Nancy May, RN
Department of Psychiatry, Bryn Mawr Hospital

We hear a lot today about how stress affects our lives, and it is evident that stress, depression, pain, and insomnia are closely related, interacting in a vicious cycle.  One may start with any one of the four and eventually experience one or all of the other three in any order.

The onset of stress triggers the release of certain hormones:. norepinephrine, adrenaline, cortisol, and cortisone.  The autonomic nervous system's sympathetic response to stresses is "flight-or-fight," also known as the "acute stress response."  "Good" acute stress can be beneficial in that it helps to create emotional memories and improve mood and it helps people to view problems as challenges.

When highly stressed for long periods of time, the neurochemistry and changing concentrations of these hormones negatively affect the brain, which recent studies have suggested contributes to development of many mental illnesses such as depression and anxiety disorders, as well as altered food intake and drastic mood changes.  "Bad" chronic stress is unpredictable and sensitizes neural pathways, as well as overworks certain areas of the brain and causes others to undergo atrophy.  When chronic stress persists, some brain cells are damaged and eventually killed, resulting in brain shrinkage, abnormal cell function, and in severe cases, immune system compromise.  Chronic stress shortens the Average Life Expectancy by 10 years and results in decreased cognitive function, decreased physical function, and increased cardiovascular disease events.

Depression is the most prevalent psychiatric disability.  As many as 20% of the general population has some depressive symptoms at any given time in their life, and prevalence rates are unrelated to ethnicity, education, income, or marital status.  It can occur at any age, although the average onset is in the mid 20's.  Women in the US and in other countries have been reported to experience depression about twice as often as men.  However, men are less likely than women to admit their depression, and because of societal stigma, embarrassment, and denial, they are less likely to be diagnosed with depression.  Depressive symptoms in the elderly are often missed and are frequently misinterpreted as side effects of the older patients' medications.  Depression in children had been considered a "temporary phase" in normal development until 20 years or so ago and since then has been considerably studied and recognized as such.

With depression, there is an interaction of biological, chemical, psychological, and social aspects.  A genetic predisposition is noted in some cases, i.e., some types of depression run in families and occur generation after generation, which is not to say that depression cannot also occur in people without any family history.  Biochemically, there will be decreased levels of norepinephrine, serotonin, and dopamine but increased levels of cortisol.   There may be a combination of biological (genetic) vulnerability, psychological, and environmental factors.  Serious losses, difficult relationships, financial problems, and/or any other highly stressful, unwelcome, unpredictable change in life patterns may trigger depressive episodes.  Depression is often masked by other more socially acceptable forms, such as alcohol and/or drugs, or by socially applauded habits of working long hours (workaholics.)

The combination of antidepressant medications and focused psychotherapy still prevails as the most favorable treatment, known to have lasting beneficial effects against depression.  Other alternative treatments for depression include, ECT (Electro Convulsive Therapy), exercise, herbal treatments, particularly St. John's Wort, Folate (Folic Acid),
SAMe, Omega-3 Fatty Acids, MST (Magnetic Seizure Therapy), and VNS (Vagus Nerve Stimulation.)

Depression and pain are mutually causative!  People who have Major Depression are more than twice as likely to have chronic pain when compared to people who have no symptoms of depression.  "[Even though] we all have a certain amount of pain, it could be that the perception of pain is greater in depressed people." (Dr. Schatzberg, MD, Stanford University.)  Since Serotonin, a brain chemical, plays a big role in both depression and in pain, antidepressants, such as SSRIs (Selective Serotonin Reuptake Inhibitors) are a good adjunctive medication for pain control.

Sexual differences among men and women affect the social, psychological, physiological, cellular, molecular, and genetic factors that together modulate pain.  Women are generally more vulnerable to pain than men; however, women also have greater strength to deal with pain.  Though small differences have been found, overall the burden, variance, and variability of pain is much greater among women than men.  Some studies suggest that testosterone, a male hormone, elevates pain thresholds by increasing the levels of painkillers, enkephalins.

Short term management of pain includes simple analgesics, NSAIDS (non-steroidal anti-inflammatory drugs), mild to moderate opiates, TENS (Transcutaneous Electric Nerve Stimulation), and tricyclic antidepressants.

The coexistence of insomnia and depression is reflective not of a cause-effect relationship, but rather a common pathology:  Insomnia leads to Depression leads to Pain or Pain leads to Depression leads to Insomnia.  Insomnia may occur first in some depressed patients, second in others, and not at all in some.  Again, certain antidepressants may work for treatment of both insomnia and depression.

[Information for the above article was obtained from material presented in a course titled STRESS, DEPRESSION, & PAIN, presented by the Institute for Natural Resources (INR), King of Prussia, PA, December 1, 2004.]

###