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A Psychosocial Perspective onChronic Pain and Depression in theElderlyRanjan Roy AAPSW aa Associate Professor, School of Social Work/Dept ofPsychiatry, University of Manitoba, Winnipeg, MB, R3T 2N2,CanadaPublished online: 26 Oct 2008.

To cite this article: Ranjan Roy AAPSW (1987) A Psychosocial Perspective on Chronic Painand Depression in the Elderly, Social Work in Health Care, 12:2, 27-36, DOI: 10.1300/J010v12n02_03

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A Psychosocial Perspective on chronic Pain and ~epression

in the Elderly Ranjan Roy, AAPSW

ABSTRACT. Chronic pain and depression often coexist in elderly individ- uals. This paper explores, from a clinical perspective, the antecedents for depressive symptoms in older chronic am patients. A case is made for active social work inte~ention with erderiy patients who manifest this complex syndrome of chronic pain.

INTRODUCTION

Depression in an elderly chronic pain patient is a complex issue en- countered on a daily basis in clinical practice. Chronic pain in an aged person is often accompanied by emotional distress and changing and painful life situations. Many of these individuals manifest depressive dis- orders. In others seemingly depressed mood can be accounted for by very difficult familial, economic and other psychosocial variables.

Alleviation of psychosocial stressors frequently result in both reduc- tion of pain and depression in this group of patients. That social work has a clear role in the management and treatment of these patients is beyond doubt and hopefully, this paper will make a persuasive case to that end. It also needs to be stated that contribution of social work to this emerging field of multidimensional health problem viz., chronic pain, remains lim- ited.

LITERATURE REVIEW

During the past two decades the problem of chronic noncancer pain has attracted immense attention in the literature and specialized pain clin- ics are now a common feature of most medical schools in North America

Ranjdn Roy is Associate Professor, School of Social Work and Dcpl. of Psychiatry, University of Manitoba, Winnipeg. Canada R3T 2N2.

Social Work in Hcalth Care. Vol. 12(Z). Winlcr 1986 O 1987 by Thc Haworth Prcss, Inc. All rights reserved. 27

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and Western Europe. A simple definition of chronic benign pain is a pain problem that has lasted for 6 or more months, is idiopathic and has been unresponsive to conventional treatment. In some instances, the complain- ing of pain and associated disability is disproportionate to an existing pathology.

Elderly people frequently suffer from a variety of chronic ailments including chronic pain. Joint and muscle pain due to connective tissue disorder is commonly associated with the aging process. It is, therefore, not surprising that the problem of chronic benign pain in the elderly has been by and large ignored in the literature. Hunt (1980) in a review of pain problems in old age concluded that "pain is considerably modified in its perception as a result of physiological age-related changes. Diag- nostic difficulties also arise because of various other changes in the older person, for example, memory loss." Perhaps, for these reasons, problems of pain are taken for granted or underestimated in the elderly population.

Incidence and prevalence of chronic benign pain amongst the elderly is virtually unknown. In a recent study of 132 elderly subjects, 97 of whom were residents in a nursing home and 35 day-patients at the same nursing home, 83% reported having some form of current pain-related problems (Roy & Thomas, 1986). Persons with known physical and mental disabil- ities of a serious nature were excluded from this study. The paucity of epidemiological data is not just confined to the elderly. Accurate data does not seem to be available on the prevalence of chronic pain in the general population either, but rough estimate is that 35% of all Americans are afflicted by pain (Bonica, 1977). Crook, Rideout and Browne (1984) found that 16% of individuals in 500 randomly selected households suf- fered from pain symptoms. Approximately 50 million Americans consult their physicians every year because of severe or frequent headaches (Ra- popart et al., 1983). A significant percentage of these patients are elderly.

Depression in the elderly is also a common problem and a complex one. Weissman and Myers (1979) found a prevalence rate of 10% for depression in an elderly group of subjects aged between 66 and 75 years. They noted that epidemiological studies of depression in the elderly had serious shortcomings and were plagued by conceptual and methodologi- cal problems.

The diagnosis and the course of depression in the elderly is compli- cated by a number of factors (Cole, 1983; Fogel & Fretwell, 1985; Schatzberg et al., 1984). First, lowering of mood and sadness associated with loss of self-esteem are common features of many physical illnesses as well as side effects of treatment. Ouslander (1982) noted that a number of physical illnesses were associated with depression in the elderly. Alter- natively, "in many instances depression develops in response to the chronic pain, loss of function and self-esteem, dependence, and fear of death that accompany physical illness in the elderly." Social factors also

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Ranjan Roy 29

seem to have some significance in the genesis of depression in the elderly. Murphy (1982) compared elderly depressive subjects with normal elderly in the general population and found an association between severe life events, major social difficulties, poor physical health and onset of de- pression. Subjects from a working class background within the general population demonstrated a higher incidence of depression and an associa- tion was found between higher incidence of depression and their general poor health and higher levels of social difficulties. In addition, those elderly individuals who did not have a confiding relationship demon- strated a higher level of vulnerability to depression. In short, while de- pression is a common problem of old age, it is vastly complicated by psychological, social and health reasons.

Depression is not an uncommon feature of chronic pain syndrome. Some authors have even claimed that is a variant of depressive disorders (Blumer & Heilbronn, 1982). Several studies have reported a very high prevalence of depression in this population. However, recent reviews of research investigations raise serious questions about the validity of many of the findings demonstrating a high correlation between depression and chronic pain (Romano & Turner, 1985; Roy et al., 1984). The shortcom- ings of many of the studies centered on poor and varied definition of the concept of depression itself, poor measurement for pain, highly selected subjects and lack of controls.

CASE EXAMPLES

The remainder of the paper is devoted to an exploration and case illus- trations of the complexities that surround the problems of depression in elderly chronic pain sufferers. These examples have been selected from a population of chronic pain patients attending a pain clinic at a teaching hospital to demonstrate that they experience a similar range of psychoso- cia1 problems as do their younger counterparts, with complex underlying emotional factors and difficult life situations. A few of these patients manifest depressive disorders. In others, seemingly depressed moods can be accounted for by difficult familial, economic and other psychosocial variables. They demonstrate a whole range of mood related problems encountered in the elderly population and they represent the younger end of the old age continuum.

Mr. C., Age 69: Where Is the Pain?

Mr. C. was referred by his family physician. This man had a long history of head pain which had increased since his retirement at age 66. Apparently, he had had this pain from his late adolescence, but never

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sought medical help until about 2 years ago. Another aspect of his head pain was that he categorically refused to take any medication for his pain. Other than his problem of headaches, he was a healthy person.

Mr. C. had a highly successful business career. At the time of his retirement, he was vice-president for a well known multinational firm. He was also very active in charitable activities. A notable aspect of his behaviour was that from the very outset of interview, he minimized his pain problem. He revealed that he was confronted with a number of seri- ous issues, Retirement had proven to be a more hazardous event for him than he anticipated. Besides, his wife was seriously ill with diabetes and had lost her sight a year ago. He seemed unusually detached and almost clinical as far as wife's medical problem was concerned. He was proud of the fact that he had never had a serious argument with anybody. No one could accuse him of losing his temper.

Conceptually, he seemed to fit the description of individuals who uti- lize head pain or any other kind of pain problem to convey negative affects. These individuals experience great difficulty in giving expres- sion to their sadness. From a clinical perspective, the problem of Mr. C.'s head pain was so nominal that one wondered why he was spending so much time seeking help for it. For a man of his intellect and personality, it was not surprising that he sought help through his physical symptoms for underlying psychological distress about which he only had a very vague appreciation.

As far as interventions were concerned, in the first place it was of a negative nature. He was actively discouraged by the pain clinic staff from seeking active medical help for his head pain and engaging in doctor shopping. He was engaged in short-term individual treatment to come to terms with his retirement and wife's illness. His headache was masking his sense of loss and psychotherapy enabled him to confront these issues. His headaches disappeared. In summary, a 69-year-old man with a suc- cessful career encountered serious difficulties with post-retirement adap- tation as well as deteriorating health in his spouse with the serious disabil- ity of blindness. His headache served the primary function of conveying his lcvel of psychosocial distress.

Miss B., Age 68: Where Is the Depression?

Miss B., was referred to the pain clinic with an unremitting complaint of back pain which had commenced some 3 years earlier and had contin- ued unabated. She had been thoroughly investigated from neurological, orthopedic and other medical perspectives, none of which yielded posi- tive finding for her back pain. Miss B. complained that since the onset of her pain she had been more or less confined to her apartment and in general terms, was living the life of an invalid. She had a sister living

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nearby whom she rarely saw. In any event, she had little need to socialize or interact and clearly stated that her pain was dominating her waking as well as sleeping hours in view of the fact that she was not sleeping very well. She denied any significant feelings of sadness and depression.

Her past history revealed she was a competent woman who had run her business most of her working life and devoted the rest of her life looking after her sick and elderly mother. She was very active in her business community in the Chamber of Commerce, etc. Six months prior to the onset of her pain problem, she retired and a year later her mother died. From all accounts, she decompensated very quickly. For the past 3 years or more she had been on a medical treadmill going from doctor to doctor trying to find an answer and cure for her back pain.

Although she denied any feelings of depression, there was significant evidence of other vegetative symptoms normally associated with depres- sion such as early morning waking, a massive loss of appetite, anhedo- nia, lack of energy and drive. This is not an uncommon manifestation of depression in patients with chronic pain where the pain becomes a substi- tute for sadness and depression. However, in older chronic pain patients the vegetative symptoms can be an integral part of the pain problem it- self. The diagnosis of clinical depression has to be made with some cau- tion. In older subjects, according to Dessonville and his colleagues (1985), symptoms of self-depreciation are key to an accurate diagnosis for clinical depression. In the case of Miss B., there was indeed much evidence of self-depreciation and in spite of the fact that she had led a highly successful life, she now regarded herself as a total failure.

As far as treatment was concerned, she was placed on 75 mg of tricy- clic anti-depressant and the social work intervention consisted of ena- bling this woman to re-integrate into the community at large. She en- gaged in a number of volunteer activities, took in a lodger in the person of her nephew who was a university student, as well as resumed her relation- ship with her sister. This translated into taking a winter holiday. In a matter of 2 months, Miss B. reported a significant reduction in her pain problem and was beginning to function at a level that had counteracted her sense of being a failure. In other words, there was much evidence of improvement in her general outlook and in her mood. The efficacy of anti-depressant in the treatment of chronic pain and depression has been widely reported. Combining that form of treatment with a task-centered approach as developed by Reid and Epstein (1978) often proves a power- ful combination for counteracting pain and depression.

Mrs. H., Age 65: Pain of Desertion

Mrs. H. presented with a curious history of pain. The pain did not seem to be confined to any particular location, but varied from day to

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day. Initially, her pain complaints commenced with that of back pain. Extensive investigation of her pain complaint failed to reveal any organic basis.

Mrs. H. was married for 24 years to an alcoholic and had three daugh- ters by this marriage. The marriage was stormy, marred by arguments and physical fights. Once she broke away from this marriage, she remar- ried a man with a strong religious background. This marriage was charac- terized by lack of affection and Mr. H. pointed out that he had had a great deal of difficulty expressing his emotions. In contrast, Mrs. H. described herself as normally outgoing and an effervescent person. Sexual relation- ship was totally absent and the patient's general feeling was that her hus- band was basically unsympathetic and distant.

She displayed a substantial loss of libido, an inability to enjoy herself, loss of self-esteem combincd with pervasive sleep disturbance and loss of appetite. There was also a loss of about 20 pounds in weight over a 12- month period. Her mood was characterized by sadness and she cried eas- ily and frequently. She gave very little overt evidence of any suffering with her pain problem. On the other hand, she was very easily upset at the thought that her three daughters had virtually abandoned her. In es- sence, this woman felt abandoned by everyone including the medical profession. She had the feeling that physicians accused her of lying about her pain to get attention and in general, nobody really had an adequate understanding of her pain and suffering.

Given the harshness of her life situation, it was not surprising that this woman had developed a certain level of depression. Her self-esteem was severely compromised and her persistent complaint of pain seemed to convey her general disaffection with life. In view of the pervasiveness of the vegetative symptoms such as insomnia, loss of libido, and appetite as well as loss of self-esteem, she was placed on tricyclic anti-depressant. She and her husband were recommended to enter into conjoint marital therapy which is still undcr their consideration. In the meantime, Mrs. H. has responded quite favourably to the anti-depressant medication and there is evidence of improved coping with day to day living. Her pain complaint has improved only marginally.

Mrs. S. B., Age 73: Pain of Death and Grief

Mrs. S. B. presented at the pain clinic with a complaint of severe headache which had lasted for about 2 years. She had a lifelong history of headache which only exacerbated more recently and happened to coin- cide with the sudden death of her husband. This patient came to the clinic with a daughter who stated that Mrs. S. B. had inadequately grieved her husband's death. In the course of the interview, it became very evident that Mrs. S. B. was somewhat prone to internalize her negative thoughts

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and feelings. She admitted that she did not cry at all over her husband's death; she gave little evidence of any emotion while talking about him.

She lived alone and was frequently visited by one of her two daugh- ters. She seemed to be very well connected with her neighbours, but of late she was confining herself more and more to her own home and spending an inordinate amount of time watching television in a darkened room. She complained of pervasive sleep disturbance and loss of appetite which did not fit with the fact that since the death of her husband she had gained something like 15 pounds. She denied any sad feelings and could not explain how her life would be any different if she did not have any more headaches.

Conceptualization in this case was that Mrs. S. B. was giving consid- erable evidence of persistent, albeit somewhat unusual, grieving as a result of which she was displaying marked depressive and pain symptom- atology. The complaint of headache was in effect a substitute for grief. She refused to engage in any form of treatment which included psycho- therapy, relaxation therapy and occupational therapy, with the pain clinic. Efforts are underway to persuade her to return to the pain clinic.

Mr. M. S., Age 68: Pain Complicated by Marriage

This retired civil servant presented with a long history of medical prob- lems. His pain problem was associated with herpes zoster which was of several years' duration. In addition, he had emphysema. His history of psychiatric difficulties consisted of depression and claustrophobia which he developed during the Second World War.

Psychosocial history revealed that he was married and had three chil- dren all of whom were well placed. He also had a retarded daughter who died in 1982. There was an element of unresolved grief in both him and his wife in relation to this death.

His pain seemed to be controlling his entire existence and there was considerable evidence of pain behaviours which were being reinforced by his wife. The concept of pain behaviours and the reinforcement of pain behaviours by the spouse is a topic that has received considerable atten- tion in the literature and strong empirical support (Kremer ct al., 1985). The net effect of engaging in pain behaviours and having those beha- viours reinforced by a spouse is that the pain patient tends to function at a much lower level than he is capable. That was indeed the case with Mr. M. S. In spite of the reasonable state of control of his herpes zoster and emphysema, he was virtually living the life of a semi-invalid.

This couple was engaged in short term behaviourally-oriented marital therapy primarily to help the patient to disengage from pain behaviours and the wife from reinforcing pain behaviours. The net effect of this was that Mr. M. S. reported a marked improvement in his functional abilities.

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After many years, he was venturing out of the house by himself and going for longer and longer walks. He was also beginning to help his wife around the house, something he had not done for very many years. There was some evidence that their level of intimacy was beginning to improve, but Mrs. S . was quite adamant there was going to be no resumption of sexual activities as she was quite afraid of Mr. S.'s breathing difficulties. This was indeed another sign of reinforcement of illness behaviour, but for her own reasons Mrs. S. refused to negotiate any change as far as their sexual relationship was concerned. In spite of that particular drawback, there was marked improvement in Mr. M. S.'s mood as well as his general level of functioning. At the point of his 6 month follow-up he was seem- ingly maintaining his improvement.

ROLE FOR SOCIAL WORKERS

The case examples furnish ample evidence that while these patients presented themselves at the pain clinic with clear complaints of pain, a careful psychosocial investigation of their environment revealed in each case powerful information of social dysfunction and psychological dis- tress. As is often the case, pain in many of these instances served to convey a variety of negative emotions such as sadness, rejection, grief, and loneliness (Roy, 1984). That the problem of pain was rcal is undeni- able and a few of the patients presented here also displayed clear evidence of mood disorder which primarily consisted of vegetative signs plus a marked sense of self-depreciation. Some of them clearly denied any sad feelings. They responded favourably to tricyclic anti-depressant medica- tion. Although somewhat controversial, value of anti-depressants in the treatment of pain and dcpression is well documented (France et al., 1984; Rosenblatt et at., 1984).

However, it is from a social work perspective that the cases assume considerable significance. A clearly defined task-centered approach proved to be efficacious in one case. Marital therapy, other forms of psychotherapy, advocacy, environmental manipulations are also relevant modes of intervention by social workers with the aged as they are with younger populations.

There may indeed be a tendency to describe pain and depression in the elderly as a naturally occurring phenomenon and almost as a part of being old. A recent study revealed that in an elderly nursing home population, pain problem was not recognized in 16% of the residents and among a group of 35 day-hospital patients age 65 years and over at the same nurs- ing home, depression remained an unrecognized phenomenon (Roy & Thomas, 1986). It is also a fact that pain problems in the elderly are generally treated with analgesics and other forms of treatment for chronic

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pain do not seem to be readily available to this group of patients. Reports of behavioural treatment for chronic pain in the elderly are few and far between (Miller & Le Lieuvre, 1983). As a matter of fact, for the type of pain problems in the elderly described in this paper, the benefits of adopt- ing a cornprehcnsive approach which includes medical, psychological, social and familial, are not readily acknowledged. The role of social work in relation to chronic pain is an emerging one. It has been argued else- where that for any kind of comprehensive approach to the treatment of chronic pain, social work has to be an integral component of an interdis- ciplinary team (Roy, 1981; 1987). The same argument can be made in relation to the treatment of chronic pain in the elderly.

For reasons that are unclear, relatively few elderly patients present themselves at chronic pain clinics. Conceivably, their physicians and other caretakers may not regard the pain problems of the elderly as requir- ing specialized attention of a pain clinic. On the other hand, when the elderly patients present themselves at the pain clinics, their emotional and other psychosocial problems appear to be just as serious as they are in their younger counterparts. Social workers working.in pain clinics and other strategic locations where they are likely to interact with the elderly such as in nursing homes and hospital-based geriatric programs should maintain a high level of vigilance to avoid the problems of an elderly chronic pain sufferer being taken for granted. The treatment of chronic pain and depression in the elderly require just as comprehensive an ap- proach including biological, psychological, social and familial perspec- tives as they do for younger patients.

CONCLUSION

Coexistence of pain and depression is perhaps not an uncommon phe- nomenon in old age. Depression has many different causes and manifes- tations in the elderly. Case examples in this paper demonstrate the mes- sage value of pain from many diffcrent perspectives. Regardless of whether or not these patients were clinically depressed, they demon- strated the need for social work assessment and 4 out of 5 cases gave some evidence of improvement in their level of functioning as a result of social work intervention. The elderly patients encounter a whole range of social problems and losses that must only exacerbate their painful states.

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