Kurt Kroenke, MD, Research Scientist at Regenstrief Institute, talks about the link between chronic pain and depression.
Interview conducted by Ivanhoe Broadcast News in 2024.
We’re talking about the link between pain and depression and/or anxiety, and you explain this in a feedback loop. Explain what that is.
Kroenke: Feedback loop means that as pain gets worse, depression gets worse, and then as depression gets worse, pain gets worse. We sometimes use the word reciprocal. Probably that’s partly because pain and depression come from some of the similar areas of the brain and pathways. It makes sense to people that pain can cause depression. Sometimes the opposite pathway – depression causing pain — is less clear to patients.
If you have pain, maybe there’s a higher chance you would have depression or anxiety because it all connects together, correct?
Kroenke: Simple way of thinking about this is that about half the people with depression have some pain symptoms and about half the people with pain have some depression symptoms, and either condition about doubles your risk of the other.
Do you think people realize there’s that connection there?
Kroenke: Some people think that if I have pain it makes sense that it’s going to affect my sleep and my mood and my energy. I think the connection of people having depression and their pain thermostat being lowered in the brain is less clear. Also, sometimes treating one can benefit the other, but not always. Sometimes you have to use separate treatments. An example I use is people can be overweight and have diabetes. Sometimes losing weight is enough if you have mild diabetes, but sometimes if it’s not mild, you need to lose weight and use medications to treat the diabetes. Sometimes treating one is sufficient, sometimes you need to treat both.
You say that addressing depression and anxiety can improve pain. How is that?
Kroenke: It’s partly because they share some similar pathways in the brain. So maybe we’re targeting similar areas of the brain with our treatment. Sometimes as I said, there’s a feedback loop. So by lowering the “temperature” of depression, you may in parallel lower the “temperature” of pain.
But it doesn’t necessarily always work the other way with treating pain and helping with depression and anxiety, right?
Kroenke: So even though I’ve said there’s a similar feedback loop, it’s not exactly equal. There’s better evidence that if you treat depression, you’ll get benefit in pain. On the other hand, treating pain may have a smaller effect on depression, and you may need to treat both conditions, In some people with pain, treating the depression may be enough, but that’s probably more so if the pain is milder. If the pain is more severe, you probably need to treat both the pain and the depression.
When someone goes to the doctor, most often it’s for a pain-related issue. You say it’s important for the patient and the doctor to also talk about any psychological issues or symptoms that they’re dealing with. Talk about that a little bit.
Kroenke: It’s not going to be every patient with pain. So an example might be if you have what we call acute pain like you broke your leg or you just had surgery a day ago. We don’t ask all of those patients about depression. So one clue would be chronic pain. What we mean by chronic is that the pain doesn’t last a few days or a week but instead persists a month or two or three months. So particularly ask about mood or anxiety symptom in patients whose pain is persistent. And a second clue would be in those whose pain doesn’t get better with one or two treatments. So I think those would be the two clues, pain that lasts a few months or longer or pain that’s not getting better with treatment.
If that’s happening to you, as a patient, it’s important to, when you’re at the doctor, to bring up any psychological issues, correct?
Kroenke: A couple of other clues for the patient would be other common symptoms, in particular, trouble sleeping, no energy, trouble concentrating. So in addition to the pain, if you’re not sleeping and tired all the time and not able to think straightly, that can be a clue. Another clue would be in most people, depression doesn’t come out of the blue. They’ve had it in the past. Maybe it went away for a while. So we say a previous history of problems with mood or depression, or maybe recent stressful events are reasons to consider psychological factors complicating chronic pain.
What would be your message to patients and doctors to really stress the importance of looking at the full circle of what’s going on to really make this happen when you go to the doctor?
Kroenke: Hopefully, as we educate health-care providers, they’ll think of that as well. We don’t want to put all the responsibility on the shoulder of the patients, but in busy practices and if you’re going for your pain, often, that will be the focus. I think we also have to destigmatize both depression or pain. To a lot of people diseases like cancer and heart disease and diabetes make sense. Pain and depression are both invisible. And a lot of people who don’t have them think, well, it’s just that you have a headache, or your mood is low. So I think understanding that chronic pain and chronic depression are every bit as disabling as other medical diseases is part of the way we can get over this barrier.
There is a lot of stigma when you think of mental issues. What would your advice be to someone and what should they look out for?
Kroenke: People do have a bad day, people have a bad week. That’s not depression. So we don’t want to over diagnose depression. We all can have a bad day or bad week. Rather it’s more like a bad month. In fact, the way we diagnose depression, technically, is you got to have these symptoms, most of the days for at least two weeks. So if one wanted to pick maybe a threshold two weeks, but in many people, it’s one or two months. So that’s a way of sorting it out from merely a bad day or a bad week.
You are part of a growing field called symptomology. Explain what that is.
Kroenke: It’s not a common term used, but let me just tell you a little bit about symptoms, and pain and depression are two of the most common, but there’s others. We’ve mentioned anxiety. There’s other physical symptoms like fatigue, and insomnia, and gastrointestinal complaints.A third to half of all healthcare visits are for symptoms like this. However, symptoms don’t seem quite as intriguing to a lot of people because there’s no lab test or X-ray or fancy procedure. Instead, it’s really what the patient is experiencing and reporting in their own words. Symptoms also don’t get as much research, as diseases like cancer and heart disease and diabetes. But one fact people are not aware of is that symptoms are the most disabling conditions worldwide. So let me be specific about that. There’s a term called years lived with disability. It’s a measure of how long a disease lasts, how much disability it causes, and at what age it starts. Most depression and pain starts earlier in life rather than when you’re 50 or 60. So there’s many years lived with disability. So of the 10 most common diseases that cause years lived with disability,seven of them are depression, anxiety, and five pain conditions Together, these account for more years lived with disability than cancer, heart disease, diabetes, lung disease put together. The famous writer, Joan Didion, who suffered from chronic migraine her whole life, said, “I know that I’m not going to die from it, but in the midst of an attack, that’s an ambiguous blessing.” And anybody who suffers from chronic pain knows that it just takes over, and the same with depression.
Is that something that you think, maybe it’s hard for people to go to the doctor if they’re dealing with this, because they know you are saying, there’s not a test that’s going to for sure say it’s this or this, and there’s a clear treatment. Do you think, in the back of their mind, there might be that hesitancy because they’re like, “What are they going to do or how are we going to fix this or how long is it going to take to figure this out?” Is there a little hesitancy there?
Kroenke: Well, the good thing is that now recognizing depression does not take that long. Certainly, understanding depression deeply is going to take more than one visit. But we do have brief scales that we use now, some of which we’ve developed. This includes a popular depression measure called the PHQ-9 and one for anxiety called the GAD-7 and a measure for pain called the PEG. These have been widely used because they’re free and they’ve been translated into more than 100 languages. They’re been used in many millions of people worldwide, including in national surveys like the US Census, the CDC, and so forth. So they’re very simple. They’re commonly used in office practice now. Many practices are using them routinely. Also, individuals can go online to access these measures. They don’t want to diagnose depression or a pain condition based simply upon a scale score, but it can be an indicator that something is going on that might warrant attention. There’s many effective treatments that we have now.
The tools you’re talking about – that’s almost like a survey or questionnaire that doctors go through for different reasons and they can see where patients fall, right?
Kroenke: These are simple measures or scales and they’re brief. The depression measure is nine questions, the anxiety seven, but we also have a two-item version of each. So it doesn’t take more than a minute or two to complete them. And then when you are finished, you get a score. So it’s like going to the doctor and being told, “Your blood pressure is up.” This is a way of saying, your blood pressure is up except it’s your depression score that is up. People have found that a measure is helpful, because it tells them how bad their symptoms are. It’s not enough by itself, but it’s helpful just like people following their blood sugar with diabetes. It gives them a sense of how bad is it now and, is the treatment helping, is my depression or pain score getting better?
If you had to sum all of this up in a couple of sentences, something you really want to get across to people, to understand this link between pain and depression and/or anxiety, what would you want people to know about this?
Kroenke: I would say, first of all, they’re common fellow travelers. Second, they’re quite measurable, because with a limited number of questions, we can tell how severe it is and whether symptoms are getting better with treatment.Third, they’re treatable. If one treatment doesn’t work, we have a number of treatments, both medicines and what we call nonpharmacologic treatments, behavioral treatments. If one treatment doesn’t work, we have another one we can use or sometimes we combine treatments. So I’d say they’re measurable and treatable.
It’s interesting that, when you go to the doctor for certain things, you can get tested and you get a result a few days later, but some things you just really have to realign yourself to talk about what’s going on.
Kroenke: Well, as we said, I think people have to get over the stigma. I think this will improve with continuing public health education and as doctors get better educated about pain and depression. Once doctors became good at treating blood pressure, they felt comfortable with it being part of their job. And now I think with measuring depression and some treatments most doctors can use they can do the initial recognition and management of pain,depression, and anxiety. And for patients who do not get better, they can be referred to a specialist.
Do you think this is an opinion? Do you think the stigma is going down?
Kroenke: Maybe 30%. We got another 70% to go, but such things are a long journey. A Stanford pain specialist said once, why do people not take pain as seriously? Well, they do take it seriously if their family member suffered from it, but if they haven’t, you just got a headache. Your back just hurts. He said pain doesn’t kill, unlike cancer or heart disease from which some people die. However, we have good treatments now for many patients with cancer and it is the same with heart disease. But it’s this chronic disability. People live with it for years. It affects their work, their social life, their personal life. It is overwhelming. Yet symptoms like pain and depression don’t get the same public attention nor the amount of research as diseases like cancer and heart disease and diabetes. And symptoms doesn’t get as much attention in the training programs of doctors and nurses and other health care providers. But there is incremental progress.
What are some of the most common reasons for chronic pain? Is it back pain or what are the most chronic issues?
Kroenke: When I mentioned the 10 most disabling conditions, the most common pain conditions are low back pain, neck pain, arthritis and headache.
Can you figure out the problem?
Kroenke: We often have to try more than one treatment. People don’t necessarily get cured, but if we can reduce it, 50% so that they can function with it, people often accommodate, but it’s not a short road. But treating heart failure, diabetes is not a short road either. Like these diseases, depression and pain can be chronic conditions, but we do many things that can improve outcomes..
END OF INTERVIEW
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