Depression is the most common type of emotional disorder.  In the general population, approximately 5% of people are depressed at any one point in time and about 20% experience a clinical depression during their lives.  In general, there is a relationship between chronic pain and depressive illnesses. Patients with chronic pain are more likely to be depressed, to have thoughts of suicide and to attempt suicide than those without pain.  As you might expect, rates of depression are significantly higher among patients with Fibromyalgia Syndrome (FS).  Approximately 30% of patients who have FS also suffer from a clinical depression.

So what is depression?

When psychologists and psychiatrists talk about depression, it has a very specific meaning.  A clinical depression or what is called a Major Depressive Episode is characterized by changes in the following areas:

•   physical (e.g. weight change),
•   motivational (e.g. lack of interest in life),
•   mood (e.g. feelings of sadness),
•   social (e.g. withdrawal from others)
•   cognitive (e.g. difficulties thinking or concentrating) and
•   self-esteem changes (e.g. feelings of worthlessness)

In order to meet established diagnostic criteria, these symptoms must persist for at least two weeks.  Depression is different than the periods of sadness that are part of the normal human experience.  When someone close to us dies or we are unable to reach an important personal goal, our sad feelings are a normal reaction.  In fact, it would be abnormal if we didn't feel sad in such circumstances.  This type of mild, transient depressed mood usually  passes quickly - especially if you are able to use your usual reliable coping strategies (e.g, talking to a friend, distracting yourself, socializing).  But depression is different.  Unlike healthy sadness, depression goes on and on.  We feel a loss of self-esteem, we feel hopeless, our thinking becomes distorted, our normal coping strategies are ineffective and as a result, we have difficulty functioning on a day-to-day basis.

With FS, it is normal to feel hurt and grief over the losses that have been experienced.  Loss of some physical abilities, job loss, changes in relationships with others and elimination of future plans are all experiences that can precipitate grieving.  We must grieve before we can accept our losses and move on emotionally.  But if we are unable to grieve and/or these feelings persist, a depressive disorder may have developed.   However, it is often difficult to determine if a person with FS is depressed because depressive symptoms also overlap with those of FS.

Like FS patients, those with depression often have sleep problems, fatigue, concentration problems and have difficulty working and participating in social activities.  Both disorders are also associated with lower levels of the neurotransmitter serotonin in the brain.  This is one reason why certain antidepressant medications such as amitriptyline that increase serotonin are frequently used to treat FS.  The observation that depression and FS share this serotonin abnormality has also led some researchers to speculate that depression and FS may have a common physiological basis.  However, this view has received little scientific support and other neurotransmitters such as Substance P appear to play an important role in FS but not depression.  It seems most likely that, in general, the depression that occurs in people with FS is similar to that seen in patients with other chronic illnesses such as rheumatoid arthritis.  Certainly chronic illness can cause depression.  But it is also possible to develop emotional problems for reasons that are indirectly related or unrelated to FS.  Interpersonal problems, marital and family problems, alcohol or drug dependency, problems at work and other stresses of life can increase the likelihood of becoming depressed.  Whatever the reason, depression is likely to increase the intensity of symptoms in FS.  Emotional distress will increase pain and fatigue at the very time your ability to cope with these symptoms is reduced.

When to seek help for psychological problems

Despite our best efforts, there can be times when we become overwhelmed emotionally and become depressed.  The point at which depression occurs is different for everyone and depends upon our individual coping abilities, previous life experiences, current emotional demands and our ability to tolerate emotional distress.  But when we run out of ways to cope and our problems persist, professional help should be considered.  Sometimes it is clear that help is needed.  Anxiety and depression can be so severe that they demand attention.  For example, if a person becomes desperate enough to view suicide as a viable option or even has suicidal thoughts, help should be sought immediately.

In other circumstances, the need for help may be less clear.  It is up to you to decide whether or not your problems are overwhelming your ability to cope.  If you decide that professional assistance would be useful to you, here are some of the places you can look:

•   psychologists
•   psychiatrists
•   social workers and counsellors
•   your workplace Employee Assistance Program

Because depression can sometimes be related to medical problems other than FS (e.g., hypothyroidism), it is a good idea to discuss your symptoms with your family doctor or rheumatologist.  It is also important to find a mental health professional who accepts the diagnosis of fibromyalgia and is knowledgable about the many stressors one confronts when living with chronic pain.  The person you consult should be someone with whom you feel comfortable discussing your personal problems.   Those who fail to listen, treat you in a judgmental manner or don't take your concerns seriously are not likely to be effective in helping you deal with emotional problems.  The importance of a trusting relationship between you and the person providing the therapy cannot be underestimated.  Friends who have had therapy in the past, your family doctor, priest, rabbi or pastor can often be helpful in recommending a therapist.

There are basically two types of treatment for depression: psychotherapy and drug therapy.  Within the category of psychotherapy, there are a number of basic approaches.  These include:

•   behaviour therapy: teaches new coping skills; seeks to change behaviour rather than personality
•   psychodynamic therapy: focuses more on underlying personality and drives that determine behaviour
•   cognitive-behavioural therapy: focuses on negative thinking patterns and emotions as well as behaviour
•   interpersonal therapy: focuses on interpersonal relationships and conflicts in relationships

The most effective therapies for depression are action-oriented, focused and specific.  The most important questions are: What is making you unhappy? and What can you do about it?  Effective treatments are more than just talking about your symptoms. They should involve a concrete plan of action.  This type of therapy can often produce a quick improvement in symptoms, typically within a matter of weeks.

Drug therapy can also be useful for people who are experiencing a severe depression.  For people who are so depressed that they are unable to function or are suicidal, antidepressant drugs can be, literally, a lifesaver.  These medications can often improve your mood enough to allow your regular coping strategies to be effective again.  However, psychotropic drugs often have significant side effects especially when taken together with other prescription medications.  The non-compliance rate for these medications is as high as 60 or 70%.  It is very important that these drugs be prescribed by a doctor who has specific training in psychopharmacology and is knowledgable about their proper dosages, side effects, and interactions with other medications.  They should also be able to explain these things to you in a clear, understandable manner.

Although it is often difficult to admit that help is needed, especially where emotions are involved, obtaining that help will help you get things back on track - sometimes even more quickly than you expected!