Dr. David B. Adams – Psychological Blog

Psychology of Illness, Pain, Anxiety and Depression

Antidepressants and Pain

A patient sustained a significant back injury. This was three years ago. He eventually had surgery, and then they sent him to a pain clinic. There is nothing more that can be done. He is capable of alternate work, but he does not mobilize.

The most simple and direct approach is to begin earlier in the management of the patient. The most common pattern is that the patient was treated for many months with medication and physical therapy and no MRI. Then the MRI is finally authorized, and he is given a series of injections and more physical therapy with a change in medication.

He is frustrated and asks for a change of provider. He is seen and given more medication, more therapy and more injections and told that he is a poor surgical candidate.

After two more IME_s, he is told that he needs a diskectomy, laminectomy and/or fusion. There are more delays because this conflicts with previous opinions. He is led to believe that surgery will resolve everything. It is finally authorized, and he (along with everyone else) is disappointed to note that he still has substantial pain.

Rather than assess this as a permanent and partial disability, he is referred to a _pain center_ where he is initially seen frequently, on a host of medications including narcotics (despite his personal and family history of addiction), has more injections and is now seen solely for medication refills.

He is now deconditioned. He sleeps away his days and/or watches television. He and his family have moved into a smaller home, apartment, trailer or with parents. He has adjusted to his minimal income, nonproductivity, dependency upon others and a year ago applied for social security benefits which he now conceptualizes as the core of his financial well-being.

Most often cases are driven by patient complaints rather than a true assessment of probable outcome and recommended course of action. After several years, the case takes on a life of its own, having less and less to do with injury.

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