SYMPOSIA

[PS-15]
Symposium Title: Depression and pain
Impact of pain on treatment in depression
Cengiz Akkaya
Departments of Psychiatry, Uludag University, Bursa, Turkey
E-mail: cakkaya@uludag.edu.tr
Bulletin of Clinical Psychopharmacology, Vol: 21, Supplement: 2, 2011 - www.psikofarmakoloji.org
Abstracts of the Invited Speakers
Major depressive disorder (MDD) is a chronic, disabling condition with a wide range of symptoms, including core mood symptoms of
depression and anxiety, cognitive and behavioral deficits, and somatic/physical disturbances. Approximately two-thirds of patients with
depression experience physical pain symptoms (e.g. headache, neck and back pain, abdominal pain, diffuse musculoskeletal pain). Pain
as a symptom of depression, often has a negative impact upon other depressive symptoms (for example, it may induce or exacerbate
low energy, sleep disturbance, and anxiety), adherence to medication, and obtaining adequate therapy. Therefore, pain influences both
the course of depressive illness and the treatment outcome. Also the severity of pain is found to be a strong predictor of poor response
and health-related quality of life. Impairments in social and occupational functioning may increase when depression and pain coexist.
Patients who fail to achieve remission after antidepressant therapy are more likely to suffer residual pain and other physical symptoms
compared with remitted patients.
The close relationship between pain and depression, and the growing evidence of a connection between treatment outcomes in these
conditions, suggests that maximal patient benefit may result from treatments which effectively address both emotional and physical
symptom domains. Therefore, treatments that address both depression and pain are highly desirable. Neurobiological evidence suggests
that mood and chronic pain are connected via serotonin and noradrenaline neurotransmitter pathways. Serotonin and norepinephrine
play a key modulating role in pain mechanisms in the central nervous system. Serotonin modulates both descending inhibitory and
facilitatory pathways and thus exerts both an antinociceptive and a pronociceptive effect. Noradrenaline, however, typically acts centrally
in an antinociceptive manner, exerting its effects via a-2-adrenoreceptors in the descending antinociceptive pathways.
Efficacy for treating pain is best established for tricyclic antidepressants. But through the last decade, antidepressant medications,
particularly selective serotonin reuptake inhibitors (SSRIs) and selective serotonin and norepinephrine reuptake inhibitors (SNRIs), are
widely used in the management of MDD. SSRIs are often favored in practice because of their tolerability and safety. However, their efficacy
in pain is thought to be relatively weak. On the other hand the mechanism of SNRIs has been hypothesized to confer analgesic effects
independent of antidepressant action. Evidence suggests that potentiation of both serotonin and norepinephrine is required for effective
analgesia; drugs that inhibit only one of these systems (particularly serotonin) appear to have a limited effect. Whether antidepressants
relieve pain through direct analgesic effects or indirectly through antidepressant action is still under discussion. There may be a close
association between analgesic and antidepressant effects and pain relief may be secondary to mood improvement.
Key words: Pain, depression, antidepressant
Bulletin of Clinical Psychopharmacology 2011;21(Suppl. 2):S81
Clinical characteristics and mechanism of pain in depression
Selçuk Kırlı
Department of Psychiatry, Uludag University, Bursa, Turkey
E-mail: kselcuk@uludag.edu.tr
Although there is a large amount of data indicating that depression and pain symptoms are closely interrelated, they are not included in
depression symptoms in the classification systems. Even so, new developments in neuroscience have carried the data on this interrelation
and co-occurrence beyond the epidemiological dimension to the awareness of a common underlying mechanism (1,2).
Although such a co-occurrence and the mechanisms that influence it are being discussed more and more, pain symptoms still cannot
be well assessed or monitored and they are usually described by terms such as ‘medically unexplainable’, ‘functional’ or ‘psychosomatic’.
The following statements may be made about the clinical characteristics of the symptoms (1):
• They do not conform to the anatomic localizations which would help explain their causes.
• They may vary in severity and location.
S81