Jump to ContentJump to Main Navigation
Show Summary Details
More options …
New at De Gruyter

Scandinavian Journal of Pain

Official Journal of the Scandinavian Association for the Study of Pain

Editor-in-Chief: Breivik, Harald

4 Issues per year


CiteScore 2017: 0.84

SCImago Journal Rank (SJR) 2017: 0.401
Source Normalized Impact per Paper (SNIP) 2017: 0.452

Online
ISSN
1877-8879
See all formats and pricing
More options …
Volume 2, Issue 2

Understanding the link between depression and pain

Steven J. Linton / Sofia Bergbom
Published Online: 2011-04-01 | DOI: https://doi.org/10.1016/j.sjpain.2011.01.005

Abstract

Background and aims

Patients seeking care for a pain problem very often also report symptoms of depression.In fact, depression is associated with the development of chronic pain as well as poor treatment results. Yet, the mechanisms by which depression and pain impact upon one another are not clear. This paper provides a critical review of the literature with the aim of shedding light on the relationship between pain and depression. Further, we introduce the Örebro Behavioral Emotion Regulation Model which may stimulate understanding in addition to research.

Method

Data bases (MedLine and PsychINFO) were searched as well as reference lists to locate relevant articles, especially previous reviews, published since 2000. We located 244 articles including 6 reviews.

Results

We found that while depression is strongly linked to pain, there is little understanding of how this link works or how it might be utilized in clinical settings. It is not clear whether one of the symptoms precedes the other, but when both are present prognosis is significantly affected. Clinicians often fail to assess both depression and pain resulting in probable “under” treatment of one or both problems. There is little evidence that treating the pain will result in the disappearance of the depression. Indeed, early improvements in depression are associated with overall treatment gains for patients with musculoskeletal pain. Therefore, treatment outcomes might be substantially enhanced by addressing both the pain and the depression. Moreover, directly addressing the depression early in treatment may be especially valuable. While pharmacological treatments of depression are often pursued for pain patients, the results for depression, pain and function are not impressive. Although there are effective cognitive-behavioral techniques for depression, these have not been properly evaluated in patients with co-morbid pain and depression.

We found two likely mechanisms that can help to explain the link between depression and pain. First, catastrophizing plays a central role in models of both pain and depression and hence might form an important link between them. Second, emotion regulation is important in both depression and pain since they both can be viewed as significant emotional stressors. We offer a model which focuses on the recurrent nature of pain and depression. It hypothesizes that flare-ups trigger catastrophic worry which in turn strains the individual’s emotion regulation system. Successful behavioral emotion regulation is said to result in coping while negative behavioral emotion regulation results in spiraling negative affect, pain and mood related disability and, in the long term, a consequent relapse.

Implications

Since both pain and depression are closely linked and are both involved in the development of long-term problems, it is important for clinicians to assess them as early as possible. Moreover, both symptoms should be monitored and addressed in treatment to maximize outcome results. Because pharmacological treatment has limited effects, cognitive-behavioral therapy is an alternative. Behavioral emotion regulation may be an important mechanism linking depression and pain.

Conclusions

It is concluded that pain and depression impact on each other and play an important role in the development and maintenance of chronic problems. Future studies of treatments for co-morbid depression and pain are urgently required. The purposed Örebro Behavioral Emotion Regulation Model provides much needed guidance for investigating the psychological mechanisms involved.

Keywords: Chronic pain; Back pain; Depression; Treatment; Risk factors

DOI of refers to article: 10.1016/j.sjpain.2011.02.003.

References

  • [1]

    Bair MJ, Robinson RL, Katon W, Kroenke K. Depression and pain comorbidity. Archives of Internal Medicine 2003;163:2433–45.PubMedCrossrefGoogle Scholar

  • [2]

    Clyde Z, Williams AC. Depression and mood. In: Linton SJ, editor. New avenues for the prevention of chronic musculoskeletal pain and disability. Amsterdam: Elsevier; 2002. p. 105–21.Google Scholar

  • [3]

    Blyth F, March LM, Brnabic AJM, Jorm LR, Williamson M, Cousins MJ. Chronic pain in Australia: a prevalence study. Pain 2001;89:127–34.PubMedCrossrefGoogle Scholar

  • [4]

    Pincus T, Burton AK, Vogel S, Field AP. A systematic review of psychological factors as predictors of chronicity/disability in prospective cohorts of low back pain. Spine 2002;27:E109–20.PubMedCrossrefGoogle Scholar

  • [5]

    Pincus T, Vogel S, Burton AK, Santos R, Field AP. Fear avoidance and prognosis in back pain: a systematic review and synthesis of current evidence. Arthritis and Rheumatism 2006;54:3999–4010.CrossrefGoogle Scholar

  • [6]

    Shaw WS, Linton SJ, Pransky G. Reducing sickness absence from work due to low back pain: how well do intervention strategies match modifiable risk factors? Journal of Occupational Rehabilitation 2006;16:591–605.PubMedCrossrefGoogle Scholar

  • [7]

    Shaw WS, Pransky G, Fitzgerald TE. Early prognosis for low back disability: intervention strategies for health care providers. Disability Rehabilitation 2001;23:815–28.CrossrefGoogle Scholar

  • [8]

    Linton SJ. A review of psychological risk factors in back and neck pain. Spine 2000;25:1148–56.CrossrefGoogle Scholar

  • [9]

    Steenstra IA, Verbeek JH, Heymans MW, Bongers PM. Prognostic factors for duration of sick leave in patients sick listed with acute low back pain: A systematic review of the literature. Occupational and Environmental Medicine 2005;62:851–60.CrossrefPubMedGoogle Scholar

  • [10]

    Crook J, Milner R, Schultz IZ, Stringer B. Determinants of occupational disability following a low back injury: A critical review of the literature. Journal of Occupational Rehabilitation 2002;12:277–95.PubMedCrossrefGoogle Scholar

  • [11]

    Currie SR, Wang JL. Chronic back pain and major depression in the general Canadian population. Pain 2004;107:54–60.CrossrefPubMedGoogle Scholar

  • [12]

    Druss BG, Rosenheck RA, Sledge WH. Health and disability costs of depressive illness in a major US corporation. American Journal of Psychiatry 2000;157:1274–8.CrossrefGoogle Scholar

  • [13]

    Nicholas MK. Mental disorders in people with chronic pain: an international perspective. Pain 2007;129:231–2.PubMedCrossrefGoogle Scholar

  • [14]

    Sullivan MJL, Adams H, Thibault P, Corbiére M, Stanish WD. Initial depression severity and the trajectory of recovery following cognitive-behavioral intervention for work disability. Journal of Occupational Rehabilitation 2006;16:63–74.PubMedGoogle Scholar

  • [15]

    Vowles KE, Gross RT, Sorrella JT. Predicting work status following interdisciplinary treatment for chronic pain. European Journal of Pain 2004;8:351–8.CrossrefGoogle Scholar

  • [16]

    Sullivan MJL, Adams H, Tripp D, Stanish WD. Stage of chronicity and treatment response in patients with musculoskeletal injuries and concurrent syptoms of depression. Pain 2008;135:151–9.CrossrefGoogle Scholar

  • [17]

    Estlander A, Takala E, Verkasalo M. Assessment of depression in chronic musculoskeletal pain patients. The Clinical Journal of Pain 1995;11:194–204.CrossrefPubMedGoogle Scholar

  • [18]

    Nicholas MK, Coulston CM, Asghari A, Malhi GS. Depressive symptoms in patients with chronic pain. Medical Journal of Australia 2009;190(7 Suppl.):S66–70.Google Scholar

  • [19]

    Sullivan M, Adams H, Horan S, Maher D, Boland D, Gross R. The role of perceived injustice in the experience of chronic pain and disability: scale development and validation. Journal of Occupational Rehabilitation 2008;18:249–61.CrossrefPubMedGoogle Scholar

  • [20]

    Banks SM, Kerns RD. Explaining high rates of depression in chronic pain: a diathesis–stress framework. Psychological Bulletin 1999;119:95–110.Google Scholar

  • [21]

    Croft PR, Papageorgiou AC, Ferry S, Thomas E, Jayson MI, Silman AJ. Psychologic distress and low back pain. Evidence from a prospective study in the general population. Spine 1996;20:2731–7.Google Scholar

  • [22]

    Estlander A, Takala E, Viikari-Juntura E. Do psychological factors predict changes in musculoskeletal pain?: A prospective, two-year follow-up study of a working population. Journal of Occupational and Environmental Medicine 1998;40:445–50.CrossrefPubMedGoogle Scholar

  • [23]

    Smith BW, Zautra AZ. The effects of anxiety and depression on weekly pain in women with arthritis. Pain 2008;138:354–61.CrossrefPubMedGoogle Scholar

  • [24]

    Young-Casey C, Greenberg MA, Nicassio PM, Harpin RE, Hubbard D. Transition from acute to chronic pain and disability: a model including cognitive, affective, and trauma factors. Pain 2008;134:69–79.CrossrefPubMedGoogle Scholar

  • [25]

    Dickens C, McGowan L, Dale S. Impact of depression on experimental pain perception: a systematic review of the literature with meta-analysis. Psychosomatic Medicine 2003;65:369–75.CrossrefPubMedGoogle Scholar

  • [26]

    Bair M, Robinson RL, Eckert GJ, Stang PE, Croghan TW, Kroenke K. Impact of pain on depression treatment response in primary care. Psychosomatic Medicine 2004;66:17–20.CrossrefPubMedGoogle Scholar

  • [28]

    Downes-Grainger E, Morriss R, Gask L, Faragher B. Clinical factors associated with short-term changes in outcome of patients with somatized mental disorder in primary care. Pscyological Medicine 1998;28:703–11.CrossrefGoogle Scholar

  • [29]

    Karp J, Scott J, Houck P, Reynolds 3rd CF, Kupfer DJ, Frank E. Pain predicts longer time to remission during treatment of recurrent depression. The Journal of Clinical Psychiatry 2005;66:591–600.PubMedCrossrefGoogle Scholar

  • [30]

    Urquhart D, Hoving JL, Assendelft WW, Roland M, Van Tulder MW. Antidepressants for non-specific low back pain. Cochrane Database of Systematic Reviews (Online) 2008:1.Google Scholar

  • [31]

    Chou R, Huffman L. Medications for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Annals of Internal Medicine 2007;147:505–10.PubMedCrossrefGoogle Scholar

  • [32]

    Perrot S, Javier R, Marty M, Le Jeunne C, Laroche F. Is there any evidence to support the use of antidepressants in painful rheumatological conditions? Systematic review of pharmacological and clinical studies. Rheumatology 2008;47:1117–23.CrossrefGoogle Scholar

  • [33]

    DeVeaugh Geiss A, West SL, Miller WC, Sleath B, Gaynes BN, Kroenke K. The adverse effects of comorbid pain on depression outcomes in primary care patients: results from the artist trial. Pain Medicine 2010;11:732–41.CrossrefGoogle Scholar

  • [34]

    O’Malley PG, Jackson JL, Santoro J, Tomkins G, Balden E, Kroenke K. Antidepressant therapy for unexplained symptoms and symptom syndromes. Journal of Family Practice 1999;48:980–90.Google Scholar

  • [35]

    Cuijpers P, van Straten A, Andersson G, van Oppen P. Psychotherapy for depression in adults: a meta-analysis of comparative outcome studies. Journal of Consulting and Clinical Psychology 2008;76:909–22.CrossrefPubMedGoogle Scholar

  • [36]

    Martell CR, Addis ME, Jacobson NS. Depression in context: strategies for guided action. New York: W.W. Norton; 2001.Google Scholar

  • [37]

    Statens beredning för medicinsk utvärdering. Treatment of depression: a systematic review. Stockholm: SBU; 2004.Google Scholar

  • [38]

    Cuijpers P, Smit F, Van Straten A. Psychological treatments of subthreshold depression: a meta analytic review. Acta Psychiatrica Scandinavica 2007;115:434–41.PubMedCrossrefGoogle Scholar

  • [39]

    Kroenke K, Bair MJ, Damush TM, Wu J, Hoke S, Sutherland J, Tu W. Optimized antidepressant therapy and pain self-management in primary care patients with depression and musculoskeletal pain: a randomized controlled trial. JAMA 2009;301:2099–110.PubMedCrossrefGoogle Scholar

  • [40]

    Teh C, Zaslavsky AM, Reynolds III CF, Cleary PD. Effect of depression treatment on chronic pain outcomes. Psychosomatic Medicine 2010;72:61–7.PubMedCrossrefGoogle Scholar

  • [41]

    Harvey A, Watkins E, Mansell W, Shafran R. Cognitive behavioural processes across psychological disorders: a transdiagnostic approach to research and treatment. Oxford: Oxford University Press; 2004.Google Scholar

  • [42]

    Beck A, Rush AJ, Shaw BF, Emery G. Cognitive therapy of depression. New York: Guilford Press; 1979.Google Scholar

  • [43]

    Clark DM, Beck AT, Alford BA. Scientific foundations of cognitive theory and therapy of depression. New York: Wiley; 1999.Google Scholar

  • [44]

    Vlaeyen JWS, Linton SJ. Pain-related fear and its consequences in chronic musculoskeletal pain. In: Linton SJ, editor. New avenues for the prevention of chronic musculoskeletal pain and disability. Amsterdam: Elsevier; 2002. p. 81–103.Google Scholar

  • [45]

    Leeuw M, Goossens ME, Linton SJ, Crombez G, Boersma K, Vlaeyen JW. The fear-avoidance model of musculoskeletal pain: current state of scientific evidence. Journal of Behavioral Medicine 2007;30:77–94.CrossrefPubMedGoogle Scholar

  • [46]

    Linton SJ, Nicholas MK, MacDonald S, Boersma K, Bergbom S, Maher C, Refshauge K. The role of depression and catastrophizing in musculoskeletal pain European Journal of Pain 2010, in press, doi:10.1016/j.ejpain.2010.08.009, Sep 28. [Epub ahead of print].Google Scholar

  • [47]

    Bergbom S, Boersma K, Overmeer T, Linton SJ. The relationship between pain catastrophizing, depressed mood and outcome across physical therapy treatment. Physical Therapy, in press.Google Scholar

  • [48]

    Gross JJ. The emerging field of emotion regulation: an integrative review. Review of General Psychology 1998;2:271–99.CrossrefGoogle Scholar

  • [49]

    Campbell-Sills L, Barlow DH. Incorporating emotion regulation into conceptualizations and treatments of anxiety and mood disorders. In: Gross JJ, editor. Handbook of emotion regulation. New York: Guilford Press; 2006. p. 542–59.Google Scholar

  • [50]

    Linton SJ. Understanding pain for better clinical practice. Edinburgh: Elsevier; 2005.Google Scholar

  • [51]

    Main CJ, Sullivan MJL, Watson PJ. Pain management: practical applications of the biopsychosocial perspective in clinical and occupational settings. London: Churchill-Livingstone; 2007.Google Scholar

  • [52]

    Nicholas MK, Linton SJ, Watson PJ, Main CJ. Yellow flags: the identification and management of psychosocial risk factors in patients with low back pain. Physical Therapy, in press.Google Scholar

  • [53]

    Main CJ, Spanswick CC. Pain management: an interdisciplinary approach. Edinburgh: Churchill-Livingstone; 2000.Google Scholar

  • [54]

    Main CJ, Wood PL, Hollis S, Spanswick CC, Waddell G. The distress and risk assessment method: a simple patient classification to identify distress and evaluate the risk of poor outcome. Spine 1992;17:42–52.CrossrefGoogle Scholar

  • [55]

    Von Korff M, Simon GE. The relationship between pain and depression. British Journal of Psychiatry 1996;168(Suppl. 30):101–8.Google Scholar

  • [56]

    Linton SJ, Gross D, Schultz IZ, Main C, Côté P, Pransky G, Johnson W. Prognosis and the identification of workers risking disability. Journal of Occupational Rehabilitation 2005;15:459–74.PubMedCrossrefGoogle Scholar

  • [57]

    American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-IV-TR. 4th ed. Arlington, VA: American Psychiatric Publications; 2000.Google Scholar

About the article

Received: 2010-11-09

Revised: 2011-01-26

Accepted: 2011-01-30

Published Online: 2011-04-01

Published in Print: 2011-04-01


Disclosure statement: Neither author has any economic or other conflicts of interest concerning this article.


Citation Information: Scandinavian Journal of Pain, Volume 2, Issue 2, Pages 47–54, ISSN (Online) 1877-8879, ISSN (Print) 1877-8860, DOI: https://doi.org/10.1016/j.sjpain.2011.01.005.

Export Citation

© 2011 Scandinavian Association for the Study of Pain.Get Permission

Citing Articles

Here you can find all Crossref-listed publications in which this article is cited. If you would like to receive automatic email messages as soon as this article is cited in other publications, simply activate the “Citation Alert” on the top of this page.

[2]
Doireann Twomey, Samuel Stuart, and Katherine Baker
International Journal of Therapy and Rehabilitation, 2018, Volume 25, Number 6, Page 301
[3]
Carolina Marpaung, Maurits K.A. van Selms, and Frank Lobbezoo
Community Dentistry and Oral Epidemiology, 2018
[4]
Steven J Linton, Ida K Flink, and Johan W S Vlaeyen
Physical Therapy, 2018, Volume 98, Number 5, Page 315

Comments (0)

Please log in or register to comment.
Log in