The Implications of Pain and Physical Symptoms in Depression
Rakesh Jain, MD, MPH
Psychiatric Drug Research, R/D Clinical Research, Inc, Lake Jackson, Tex
Impact of Pain and Physical Symptoms from Depression on Remission
Pain and physical symptoms are common in patients with depression,1 but how does this relationship affect clinical practice and patient outcomes? Von Korff and Simon2 found that depression and pain have a reciprocal relationship in that each heightens the severity of the other. Additionally, pain appears to be a barrier to achieving the goals of remission and recovery for patients with depression. A 3-year study3 of 327 depressed adults aged 55 to 85 years reported that only 9% of patients with both pain and depression at baseline fully recovered compared with 47% of patients with only depression at baseline. Age did not affect the longitudinal pain-depression relationship. In a study of acute treatment for depression, Karp et al.4 compared 230 patients aged 21 to 65 years with and without pain. Again, pain was not correlated with age. After controlling for depression severity, patients with pain had lower remission rates (AV 1) and took longer to achieve remission (median 17 weeks) than those without pain (median 12 weeks). Thus, the close association between painful symptoms and depression emphasizes the need for comprehensive treatment strategies.
Further, the level of improvement in pain during depression treatment influences patients’ achievement of remission. In two 9-week studies of antidepressant treatment for adults aged 18 to 75 years, Fava et al.5 found that depressed patients who achieved < 50% improvement in pain had a remission rate of only 17.8%, compared with 36.2% of patients who had an improvement in pain of ≥ 50% (AV 1). Improvement of painful physical symptoms also was associated with improvements on the Clinical Global Impressions-Severity (CGI-S) and Patient Global Impression of Improvement (PGI-I) scales for depression. Therefore, screening for painful physical symptoms before starting antidepressant treatment is an integral step in helping patients with depression achieve remission.
Impact of Painful Physical Symptoms in Depression on Functioning
The relationship between depression and painful physical symptoms negatively impacts not only course and treatment but also functioning of patients with these co-occurring conditions. For example, Demyttenaere and colleagues1 reported that patients with both depression and painful physical symptoms were less productive (based on lost work days per month) than those with only painful physical symptoms or only depression (AV 2). This study1 shows that having depression and pain negatively impacts patients’ occupational functioning.
In a recent study by Machado et al.,6 the physical and psychological consequences of osteoarthritis pain were examined in adults aged 55 years or older. Patients were assessed at study onset and 18 months later on physical symptoms, depressive symptoms, activity limitations, and participation restrictions. The relationship between each of the domains was significant, and the regression coefficients among these 4 domains are illustrated in AV 3. Both physical and depressive symptoms limited participants’ activity at baseline, and both depressive symptoms and activity limitations at baseline decreased later participation in social and leisure activities. Thus, painful physical symptoms and depression impact not only occupational functioning but also social functioning.
Another recent, larger study7 examined the combined effects of depression, somatic disorders, and pain symptoms on general functioning according to patients’ physical and mental well-being. Among 4 groups of patients (N = 4181; with no depression and no pain, depression and no pain, no depression and pain, and both depression and pain), physical and mental well-being scores were lowest in those with both depression and pain, with a substantial effect on mental well-being. An increasing number of pain locations had more impact on functioning than the location of pain. Clinicians should be aware that pain affects patients’ overall functioning and may signify and exacerbate depressive disorder.
A reciprocal relationship exists between painful physical symptoms and depression (AV 4). The presence of painful physical symptoms not only slows patients’ time to remission but also decreases their chance of depression remission and recovery. Further, painful physical symptoms also negatively affect the occupational, social, and global functioning of patients with depression. These findings clearly indicate that clinicians must be aware of the common co-occurrence of pain and depression in order to effectively treat and encourage remission for their patients with this comorbidity.
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- Demyttenaere K, Bonnewyn A, Bruffaerts R, et al. Comorbid painful physical symptoms and depression: prevalence, work loss, and help seeking. J Affect Disord 2006;92:185–193
- Von Korff M, Simon G. The relationship between pain and depression. Br J Psychiatry Suppl 1996;(suppl 30):101–108
- Geerlings SW, Twisk JWR, Beekman ATF, et al. Longitudinal relationship between pain and depression in older adults: sex, age and physical disability. Soc Psychiatry Psychiatr Epidemiol 2002;37:23–30
- Karp JF, Scott J, Houck P, et al. Pain predicts longer time to remission during treatment of recurrent depression. J Clin Psychiatry 2005;66:591–597
- Fava M, Mallinckrodt CH, Detke MJ, et al. The effect of duloxetine on painful physical symptoms in depressed patients: do improvements in these symptoms result in higher remission rates? J Clin Psychiatry 2004;65:521–530
- Machado GP, Gignac MA, Badley EM. Participation restrictions among older adults with osteoarthritis: a mediated model of physical symptoms, activity limitations, and depression. Arthritis Rheum 2008;59:129–135
- Baune BT, Caniato RN, Garcia-Alcaraz MA, et al. Combined effects of major depression, pain and somatic disorders on general functioning in the general adult population. Pain 2008;138:310–317