Depression in the patient with chronic pain.

The management of patients with chronic pain is a challenging clinical problem that frequently requires a multi-disciplinary approach. Depression is a common comorbidity associated with chronic pain, occurring in as many as 50% of chronic pain patients. Depression may develop secondarily or independently of the chronic pain syndrome, or it may occur as the primary cause of chronic pain. Regardless of their etiology, evidence exists to suggest that depression and chronic pain share common biologic pathways, namely, the serotonergic (5-HT) and noradrenergic systems. Chronic pain patients who are depressed require aggressive, full-dose treatment with antidepressants. Treatment should be selected based on a prior clinical response, the side-effect profile, the dosing schedule, and the potential for drug interactions. The newer antidepressants, including the selective serotonin reuptake inhibitors venlafaxine and nefazodone, are therapeutic options for the treatment of depression in the patient with chronic pain.