Which Comes First – Fibromyalgia or Depression?

The prevalence rate of major depressive disorders (MDD) is between 5% and 12% for men and 10% and 25% for women. Yet, among those with fibromyalgia syndrome (FMS), it is as high as 74% with atypical depression being more common than other types of depression.[1] In addition, those who suffer from depression are more severely affected by related symptoms of fibromyalgia than those who do not have this psychiatric condition.

In fact, during the past, researchers have argued that fibromyalgia is actually a depression-related symptom. Others have stated it is an “affective spectrum disorder”[2] or, specifically, a depression spectrum disorder.[3] Yet, many doctors consider the two issues as intertwined but separate medical problems possessing a similar pathophysiology. The widespread pain associated with fibromyalgia separates it from psychologically-based subgroups and places it within somatic disorders. There also exists a separation between those who have FMS and those who have fibromyalgia with depression, whether the depression is clinical, atypical or a major depressive disorder. The latter group, as a result, is often considered a psychologically distressed subgroup of fibromyalgia.

While there is no doubt that depression and FMS are interlinked, the question that continues to be debated is the following: Which came first – fibromyalgia or depression? It is not a question that can be answered easily. In fact, the question continues to be debated and researched due to the similar etiology and interrelated symptoms of FMS and MDD. They include genetic and familial predisposition as well as both psycho-social and environmental factors including stress and illness.

Addressing the Theories

Several theories are offered concerning the relationship between fibromyalgia and depression. One school believes that FMS is actually a type of “masked” major depressive disorder. In this theory the two conditions are the same medical problem. Essentially this approach believes that FMS and depression represent a single syndrome. Yet, some research contradicts this. As noted by Normand and associates, while both FMS and MDD are linked by increased sensitivity to pain (hyperalgesia), hyperalgesia is more prominent in fibromyalgia.[4] Moreover, the lower levels of chemical substances that inhibit pain are only found in fibromyalgia patients and not those with depression. Consequently, the results suggest that fibromyalgia is not the same as major depressive disorder. It is a distinct syndrome.

Another approach focuses on pain as a causal factor for depression. It is possible that depression can be a reaction to the pain symptoms of fibromyalgia. Aggravating factors may be the other co-morbidities common to fibromyalgia. According to Gracely and Aguglia et al. one theoretical approach holds that depression can be a natural reaction to anyone who suffers from pain of any type.[5] The argument is that pain reduces the individual’s ability to cope, negatively affecting their self-esteem, physical stamina and other aspects of self-identification and creates a sense of social alienation. The individual becomes more withdrawn and “succumbs” to depression. In accordance with this theory, any individual who suffers from a chronic painful and disabling disorder such as fibromyalgia is involved in a depressing event. Acceptance of this theory would indicate that fibromyalgia precedes an onset of depression.

Yet, Gracely also notes the fact that one particular form of depression – major depressive disorder – shares similar features with fibromyalgia that may precipitate and predispose an individual to MDD and/or FMS and may provide an intricate link between the two medical issues. While linkages occur and the two issues may both be members of the same affective spectrum, exhibiting in particular the same mechanisms such as altered levels of serotonin and melatonin and changed substance P and HPA axis functioning, according to Aguglia and associates they are not the same. This indicates the possibility that neither is a precursor to the other. It supposes a parallel path in which MDD and FMS may occur at the same time. However, during the course of the FMS and MDD conditions, one then the other may predominate providing the illusion that one preceded the other.

Still another concept is that depression precedes fibromyalgia. The argument states that being depressed may alter the brain chemistry. This creates abnormalities in the nervous system affecting the neurotransmitters. The result can be illness and/or a trauma that may result in the development of FMS. It is true that those with FMS and chronic pain may suffer from depression.[6] However, many individuals who develop fibromyalgia do not become clinically depressed or exhibit symptoms of major depressive disorder.

No Answers Yet to the Question of Which Comes First

As of now, no one knows which comes first – depression or fibromyalgia. Research indicates that depression can precede the onset of fibromyalgia in certain cases. Yet, some studies instead reveal that fibromyalgia can be present before the development of depression. Still other research indicates the two may occur in conjunction. A diagnosis of fibromyalgia usually means multiple symptoms are present which might mean co-morbidity is an issue. Usually there are degrees of pain, anxiety, depression and other co-morbid emotional and physical health problems present. The overall picture appears to reveal two related disorders that have similar roots, comparable triggers and related factors of predisposition. Both are intricately tied to one specific element – pain. Consequently, the entwined patterns of FMS and depression perpetuate the concept that one is predominant in some instances and not in others.

Treatment Complications

What ultimately have emerged with research are further indications that fibromyalgia is a complex condition and may not occur alone. The existence of fibromyalgia individuals with and without depression or MDD clearly indicates the existence of subgroups within the larger group. This points towards the need to be careful in analysis and treatment approaches. For medical professionals, the decision to treat fibromyalgia or major depressive disorder should clearly be dependent upon the specific characteristics of the individual, both emotional and physical, and not be a one-size-fits-all supposition.

References

[1] Ross, RL; Jones, KD; Ward, RL; Wood,LJ; and  Bennett, RM (2010). “Atypical Depression is More Common than Melancholic in Fibromyalgia: An Observational Cohort Study.” BMC Musculoskeletal Disorders, 11(June):120-128.

[2] Gracely, RH; Ceko,M; and Bushnell, MC (2011). “Fibromyalgia and Depression.” Pain Research and Treatment, 2012: 1-9.

[3] Raphael, KG; Janal, MN; Nayak, S; Schwartz, JE; and Gallagher, RM (2004). “Familial Aggregation of Depression in Fibromyalgia: A Community-Based Test of Alternate Hypotheses,” Pain, 110, (1-2): 449–460.

[4] Normand, E; Potvin, S; Gaumond, I; Cloutier, G; Corbin, J. F; and Marchand, S (2011) “Pain Inhibition is Deficient in Chronic Widespread Pain but Normal in Major Depressive Disorder.” Journal of Clinical Psychiatry, 72(2):219-24.

[5] Aguglia, A; Salvi, V; Maina, G; Rossetto, I; and Aguglia, E (2011). “Fibromyalgia Syndrome and Depressive Symptoms: Comorbidity and Clinical Correlates,” Journal of Affective Disorders, 128(3):262-266.

[6] Giesecke, T; Gracely, RH; Williams, DA; Geisser, ME; Petzke, FW; and Clauw, DJ (2005). “The Relationship between Depression, Clinical Pain, and Experimental Pain in a Chronic Pain Cohort.”Arthritis and Rheumatism, 52(5): 1577–1584.

This article was originally published on July 11, 2012 and last revision and update of it was 9/7/2015