By Dr. David Woo - March 12, 2021

Depression causes pain in many different ways. Depression is often associated with painful emotional states like sadness, irritability, and guilt, but it can also cause physical symptoms, like back pain and headaches. In fact, more than two-thirds of patients with depression experience pain.(1) Why does depression affect our bodies, and in what ways can depression manifest itself in the body?

The Physical Effects of Depression

Depression can cause the following physical symptoms:

• Fatigue
• Aches and pains (back, joint, and limb)
• Digestive issues (1)
• Headaches (2)

It’s important to understand that while depression can cause physical pain, physical pain can also contribute to depression, make depression worse, and increase the risk of relapse. 

Why Does Depression Cause Physical Pain?

Scientists don’t know the exact reason why depression causes physical pain, but some studies have provided clues. 

The emotional symptoms of depression, such as sadness and feelings of worthlessness, are associated with abnormal levels of two chemicals in the brain called serotonin and norepinephrine. One study shows that abnormal levels of serotonin and norepinephrine are also associated with pain.(1)

Serotonin is important for our emotional response, mood, sleep, learning, and how we perceive pain. Low levels of serotonin in the brain may affect its ability to provide pain relief.(3,4) Another study shows that low levels of serotonin and norepinephrine may also cause persistent pain.(6) 

Depression Treatments That Can Help With Pain

Early research suggests that antidepressants that increase the concentration of serotonin and norepinephrine in the brain may be used as first-line treatments in depressed patients who are experiencing physical pain.(1) Multiple research initiatives show that antidepressants can effectively treat patients with conditions that cause chronic pain, such as diabetic neuropathy and fibromyalgia.(6,7,8) 

Transcranial magnetic stimulation (TMS) is a medication-free treatment alternative to antidepressants. TMS is FDA-approved to treat depression and multiple clinical trials show that it is safe and effective for treating chronic pain and migraines. An analysis of five clinical trials reveals that TMS is effective in treating migraines. However, more research is needed to assess the efficacy of TMS in treating migraines compared to traditional treatments.(9) 

An analysis of nine clinical trials shows that TMS improves the efficacy of traditional treatments for chronic pain. These results suggest that TMS may reduce the need for opioid pain medications, whose misuse has increased exponentially in the past three decades.(10)

Talking to Your Doctor About Your Symptoms

If you’re suffering from physical pain or discomfort, ask yourself whether you’ve also been experiencing emotional symptoms of depression. Loss of interest in things you used to enjoy, low energy, and persistent sadness are common emotional signs of depression. In order for your doctor to suggest the most appropriate treatment, they’ll need to know all of your emotional, mental, and physical symptoms. 

Work closely with your doctor throughout treatment. It’s important for patients and their doctors to consider both emotional and physical symptoms when keeping track of symptom improvement throughout treatment. Improvement in both emotional and physical symptoms is necessary to reduce the risk of relapse. Pain can worsen the emotional symptoms of depression and can increase the risk of relapse. 

Resources: 

1. Bair MJ, Robinson RL, Eckert GJ, et.al. Impact of pain on depression treatment response in primary care. Psychosom Med. 2004;66(1):17-22. Link. Accessed February 10, 2021.

2. Ratcliffe GE, Enns MW, Jacobi F, Belik SL, Sareen J. The relationship between migraine and mental disorders in a population-based sample. Gen Hosp Psychiatry. 2009;31(1):14-9. Link. Accessed February 10, 2021.

3. Cortes-Altamirano JL, Olmos-Hernandez A, Jaime HB, et.al. Review: 5-HT1, 5-HT2, 5-HT3 and 5-HT7 Receptors and their Role in the Modulation of Pain Response in the Central Nervous System. Curr Neuropharmacol. 2018;16(2):210–221. Link. Accessed February 10, 2021.

4. Paredes S, Cantillo S, Kenneth D Candido KD, Knezevic NN. An Association of Serotonin with Pain Disorders and Its Modulation by Estrogens. Int J Mol Sci. 2019;20(22):5729. Link. Accessed February 10, 2021.

5. Moret C and Briley M. The importance of norepinephrine in depression. Neuropsychiatr Dis Treat. 2011;7(Suppl 1):9-13. Link. Accessed February 10, 2021.

6. Marks DM, Shah MJ, Patkar AA, Masand PS, Park GY, Pae CU. Serotonin-norepinephrine reuptake inhibitors for pain control: premise and promise. Curr Neuropharmacol. 2009;7(4):331-6. Link. Accessed February 10, 2021.

7. Onghena P, Van Houdenhove B. Antidepressant-induced analgesia in chronic non-malignant pain: a meta-analysis of 39 placebo-controlled studies. Pain. 1992;49:205–219. Link. Accessed February 10, 2021.

8. Sansone RA and Sansone LA. Pain, pain, go away: antidepressants and pain management. Psychiatry (Edgmont). 2008;5(12):16-9. Link. Accessed February 10, 2021.

9. Lan L, Zhang X, Li  X, et.al. The efficacy of transcranial magnetic stimulation on migraine: a meta-analysis of randomized controlled trails. J Headache Pain. 2017;18(1):86. Link. Accessed February 11, 2021.

10. Goudra B, Shah D, Balu G, et.al. Repetitive Transcranial Magnetic Stimulation in Chronic Pain: A Meta-analysis. Anesth Essays Res. 2017;11(3):751-757. Link. Accessed February 11, 2021.

Dr. David Woo

Dr. Woo has been seeing patients in private practice since 2002, always with the goals of combining evidence-based medicine with psychodynamic psychotherapy and collaborating with other mental health professionals to ensure the best possible outcomes for his patients. He has been certified to administer TMS at his practice since 2017. His greatest clinical interests include helping patients suffering from depression, anxiety, and obsessive compulsive disorder.