Clinical Manual of Pain Management in Psychiatry

Chronic pain and mental illness are inexorably linked, both initiating and exacerbating one another. Indeed, all psychiatrists ultimately treat chronic pain, either unwittingly or intentionally, because it occurs so frequently in psychiatric patients, complicating their recovery. Furthermore, given recent evidence indicating that chronic pain promotes impulsivity and brain degeneration, it is likely that some forms of chronic pain will ultimately be considered as neuropsychiatric disorders. Because of these issues, there is considerable need for practical texts which educate and support psychiatrists in treating pain in patients.

The author of this book, Dr. Raphael J. Leo, is one of few academic psychiatrists who have focused their efforts on chronic pain. Dr. Leo’s previous work, Concise Guide to Pain Management for Psychiatrists, published in 2003, is a well written and useful clinical reference for psychiatrists. His most recent book is an expanded and updated version of the earlier text.

There are ten chapters, which can be divided into three sections according to content. The first third of the book provides an overview of the field and creates a knowledge base for pain management, reviewing relevant topics in the neurobiology and assessment of pain. Psychiatric comorbidities associated with chronic pain, including depression, anxiety, and somatoform and psychotic disorders, are reviewed. Readers learn that the majority of psychiatric disorders interact with pain in a mutually exacerbating manner, but that psychotic disorders may decrease pain sensitivity.

The next third, and lengthiest portion, of the book reviews pharmacologic, psychotherapeutic, and interventional modes of pain management. The chapter on pharmacology covers opioid and non-opioid analgesics, antidepressants, anticonvulsants, and medications from other classes including benzodiazepines, muscle relaxants, and antihistamines. This section imparts a better understanding of how to use standard psychiatric medications to treat pain. For example, relevant studies comparing the use of antidepressants and anticonvulsants are presented to provide a rationale for their use in pain management. The section on opioids serves as a useful introduction for those new to pain management.

The chapter on psychotherapy provides an overview of behavioral, cognitive behavioral, and psychodynamic treatments, with brief comments on group and family therapies. This chapter provides a helpful overview of these therapies, particularly for trainees and non-psychiatrist pain specialists. One consideration is that it would have been useful to provide an evidence-based review of these therapies, similar to that provided for antidepressants. For example, because cognitive behavioral therapy in the treatment of pain is more thoroughly studied than psychodynamic therapy, there is better evidence to support that approach.

Interventional techniques commonly employed in pain management are next reviewed, and methods covered range from minimally invasive acupuncture to more invasive techniques such as spine decompression surgery and implanted spinal cord stimulation. I would have appreciated a more extensive discussion on the pitfalls of using implanted pumps in complex cases, in particular for those patients with histories of substance use.

The final third of the book covers specific pain disorders and special topics. Chapter 8 reviews the pain disorders that psychiatrists are most likely to treat, including headaches and lower back and myofascial pain, including fibromyalgia, arthritis, and neuropathy. These reviews contain the clinically relevant information needed to address the use of single or combined medications in treating co-occurring pain and psychiatric disorders. Chapters 9 and 10 discuss additional topics in pain management, including pediatric and geriatric pain, end-of-life pain, and one of the most challenging patient populations: patients with co-occurring pain and addiction. The chapter on forensic issues reviews topics ranging from capacity examinations to confidentiality.

I like this book and find it helpful in the clinic. It is well written, concise, and accurate. It is a useful clinical manual, and with its expanded references and enhanced sections on psychopharmacology, special patient populations, and forensics, it is both an excellent primer and update of the field. Medical students, residents, and psychiatrists new to chronic pain issues will benefit by reading it. Psychiatrists specializing in pain medicine will find it a useful reference. Finally, medical practitioners from other specialties will find the sections on pain assessment and the use of psychotherapy in pain management informative.