Fibromyalgia and Depression: What's The Connection? by Akiko Okifuji, Ph.D. Despite decades of research, the cause of fibromyalgia remains elusive and there are no treatments that reliably help everyone with FM. As you may know, FM patients usually have normal results on most standard medical tests. Many people with FM appear sad, depressed or anxious. As a result, some physicians and researchers think FM is at heart a psychological disorder. Some believe that FM is psychogenic (caused by psychological issues), while others suspect that a single underlying disorder causes FM and conditions like depression and anxiety. Yet the research evidence supporting such connections is relatively weak. Why aren't all FM patients depressed? If depression or anxiety were at the core of fibromyalgia, research should uncover these conditions in virtually everyone with FM. But less than half the subjects in my studies meet the criteria for depression, and other researchers have found depression rates ranging from 14 to 71 percent. The disparity seems to stem from different methods of diagnosing FM and depression, as well as variations in study participants. Despite some inconsistencies in FM research, review of the more than 2,000 published studies yields important clues. Although the depression rates found in FM vary widely, by even the lowest estimate of 14 percent it is clear that depression is far more common with FM than among healthy people. (Depression is estimated to affect only 2.7 to 4.6 percent of healthy men, and from 4.6 to 6.5 percent of healthy women.) On the other hand, research on other serious illnesses - such as cancer, lupus and rheumatoid arthritis - also finds high depression rates, ranging from 23 to 55 percent. Adding to the mystery is research showing that people with FM who do not seek medical treatment seem to have the same depression risk as healthy people. Mismatches versus similarities One striking research finding is that FM diagnosis correlates with a personal and family history of depression. Even more influential is the finding that decreased levels of the neurotransmitter serotonin are common in both depression and FM. Serotonin helps to regulate mood, sleep and pain. What's more, there are significant overlaps in symptoms of FM and depression, such as chronic fatigue and sleep disturbance. However, results on other research lab tests turn up contrasting results. Tests of cortisol levels, dexamethasone suppression, and urinary neopterin levels indicate that these biochemical substances behave differently in FM and depression. A few studies comparing FM with affective disorders found significant differences in pain sensitivity and sleep patterns. So past research really does not support the idea that FM is the physical expression of a depressive disorder. Is depression a reaction to having FM? An obvious question is whether depression can be a reaction to FM. This sounds reasonable, yet here again research suggests that the link is not so simple. You might expect that those with the most severe FM symptoms would be the most likely to be depressed. But in a study of 69 FM patients, my colleagues and I found that depression was not correlated with pain severity, number of tender points, or length of illness. Instead, depression was linked to certain negative thinking styles, living alone, feeling very limited in the ability to do daily activities, and not having undergone physical therapy. Surprisingly, the depressed and nondepressed people in our study reported similar usage of pain medications, antidepressants, and psychotherapy. Pain levels were the same regardless of antidepressant usage and psychotherapy, a result that again supports a distinction between FM and depression. The thinking style our study linked with depression is unduly negative, like the view of the glass as half empty rather than half full. An example of such thinking is "I feel awful and I'll never get better," while a more helpful thought is "I feel bad now, but I probably will feel better later." Another example is, "I am so sick that exercise is impossible," while a more adaptive thought is, "My illness makes exercise difficult, but I can try to find exercises that help and don't harm me." Our findings on physical therapy may be due to the fact that exercise can help combat depression and pain hypersensitivity. Regular exercise can also help you build strength that allows you to enjoy more life activities. It also is possible that, if you are not depressed, you may be more likely to try physical therapy. Our nondepressed study participants rated themselves as more active, less disabled, and more in control of their lives despite FM, as compared to the 48 percent of the participants who met criteria for depression. This probably reflects more than just a positive attitude; these nondepressed participants most likely had learned how to minimize pain's interference with daily life. As this study suggests, there are several ways to fend off the depression that can accompany FM. Physical therapy and pain management skills training may give you more control over your life despite FM. Sustained cognitive-behavioral therapy may be especially helpful in developing a more positive thinking style, as well as in boosting physical functioning and social support. How does this affect you? Depression and FM are both quite real conditions that can cause suffering and disability. Understanding the relationship between these conditions is important to help guide research and treatment. Meanwhile, the best course is to get careful evaluation and treatment for your own particular symptoms. If you can assess your sensations and feelings carefully, and speak openly with your health-care providers, you have the best chance of improving your quality of life. The mind is not truly separate from the body - after all we cannot live with only one of them! - although science has an unfortunate history of viewing them as different domains. I believe FM is a biopsychosocial condition; that is, not only physiological but also psychological and social factors can influence its course. Psychological and social changes inevitably result from FM, regardless of whether they play roles in causing it. And psychological and social changes can have very real physiological effects, both positive and negative. To combat FM, we must take all of these issues into account. Even if you do not feel depressed or anxious, you may still benefit from group or one-to-one sessions that address pain physiology, the rehabilitation process, and pain management skills that work well with medications that target FM symptoms. If you do have feelings of depression or anxiety, be sure to discuss them openly with a physician or therapist. Medication, exercise, support groups, counseling and stress-management training are among the options available to help overcome suffering associated with FM. Pain is always real. Even though pain is invisible, there are many treatments that can help. Just remember that, since everyone is unique, it may take some time to find what works best for you. Editor's note: How can you tell if you are depressed? Fill out the quick questionnaire at the New York University Medical School web site to get an idea of whether you should seek professional evaluation and treatment. About the author: Akiko Okifuji is an associate professor in the University of Utah's Anesthesiology Department, as well as Director of Behavioral Medicine at the University's interdisciplinary Pain Management Center. She treats pain clinic patients with an approach that combines cognitive-behavioral therapy with elements of interpersonal and dynamic therapy. She also serves on the Advisory Board of the Organization for Fatigue and Fibromyalgia Education and Research (OFFER). A licensed clinical psychologist, Dr. Okifuji earned a Ph.D. at the State University of New York at Binghamton and then completed an internship and a postdoctoral fellowship at the University of Pittsburgh School of Medicine. She is conducting several fibromyalgia studies funded by the National Institutes of Health, including a study of how pain and other FM symptoms vary across time in premenopausal women. If you would be interested in volunteering for one of Dr. Okifuji's studies, please see the painresearch at utah website or call her lab at (801) 585-7695.