because of feeling unable to control it)?
4. How to deal with this –  tough love and a kick up the butt or love and care and psychotherapy?
5. He is also in a seemingly codependent relationship where his wife does not deem it necessary for him to see any mental health therapist –  she insists it is a matter of will?

Your comments would be greatly appreciated!

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Our expert says:
Expert ImageCyberShrink

Of course the depression will increase the pain, and the pain will increase the depression.
Unless and until the usual antidepressants have been tried properly individually in normal doses, I don't see any reason to give 2 ADs at once.
The main variety of counselling / therapy that has been shown by good research to be effective in managing depression and anxiety, is Cognitive-Behaviour therapy, CBT. And that would sound really advisable for him. CBT works fine with medication, but selecting, monitoring and balancing meds is best done with the advice of a psychiatrist.
Chronic pain hurts, whatever proportion is "physical" or "psychological", and both causes fed each other, so trying to sepaate them is artificial.
Learned helplessness is surely part of the mechanisms that relate to a person with any chronic condition tending to give up or even sabotage their treatment. Such self-defeating attitides are best dealt with by CBT
One of the useful truths of tough love is to love the person, not necessarily the behaviour.
His wife surely sounds like a significant risk factor. People who say dangerously stuipid things about "pull yourself together" and "it's all basicall a matter of will" are not practising tough love, but reckless ignorance. Especially if she is foolish enough to discourage him from seeing a proper mental health expert - clearly her expertisde hasn't solved any of the problems.


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Our users say:
Posted by: cybershrink | 2011/01/12

Of course the depression will increase the pain, and the pain will increase the depression.
Unless and until the usual antidepressants have been tried properly individually in normal doses, I don't see any reason to give 2 ADs at once.
The main variety of counselling / therapy that has been shown by good research to be effective in managing depression and anxiety, is Cognitive-Behaviour therapy, CBT. And that would sound really advisable for him. CBT works fine with medication, but selecting, monitoring and balancing meds is best done with the advice of a psychiatrist.
Chronic pain hurts, whatever proportion is "physical" or "psychological", and both causes fed each other, so trying to sepaate them is artificial.
Learned helplessness is surely part of the mechanisms that relate to a person with any chronic condition tending to give up or even sabotage their treatment. Such self-defeating attitides are best dealt with by CBT
One of the useful truths of tough love is to love the person, not necessarily the behaviour.
His wife surely sounds like a significant risk factor. People who say dangerously stuipid things about "pull yourself together" and "it's all basicall a matter of will" are not practising tough love, but reckless ignorance. Especially if she is foolish enough to discourage him from seeing a proper mental health expert - clearly her expertisde hasn't solved any of the problems.


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