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Expert Q&A

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What meds work for depression caused by physical pain?

Asked by Greg Urban, London, Ohio

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I have a stainless steel shoulder joint that causes me constant chronic pain. I've also had a small stroke, prostate and skin cancer that required three surgeries and I have two stents in my heart. All of this caused me to have depression and anxiety attacks. One doctor had me on Cymbalta and Xanax, but they didn't help. A different doctor put me on Wellbutrin 150 mg. and Zoloft a month later. For the next six months I felt better than I had for about eight years, but now the depression and anxiety issues are coming back. I most likely need a change in my medication or an adjustment in dosage. What is your advice? I am a 65-year-old retired man who rarely leaves my house and has trouble sleeping.

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Mental Health Expert Dr. Charles Raison Psychiatrist,
Emory University Medical School

Expert answer

Dear Greg,

Unfortunately, the story you tell really highlights how closely depression and anxiety are related to physical pain and medical illness. Especially later in life, pain and sickness drive many people into depression, even those who never have had this problem when younger.

I agree that you probably need to explore ways to change your medication regimen with your clinician. There are a number of possible medications and medication combinations that might help you. It is promising that you had a good response to Wellbutrin and Zoloft, at least for a while.

I can't tell you which medication or combination of medications is going to work for you because we never know this in advance. It's always a matter of trial and error. While all antidepressants are about equally effective when looked at in big groups of people, individuals can have wildly different responses, even to agents that are fairly similar to each other. Given your pain complaints, however, you might talk to your clinician about adding a medication like gabapentin (brand name Neurontin) or pregabalin (sold as Lyrica), both of which can help with chronic pain, and often anxiety.

If the medications require a bit of trial and error, there are other very important treatments for depression that are more certain and that I highly recommend for you. If you are still having problems with shoulder pain, you need to do everything you can to diminish this pain, (except for taking chronic opiate medications if you can help it), because these can worsen depression. Have you made maximal use of physical therapy?

Here are two very important interventions you should try to apply to yourself:

First, you need to find a way to get out of the house and try to do things you enjoy with people you like seeing. I realize this might not be easy, but in fact getting out and being as active as you can be within the limitations imposed by your health is probably the single most powerful thing you could do to help yourself feel better. This can be hard when you are feeling down, and it's not very high-tech, but there's lots of evidence that being proactive in these ways can powerfully combat depression.

Second, you should try to improve your sleep. I recommend getting a book or going online to learn of simple behavioral techniques for sleeping better. If these don't work, I'd talk to your doctor about one of the newer sleeping medications. It is almost impossible not to be depressed if your sleep is disturbed and you are isolated and lonely. Please try to address these issues. Medications are good, but don't think of them as the end-all and be-all of how you can get better.

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