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Aims: Patients with depression often have co-morbid pain symptoms. However, rates of service utilization by psychiatric in-patients with co-morbid pain symptoms are unknown. The purpose of this study is to estimate whether patients with major depression and co-morbid pain access medical treatment for their pain as much as their counterparts with psychiatric diagnoses other than major depression.
Methods: A total of 103 patients (62 female; 41 male) were assessed for a diagnosis of major depression applying a psychiatric clinical interview followed by a self-report pain questionnaire, which assessed physical pain in psychiatric patients.
Results: Patients with major depression reported higher rates of pain symptoms in the past 6 and 12 months than their counterparts with a psychiatric diagnosis other than major depression. Analysis of variance showed that patients with depression were less likely to attend medical and specialist services for their pain symptoms than their counterparts. On the contrary, depressed patients with pain attended more frequently general in-patient services than non-depressed patients with pain.
Conclusions: Patients with depression suffer high rates of pain symptoms, but are at higher risk of not accessing appropriate services suggesting inadequate service utilization. The results have implications for screening and health care delivery for psychiatric patients with pain.
PAIN SYMPTOMS ARE among the most disabling and distressing symptoms that patients experience.1 Lyndsay and Wyckoff examined the rates of depression in pain centre patients and found that around 87% of their patients referred for pain symptoms were depressed.2 Indeed, it appears that persons with pain have high rates of associated depressive symptoms and their quality of life is markedly affected.3,4 Ericsson et al. (2002) found that depression was an important disability predictor in long-term chronic pain patients, indicating a correlation between depression and pain.5 This association is supported by evidence that effective and well coordinated medical interventions can significantly improve the psychological outcomes for pain sufferers.6 Treating co-morbid depression in sufferers of pain can also reduce morbidity and improve quality of life.7–9
Unfortunately, epidemiological evidence suggests that pain sufferers often do not access appropriate treatments,10 and therefore often receive suboptimal care. An essential aspect of effective interventions is therefore access and attendance to appropriate medical treatment. Consequently, understanding the factors that might impede depressed patients with pain symptoms accessing medical services is important in planning interventions. Given that pain sufferers do not readily access medical treatment and that depression is often associated with physical pain, it is of importance to estimate the rate of service utilization by depressed patients with co-morbid pain. The present study will seek to investigate rates of service utilization by psychiatric in-patients with co-morbid pain symptoms as well as estimate whether depressed patients with co-morbid pain access medical treatment for their pain as much as their counterparts with a psychiatric diagnosis other than major depression.
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Characteristics of the group are outlined in Table 1. Mean age was 38.7 ± 11.5 without showing significant differences between male (38.5 ± 8.8) and female (38.8 ± 12.9; p = 0.89) patients both with (38.7 ± 12.3) or without (38.8 ± 11.2; P = 0.95) a diagnosis of depression. Moreover, age was not related to the prevalence of pain in this sample. In total, 34.0% of the patients were diagnosed with major depression, whereas the remaining patients had a diagnosis of mood disorders (other than major depression: 22.2%), schizophrenia (19.0%), neurotic and somatoform disorders (19.0%), or personality disorders (5.8%). Patients with major depression were 68.6% women, and 31.4% men (χ2 = 1.55; P = 0.21). Pain symptoms were common across all diagnoses. Persons with depression had significantly higher rates of pain symptoms than those without over the last six (88.6% vs 69.1%) and twelve months (91.4% vs 69.1%). This difference held true for each single pain location except for chest/abdominal pain over the past twelve months, which was more common in those without major depression (Table 2).
Table 1. Demographic characteristics among 103 patients
|Yes %||No %||P-value*||Total|
|Gender|| || ||0.21|| |
| Female (n = 62)||38.7||61.3|| ||62 (58%)|
| Male (n = 41)||26.8||73.2||41 (38%)|
|School degree|| || ||0.79|| |
| High (n = 53)||35.8||64.2|| ||53 (44%)|
| Low (n = 48) Missing (n = 2)||33.3||67.7||48 (40%)|
|Current employment|| || ||0.49|| |
| Yes (n = 39)||41.0||59.0|| ||52 (49%)|
| No (n = 53)||30.2||69.8||39 (37%)|
| Retired (n = 11)||27.3||72.7||11 (10%)|
Table 2. Prevalence of pain among 103 depressed and non-depressed psychiatric patients
|12 months prevalence across locations†||Back||Head||Neck / shoulder||Chest / abdomen||Arms / legs|
|Depression|| || || || || |
| Yes (n = 35), %||60.0||48.6||42.9||25.7||31.4|
| No (n = 68), %||44.1*||47.1*||29.4*||36.8*||20.6*|
|Prevalence of all pain locations‡||2 weeks‡||6-months§||12-months¶|
|Depression|| || || |
| Yes (n = 35), %||54.3||88.6||91.4|
| No (n = 68), %||50.0||69.1**||69.1**|
Patients with pain and associated depression had similar patterns of accessing treatment modalities and disciplines as patients without depression (Table 3). There was however, a significant difference in the number of visits to general practitioners and to medical specialists for treatment of pain (Table 4). Patients without depression on average visited a doctor nearly twice as often over a twelve-month period as their depressed counterparts (4.9 vs 2.9). Patients without depression also saw a pain specialist more often and equally utilized treatment modalities for their pain. Patients with depression, however, were more likely to receive in-patient treatment for their pain symptoms. In a secondary analysis, excluding patients with neurotic or somatoform did not significantly change the reported results in relation to the prevalence rates of pain as well as to health service utilization rates. Overall, the results underline the relevance of pain in major depression.
Table 3. Disciplines* and modalities** for the treatment of pain among patients reporting pain with and without depression in the past 12 months (n = 79)
|Depression||Yes (n = 32)||No (n = 47)||P-value*|
|Mean (SE)||Mean (SE)|
|Number of disciplinesa consulted for treatment of pain|
| Medicalc||2.2 (0.4)||2.8 (0.4)||0.2|
| Psychologicald||0.2 (0.07)||0.3 (0.07)||0.3|
| Surgicale||0.5 (0.1)||0.4 (0.1)||0.7|
|Number of applied pain treatment modalitiesb|
| Medicalf||1.3 (0.3)||1.6 (0.2)||0.5|
| Psychologicalg||0.4 (0.1)||0.7 (0.1)||0.2|
| Physicalh||1.6 (0.3)||1.2 (0.2)||0.2|
Table 4. Utilization of pain specialized services compared to general medical services among depressed and non-depressed patients with pain in the past 12 months (N = 79)
|Number of . . . ||GP visits||Doctors for treatment of pain||Pain treatment modalities||Inpatient treatments|
|Depression||Mean (SE) P-value*||Mean (SE) P-value*||Mean (SE) P-value*||Mean (SE) P-value*|
|Yes (n = 35)||2.9 (0.7) 0.032||2.3 (0.5) 0.034||3.3 (0.5) 0.48||2.0 (0.07) 0.008|
|No (n = 68)||4.9 (0.6)||3.8 (0.4)||3.3 (0.4)||1.7 (0.05)|
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This study explored whether depressed patients with co-morbid pain access medical treatment for their pain as much as their counterparts with a psychiatric diagnosis other than depression. Results showed that although they possessed higher rates of pain symptoms, depressed patients were less likely to attend medical and specialist services for their pain symptoms than their counterparts with a psychiatric diagnosis other than depression, however, as in-patients they tended to access more treatment for their pain symptoms.
The robust relationship between pain and depression has been amply documented in the published reports with theories that depression might increase pain perception or that depression is a common consequence of experiencing pain.12,13 Indeed, medical utilization by psychiatric patients tends to be primarily described in the published reports in terms of the economic burden caused by this cohort.14,15 However, our results indicate that people with co-morbid depression and pain manifest less health seeking behaviors. This is in contrast to individuals with other conditions such as anxiety disorders such as panic disorder.16–18
Barriers to care, including the expense of specialist services, are substantial and this might be responsible for this cohort of depressed patients failing to access specialty pain care. Interestingly, depressed patients with pain tend to access more medical in-patient services, again indicating that it might only be within the supervised in-patient health care setting that patient's pain difficulties are identified and managed. In 1997, Fishbain et al. undertook a review of the published reports on the relationship between pain and depression and posited the ‘consequence hypothesis’, which asserts that pain is a better predictor of depression than vice versa.12 In this instance, patients presenting with chronic pain might be masking the existence of depressive illness. Alternatively to the ‘consequence hypothesis’, patients with pre-existing high scores on somatization before surgical treatment for back pain, have a significantly worse outcome 6 months after lumbar discectomy than those without preoperative somatisation.19
By contrast, whilst unipolar major depression is ranked as the number one cause of disability worldwide,20 it is also a risk factor for other high burden conditions like cardiovascular disease (CVD),21 therefore, under-treating of pain symptoms in this cohort, as found in the present study, could potentially be placing patients at risk of undiagnosed serious physical conditions like CVD.
The results indicate that it is important for practitioners to identify physical pain symptoms amongst depressed patients. In particular, being able to address the reasons for why these patients are not accessing services for their symptoms is imperative. It could be expected that depressed patients might think that the physical symptoms experienced are simply a by-product of their condition or there might be a sense of feeling unworthy to mention their ailments.
The present study would have benefited from researching the presentation of patients, that is, with anxiety disorders or at least anxiety symptoms, as it might be that their higher service utilization rates are a result of higher levels of anxiety than people who were in the depressed cohort. Consequently, the study ought to have included more comparative groups, such as people with other diagnoses like anxiety disorders or schizophrenia. In addition, the restriction of the study sample to inpatients does not allow a generalization of the findings to patients with depression, that is, to those with less severity of depression or patients with depression treated in the community. Given the high level of disability in these populations, an understanding of how co-morbid pain is managed by these groups would be of much interest. Measures of severity of social disability might also have provided a clearer picture of the presentation of the patients with co morbid pain and depression. As opposed to prospective studies, the cross-sectional nature of this study allowed no evaluation of the causality between depression, pain and service utilization. Future studies should also employ measures of severity of depression and pain as well as semi-structured psychiatric interviews.
The results presented here have numerous implications for the identification and treatment of depression in psychiatric inpatient units. Findings highlight a need for practitioners to routinely investigate the existence of pain symptoms in depressed patients. The introduction of basic pain inventories might be a way to do this effectively. Future studies ought to address the limitations outlined here. Whilst pain symptoms can often be effectively treated with multimodal interventions, it is concerning that persons with depression are less likely to access medical interventions for pain, since this suggests they are being under treated and/or serious medical conditions are only being diagnosed at a more advanced stage. The recommendations made herein are in accordance with the provision of best clinical practice for improving treatment of depression and pain in psychiatric in-patient units.