News from the Johns Hopkins Department of Psychiatry and Behavioral Sciences
You might call Terry Martin* a modern Job. Her family was rife with psychiatric problems—obsessive-compulsive disorder, alcohol and drug addiction and depression ending in suicide. Depressed at the ripe age of 5, Martin turned to alcohol. Then there were suicide attempts. And pain. In 1995, now middle-aged, Martin had surgery for carpal tunnel syndrome but got no relief. Later, she experienced pain so severe in both legs—reflex sympathetic dystrophy, she was told—she couldn’t walk. In 2001, it was an irritable, obese, depressed woman in pain who rolled into Meyer 6 on a motorized scooter, seeking help from the Pain Treatment Program (PTP).
“Chronic pain is rarely simple,” says psychiatrist Michael Clark. It often appears, like lightning, from a cloud of other problems, not the least of which is depression. While the frequent pairing of low mood with constant pain hasn’t escaped clinicians, consistently good, rational therapy has, says Clark. Two decades of experience, however, are combining with studies he’s undertaken to define what’s occuring—a key step toward therapy. And the PTP, which Clark heads, works those results into an already very effective program.
“When this field began,” says Clark, “few realized how patients like Mrs. Martin were suffering.” Today, more physicians understand that all pain is real. And treatment has newer options including group therapy, stress reduction, nerve stimulators. Yet while that’s a boon, Clark adds, it’s not ideal. “Because patients have such difficult, variable problems, the temptation to shotgun exists,” he says. “Give a bit of everything and people get a bit better. But shotgunning obscures the fact that we still don’t know exactly what we’re treating! What’s needed is more sophisticated diagnosis. That will drive treatment and not the other way around.”
As a start, Clark aims to clarify the depression that dogs chronic pain. Depression and the pain experience appear to be uniquely intertwined, he says, citing research where people suffering both chronic pain and depression follow inheritance patterns similar to those of affective disorders. Are they two separate problems? Any number of studies show people with both differ from those just in pain: Their pain feels more intense; they’re more disabled; surgery is less effective. As Martin says, “The pain level may be the same whether I’m depressed or not, but how I cope with it is entirely different.”
Significantly, one large study by Clark and colleagues that followed people with depression for 13 years found them far more prone to chronic pain, not the reverse.
“So you’re in your office with someone with a mood disorder,” says Clark. “If there weren’t enough reasons to treat it aggressively, now you have one more. A chronic pain syndrome could wait down the road. Similarly, if I see chronic pain patients who aren’t obviously depressed, I now take a more careful history. Am I missing a masked depression? It could make such a difference.”
As for Martin, a series of stays in the PTP—with both in- and outpatient facilities—have done well by her. She was weaned off a drawerful of short-acting pain drugs and treated aggressively for depression, while neurologists fine-tuned pain treatment. The structured program of group, occupational and physical therapy helped her regain her ability to cope. She’s not pain-free, but she’s walking independently and, at last, has a healthful attitude. “What helped the most?” she asks. “They didn’t give up on me.”
*not her real name.
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