6 Reasons Why Major Depression Is So Painful

Research reveals why we hurt emotionally.

Posted Feb 26, 2018

Zivica Kerkez/Shutterstock
Source: Zivica Kerkez/Shutterstock

Anyone who's experienced an episode of major depressive disorder will tell you depression is painful. I've seen the pain in countless people who've sat across from me in my therapy office; it's evident in their facial expressions, their voices, their body language. The pain can be preoccupying, just like physical pain, making it hard to focus on anything else. 

When we say we're "hurting emotionally," we mean that in more than a metaphorical sense: Deep depression is painful. Perhaps the best evidence that depression is painful is also the most tragic — a staggering number of people find the pain so intolerable that they choose to end their lives to end the suffering.

Many studies have been done to try to understand the connection between depression and pain. The following factors have emerged as possible explanations for why depression hurts.

1. Common Brain Areas.

Multiple studies have shown that psychological pain and physical pain activate some of the same brain regions. Areas that are often associated with both types of pain include the insula (which facilitates awareness of our internal states), regions of the frontal cortex, including the anterior cingulate cortex, and the thalamus (the brain's relay station). The most notable difference in the brain between physical and psychological pain seems to be that physical pain activates somatosensory brain regions, which are involved in our sense of touch. Thus, the brain seems to be interpreting psychological distress in similar ways to physical distress without a specific area of the body from which the pain emanates.

2. Common Neurotransmitters.

In addition to common brain areas, physical and emotional pain appear to involve similar neurotransmitters, including serotonin, GABA, glutamate, and norepinephrine. In fact, medications that can relieve depression symptoms, such as selective serotonin reuptake inhibitors (SSRIs), are also prescribed for some pain conditions. There is evidence that a neurotransmitter called "Substance P," which is closely linked to our ability to detect threats and experience physical pain, is involved in depression as well. What's more, the levels of Substance P among depressed individuals are correlated with certain depression-related structural differences in the brain.

3. Inflammation.

Inflammatory cytokines are chemicals in the body that promote the inflammation response. Inflammation is closely connected to physical pain (explaining why anti-inflammatory drugs like ibuprofen relieve pain), and inflammatory cytokines are also elevated in some individuals with depression. Additional research has shown that chronic stress triggers the chronic release of inflammatory cytokines, which in turn leads to neuroinflammation (inflammation within the brain) and subsequent depression.

4. Greater Pain Sensitivity.

When we're depressed, we tend to be more sensitive to pain — the clinical term is hyperalgesia. The common factor in depression and pain sensitivity may be chronic stress; acute stressors often lead to decreased sensitivity to pain (like when a soldier barely notices a serious wound in the heat of battle), whereas prolonged stress tends to sensitize us to pain. This hyperalgesia in depression can make us notice even minor pains that we would otherwise ignore.

5. Everything Is Hard.

It can be a struggle just to take care of the basics when we're really depressed — eating, bathing, getting dressed. Taking care of our daily responsibilities, like going to work and taking care of our kids, can require an enormous amount of energy, especially when depression is telling us to just throw in the towel. The intense exertion it takes just to keep going makes everything feel like a painful, uphill battle.  

6. Getting Our Attention.

Physical pain is hard to ignore, and for good reason — it alerts us that something is wrong so we can take action to fix it (like pulling a splinter out of our foot). Psychological pain may serve a similar function, letting us know that all is not well and compelling us to do something about it. In my experience, this pain is often what drives us to psychotherapy, motivating us to make changes that will boost our mood and alleviate our suffering.

In most cases, thankfully, there is good reason to hope, despite the hopelessness that depression often brings. The majority of people get a lot of relief from treatment, whether in the form of psychotherapy or medication. If you or someone you love is clearly in emotional pain, consider taking one of the following steps:

  • Talk to a loved one about how you've been feeling, and come up with a plan together to find relief.
  • Schedule an appointment with your primary care doctor to discuss your mood.
  • Look into psychotherapists in your area who specialize in treating depression. You can use the Psychology Today Find a Therapist search function. 
  • Look into self-guided treatments for depression. I wrote a workbook for treating depression and anxiety, and I also was excited to see a new book that offers many evidence-based techniques for managing depression. You can check it out here: The 10-Step Depression Relief Workbook. (Full disclosure: It's from the same publisher as my workbook, and the first author is a professional acquaintance of mine.)
  • Read more about depression from reputable sources to determine if you're currently depressed. You might start with the National Institute of Mental Health

Through the right treatment, it's possible to find joy and ease again.

References

Goesling, J., Clauw, D. J., & Hassett, A. L. (2013). Pain and depression: An integrative review of neurobiological and psychological factors. Current Psychiatry Reports, 15, 421-428.

Imbe, H., Iwai-Liao, Y., & Senba, E. (2006). Stress-induced hyperalgesia: Animal models and putative mechanisms. Frontiers in Bioscience, 11, 2179-2192.

Kim, Y. K., Na, K. S., Myint, A. M., & Leonard, B. E. (2016). The role of pro-inflammatory cytokines in neuroinflammation, neurogenesis and the neuroendocrine system in major depression. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 64, 277-284.

Meerwijk, E. L., Ford, J. M., & Weiss, S. J. (2013). Brain regions associated with psychological pain: Implications for a neural network and its relationship to physical pain. Brain Imaging and Behavior, 7, 1-14.

Schwarz, M. J., & Ackenheil, M. (2002). The role of substance P in depression: Therapeutic implications. Dialogues in Clinical Neuroscience, 4, 21-29.

Sommer, C., & Kress, M. (2004). Recent findings on how proinflammatory cytokines cause pain: Peripheral mechanisms in inflammatory and neuropathic hyperalgesia. Neuroscience Letters, 361, 184-187.

Won, E., Kang, J., Choi, S., Kim, A., Han, K. M., Yoon, H. K., ... & Kim, Y. K. (2017). The association between substance P and white matter integrity in medication-naive patients with major depressive disorder. Scientific Reports, 7, 9707.