PainEDU interviews Cal Robinson Psy.D., FICCP (Medical Psychologist), the Clinical Director of the Pain Management Center at Elliot Hospital in Manchester, N.H., and the current President of the New England Pain Association. He discusses treating pain patients who experience depression and anxiety.

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Questions

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Evelyn:

Why do you think it is important to discuss depression and anxiety when talking about pain management?

Cal Robinson, Psy.D.: It is appropriate to talk about depression and anxiety at the same time we talk about chronic pain because they are often part of the chronic pain challenges. This is certainly expectable when we think about the discouragement these patients face, and the loss of overall functioning. Actually, I typically expect to see some signs of depression and might be concerned about a patient who is trying so hard to filter out these feelings, at times denying the depressive reality, that it causes even more stress.

We know statistically that 60% to 80% of individuals with chronic pain have psychiatric co-morbidities. These problems can amplify their sensitivity to pain and increase their level of disability. It has been estimated that major depression affects 30% to 50% of all chronic pain patients. The International Association for the Study of Pain (IASP) identifies pain as an "unpleasant sensory and emotional experience". In addition to depression, psychiatric co-morbidities may include anxiety disorder, personality disorder, somatoform disorder, and substance abuse.

EC: When patients have depression or anxiety and chronic pain, how do you answer the question about what came first?

CR: From where I sit as a psychologist in a pain clinic, I see pain as the major culprit leading to depression and anxiety. Some people are more fortunate. They seem to respond better and appear able to filter out their pain from their general world views. Some people are less likely to feel anxiety because they don’t perpetuate to cognitive distortions.

Any physiologic challenge that lasts and lasts with no expectation of a cure will absorb and deplete a person’s resources. For people with an anxiety disorder, their autonomic nervous system is often aroused as they respond to perceived threats. This arousal response is similar to a pain response. They often respond very well to a cognitive behavioral approach, at times supplemented with psychotropic medication.

EC: What special training do psychologists have to treat patients with chronic pain?

CR: Clinical psychologists have the opportunity to seek specialized training in many areas. While psychologists may be more widely thought of as being involved with measurement and testing, a large group have become interested in health psychology, that is, the relationship between psychological factors and health. In order for a psychologist to practice ethically, they need the appropriate training and experience for their work. Unfortunately, there are very few, post doctoral residencies for psychologists who want to specialize in pain. Because of our health insurance system, which separates treatment for physical and mental health, and the resulting cost disparities, treatment for the psychological consequences of pain may not be available to every patient who needs it.

EC: Caring for a patient with both chronic pain, and depression or anxiety, usually requires more than one health care provider. How do you maintain the necessary collaboration and communication?

CR: The medical system in the United States relies on referrals from primary care doctors, and all communication and coordination should go through this provider. This can be a challenge for pain patients as many primary care doctors are reluctant to assume the responsibility of managing a patient whose treatment is chronic opioids. Therefore we do a lot of the management while trying to maintain very good communication, by sending notes back and forth. Our goal is always to get the patient back to the primary care provider after being stabilized, just like other specialists.

Referring patients to a multidisciplinary pain center does expose the patient to a variety of treatment options. Health care providers need to recognize the limitations of their treatments. For example, opioids or implantable devices do not help everyone. If a patient tries one thing and that fails, they may feel like a failure. We need to learn how to be healers, rather than just technicians.

EC: What is the best form of psychological "maintenance" treatment for patients who are dealing with multiple chronic conditions?

CR: It is important for patients to not just "medicalize" their approach to pain management, so that their life does not become the search for the perfect pill.

There are basic skills that patients need to learn in order to be able to restructure negative and catastrophic thinking. This is an important part of my work. Once patients have these skills, they need to recognize the limitations of medicine and learn that the ongoing management of their chronic conditions involves not just medical and surgical treatment, but self-care. The earlier the patient understands these concepts, the more likely they are to manage effectively over time. I see my job as being there to help people improve the quality of their life. Sometimes people who have been doing well for a while need some extra assistance if they are relapsing into old ways, so I want my door to be open to them.

A pain self-management group is a very effective model of providing maintenance care for people with chronic illness. At Elliot Hospital we don’t charge for our groups. Patients pay for the work books and audiotapes they use, but the series of 10 weekly programs is at no cost. And people can, and do, return to the group when they feel the need for a boost.