Abstract
Pain and depression are the most prevalent physical and psychological symptom-based
disorders, respectively, and co-occur 30 to 50% of the time. However, their reciprocal
relationship and potentially causative effects on one another have been inadequately
studied. Longitudinal data analysis involving 500 primary care patients with persistent
back, hip, or knee pain were enrolled in the Stepped Care for Affective Disorders
and Musculoskeletal Pain (SCAMP) study. Half of the participants had comorbid depression
and were randomized to a stepped care intervention (n = 123) or treatment as usual
(n = 127). Another 250 nondepressed patients with similar pain were followed in a
parallel cohort. Outcomes were assessed at baseline, 3, 6, and 12 months. Mixed effects
model repeated measures (MMRM) multivariable analyses were conducted to determine
if change in pain severity predicted subsequent depression severity, and vice versa.
Change in pain was a strong predictor of subsequent depression severity (t-value =
6.63, P < .0001). Likewise, change in depression severity was an equally strong predictor
of subsequent pain severity (t-value = 7.28, P < .0001). Results from the full cohort were similar in the clinical trial subgroup.
In summary, pain and depression have strong and similar effects on one another when
assessed longitudinally over 12 months.
Perspective
This study strengthens the evidence for a bidirectional and potentially causative
influence of pain and depression on one another. A change in severity of either symptom
predicts subsequent severity of the other symptom. Thus, recognition and management
of both conditions may be warranted, particularly when treatment focused on 1 condition
is not leading to an optimal response.
Key words
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References
- Relationships among depression, chronic pain, chronic disabling pain, and medical costs.Psychiatr Serv. 2009; 60: 344-350
- Comorbid depression, chronic pain, and disability in primary care.Psychosom Med. 2006; 68: 262-268
- Impact of pain on depression treatment response in primary care.Psychosom Med. 2004; 66: 17-22
- Depression and pain comorbidity: A literature review.Arch Intern Med. 2003; 163: 2433-2445
- Reciprocal relationship between pain and depression in older adults: Evidence from the English Longitudinal Study of Ageing.J Affect Disord. 2007; 102: 115-123
Cleeland CS: Measurement of pain by subjective report, in Chapman CR, Loeser JD (eds): Advances in Pain Research and Therapy. vol 12. lssues in Pain Measurement. New York, NY, Raven Press, 1989, pp 391-403
- A biopsychosocial model of pain and depression in rheumatoid arthritis: A 12-month longitudinal study.Rheumatology (Oxford). 2003; 42: 1287-1294
- Comorbid painful physical symptoms and depression: Prevalence, work loss, and help seeking.J Affect Disord. 2006; 92: 185-193
- Chronic pain and psychopathology: Research findings and theoretical considerations.Psychosom Med. 2002; 64: 773-786
- Re-engineering systems for the treatment of depression in primary care: Cluster randomised controlled trial.BMJ. 2004; 329: 602-605
- Interpreting the clinical importance of treatment outcomes in chronic pain clinical trials: IMMPACT recommendations.J Pain. 2008; 9: 105-121
- Depression and comorbid pain as predictors of disability, employment, insurance status, and health care costs.Psychiatr Serv. 2005; 56: 468-474
- Chronic pain-associated depression: Antecedent or consequence of chronic pain? A review.Clin J Pain. 1997; 13: 116-137
- Longitudinal relationship between pain and depression in older adults: Sex, age and physical disability.Soc Psychiatry Psychiatr Epidemiol. 2002; 37: 23-30
- A cross-national study of the course of persistent pain in primary care.Pain. 2001; 92: 195-200
- A longitudinal study to explain the pain-depression link in older adults with osteoarthritis.Arthritis Care Res (Hoboken). 2010 Jul 26; ([Epub ahead of print])
- Cross-sectional and longitudinal associations of low-back pain and related disability with psychological distress among patients enrolled in the UCLA Low-Back Pain Study.J Clin Epidemiol. 2003; 56: 463-471
- Antidepressants and cognitive-behavioral therapy for symptom syndromes.CNS Spectr. 2006; 11: 212-222
- Stepped collaborative care for primary care patients with persistent symptoms of depression: A randomized trial.Arch Gen Psychiatry. 1999; 56: 1109-1115
- Pain symptoms in depression: Definition and clinical significance.Clin Med. 2005; 5: 390-395
- Effect sizes for interpreting changes in health status.Med Care. 1989; 27: S178-S189
- Development and initial validation of the PEG, a three-item scale assessing pain intensity and interference.J Gen Intern Med. 2009; 24: 733-738
- The interface between physical and psychological symptoms.J Clin Psychiatry Primary Care Companion. 2003; 5: 11-18
- Somatic symptoms and depression: A double hurt.Prim Care Companion J Clin Psychiatry. 2005; 7: 148-149
- Stepped Care for Affective Disorders and Musculoskeletal Pain (SCAMP) study: Design and practical implications of an intervention for comorbid pain and depression.Gen Hosp Psychiatry. 2007; 29: 506-517
- Optimized antidepressant therapy and pain self-management in primary care patients with depression and musculoskeletal pain: A randomized controlled trial.JAMA. 2009; 301: 2099-2110
- Impact of pain on the outcomes of depression treatment: Results from the RESPECT trial.Pain. 2008; 134: 209-215
- The PHQ-9: Validity of a brief depression severity measure.J Gen Intern Med. 2001; 16: 606-613
- An ultra-brief screening scale for anxiety and depression: The PHQ-4.Psychosomatics. 2009; 50: 613-621
- Similar effectiveness of paroxetine, fluoxetine, and sertraline in primary care: A randomized trial.JAMA. 2001; 286: 2947-2955
- Somatic symptoms in patients with cancer experiencing pain or depression: Prevalence, disability, and health care use.Arch Intern Med. 2010; 170: 1686-1694
- Conditional and marginal models: Another view.Statistical Science. 2004; 21: 219-238
- Painful physical symptoms and treatment outcome in major depressive disorder: A STAR∗D (Sequenced Treatment Alternatives to Relieve Depression) report.Psychol Med. 2009 Jun 3; ([Epub ahead of print])
- On the appropriateness of marginal models for repeated measurement in clinical trials.Statist Med. 1998; 17: 447-469
- A review of psychological risk factors in back and neck pain.Spine. 2000; 25: 1148-1156
- Monitoring depression treatment outcomes with the patient health questionnaire-9.Med Care. 2004; 42: 1194-1201
- Effect of depression treatment on depressive symptoms in older adulthood: The moderating role of pain.J Am Geriatr Soc. 2007; 55: 202-211
Max MB, Wu T, Atlas SJ, Edwards RR, Haythornthwaite JA, Bollettino AF, Hipp HS, McKnight CD, Osman IA, Crawford EN, Pao M, Nejim J, Kingman A, Aisen DC, Scully MA, Keller RB, Goldman D, Belfer I: A clinical genetic method to identify mechanisms by which pain causes depression and anxiety. Mol Pain 2:14-doi:10.1186/1744-8069-2-14, 2006
- Disabling low back pain and depressive symptoms in the community-dwelling elderly.Spine. 2007; 32: 2380-2386
- Comorbid chronic pain and depression: Who is at risk?.J Pain. 2009; 10: 619-627
- Do ultra-short screening instruments accurately detect depression in primary care? A pooled analysis and meta-analysis of 22 studies.Br J Gen Pract. 2007; 57: 144-151
- Serious psychological distress in U.S. adults with arthritis.J Gen Intern Med. 2006; 21: 1160-1166
- Utility of a new procedure for diagnosing mental disorders in primary care. The PRIME-MD 1000 study.JAMA. 1994; 272: 1749-1756
- Pain limits the effectiveness of collaborative care for depression.Am J Geriatr Psychiatry. 2007; 15: 699-707
- Collaborative care management of late-life depression in the primary care setting: A randomized controlled trial.JAMA. 2002; 288: 2836-2845
- Grading the severity of chronic pain.Pain. 1992; 50: 133-149
- Treatment of dysthymia and minor depression in primary care: A randomized controlled trial in older adults.JAMA. 2000; 284: 1519-1526
- Depression and pain: An overview.Acta Neuropsychiatrica. 2006; 18: 79-87
- Outcomes of newly referred neurology outpatients with depression and pain.Neurology. 2004; 63: 674-677
- Prevalence and impact of pain and depression in neurology outpatients.J Neurol Neurosurg Psychiatry. 2003; 74: 1587-1589
Article info
Publication history
Published online: June 17, 2011
Accepted:
March 8,
2011
Received in revised form:
February 15,
2011
Received:
August 20,
2010
Footnotes
Supported by a grant from the National Institute of Mental Health to Dr. Kroenke (MH-071268).
Dr. Kroenke has received honoraria from Eli Lilly and Forest Pharmaceuticals for serving on advisory boards and speaking. None of the other authors have any financial or other conflicts of interest to disclose relevant to this paper.
Identification
Copyright
Published by Elsevier Inc.
