Depression

Depression prevalence rates among patients with chronic pain are substantially higher than those in the general population, with reported prevalence rates of depression ranging from as low as 10% to as high as 100% (Banks and Kerns 1996, Romano and Turner 1985). Estimates vary depending on the variety of pain conditions examined, whether patients were sampled from clinical or community settings and the methodologies employed to diagnose depression. Nonetheless, depression constitutes a common psychiatric comorbidity among patients with chronic pain (Fishbain 1999, Koenig and Clark 1996).

Although much of the data suggest that chronic pain predisposes patients to depression (Fishbain et al. 1997), some longitudinal studies suggest that depression predicts future pain. For example, a 10-year study of industrial workers revealed that depression predicted the development of subsequent low back pain and other musculoskeletal impairments (Leino and Magni 1993) and in another 5-year follow-up survey, subjective assessments of depression predicted the development of fibromyalgia (Forseth et al. 1999).

As alluded to previously in the description of the neuromatrix theory, emerging evidence has suggested putative neurobiological mediators of the relationship between pain and depression (Blackburn-Munro and Blackburn-Munro 2001, Nestler et al. 2002, Raison et al. 2006). Given that there are common underlying substrates for these conditions, it is unsurprising that they co-occur at such high rates.

Depression among persons with chronic pain may result in perpetuation of pain, increasing the number, severity, and duration of physical symptoms, and enhancing subjective assessments of pain-related disability, e.g., higher unemployment rates (Bairs et al. 2003, Burns et al. 1998). Additionally, comorbid depression can impede treatment efforts (Haythornthwaite et al. 1991). Depression is associated with poor prognosis among patients with pain (Bair et al. 2003), influencing adaptation to illness and quality of life. Health risk behaviors are often associated with depression, e.g., cigarette smoking, overeating, and decreased physical activity, complicating the functional disability of patients with pain. Furthermore, depression is associated with higher non-adherence rates than that of non-depressed patients, undermining rehabilitative efforts and increasing health care utilization (DiMatteo et al. 2000). Treatment of depression, therefore, is a necessary component to multimodal treatment approaches to address pain; when effectively treated, patients experience dramatically less interference from pain (Lin et al. 2003).

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