|Year : 2014 | Volume
| Issue : 3 | Page : 166-172
Chronic pain and depression: An online survey on Indian experiences
Santosh K Chaturvedi1, G Prasad Rao2, Kushal D Sarda3, Sachin Y Suryawanshi3
1 Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India
2 Department of Schizophrenia, Asha Psychiatric Hospital and Research Center, Hyderabad, Andhra Pradesh, India
3 Department of Medical Services, Ranbaxy Labs Ltd., Mumbai, Maharashtra, India
|Date of Web Publication||11-Aug-2014|
Kushal D Sarda
Medical Advisor, Ranbaxy Laboratories Ltd, Western Edge-I, Unit no. 201-204, 2nd Floor, Western Express Highway, Borivali (E), Mumbai - 400 066, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: It is now well-established that chronic pain and depression are interrelated but the exact reasons for this association remain unclear. Although, in the majority, chronic pain is the source of depression; in a few, chronic pain is a manifestation of depression. The objective of this survey was to study the pattern of socio-demographic characteristics of persons with depression and chronic pain carried out by online survey. Materials and Methods: Two-hundred and ten psychiatrist from all over India were selected randomly from those who were registered with the Indian Psychiatry Society. Online survey was conducted with these psychiatrists. Survey questionnaire included 16 questions on depression with chronic pain. Results: One hundred and fourteen psychiatrist responded on online survey. The data was compiled and analyzed. The results showed that 201 patients/week visit psychiatric clinics.47% psychiatrist say 15-30% present with chronic pain, 35% say depression with chronic pain is present in 20-40% patients. Eighty-four percent psychiatrist say pain and depression are related to each other. Forty-one say 25-50% patients of chronic pain have depression. Conclusion: The results of this survey showed that chronic pain and depression co-exist commonly.
Keywords: Chronic pain, depression, online survey, socio-demographic
|How to cite this article:|
Chaturvedi SK, Rao G P, Sarda KD, Suryawanshi SY. Chronic pain and depression: An online survey on Indian experiences
. Indian J Pain 2014;28:166-72
| Introduction|| |
Depression and chronic pain are two contrast ailments which affect different parts of a human body. Depression is a psychiatric condition while pain is a distinctly physical condition with many physically presentable symptoms. It is now well - established that chronic pain and depression are related but the reasons for this association remain unclear.  According to studies 2-4% of persons in the community, 5-10% of primary care patients, and 10-14% of medical inpatients suffer from major depression.  Studies done in primary care set up in India, however, have estimated the prevalence rate of depression as high as 21-40%.  Depression is more prevalent in chronic pain patients (CPPs) than in the general population as a consequence of the presence of chronic pain. 
Prevalence estimates for chronic pain (that is, pain lasting 3-6 months or longer) range from 9-33%. A review of the literature revealed that depression is present in 31% to 100% of people with pain. Other studies have shown that the prevalence of depression in pain ranges from 4-66% across retirement community, primary care, pain clinic, and community samples.  In terms of depression risk factors, Magni and colleagues found that various demographic factors (e.g., sex, income, education) and the presence of pain predicted high levels of depressive symptoms.  However, differential correlates of chronic pain versus comorbid illness were not explored. The findings on gender as a correlate of comorbid depression are mixed. Women with pain may be at a higher risk for depression,  whereas other research fails to show an association. Furthermore, in a study of depressed outpatients, younger, African American, Hispanic, or less educated people were more likely to report pain. 
Pain has been reported from India in patients suffering from such psychological illnesses as depression and hysteria. On the other hand certain authors reported seeing very few patients with a depressive illness in the pain clinics. 
Although, in the majority, chronic pain is the source of depression; in a few, chronic pain is a manifestation of depression. Certain other factors such as financial burden due to chronicity of the disease, restricted physical movements, dependence on others, sleep disturbances, occupational issues, reduced sexual activities, social isolation, are also responsible for depression in these patients. 
To our knowledge the prevalence of depression in Indian population with chronic facet pain is not well studied. The objective of this study was to study socio-demographic characteristics of depression in persons with chronic pain in Indian clinical practice through online survey questionnaire.
| Materials and Methods|| |
The online survey was carried out for period of 3 months (from February 2013 to April 2013). Twenty questions based on chronic pain and depression was prepared. They were validated by doing a pilot study at five Psychiatrists. After corrections, additions and deletions of questions from pilot study, the questionnaire was finalized with 16 questions. Two-hundred and ten psychiatrist from all over India were selected randomly who were registered with Indian Psychiatry Society. There email ids were obtained from the list and questionnaire link was shared with these psychiatrists to respond. The questions were related to:
- On an average how many patients do you see per week?
- In your clinic, what percentage of your patients report 'Chronic Pain' as a main problem/symptom?
- In your clinic, what percentage of your patients with depressive disorder report 'Chronic Pain' as a main problem?
- In context of 'Chronic Pain and Depression', which of the following statements is appropriate?
- Pain as a cause of depression
- Depression as a cause of pain
- Both depression and pain are related to each other
- Both depression and pain are not related to each other
- Cannot comment
- According to you, what percentage of 'Chronic Pain' patients suffers from Depression?
- What are the major challenges in diagnosing depression among 'Chronic Pain' patients?
- Furthermore, what is the percentage distribution of 'Pain intensity' in these patients?
- Apart from Depression, which other psychiatric disorders co-exist with chronic pain?
- What are the most common manifestations of 'Depression with chronic pain'?
- What percentage of these patients express impairment that is 'in excess of' their physical findings?
- Does depression decrease the effectiveness of 'Chronic Pain' treatment?
- What is the gender wise distribution of 'Chronic Pain with Depression" patients?
- What is the religion-wise distribution of such patients in your practice (in percentage)?
- What is the age-group wise distribution of such patients in your practice (in percentage)?
- In your practice, most patients of 'Chronic Pain and Depression' fall into which of the following socio-economic class?
- What is the education wise distribution of these patients (in percentage)?
Psychiatrists were requested to visit link and respond in 3 months duration, if they consented to this survey. After obtaining the response of doctors on survey questionnaire, data was entered in Microsoft Excel sheets and analysis was done.
| Results|| |
Out of 210 Psychiatrist approached for survey, 114 (54%) responded on online survey. We included the Psychiatrist who responded within 3 months of duration.
From the first question it was shown that on an average a psychiatrist see 201 patients per week. Around 47% psychiatrists reported that 15-30% patients have chronic pain as their main problem/symptom presenting to their clinic [Figure 1]. Whereas 35% Psychiatrists say that there are around 20-40% patients of depressive disorder who report chronic pain as their main problem [Figure 2].
|Figure 1: Q 2. In your clinic, what percentage of your patients report 'Chronic Pain' as a main problem/symptom?|
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|Figure 2: Q 3. In your clinic, what percentage of your patients with depressive disorder report 'Chronic Pain' as a main problem/symptom?|
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Next question was asked related to what psychiatrist thinks about association of 'Chronic Pain and Depression', 84% Psychiatrists believe that both depression and chronic pain are related to each other whereas only 1% believes that both are not related [Figure 3].
|Figure 3: Q 4. In context of 'Chronic Pain & Depression', which of the following statements is appropriate?|
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According to response, 41.23% of psychiatrist says that 25-50% patients suffer from depression due to chronic pain and 37.72% psychiatrist feel that 50-75% patients suffer from depression due to chronic pain [Figure 4].
|Figure 4: Q 5. According to you, what percentage of 'Chronic Pain' patients suffer from Depression?|
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Question number 6 was a subjective, what major challenges does a psychiatrist face while diagnosing depression in chronic pain patients. 30.91% psychiatrists say social stigma towards psychiatry and patients' unwillingness to accept depression as a cause for pain was a major challenge followed by 28.36% saying unawareness among the population. Others included lack of diagnostic tools, comorbid conditions such as arthritis, obesity, lack of compliance etc [Figure 5].
|Figure 5: Q 6. What are the major challenges in diagnosing depression among 'Chronic Pain' patients?|
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Furthermore, we asked psychiatrist what is the intensity of pain reported by these patients, 22.40% psychiatrist said that patient have severe pain, whereas 39.72% psychiatrist said moderate pain and 37.86% psychiatrist said have mild pain which needs treatment [Figure 6].
|Figure 6: Q 7. What is the percentage distribution of 'Pain intensity' in these patients?|
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Apart from depression, 29.87% psychiatrist said that patients complain of somatoform disorder co-existing with chronic pain, followed by 26.58% for generalized anxiety disorder, 22.28% for substance abuse. Others included stress disorder, conversion disorders, schizophrenia, chronic fatigue syndrome, disturbed sleep, panic disorder [Figure 7].
|Figure 7: Q 8. Apart from Depression, which other psychiatric disorders co-exist with Chronic pain?|
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Twenty-four percent psychiatrists say patients complain of disturbed sleep followed by irritability and sadness respectively seen as manifestations of depression with chronic pain [Figure 8].
|Figure 8: Q 9. What are the most common manifestations of ‘Depression with chronic pain’?|
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Out of these patients, 51.36% express impairment that is in excess of their physical findings as per psychiatrists. Seventy-nine percent psychiatrist says that depression decreases the effectiveness of chronic pain treatment where as 6% say it does not affect the treatment of chronic pain. Coming to gender wise distribution, 64% female patients report chronic pain with depression compared to 36% male.
[Figure 9] shows religion wise distribution of patients, 43.93% are Hindu followed 33.18% are Muslims. [Figure 10] shows age wise distribution of such patients, 36.97% patients are in 35-50 years of age has maximum chronic pain with depression complaints followed by almost equal in age group of 20-34 years and 51-64 years respectively.
|Figure 9: Q 13. What is the religion-wise distribution of such patients in your practice (in percentage)?|
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|Figure 10: Q 14. What is the age-group wise distribution of such patients in your practice (in percentage)?|
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We also asked psychiatrist about the socioeconomic classification of their patients, for which we followed Modified Kuppuswamy's socioeconomic scale. In response 46% psychiatrist say patients were from lower middle class followed by 30% from upper middle class.  [Figure 11].
|Figure 11: Q 15. In your practice, most patients of 'Chronic Pain & Depression' fall into which of the following Socio-economic class?|
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Lastly, education wise distribution of these patients was asked to psychiatrist who said that 37.76% patients have done higher school secondary education followed by 36.67% done primary education [Figure 12].
|Figure 12: Q 16. What is the education wise distribution of these patients (in percentage)?|
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| Discussion|| |
The range of pain experiences is wide and varied. An individual's response to chronic pain reflects characteristics of the pain and the person's thoughts and behavior developed during the course of the illness, which are subject to positive and negative reinforcement.  Major depression is the most common mental illness associated with chronic pain.  So the present study was carried out using online survey in psychiatrist doctors to see the relation between chronic pain and depression among their patients.
In our study, it was observed that on an average a psychiatrist see 201 patients per week. Out of this, 47.37% psychiatrist says 15-30% patients come with chronic pain as main problem whereas more than 16% psychiatrist says it is more than 30%. One study found that prevalence rates of pain patients were 38% in psychiatric clinics.  Stengel et al., had reported pain as a presenting symptom in 45-60% of cases in psychiatric clinics.  In [Figure 2], we can see that 35.09% psychiatrist says 20-40% depressive patients visiting their clinic have chronic pain as main problem other 30% psychiatrist says it is more than in 40% of patients. A study based on interviews by skilled clinicians determined that according to standardized criteria, depression afflicted 87% of 300 patients with chronic pain. 
The co-occurrence of pain and depression is common. Depression is more prevalent in CPPs than in the general population as a consequence of the presence of chronic pain.  In our study, 84% psychiatrist says pain and depression are related to each other, whereas 12% doctors feel it is the pain which causes depression. Bair et al., reviewed the literatures on prevalence rate of major depression among CPPs and found the prevalence rate to be varying within a wide range of 1.5-100% which included studies from pain clinic, psychiatric clinic, orthopedic clinic, dental clinic, gynecologic clinic, surgical patients, and primary care settings. They found the mean prevalence rate of major depression in CPPs from pain clinics to be 52% which included 15 studies.  Our study demonstrated 50% of psychiatrist saying that more than 50% of patients having chronic pain suffer from depression, 41.23% psychiatrist says it falls between 25-50% of range.
Further we asked what are challenges faced by psychiatrist in diagnosing depression in chronic pain [Figure 5]. Few psychiatrists (30.91%) say social stigma towards psychiatry and patients unwillingness to accept depression as a cause for pain was a major challenge followed by 28.36% saying unawareness among the population. Others included lack of diagnostic tools, comorbid conditions such as arthritis, obesity, lack of compliance etc. Several studies report that depression is associated with more pain complaints, greater pain intensity, longer duration of pain and greater likelihood of non-recovery.  So we included question regarding the pain intensity, 22.40% psychiatrist said patients complain of severe pain whereas 39.72% said have moderate pain and 37.86% said patients have mild pain but require treatment which was contrary to the study which reported 66% patients complaining of mild pain intensity. 
Recently, a worldwide study examining a population-based sample from 18 developed and developing countries, has carefully examined the relationship between chronic pain and mental disorders. They have concluded that chronic pain is associated with mood and anxiety disorders.  In our study we also wanted to see what other psychiatric disorders are presented by chronic pain patient. Patients complaining some form of somatoform disorder was observed by 29.87% Psychiatrist, followed by 26.58% for generalized anxiety disorder, 22.28% for substance abuse. Others included stress disorder, conversion disorders, schizophrenia, chronic fatigue syndrome, disturbed sleep, and panic disorder.
We also asked psychiatrist what are the clinical features with which a patient of depression with chronic pain present to your clinic, 24% says have disturbed sleep, 18.35% irritability, 17.65% sadness, 13.88% weakness, 13.18% loss of appetite, others included decreased concentration, stress, headache. 51.36% of psychiatrist said these patients express impairment that is 'in excess of' their physical findings as per psychiatrists. Presence of depression in a patient with chronic pain is associated with decreased function, poorer treatment response and increased health care costs.  In our study, 79% psychiatrist says that depression decreases the effectiveness of chronic pain treatment, where as 6% say it does not affects the treatment of chronic pain. Coming to gender wise distribution, 64% psychiatrist said female patients report chronic pain with depression in OPD compared to 36% psychiatrist males. The finding that female patients and those with higher education present with chronic pain significantly more often has already been observed by other researchers. There is no sound explanation offered for this predilection of the pain problem in female patients. 
Considering the socio-demographic characteristics, we did not find any much difference when it came to religion wise distribution of patients. Hindu, Muslims, and all other caste had almost same distribution. Age-group wise distribution of patients having depression with chronic pain was high in 35-50 years age which was 36.97% followed by almost equal in age-group of 20-34 years and 51-64years respectively. Socio-economic classification of patients revealed that 46% belong to middle class and 30% belong to upper class, this is contrary to studies done which says depression with chronic pain is seen in low socioeconomic status. , Lastly, it was estimated that more than 70% of patients is from lower level of education.
The present study has some limitations. Sample size of psychiatrist was low, so we cannot apt for whole population. In conclusion, this study demonstrated that psychiatrists are aware of chronic pain and depression co-existence. Demographic characteristics are also important when it comes to treating patients of chronic pain with depression.
| Acknowledgement|| |
The Authors are grateful to Mr. Govindarajan Dorairajan, business unit head, Mr. Mukesh Sehgal, senior manager-marketing and Solus and Solus Care team, Ranbaxy Laboratories Limited, Mumbai for their support and constant encouragement.
| References|| |
|1.||Romano JM, Turner JA. Chronic pain and depression: Does the evidence support a relationship? Psychol Bull 1985;97:18-34. |
|2.||Katon W, Schulberg H. Epidemiology of depression in primary care. Gen Hosp Psychiatry 1992;14:237-47. |
|3.||Grover S, Dutt A, Avasthi A. An overview of Indian research in depression. Indian J Psychiatry 2010;52:S178-88. |
|4.||Fishbain DA, Cutler R, Rosomoff HL, Rosomoff RS. Chronic pain associated depression: Antecedent or consequence of chronic pain? A review. Clin J Pain 1997;13:116-37. |
|5.||Miller LR, Cano A. Comorbid chronic pain and depression: Who is at risk? J Pain 2009;10:619-27. |
|6.||Magni G, Caldieron C, Rigatti-Luchini S, Merskey H. Chronic musculoskeletal pain and depressive symptoms in the general population. An analysis of the 1st National Health and Nutrition Examination Survey data. Pain 1990;43:299-307. |
|7.||Munce SE, Stewart DE. Gender differences in depression and chronic pain conditions in a national epidemiologic survey. Psychosomatics 2007;48:394-9. |
|8.||Husain MM, Rush AJ, Trivedi MH, McClintock SM, Wisniewski SR, Davis L, et al. Pain in depression: STAR*D study findings. J Psychosom Res 2007;63:113-22. |
|9.||Chaturvedi SK, Varma VK, Malhotra A. Depression in patients with non-organic chronic intractable pain. NIMHANS J 1985;3:121-6. |
|10.||Dutta D, Bharati S, Roy C, Das G. Measurement of prevalence of 'major depressive syndrome' among Indian patients attending pain clinic with chronic pain using PHQ-9 scale. J Anaesthesiol Clin Pharmacol 2013;29:76-82. |
|11.||Bairwa M, Rajput M, Sachdeva S. Modified Kuppuswamy's socioeconomic scale: Social researcher should include updated income criteria, 2012. Indian J Community Med 2013;38:185-6. |
|12.||Caltabiano ML, Byrne D, Sarafino EP. Health psychology: Biopsychosocial interactions, an Australian perspective. (2 nd ed.). Brisbane, Qld: John Wiley & Sons, 2008. |
|13.||Demyttenaere K, Bruffaerts R, Lee S, Posada-Villa J, Kovess V, Angermeyer MC, et al. Mental disorders among persons with chronic back or neck pain: Results from the World Mental Health Surveys. Pain 2007;129:332-42. |
|14.||Cheatle MD. Depression, chronic pain, and suicide by overdose: On the edge. Pain Med 2011;12 Suppl 2:S43-8. |
|15.||Stengel E. Pain and the psychiatrist. Br J Psychiatry 1965; 111:795-802. |
|16.||Lindsay PG, Wyckoff M. The depression-pain syndrome and its response to antidepressants. Psychosomatics 1981;22:571-7. |
|17.||Bair MJ, Robinson RL, Katon W, Kroenke K. Depression and pain comorbidity: A literature review. Arch Intern Med 2003;163:433-45. |
|18.||Varma VK, Malhotra A, Chaturvedi SK, Chari P. Sociodemographic study of patients with chronic pain. Indian J Psychiatry 1986;28:119-25. |
|19.||Gureje O, Von Korff M, Kola L, Demyttenaere K, He Y, Posada-Villa J, et al. The relation between multiple pains and mental disorders: Results from the World Mental Health Surveys. Pain 2008;135:82-91. |
|20.||Anap DB, Keerthi R, Khatri S. Does chronic facet pain cause depression in rural indian population? J Pain Relief 2013;S2:001. |
|21.||Chaturvedi SK. Prevalence of chronic pain in psychiatric patients. Pain 1987;29:231-7. |
|22.||Ramachandran V, Menon MS, Arunagiri S. Socio-cultural factors in late onset depression. Indian J Psychiatry 1982;24:268-73. |
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