Footstep 6

Managing moods

Mood problems are very common in people with chronic pain. It is important to look out for low moods, negative thinking, anger, anxiety and depression – their ongoing presence indicates greater disability and dependence.

Your role is to ask about these moods regularly and explain how they impact upon the subjective experience of pain.

At least 50% of people with chronic pain are depressed so it is worth addressing this changeable factor.

Action to take

Identify mood issues

To identify moods quickly, you can use these two questions, adapted for different conditions:

For depression:

  1. During the last month, have you often been bothered by feeling down, depressed or hopeless?
  2. During the last month, have you often been bothered by having little interest or pleasure in doing things?

For anger:

  1. During the last month, have you often found yourself being angry, irritable or frustrated, every day or some days?
  2. During the last month, have you found that being angry, irritable or frustrated has interfered with your day to day life, affected others or the pain itself?

For anxiety:

Exploring these useful questions can be helpful to understand and guide change in unhelpful avoidant behaviours.

  • What have you already been told/think is causing your pain? (beliefs)
  • Is there anything that you have been told/think about your pain that you don't understand or is worrying you? (fears/beliefs)
  • How does the pain affect you? (impact - explore their typical 24 hour period in the last week)
  • How does the pain affect your family/those around you? (wider impact/social support)
  • Apart from using medication, how are you managing your pain? (rest v activity, fear avoidance, beliefs about activity and rest)
  • What do you think is going to happen in the future? (catastrophisation)

Recognise this is different to managing clinical depression

It is important to note that this footstep is not about the management of clinical depression or anxiety. This is very familiar territory for clinicians, with clear clinical guidance. The emphasis here is on sharing self-management strategies for day-to-day changes in mood for patients with chronic pain in order to increase their self confidence to cope.

It is common for people to believe that when mood changes get to the point of interfering with day-to-day life there is ‘nothing that can be done’ until the mood passes. It is also common for people to blame themselves and believe they ‘should be able to snap out of it’.

Just being told that changes in mood come and go can be helpful. Some people think of this like clouds passing in the sky.

Beliefs, thoughts and feelings

Explore this Footstep alongside the Beliefs, thoughts and feelings and how to change them summary.

Encourage self-care strategies

You can encourage the patient to use self-care strategies that can help moods to pass quicker and reduce the chances of becoming entrenched.

Some useful self-care strategies

Encourage your patients to:

  • Explore the five areas model from Cognitive Behavioural Therapy (CBT). This can help a patient to see possibilities of change in different areas and focus efforts more effectively.
  • Practice kindness and self-compassion: this is about encouraging acceptance that none of us are perfect or able to deliver 100% all of the time. If we judge ourself against a yard stick of perfection we will constantly come up short and this will promote increased negative thinking and self-judgement.
  • Notice negative thoughts and try to balance them with more realistic and positive evidence.
  • Be thier own best friend: when these negative thoughts pop into their mind, encourage your patient to ask themselves: ‘what would my best friend say at this point to have a balanced perspective?’
  • Practice relaxation techniques or explore mindfulness approaches
  • Keep a record of positive things that have happened each day or week – this will serve as positive real evidence to counter ‘can’t do’ and ‘failure’ thinking. If your patient is unlikely to write things down, this can even be done Instagram-style by taking photos, to make it very easy and low intensity.
  • Work towards fun goals and things that are meaningful.
  • Learn from and get support from peers in a similar situations.
  • Build helpful habits – if something worked one week, then build on it the next week.
  • Build in regular enjoyable rewards for making progress in managing moods, progressing goals or other changes.

Resources for your patient

NHS guidance on the five steps to mental wellbeing:

A wide range of CBT based resources in all formats: written, audio, MP3 and relaxation exercises:

Free mindfulness audio meditations from Breathworks:


More resources for you

Read this really interesting paper about where anger, pain and poor outcomes really stand:

A very useful book with a chapter on managing moods:

Managing moods

Summary of key points

  • Mood impacts on persistent pain and persistent pain impacts on mood
  • Moods tend to come and go, so it helps patients become aware of them and use self-care strategies
  • There are plenty of strategies which can help patients keep themselves in a positive mood for more of the time
  • You should also look for clinical depression and anxiety and treat this (50% of people with pain have depression)
  • Assess the role of medications such as opioids in contributing to mood changes

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