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Can Mood Disorders Cause Physical Pain?

Can Mood Disorders Cause Physical Pain?

Two of the most common health problems reported by patients attending primary care are depression and chronic pain. Increased use of health resources and impaired health-related quality of life is produced by both of the conditions mentioned above.

With some studies showing a prevalence ranging from 15% to 100%, depression and chronic pain are frequently comorbid processes. Likewise, the clinical presence and severity of chronic pain are recognized as predictors of the degree of depression in these patients with the association of both processes producing a greater impact on the patients than either one of the disorders alone.


People with comorbid chronic pain and depression become heavy consumers of medical services and they consult their doctor more often. Additionally, some studies have suggested that patients with chronic pain and depression are much more likely not to be satisfied with their healthcare.


Depression is usually undiagnosed in primary care, especially in cases of patients who suffer from chronic pain. It seems that primary care physicians detect only 39.1% of cases of current depression, according to a study done by the World Health Organization (WHO) on psychological disorders in general health. Physicians in these settings fail to accurately diagnose at least 50% of patients with major depression according to Bair et al, and that the treatment of somatic complaints usually takes precedence over the identification and treatment of depression.


Chronic pain and depression share similar neurobiological mechanisms and central nervous structures from a neurobiological perspective. For instance, both processes implicate serotonin and noradrenaline, and it is well known that antidepressants that enhance serotonin and noradrenaline are effective analgesics. This relationship was reported by neuroimaging studies more recently.


Studies concerning the comorbidity of chronic pain, particularly unexplained chronic pain, with other mood disorders are scarce, in spite of the overwhelming data demonstrating the relationship between chronic pain and depression. The relationship of pain with MDD (major depressive disorder) was the focus of most studies, while few other studies addressed other mood conditions such as bipolar disorder, minor depression, or dysthymia. Likewise, studies that use specific structured interview to assess these processes in primary care aren’t common.


In Spain between April 2006 and December 2006, a cross-sectional study was carried out in a sample of primary care centers. The number of primary care centers chosen in each Spanish region was proportionate to its number of inhabitants to obtain a representative sample. Likewise, the selection process observed Spain’s rural/urban ratio with at least 20% of the sample from primary care centers in cities of less than 50,000 inhabitants.


One general practitioner (GP) that voluntarily accepted to participate was selected in each primary care center, constituting a final sample of 600 general practitioners.


Men and women over 18 years of age were included in the study, who consulted their Primary Care Center for unexplained pain that lasted for at least 6 weeks, including head, neck, limbs, joints, or back. If the cause of their pain was unknown or, if known, was not fully explained by another medical or psychiatric disorder, the patients were considered with “unexplained chronic pain” and so eligible for the study.


This study was undertaken to investigate the comorbidity of unrecognized mood disorders and unexplained chronic pain in primary care patients, as well as to determine the possible factors that influenced such a relationship. Additionally, the use of healthcare resources as a consequence of this comorbidity was also investigated in this study.
The most important findings that are related to the aim of this study were:


  • In patients suffering from unexplained chronic pain complaints evaluated in a primary care setting, there was a high prevalence of undiagnosed mood disorders.
  • The frequent presence of other mood disorders in these patients, other than MDD
  • A greater susceptibility of women to mood disorders
  • A direct relationship between the prevalence of mood disorders and the duration of pain in the previous week
  • Absence of association between the intensity and number of pain-sites
  • If the reasons for suffering pain are unknown, a higher comorbidity
  • In patients with such comorbidity, an increased use of healthcare services.


Previous studies reporting that the presence of painful physical symptoms increases the likelihood of a diagnosis of a mood or anxiety disorder by as much as 3-fold were confirmed by the results of this latest study. These results are also in agreement with data reported by Tang et al who concluded that experimentally induced negative mood increases self-reported pain and decreased tolerance in patients with chronic back pain, with positive mood having the opposite effect.
Mood disorders are frequently undetected in spite of being very common in primary care settings. About half the patients who experience major depression aren’t diagnosed by their primary care physicians, according to a number of studies. Additionally, 50% to 80% of patients with depression initially have a painful physical symptom. The data suggest that these individuals are considerably less likely to receive an accurate psychiatric diagnosis, will have limited access to specific treatments, and a poor outcome.


Some factors that serve as barriers for suitable mental health care for GPs are reported by Rijswijk and colleges; they also mention that the most important factor is the difficulties in distinguishing between psychological problems and a complete psychiatric disorder, or the difficulties in assessing severity of the disorder. In this regard, highlighting the percentage of patients in this study who hadn’t received a diagnosis of mood disorder is important.


The high frequency of minor depression or dysthymia observed in the patients is a result found in this study that isn’t reported by other authors. The use of PRIME-MD (a module of mood state from the Primary Care Evaluation of Mental Disorders), which is better able to detect these processes in primary healthcare than instruments used in other studies could be the cause of the presence of these mood disorders in about 35% of the patients.


This study also found that women have a greater risk of experiencing a comorbid pain-mood disorder. This result is congruent with findings by Ohayon and Schatzberg. The presence of evidence that comorbid chronic pain and depression is more likely to occur in women than in men is also suggested by Campbell et al and Keogh et al. however, yet another study done by Arnow et al found that the degree of the comorbidity between chronic pain and depression doesn’t differ based on age or gender. Some experimental studies have described sex differences in sensitivity to noxious stuimuli, suggesting that biological mechanisms underlie such differences, even though differences in pain reporting between men and women are partly attributable to social conditioning and to psychosocial factors.


A direct association was found in this study between the number of pain sites and the presence of mood disorder; but after adjustment by other variables, this relationship disappeared. When compared with previous studies, these data are contradictory. Half the patients who experienced persistent pain at onset continued to have persistent pain 12 months later, as found by Gureje et al, who analyzed data from the WHO to examine persistent pain in primary care patients. The number of pain sites was the best independent predictor of persistent pain in this study. Additionally, in a more recent study, increased rates of depression and anxiety in patients complaining of multi-site pain were found by Gureje et al. Methodological differences related to differences in design, populations studied and also the fact that this latest research was adjusted for intensity and duration of pain may be the cause of such contradictions.


When the reasons for suffering pain were unknown and when a precise diagnosis of the cause of pain was lacking, a higher rate of comorbid pain-mood disorder was found. In some studies, if the etiology of the pain condition is medically unexplained when compared to patients with a more defined pain disorder such as neuropathy, the occurrence of depression is higher. Patients with unexplained pain have a higher likelihood of reporting catastrophic thoughts and they tend to think that the origin of their pain is a mystery; they feel that they have lost control and that their physician doesn’t believe their pain to be real, according to Marazziti et al.


Additionally, when pain was comorbid with a mood disorder, an increased use of health care services was found. Numerous other studies have also found this result. This coincidence can be explained by the presence of mood disorders, which complicate the management of patients with pain, resulting in a poor outcome; for instance, longer duration of pain and a greater likelihood of non recovery. Some GPs have declared that the most significant and problematic complications in treating patients with chronic pain were factors like anxiety or depression.


To better understand the frequency of this comorbidity, knowing the complex biological relationships between chronic pain and depression is quite important. The circuitry of the nervous system reflects the convergence of depression and pain. The same neurotransmitters that are involved in the regulation of mood, particularly serotonin and norepinephrine, are also involved in the brain pathways that handle the reception of pain signals, including the limbic system. Pain, along with depression and anxiety is intensified when an alteration occurs in these pathways. This is one of the reasons why in many cases antidepressants are used in treating chronic pain, mainly those that inhibit the reuptake of norepinephrine or serotonin, either alone or in combination with analgesics.


One of the limitations of this study is that the occurrence of other chronic medical or psychiatric conditions hasn’t been assessed and they’re sometimes related to depression and often prevalent among people with chronic pain. Additionally, the survey doesn’t provide information about the direction of causality between unexplained chronic pain and mood disorders because it is a cross-sectional study. Therefore, only the possible way in which establishment of the association between pain and mood disorders is postulated. However, some explanations have been offered; certain pain conditions such as migraines have been suggested to share a common predisposition with some psychiatric disorders. But to improve this understanding of chronic pain-mood disorder relationships in primary care, more follow-up studies are needed.


To consider the patients as being affected by unexplained chronic pain and thus to select the patients to be included in the study, the possible bias related to the subjective assessment of pain by the GP should be pointed out. But because of the training given to the GP, and because of the use of objective assessment of pain by a VAS, this bias should be small.


Lack of confirmation of the diagnosis by means of a structured psychiatric interview can be yet another limitation. But the PRIME-MD is an instrument with tried and tested psychometric properties. One of the strong points about this study is that the results are based on large datasets collected from a broad range of primary care centers by means of objective assessment of pain and using international criteria for mood disorder diagnosis from a validated tool.


In patients with unexplained chronic pain visiting a primary care physician, there’s a very high under-diagnosed prevalence of different mood disorders, leading to dissatisfaction with treatment processes and outcomes. So, it seems that exploring this condition more regularly in general practice is quite necessary to achieve accurate diagnoses and to select the appropriate treatment.

Prepared By: Dr. Mehyar Al-khashroum
Edited By: Miss Araz Kahvedjian

Source :

Health Finder, http://www.healthfinder.gov/

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