Session 5: Depression
I. Review of Homework – Pain Triggers
II. Signs and Symptoms of Depression
III. Chronic Pain and Depression
IV. How Does Depression Arise?
V. Treatments for Depression
VI. Homework – Scheduling Fun Activities
VII. Relaxation Technique – Deep Breathing Exercise
Session 5: Depression
I. Review of Homework – Pain Triggers
II. Signs and Symptoms of Depression:
Definition of Depression from the American Psychological Association DSM-IV-TR:
A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations.
(1) Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g. appears tearful). Note: In children and adolescents, can be irritable mood.

(2) Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)

(3) Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in one month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains.

(4) Insomnia or hypersomnia nearly every day.

(5) Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)

(6) Fatigue or loss of energy nearly every day.

(7) Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-approach or guilt about being sick).

(8) Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).

(9) Recurrent thoughts of death (not just a fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
B. The symptoms do not meet criteria for mixed episode.

C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug abuse or medication) or a general medical condition (e.g., hypothyroidism).

E. The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.
Vicious Cycle of Depression

Decreased Activity (Behaviors)
Decreased Positive Thoughts
Decreased Mood (Feelings)
III. Chronic Pain and Depression:
Reasons why chronic pain leads to depression:
1. Fighting pain is exhausting, it tends to sap a great deal of your energy. Therefore, you must make more of an effort simply to cope with the daily activities that you were able to handle quite well before your pain began.

2. Pain contributes to sleep disturbances. Without proper sleep you can’t “recharge” yourself and you feel physically tired most of the time.

3. Chronic pain contributes to worry about failure. Patients often do not know the exact reason for their pain and are concerned about being able to live a productive life in the future.

4. Most patients with chronic pain have to give up pleasurable events that they have enjoyed in the past.
Jamison, R. N. (1996). Learning to Master Your Chronic Pain. Sarasota, FL:
Professional Resource Press.

If this were true, you’d expect that there would be more depressed people with chronic pain than those who do not have chronic pain.
1. General Population: 5% of People are Depressed
2. Chronic Pain Populations: 33% of People are Depressed
3. Pain Conditions Among those that are Depressed: 40%
4. Symptoms of Depression in 67% of Population
Pain does not necessarily produce depression and depression does not necessarily produce pain. Pain and depression, however, influence one another.
IV. How Does Depression Arise?
1. Loss (of reinforcement).
· Decrease in pleasant activities, events, and interactions.

2. Distorted Thinking (stinkin thinking).
· World View: “Everything is bad”
· Future: “I’ll never be able to…”

3. Biochemical
· Genetic Predisposition (Runs in families)
· Treatments that increase certain brain chemicals influence mood.
V. Treatments for Depression
1. Biochemical Treatment – Some patients with pain and depression have abnormally low levels of serotonin a substance in the body that influences pain, sleep, and depression. Some of these patients take antidepressants.

2. Exercise and Activity – Increasing your activity (especial activity you find enjoyable) tends to alleviate depression by wearing you out physically and giving you something else to think about. Exercise also increases levels of chemicals in your body (endorphins) that help fight pain.

3. Relaxation – Using relaxation strategies on a regular basis helps you to cope more effectively with stressful situations and episodes of emotional distress, increasing your energy level and decreasing your depression.

4. Cognitive Therapy – Cognitive therapy emphasizes a problem-solving approach to dealing with negative emotions, identifying specific coping behaviors, and altering negative emotional states. Therefore, changing negative and irrational thoughts into positive thoughts.

5. Interpersonal Therapy – This therapy emphasizes social relations in treating depression. The treatment focuses on interpersonal problems you experience when interacting with others. Emotional expression is encouraged, and development of new social skills is targeted.

6. Accomplishment and Success – By taking a constructive, active approach to chronic pain and by setting realistic goals for changing your behavior in ways that will help you to cope with depression, you can regain a sense of success and accomplishment.
Jamison, R. N. (1996). Learning to Master Your Chronic Pain. Sarasota, FL:
Professional Resource Press.
VI. Homework – Scheduling Fun Activities
As mentioned earlier, increasing your activity (especial activity you find enjoyable) tends to alleviate depression by wearing you out physically and giving you something else to think about.

Make a list of activities you find enjoyable or activities you would like to engage in that you think you would find enjoyable.











Fill out one sheet for everyday of next week Make sure you fill out each column. Bring the completed sheets to the next session.

VII. Relaxation Technique – Deep Breathing Exercise
Deep Breathing Exercise
1. Lie down on the floor or sit up straight in your chair. Make sure not to cross your arms or legs.

2. Scan your body for tension.

3. Place one hand on your abdomen and one hand on your chest.

4. Inhale slowly and deeply through your nose. Feel the gentle downward push of the diaphragm. (The diaphragm pushes against the stomach, which lets the area above the naval bulge out.)

5. Exhale slowly and pull stomach muscles towards the spine during the entire exhalation.

6. Inhale, slowly and gently, being conscious of shoulders and chest being perfectly still.

7. Exhale slowly and experience a calm and peaceful feeling.

8. Continue to breathe deeply for the next 4 minutes.

9. Smile slightly and inhale through your nose and exhale through your mouth, making a quiet, relaxing, whooshing sound like the wind as you blow gently out. Your mouth, tongue, and jaw will be relaxed. Take long, slow, deep breaths that raise and lower your abdomen. Focus on the sound and feeling of breathing as you become more and more relaxed.

10. Continue to breathe making the whooshing sound for the next 4 minutes.

11. Once more scan the body for tension. Compare the tension you felt at the beginning to the tension you feel now.

Continue deep breathing for about five or ten minutes at a time, once or twice a day. Then, if you like, gradually extend this period of time twenty minutes.
Davis, M., Robbins Eshelman, E., & McKay, M. (2000). The Relaxation and Stress Reduction Workbook 5th ed. Oakland, CA: New Harbinger Publications, Inc. Strinivasan, M. (1989). A practice manual of hatha yoga. Baton Rouge, LA:


Process Questions:
Describe how relaxed you feel.
Death of a Painkiller?
2009-12-22 15:37:24

When an advisory panel to the Food and Drug Administration (FDA) recommended a ban on acetaminophen-containing pain relievers in June 2009, the response was quick and angry. We were deluged with consumer calls, says FDA spokeswoman Karen Riley. Why the outcry? The panel had suggested that the FDA remove acetaminophen from all prescription drugs, including Percocet and Vicodin, two of the most popular painkillers in the world. The panel also advised lowering the amount of acetaminophen in over-the-counter medications like Tylenol from 500 milligrams to 325, which would cap the maximum daily dose at 2,600 milligrams. The reason: Every year, about 400 Americans die and 42,000 more visit the ER because of acetaminophen overdoses, which can lead to liver damage.

The Sound of Music Eases Pain
2009-12-22 14:55:35
Researchers at Glasgow Caledonian University in Scotland found that people who were listening to their favorite music felt less pain and could stand pain for a longer period.
Running Barefoot Eases Pain
2009-12-22 14:54:49
Scientists have found that those who run barefoot, or in minimal footwear, have a very different stride from their shoe-wearing peers. The sneaker-less tend to avoid "heel-striking," and instead land on the ball of the foot or the middle of the foot. By landing on the middle or front of the foot, barefoot runners have almost no impact collision, much less than most shod runners generate when they heel-strike.