Depression and anxiety in adolescents aggravate abdominal pain, and abdominal pain deepens depression which increases suffering from chronic pain

Harald Breivik

doi:10.1016/j.sjpain.2014.05.003

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Depression and anxiety in adolescents aggravate abdominal pain, and abdominal pain deepens depression which increases suffering from chronic pain

Harald Breivik

Veröffentlicht/Copyright: 1. Juli 2014

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Aus der Zeitschrift Scandinavian Journal of Pain Band 5 Heft 3

In this issue of the Scandinavian Journal of Pain Niklas Stabell, Trond Flægstad, Audun Stubhaug and Christopher S. Nielsen report from a pain-project in Tromsø in Northern Norway [1]. They studied more than 1000 adolescents who were 15–17 years old [1]. The focus in that study was on chronic abdominal pain (AP) and irritable bowel syndrome (IBS) and their association with depression.

1 Chronic abdominal pain and depression are common in adolescents

They report that recurrent (at least monthly) abdominal pain (AP) occurred in more than a quarter of adolescents whereas irritable bowel syndrome (IBS) occurred in almost 10%.

Depression was twice as frequent in girls (16%) as in boys (7%). Depression occurred in 1 in 4 of those suffering from AP or IBS compared with less than 1 in 10 of the adolescents not having AP or IBS. Compared with pain-free adolescents, depression occurred 3–5 times more often in those with severe or widespread AP and in those who also had chronic pain in other parts of the body [1]. These observations agree with similar findings in adult populations: chronic pain and depression often co-exist [2,3,4].

2 Diagnosing depression in chronic pain patients

Patients suffering from chronic pain may have some of the somatic symptoms typical for clinical depression, without being depressed. Thus, Williams and Richardson found that among chronic pain patients who were not clinically depressed 95% had difficulties performing their work, 85% had sleep disturbances, 85% had fatigue, 65% were preoccupied with somatic health problems, 65% lost libido, 48% lost their appetite, and 25% lost weight [5]. The Short Mood and Feeling Questionnaire (SMFQ) does not include questions about somatic symptoms of pain [1]. Linton and Bergbom [3], and Nicholas [2] observed: When pain and depression co-exist they impact on each other and play important roles in the development and maintenance of chronic ill health and psychosocial problems. The Örebro Behavioral Emotion Regulation Model provides much needed guidance for investigating the psychological mechanisms involved [3].

3 Common mechanisms in pain and depression rather than “the chicken-or-the-egg”

The conundrum of how depression and chronic pain relate to each other remains: there may be a common biological mechanism in depression and chronic pain [4]. It is possible that depression somehow sensitizes the pain-modulating systems of our CNS so that pain stimuli such as in visceral abdominal pain are experienced more severely [4,6]. Chronic pain is an enormously stressful health problem, and so is depression [3]. Anxiety and catastrophizing mental processes accompany both unclear pain, and severe mental depression [3]. Exhaustion and fatigue from a constantly gnawing chronic pain condition naturally lead to deeper depression, apathy, and catastrophic ideation [3].

The strong associations and obvious negative interactions between intense and widespread abdominal pain and depression in these young persons of only 15–17 years may have even more important implications than in adults [1]. Screening for affective disorders is indeed indicated when adolescents present with symptoms of visceral pain, or with symptoms of IBS. Examining and treating comorbid depression must be as important as trying to find effective treatment for their painful conditions [1,3,4,6].

4 Treatment options: drugs and behavioural therapies synergize and are effective

Pharmacological treatments of chronic pain and of severe depression have some effects, but are seldom effective enough alone. Cognitive behavioural treatment is effective for depression [2,3], and such psychological treatments also have beneficial effects on chronic pain [2,3,7], although much of the effect appears to be due to context sensitive effects rather than a specific effect [7]. It is important to note that psychological treatments appear to be especially effective in children and adolescents (<18 years of age) with complex pain conditions [8].

5 The seriousness of depression in young chronic pain patients: a real risk of suicide

Patients with chronic pain have a quadrupled risk of suicide attempts compared with the general population in Denmark [9]. This fact speaks to the importance of evaluating symptoms of depression as part of the complex health problems around chronic pain [10].

The risk of suicide in immature adolescents suffering from chronic pain is at least as high as for adult patients. An adolescent ending his/her life because we did not understand the seriousness of the interactions of pain and depression, and we failed to treat effectively, this is likely to be the most tragic failure any health care provider can experience.

Future studies of treatments for co-morbid depression and pain are urgently required [2,3].

The Örebro Behavioral Emotion Regulation Model provides guidance for investigating the psychological mechanisms involved [3].

DOI of refers to article: http://dx.doi.org/10.1016/j.sjpain.2014.04.003.

Oslo University Hospital, Department of Pain Management and Research, PB 4950 Nydalen, 0424 Oslo, Norway. Tel.: +47 23073691; fax: +47 23073690.

References

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[10] Breivik H, Endresen Reme S, Linton SJ. High risk of depression and suicide attempt among chronic pain patients: always explore catastrophizing and suicide thoughts when evaluating chronic pain patients. Scand J Pain 2014;5:1–3.Suche in Google Scholar

Published Online: 2014-07-01

Published in Print: 2014-07-01

Artikel in diesem Heft

https://doi.org/10.1016/j.sjpain.2014.05.003