Idiopathic pain and depression

Are sleep problems and non-specific health complaints risk factors for chronic pain? A prospective population-based study with 17 year follow-up

Introduction

Chronic musculoskeletal pain represents a significant health problem among adults in Norway. The prevalence of chronic pain can be up to 50% in both genders. However, the prevalence of chronic widespread pain is significantly higher in females than in males. Chronic widespread pain is seen as the end of a continuum of pain. There is rather sparse knowledge about the incidence of pain in initially pain free individuals and the course of self-reported pain over time. Moreover, little is known about risk factors for incidence of chronic pain or prognostic factors for the course of self-reported pain. We believe that such knowledge may contribute to develop strategies for treatment at an early stadium of the pain condition and thereby reduce the prevalence of chronic pain included chronic widespread pain.

Aims of the study

The aims of this study were threefold: (1) to calculate the incidence of self-reported musculoskeletal pain in a female cohort, (2) to describe the course of pain and (3) to investigate whether or not health complaints and sleep problems are predictive factors for onset of pain or prognostic factors for the course of pain.

Methods

This is a prospective population-based study of all women between 20 and 50 years who were registered in Arendal, Norway, in 1989 (N = 2498 individuals). A questionnaire about chronic pain (pain >3 months duration in muscles, joints, back or the whole body), modulating factors for pain, sleep problems and seven non-specific health complaints was mailed to all traceable women, in 1990 (N =2498), 1995 (n = 2435) and 2007 (n = 2261). Of these, 1338 responded on all three occasions. Outcome measures were presence and extent of chronic pain.

Results

The prevalence of chronic pain was 57% in 1990 and 61% in 2007. From 1990 to 2007, 53% of the subjects changed pain category. The incidence of chronic pain in initially pain free individuals during follow-up was 44%, whereas the recovery rate was 25%. Impaired sleep quality predicted onset of chronic pain. There was a linear association between the number of health complaints and the incidence of chronic pain in initially pain free individuals. Equivalent results were found for persistence of pain and worsening of pain.

Conclusion

The prevalence of chronic pain was rather stable throughout the follow-up period, but the prevalence of chronic widespread pain increased. Individual changes in pain extent occurred frequently. The presence of sleep disturbances and number of health complaints predicted onset, persistence and worsening of pain.

Implications

Sleep problems must be thoroughly addressed as a possible risk factor for onset or worsening of pain. Elimination of sleep problems in an early phase is an interesting approach in treating chronic pain. More research is needed to illuminate the possible pathogenetic relations between pain, non-specific health complaints, sleep problems and also depression.

Epidemiology, co-morbidity, and impact on health-related quality of life of self-reported headache and musculoskeletal pain-a gender perspective

BACKGROUND

Headache and musculo-skeletal pain are major public health problems. Substantial proportions of the general population report that they experience pain problems that affect their work, daily living and social life. Epidemiological studies have consistently shown that the prevalence of most pain conditions is higher in women than in men.

DESIGN

Cross-sectional survey in the county of Uppland, Sweden, 1995. Five thousand four hundred and four completed the questionnaire (response rate=68%). In these analyses for persons aged 20-64 years 4506 were included.

RESULTS

Back pain (22.7%) and shoulder pain (21.0%) were the most commonly reported medical problems in the population with pain in arms/legs (15.7%) in fifth and headache (12.5%) in eight place. Major gender differences were found. The prevalence of pain conditions, especially headache, was higher among women. Women reported more severe pain. Co-morbidity between pain conditions and psychiatric and somatic problems was higher among women. Health-related quality of life (SF-36) differed by gender and type of pain condition. The physical dimensions of HRQoL were more affected by headache among men; psychological dimensions were more affected among women. Among both men and women, pain conditions were associated with poorer socioeconomic conditions and life-style factors but there were gender differences. Education and unemployment were important only among men while economical difficulties, half-time work and being married were associated with pain among women. Obesity, early disability retirement, long time sick-leave and lack of exercise were associated with pain conditions generally. Factors associated with pain conditions were unevenly distributed between genders.

CONCLUSION

There are major differences between men and women in the prevalence and severity of self-reported pain in the population. Biological factors may explain some of the differences but the main explanation is presumably gender disparities in work, economy, daily living, social life and expectations between women and men. Although improved working conditions are of importance, deeper societal changes are needed to reduce the inequities in pain experiences between women and men.

Exacerbated mechanical allodynia in rats with depression-like behavior

Although a clinical connection between pain and depression has long been recognized, how these two conditions interact remains unclear. Here we report that both mechanical allodynia and depression-like behavior were significantly exacerbated after peripheral nerve injury in Wistar-Kyoto (WKY) rats, a genetic variation of Wistar rats with demonstrable depression-like behavior. Administration of melatonin into the anterior cingular cortex contralateral to peripheral nerve injury prevented the exacerbation of mechanical allodynia with a concurrent improvement of depression-like behavior in WKY rats. Moreover, there was a lower plasma melatonin concentration and a lower melatonin receptor expression in the anterior cingular cortex in WKY rats than in Wistar rats. These results suggest that there exists a reciprocal relationship between mechanical allodynia and depression-like behavior and the melatoninergic system in the anterior cingular cortex might play an important role in the interaction between pain and depression.

Disentangling dysthymia from major depressive disorder in suicide attempters' suicidality, comorbidity and symptomatology

Dysthymia and major depressive disorder (MDD) are both risk diagnoses for suicidal behaviour. The aim of the present study was to identify clinical differences between these disorders, with a special reference to dysthymia. We studied suicidal behaviour, comorbidity and psychiatric symptoms of inpatient suicide attempters with dysthymia and MDD. We used DSM III-R diagnostics, the Suicide Assessment Scale (SUAS) and the Comprehensive Psychopathological Rating Scale (CPRS), part of which is the Montgomery and Asberg Depression Rating Scale (MADRS). Suicide mortality, number of repeated suicide attempts, method of suicide attempt and comorbidity of Axis I did not differ between the groups. Dysthymia patients, however, suffered more than MDD patients from DSM-III-R Axis II diagnoses (above all cluster B). There was no significant difference in Axis III comorbidity. Total SUAS, CPRS and MADRS scores did not differ significantly between the groups. When studying separate SUAS and CPRS items in a multivariate analysis, the CPRS items "aches and pains", "increased speech flow", increased "agitation" and "less tendency to worrying over trifles" as well as young age remained independently associated with dysthymia. Dysthymia patients, who later committed suicide, more often reported increased "aches and pains" than those who did not commit suicide. In this small sample of suicide attempters, we conclude that dysthymia suicide attempters, more often than MDD patients, have a comorbidity with personality disorders, which combined with a picture of aches and pains, could be factors explaining their suicidality.

Painful symptoms in depression: under-recognised and under-treated?

Current diagnostic systems maintain an artificial division between 'physical'and 'psychological'disorders. This is exemplified by the way in which pain symptoms are dealt with in the context of depressive illness. The consequences of this are discussed, and ways to enhance the clinical care of patients with depression and pain are suggested.

The epidemiology of pain in depression

Over 75% of depressed patients in primary care complain of painful physical symptoms such as headache, stomach pain, neck and back pain as well as non-specific generalized pain. The presence of such symptoms predicts a greater severity and a less favourable outcome of depression with a poorer health-related quality of life. World Health Organization data obtained in primary care centres worldwide show that 22% of all primary care patients suffer from persistent debilitating pain and that these patients are four times more likely to have co-morbid anxiety or depressive disorder than pain-free primary care patients. Not unexpectedly, the risk of depression is greater when the pain is more diffuse, as indicated by the number of painful sites, and has a greater effect on the quality of life. Certain depressive symptoms, such as low energy and sleep disturbances, are commonly found in patients with co-morbid pain, whereas the opposite is true for symptoms such as guilt and loneliness. Increasingly, major depression is seen as being composed of psychological, somatic and painful physical symptoms. In order to achieve full sustained remission it is necessary to treat symptoms in all three of these areas. The area of painful physical symptoms is unfortunately still poorly understood and clearly merits greater attention.

Epidemiology of analgesic use: a gender perspective

BACKGROUND AND OBJECTIVE

Women consistently report significantly more frequent analgesic use in epidemiological studies. The aim of this study was to analyse the influence of medical and non-medical factors on the difference in use of analgesics between women and men from a population perspective.

METHODS

Cross-sectional survey. Postal questionnaires were sent to a random sample of the general population in the country of Uppland, Sweden (5404 answered the questionnaire, response rate: 68%).

RESULTS

34.8% of the women and 21.4% of the men had used analgesics during the two week recall period (Odds Ratio = 1.96). Social structure, social status, marital status, educational level, economic situation, lifestyle, attitudes toward drugs, medication knowledge and self-care orientation were of minor importance for the difference in use between women and men. Difference in prevalence of various types of pain and ache and the degree of pain experienced were the most influential factors affecting the difference in use. However, when all factors were analysed there remained a substantial difference in use between women and men (OR = 1.39, CI (95%) 1.20 to 1.60).

CONCLUSIONS

In the population, women use analgesics much more frequently than men. Consequently women may be at greater risk for adverse effects and dependency. Some of the gender difference is explained by the greater frequency of pain conditions among women, but a significant difference in use still remains to be explained.

A comparison of self-concept and personality disorders in women with pain accounted for by psychological factors, women with major depression, and healthy controls

OBJECTIVE

Do patients with pain accounted for by psychological factors (P) differ in their self-concept and personality disorders from patients with major depression (D) and healthy controls (C)?

METHOD

Thirty hospitalized P-patients (DSM-IV, 307.80) and 30 hospitalized D-Patients (DSM-III-R) were given the Beck Depression Inventory on admission (BDI-1) and at discharge (BDI-2). Together with BDI-2, patients filled out the Personality Disorder Questionnaire for DSM-III-R (PDQR) and the Frankfurt Self-Concept Scales (FSKN). Thirty-two healthy comparisons (C) completed the same questionnaires.

RESULTS

BDI-2 showed no significant differences between groups P and D, a prerequisite for the comparison of psychological traits. PDQR differed in the three groups. D showed more dependent, obsessive-compulsive, and histrionic personality features than group P. The three groups differed in FSKN total score and all 10 subscales (C (healthiest self-concept) > P > D). Groups P and D were different (P > D) in total score and subscales: performance, problem coping, confidence in behavior and decision taking, and self-esteem. Ten P-patients with pathological BDI-2 (P(D)) had significantly more disturbed PDQR and FSKN scores than the non-depressed (P(ND)), and closely resembled the D-patients.

CONCLUSIONS

Personality disorders and self-concept are not homogenous in female patients with P. Subgroup P(ND) differs from patients with depression (fewer personality disorders, better self-concept), whereas subgroup P(D) closely resembles them.

Psychological correlates of pain behavior in patients with chronic low back pain

Pain behaviors that are excessive for the degree of known physical disease are common in patients with chronic low back pain and are frequently assumed to arise from a comorbid depressive illness. Although some studies have confirmed an association between depression and excessive pain behavior, methodologic problems (such as the use of depression ratings that also recorded symptoms attributable to physical disease) make interpretation of this finding difficult. We recruited 54 consecutive patients with chronic (>6 months) low back pain from a hospital clinic. Subjects completed self-rated assessments of anxiety and depression (Hospital Anxiety and Depression Scale) designed to be minimally affected by physical symptoms, along with assessments of disability (ODQ), pain (visual analogue scale), pain behavior (Waddell checklist), and physical impairment. Seventeen subjects (31%) exhibited excessive pain behavior. Overall, they were no more depressed or anxious than the remainder, although men with excessive pain behavior showed a trend toward being more depressed. Patients with excessive pain behavior were more disabled (self-rated and observer-rated), reported greater pain, and were more likely to be female and to have pain of shorter duration. Pain behavior did not correlate with anxiety or depression, but correlated with measures of disability and pain intensity. Factor analysis revealed that physical disability, pain intensity, and pain behavior loaded heavily on the first factor. Anxiety and depression loaded together on a separate factor. We conclude that pain behaviors were not related to anxiety or depression in our group, although gender differences between groups could have contributed to our negative findings. Pain behaviors may influence other physical measures. Further studies are required to investigate the relation between depression and pain behavior while controlling for gender differences.

Childhood experiences and adult behavior in a group of women with pain accounted for by psychological factors and a group recovered from major depression

OBJECTIVE

In this study twenty-four women with pain accounted for by psychological factors (DSM-IV, 307.80) and twenty-four with major depression diagnosed according to DSM-III-R were compared to study the relationship between pain and depression.

METHOD

They were examined by a semi-structured, tape-recorded interview to study their childhood experiences and adult behavior. The interviews were rated by two independent and blind raters. Interrater correlation (Cohen-Kappa) varied between good and close agreement.

RESULTS

Of childhood experiences, "brutality between parents," "brutality toward child," and "sexual abuse" were often found in both groups and were more strongly represented in these than in comparison groups of former studies. As adults, the pain group had experienced more serious illness (p = 0.037) and surgery (p = 0.014). The depression group more often had a history of depression (15/24 vs. 4/24; p = 0.001). The pain group spoke negatively of its physicians (p = 0.001), was more hostile during the interview (p = 0.041), was less convinced of the benefit of the hospital stay (p = 0.029), felt less self-responsible, and was more pessimistic (p = 0.013). The pain patients also provoked negative emotions in the raters, whereas the latter's reaction to the depression group was compassion and interest (p = 0.0005) (Pearson's chi2 and Fisher's exact tests).

CONCLUSIONS

The results show that negative childhood experiences are prominent and similar in patients with pain accounted for by psychological factors and in patients after major depression. Adult behavior, however, is very different.

Chronic pain and the psychiatrist

Chronic pain is a phenomenon with important psychiatric aspects from a diagnostic as well as a therapeutic point of view. The place of chronic pain in the different versions of the Diagnostic and Statistical Manual of Mental Disorders, and the differential-diagnosis are critically discussed. The comorbidity with depression, anxiety disorders, substance abuse and personality disorders is extensively treated. Finally, the essential role of the psychiatrist in the multidisciplinary therapeutic approach of these patients is emphasised.

Citalopram in patients with fibromyalgia--a randomized, double-blind, placebo-controlled study

The effect of the selective serotonin reuptake inhibitor citalopram was studied in a randomized, double-blind, placebo-controlled, 4-month trial in patients with the fibromyalgia syndrome (FMS) who all fulfilled the American College of Rheumatology criteria. The citalopram doses varied between 20-40 mg daily. Forty female patients, 21 patients in the citalopram and 19 in the placebo group, participated. Assessment of pain, depressive symptoms and physical functioning were made using Visual Analogue Scales (VAS), the Montgomery Asberg Depression Rating Scale (MADRS) and the Fibrositis Impact Questionnaire (FIQ). In the global judgement of improvement, no significant changes were found between the citalopram and placebo groups as concerns pain or well-being, either in the Intention to Treat (ITT) analysis or in the completer analysis. However, among the completers, it was a tendency that more patients in the citalopram group (52.9%) were improved as compared to the placebo group (22.2%) concerning well-being. Furthermore, the results indicated that treatment with citalopram had a significant effect on pain on the VAS after 2 months of treatment compared to baseline. After 4 months, however, the effect had diminished. Measured with the FIQ, significant differences in the pain ratings were seen at the end of the trial. Significant effects on the depressive symptomatology measured by means of the MADRS were seen already after 1 month of treatment and were increasing further at the end of the trial, when a significant difference between the groups was also found.

Perceived family dynamics of persons with chronic pain

This qualitative study was conducted to gain an understanding of the experiences of persons with chronic pain and their relationships with family members and the family as a whole. The framework of systemic organization was used to define the areas of investigation guiding the formulation of broad questions relative to family functioning. Thirty persons with chronic pain (age 31-82 years, 73% women, 83% married, 83% European-American, 17% African-American) participated in the study. A semi-structured interview was conducted to elicit narrative descriptions of the participants' perspective of the pain experience and family functioning. The data were analysed using a constant comparison method of analysis described by Strauss. The dominant themes that emerged included: (i) emotional distress, (ii) distancing from family members, (iii) inability to share difficult feelings, (iv) intense mutual involvement with family members and identification with others' problems, (v) family isolation from community, and (vi) attempt at healing. A mid-range theory developed out of the data and explicated with the framework of systemic organization, was one of balancing and counterbalancing connectedness (spirituality) with personal autonomy or separateness (control) in order to find congruence for the family and individuals within. The pain sometimes acted as a mechanism regulating the distance and closeness among family members. Based on this information, nurses can facilitate better understanding among family members, encourage autonomy, assist individuals to express feelings and needs more directly, and facilitate members to respond to each other.

Serotonin and gender-specific psychiatric disorders

The serotonergic system has been linked to the etiology of several, albeit disparate, psychiatric disorders. The accumulation of many lines of evidence support the view that there are gender differences in the serotonergic system in humans. It is further proposed that a gender differentiated serotonergic system acts as the nidus for the development of gender-specific psychiatric disorders. Depression, anxiety and eating disorders are largely seen in females, whereas alcoholism, aggressivity and suicide predominate in males. Evidence from both animal and human studies suggesting that the serotonergic system mediates between social-environmental experience and biological states is presented and reviewed. A reconceptualization of the serotonergic system as a gender-specific psychobiological interface is proposed. (Int J Psych Clin Prac 1997; 1: 3-13).

Homeostatic disruption and depression

A putative model is presented for the nature of depression. It relies upon changes in core and defense homeostatic activity, subjecting the person either to minor or major depression. The former corresponds with the interaction between assessed brain emotion and altered organic elements which disrupt homeostasis. This is in contrast to the latter, which corresponds with the disruption of several homeostatic systems. We suggest that the frequency and severity of depression may be regulated by biological markers that represent the homeostatic baseline of biochemical, biophysical and mutual data system appraisals. In this framework, the relationship of the coefficient to the baseline of the homeostatic threshold levels evaluates the intensity of depression. The type of depression depends on the properties of the negative feedback mechanism which are replaced either by abnormal (retarded depression), or by a positive feedback mechanism (agitated depression). Homeostasis eliminates depression.

Advances in comprehensive pain management

Chronic pain is a significant public health problem and frustrating for everyone affected by it. Psychiatrists should take an active role in the care of patients with chronic pain. They no longer should wait to make a psychiatric diagnosis by exclusion in the patient who has failed to respond to multiple treatments over a period of years. Recent advances in the treatment of chronic pain include the diagnosis and treatment of psychiatric comorbidity, the application of primary psychiatric treatments to chronic pain, and the development of interdisciplinary efforts to provide comprehensive health care to the patient suffering with chronic pain.