Depression and pain: the need for a new screening tool

Review z Depression and pain Depression and pain: the need for a new screening tool Karen Cocksedge BA, PhD, MBChB, Rohit Shankar MBBS, MRCPsych, DPM...
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Review z Depression and pain

Depression and pain: the need for a new screening tool Karen Cocksedge BA, PhD, MBChB, Rohit Shankar MBBS, MRCPsych, DPM, PGC-Cl.Research, PGC-Aspergers Chantal Simon PhD, MSc, MA, BM BCh, MRCGP, DRCOG

There is a strong association between pain and depression, and the presence of pain negatively affects the recognition and treatment of depression. Here, Dr Cocksedge and colleagues’ explore the neurobiology behind this relationship and propose a new screening tool to assess patients with either condition for the coexistence of the other, with the potential for significantly better diagnosis, referral and hence treatment.


n both the ICD10 and DSM IV definitions of depression, pain is briefly mentioned as a possible symptom but is certainly not considered as a defining symptom such as low mood or as a somatic symptom. This is surprising since pain symptoms and depression commonly coexist, as has been demonstrated in a number of studies (see Table 1). Not only does there appear to be a clear association between pain and depression, but furthermore, there is a recognised concern that the presence of pain often negatively affects the recognition and treatment of depression: depressed patients have been shown to be far more likely to present with pain symptoms than they are to present with affective symptoms1 and it has been estimated that if all patients from general practice who presented with painful conditions were evaluated for possible depression, then 60% of previously undetected depressive cases would have been recognised.2 Furthermore, when depression is recognised to be present in conjunction with pain, clinicians are more likely to focus on treating the pain and are less likely to consider psychological treatments, leading to worse outcomes.1 The situation is further complicated by the fact that the subjective experience of pain is likely to have cognitive, emotional and behavioural components in addition to the underlying biological component and, in some cases, there may be no underlying biological component at all. It is likely to be very difficult to distinguish between these components, but for the purposes of considering the effect of pain on depression, the origin of the pain probably makes little difference to the established association. When pain and depression are recognised and the clinician does focus on treating the depression, the presence of pain appears to increase the resistance of depression to treatment (see Table 2 in the online version of this article). As might well be expected, a combined diagnosis of both pain and depression accounts 26

for a far greater healthcare resource utilisation in both primary and secondary care, since patients with both pain and depression have an increased number of GP visits, an increased rate of investigations, a higher rate of antidepressant drug switching and increased referral to secondary care.3 The combination of both pain and depression also has an additive effect on the work days lost through both sickness absence and productivity.4 Aim We looked to identify if there were any combined pain and depression tools by using a comprehensive literature search. We examined our search results to help outline and propose a future mechanism of screening for comorbidity of depression and pain in a primary care setting. Method We conducted an extensive literature search to investigate if any screening tools simultaneously could screen patients for both depression and pain. This was undertaken with a systematic MEDLINE, EMBASE and AMED search over the years 1946–2015 using the combined terms ‘pain’ AND ‘depression’ combined with the individual terms ‘screening’, ‘checklist’, ‘tool’, ‘questionnaire’, ‘inventory’ or ‘scale’. Results From our literature search, we found a total of 43 articles but none offered a combined general screening tool for depression and pain. The articles were analysed and divided into relevant subsections. The majority focussed on eliciting an altered mental state in conditions with known chronic pain. Two articles, however, did assess for both depression and pain: Tamiya et al.5 looked at pain, anxiety and depression in 145 Japanese women with rheumatoid arthritis. They used visual analogue scales to measure depression and anxiety and compared these with standard

Progress in Neurology and Psychiatry January/February 2016

Depression and pain z

Reference Patten


Type of study

Main findings

1 year longitudinal study of patients with chronic medical conditions

Non-depressed patients with a long-term medical condition were twice as likely to develop major depression in the following year compared with those without such a condition Painful conditions including migraine headaches, sinusitis and back problems were most closely associated with major depression

Ohayon et al. 200326

Cross-sectional study

43% of patients suffering major depression had at least one chronic painful condition, which was four times higher than those without major depression

Bair et al. 20131

Literature review – see Tables 1 and 2 in the paper

Mean prevalence of pain in depression is 65%; mean prevalence of depression in pain is 13–85%

Arnow et al. 200627

Primary care patients

Disabling chronic pain was present in 41% of those with major depression versus only 10% of those without major depression

Means-Christensen et al. 200828

Primary care patients

2.5–10 times increase in anxiety or major depression in patients with muscle pain, headache or stomach pain

Demyttenaere et al. 201029

6-month European prospective observational study (FINDER)

56% of newly diagnosed depressed patients attending psychiatric outpatient clinics were experiencing moderate to severe pain, 70% of whom had no physical explanation for their pain

Bair et al. 201030

Prospective cohort study of patients with diabetes

Pain in diabetes is strongly association with depression (p

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