Is my Foot Pain causing my depression, or is my depression causing my foot pain???

After the recent and most untimely death of the great comedian Robin Williams, I really started to think about a group of patients that we see here and there through out the practice that do take anti-depressant medications and present with uni-lateral or bilateral foot pain. And, maybe more importantly, the patients that may be depressed and do not take medication or who have not been seen by medical or counseling help.

This made me think about how many people present to our office that have foot pain, that seems pretty straight forward, but take longer than expected to get better.  Could their depression be causing their foot pain to linger longer? Or is it that having this foot pain has caused depression due to unwanted weight gain or not being able to loose weight because of their foot pain, for the already obese patient? In which case, they may be stuck in a vicious cycle, which their depression can play a vital role.

It also made me think about how we doctors are so tunneled visioned when it comes to some of our most straight forward type foot and ankle problems.  Problems, that predictably should be better within a certain time frame but just don't get better.  Some of these patients baffle us, we even write for the MRI to rule out the "Zebra" medical problem when the malingering ensues.  Only to get back a completely normal MRI.

Chronic foot and ankle pain was the recent area of interest during the Annual Meeting of The American Orthopaedic Foot and Ankle Society in 2013, linking a statistically significant amount of chronic foot and ankle pain with depression in this subset of patients.  In a study of 45 patients with chronic foot and ankle pain and 45 healthy patients as a control group, the researchers found a higher overall neuroticism and anxiety and depression scores in the patients with chronic foot and ankle pain over the control group. This study lends itself to the thought process of a multidisciplinary approach to this patient.  

Of course, chronic pain and its link to depression is not entirely a new concept.  Cymbalta is a medication that came to become a treatment for neuropathy pain associated with depression among other things.  Seems like a great option for patients suffering from chronic foot and ankle pain when associated with depression, except for the warning below as it is seen on the Cymbalta webpage:

WARNING

SUICIDAL THOUGHTS AND BEHAVIORS

Antidepressants increased the risk of suicidal thoughts and behavior in children, adolescents, and young adults in short-term studies. These studies did not show an increase in the risk of suicidal thoughts and behavior with antidepressant use in patients over age 24; there was a reduction in risk with antidepressant use in patients aged 65 and older [see WARNINGS AND PRECAUTIONS].

In patients of all ages who are started on antidepressant therapy, monitor closely for worsening, and for emergence of suicidal thoughts and behaviors. Advise families and caregivers of the need for close observation and communication with the prescriber [see WARNINGS AND PRECAUTIONS].

Cymbalta is not approved for use in pediatric patients [see Use in Specific Populations].

This does not seem to be the most encouraging warning depending on what demographic you are in. The psychiatric literature has long delved into this subject manner, exploring physical symptoms associated with depression.  As a part of our history and physical, asking patients about their mental status is always an uncomfortable subject matter to breach.  After all, these patients do not want their foot doctor to evaluate their head! As patients are not always forthcoming in this information, reading the cues in the untreated depressed patient becomes paramount. Below are the most common signs of depression according to WebMD:

• Difficulty concentrating, remembering details, and making decisions
• Fatigue and decreased energy
• Feelings of guilt, worthlessness, and/or helplessness
• Feelings of hopelessness and/or pessimism
• Insomnia, early-morning wakefulness, or excessive sleeping
• Irritability, restlessness
• Loss of interest in activities or hobbies once pleasurable, including sex
• Overeating or appetite loss
• Persistent aches or pains, headaches, cramps, or digestive problems that do not ease even with treatment
• Persistent sad, anxious, or "empty" feelings
• Thoughts of suicide, suicide attempts

  As it is extremely sad to hear of anyone taking their life, if there is anything anyone can do: the doctor, the family member or the friend to help someone find the right direction you should.  Identifying someones depression is the first step to helping them.  Opening up the lines of communication and helping them to the right professional help is also important and not always as easy. Of course this is one of those easier said than done scenarios, as society and its views on mental health are often negative.  If at the very least, all you can do is try your best to be nice and kind to everyone you meet, as you never know what is going on inside of their head. It is much better help keep their "Spark" lit:)  

  

Reference:

Platt. Paper #8. Presented at: American Orthopaedic Foot and Ankle Society Annual Meeting; July 18-20, 2013; Hollywood, Fla.