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Written by

Professor Harald Breivik Harald Breivik is emeritus professor of anaesthesiology, University of Oslo; consultant at the department of pain management and research, Oslo University Hospital, Oslo, Norway; and editor-in-chief, Scandinavian Journal of Pain

Depression and pain in adults

Published 18 September 2017

Pain expert Professor Harald Breivik looks at the relationship between chronic pain and depression, and how the management of these patients needs treatment for both comorbidities.

Depression and pain – which is the chicken and which is the egg?

The short answer is that these two emotions or sensations often interact. A chronic pain condition disrupting everyday activities lowers mood and consumes mental energy leading to fatigue and depression. A primary mental depression causes physical inactivity, a risk factor for musculoskeletal pain. The negative thoughts typical during a depressive episode can cause catastrophising thoughts about never getting better from pain and fatigue, deepening the depression.

Depression aggravates suffering from chronic pain and widespread pain aggravates the suffering from a deep depression. Clearly, management of these patients needs treatment for both comorbidities.

Professor Steven Linton in Örebro, Sweden, and his group of academic clinical psychologists emphasise comorbid depression as a negative prognostic indicator of outcome for chronic low back pain. They also demonstrate how low self-efficacy and a tendency to catastrophising thoughts about never getting better are obstructions to recovery. They report that with non-pharmacological psychotherapy, they can help these patients master their negative thoughts, lift low mood, and increase the patient’s ability to manage everyday activity and improve functions.1,2,3

Pain physicians managing patients with chronic pain with obvious comorbid depression tend to prescribe serotonin-noradrenaline reuptake inhibitors (SNRIs), especially when the patient demonstrates symptoms and signs of neuropathic pain.4 These drugs are used off label as first-line drugs for neuropathic pain and are frequently used as antidepressants. They should therefore be ideal for pharmacological treatment of neuropathic pain in patients with comorbid depression. The opioid agonist and serotonin-noradrenaline reuptake inhibitor tramadol is recommended as a second-line drug for neuropathic pain.4

However, the co-administration of venlafaxine or duloxetine with tramadol increases the risk of serotonin-syndrome. Misdiagnosed or unrecognised serotonin-syndrome has caused severe mental disturbances, neuromuscular hyperactivity and cardiovascular crisis in patients treated with venlafaxine and tramadol for pain and depression.5 For some reason, this complication remains unrecognised and therefore a potentially dangerous adverse effect of well-intended pharmacological treatment of patients with comorbid pain and depression. Tramadol can also increase the potential for SNRIs to cause convulsions.6

  • Harald Breivik is emeritus professor of anaesthesiology, Universitetet i Oslo, Norway. He is also editor-in-chief of the Scandinavian Journal of Pain


  1. Linton SJ, Bergbom S. Scandinavian Journal of Pain 2011;2:47–54.
  2. Linton SJ, Nicholas MK, et al. European Journal of Pain 2011;15:416–422.
  3. Linton SJ, Fruzzetti AE. Scandinavian Journal of Pain 2014;5:151–158.
  4. Finnerup NB, Attal, et al. Lancet Neurology 2015;14(2):162–173.
  5. Nelson EM, Philbrick AM. Annals of Pharmacotherapy 2012;46:1712–1716.
  6. Tramadol SmPC. Available at: www.medicines.org.uk/EMC/medicine/24186/SPC. (accessed 30 August 2017).

Date of preparation: September 2017; MINT/PAEU-17048