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Posted January 9, 2008

Fr. Eric, Sr. Jane & Br. Bob

Joseph P. Collins Jr., D.O., a psychiatrist, is Director of Medical Services at SLI

Case Study: Fr. Eric, Sr. Jane & Br. Bob

Pain and depression can be intimately linked, often sharing similar characteristics. An accurate diagnosis and effective treatment of both the chronic pain and the depression are essential if a person is to be treated effectively. The following cases illustrate the interplay of pain and depression and how both are addressed through medication, psychotherapy and adjunctive therapies.

Fr. Eric is a 48-year-old priest who belongs to a monastic order. About one year ago, his elderly mother was diagnosed with metastatic colon cancer that had spread to her liver and lungs. Faced with the certainty that she had not long to live, he took a leave of absence from his community to be with her during the final weeks of her life. With the assistance of home hospice he lovingly cared for her until the day she died.

Following her death, Fr. Eric understandably experienced profound sadness and grief. As with many people who have recently lost a cherished relative or friend, he experienced sleep disturbance, poor appetite, fatigue, lack of concentration, and he lost interest in spending time with others. In addition to these signs of grief, he felt an overwhelming intense physical pain throughout his body. He constantly ached, and it was almost unbearable. A bereavement period is usually characterized by a lessening of symptoms as the weeks pass. Yet for Fr. Eric the physical and psychological pain persisted and intensified. He began to slip into a clinical depression. Within a month he attempted to return to his ministry at the abbey retreat center, but he felt overwhelmed with his work and struggled to complete his duties.

When Fr. Eric was seen for a psychiatric evaluation, it was recommended that he start taking Cymbalta, an antidepressant also known to be helpful for treating physical pain. Even though his physical pain was most likely caused by psychological factors, it was a real part of his depression and not something he imagined. Within two weeks after beginning the Cymbalta, his depression began to lift and the pain eased. A month later he was free from the bodily pain and no longer experienced the crippling symptoms of depression. He felt his grief to be more manageable. He reported, “The medication hasn’t taken away the feelings I have for my mother. I still become tearful when I think of her, but I don’t slip into that deep depression any more. I also don’t feel the intense pain throughout my body.” In therapy, he finds it easier to talk about his tremendous personal loss and work through his grief.

Sr. Jane is a 54 year old inner city elementary school principal. She reported a history of migraine headaches, anxiety, and mild depression. Her neurologist in her home town prescribed a low dose of Elavil for her headaches, an antidepressant that is also used for pain. During a recent year-long community fund-raising effort to build a new gymnasium and state-of-the-art media center, her migraines began to occur on almost a daily basis. Her neurologist increased the dose of Elavil, which helped her migraines, but did not prevent panic attacks and depression that began to break through the medication because of her level of stress. At SLI she was found to be struggling with frequent bouts of tearfulness, low energy, decreased appetite, and critical thoughts about herself. She felt hopeless and helpless about her situation. Because she experienced mild dry mouth and constipation from the Elavil, a decision was made not to increase her dose, but instead to add Zoloft, another antidepressant, to help with her residual anxiety and depression. This proved to be of effective. On the combination of low doses of Zoloft and Elavil, she found the physical symptoms of anxiety, depression, and chronic migraines were well controlled. She then felt more able in therapy to focus on other issues in her life that were contributing to her difficulties, such as learning how to resolve conflicts with her religious superiors, communicate effectively with diocesan education officials, and develop a better working rapport with parents and teachers.

Br. Bob is a 37-year-old novice. He was referred to SLI for evaluation of recurrent depression. Since early adulthood, he had experienced four periods of depression that had lasted for at least one month. They tended to occur during the winter months and resolved as the weather warmed and daylight lengthened in the spring. He had been tried on various antidepressants in the past with mixed results; no medication seemed to work very well. Light therapy for the seasonal changes in his mood was only marginally effective.

Br. Bob also reported a history of trigeminal (facial nerve) neuralgia, a chronic pain condition in which the afflicted person experiences excruciating pain along the side of the face. The inflamed nerve along the jaw line produces a sharp, stabbing pain. He had been treated for this condition with Tegretol for a number of years and felt significant relief. Yet his depressions continued to recur.

During his psychiatric evaluation, he revealed that he also had periods of increased activity, irritability, racing thoughts, and a decreased need for sleep. He was more apt to act impulsively and seek out anonymous sexual encounters during these times. These periods could last up to a week or two. It became clear that his diagnosis was bipolar disorder instead of depression. So he was gradually transitioned from Tegretol to Lamictal, a mood stabilizer that is particularly effective for people with bipolar disorder who suffer from depression, and it also alleviates chronic pain. Within a month he felt much better. After he left SLI, his psychiatrist at home continued to monitor his medications. Several months later in a phone conversation, he reported that he remained “pain free” -- the pain from his trigeminal neuralgia remained in remission. In addition, he no longer experienced the bipolar mood swings of depression and hypomania.

LUKENOTES is a bi-monthly publication of Saint Luke Institute. Telephone (301) 422-5579 Fax (301) 422-5400 lukenotes@sli.org www.sli.org