Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 
  • Users Online:567
  • Home
  • Print this page
  • Email this page


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 28  |  Issue : 3  |  Page : 177-183

Depression-sleep disturbance-chronic pain syndrome


1 Daradia: The Pain Clinic, Kolkata, India
2 Department of Anaesthesia, Chacha Nehru Bal Chikitsalya, New Delhi, India

Date of Web Publication11-Aug-2014

Correspondence Address:
Mayank Gupta
14, Himvihar Apartment, Plot No. 8, I.P. Extension, New Delhi - 110 092
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-5333.138456

Rights and Permissions
  Abstract 

Context: Chronic pain, depression and poor sleep quality are the most prevalent cause of human suffering, often co-occurring in a mutually reinforcing relationship. However, the prevalence and the risk factors for development of depression and poor sleep quality in Indian patients suffering from chronic pain remains elusive. Aims: The purpose of the present study was to study the prevalence and severity of depression, self-reported sleep disturbance and their co-relation with various pain descriptors such as intensity and duration of pain in 471 Indian patients suffering from chronic pain (more than 3 months). Materials and Methods: The patients were assessed for depression and sleep disturbance by using preformed questionnaires. Depression was evaluated by 'Patient Health Questionnaire 9 (PHQ-9) depression scale', a self-administered version of mental disorder assessing tool PRIME-MD. Self-reported descriptors like 'waking up refreshed', 'waking up fatigued', 'can't find a comfortable position' and 'toss and turn frequently' were used to assess sleep quality and classify patients into those with good (waking up refreshed) or poor (waking up fatigued, cannot find a comfortable position and toss and turn frequently) sleep quality. Results: We found a high prevalence (87.6%) of depression among Indian patients suffering from chronic pain. Moderate-severe depression was found in 31.2% of patients and 68.8% of patients reportedly having poor sleep quality. Females outnumbered males in terms of suffering from chronic pain, moderate-severe depression and poor sleep quality with a female:male of 1:0.514, 1:0.43 and 1:0.6, respectively. Patients suffering from moderate-severe depression and poor sleep quality reported greater perceived intensity of pain, P = 0.005 and 0.012, respectively. Conclusion: Depression and pain frequently co-exist and evaluation and treatment of both are of paramount importance for optimal treatment. Female sex, intensity of pain and poor sleep quality act as risk factors for development of depression in Indian patients suffering from chronic pain.

Keywords: Chronic pain, depression, PHQ-9, sleep disturbance


How to cite this article:
Gupta M, Das G, Priyanka, Kumar AG. Depression-sleep disturbance-chronic pain syndrome . Indian J Pain 2014;28:177-83

How to cite this URL:
Gupta M, Das G, Priyanka, Kumar AG. Depression-sleep disturbance-chronic pain syndrome . Indian J Pain [serial online] 2014 [cited 2019 Nov 12];28:177-83. Available from: http://www.indianjpain.org/text.asp?2014/28/3/177/138456


  Introduction Top


Chronic pain is the most prevalent cause of human suffering worldwide, giving it the status of 'fifth vital' sign. [1] Depending upon the definition of chronic pain used and the study population, 7-55% of the population is expected to be suffering from chronic pain. [2],[3] Pain experience has both somatosensory as well as affective components and is determined by a multitude of factors. A number of affective disorders such as anxiety and depression have been associated with chronic pain in a mutual reinforcing relationship. Advances in neurophysiology of pain has revealed that pain and depression have interdigitating biological pathways and neurotransmitters thereby modifying each other's perception. [4] Depression often co-exists in patients with chronic pain, mean prevalence of major depression ranging from 1.5-100% in pain clinics or inpatient pain programs. [4],[5] Sleep disturbance such as difficulty in initiating and staying asleep and non- restorative sleep is major source of distress in patients with chronic pain. [6] However, the prevalence and severity of depression and sleep disturbance in Indian patients suffering from chronic pain and various factors involved in this complex interplay remains elusive. Understanding this liaison is of paramount importance given the fact that pain is one of the most common symptom with which a patient seeks medical care and neglecting the associated co-morbidities such as depression and sleep disturbance can preclude successful pain treatment leading to frustration both on the part of the patient as well as for the physician. The purpose of the present study was to study the prevalence of depression, its severity and self reported sleep disturbance and their co-relation with various pain descriptors such as intensity and duration of pain in Indian patients with chronic pain presenting to a busy pain clinic.


  Materials and Methods Top


A total of 512 patients presenting to a pain clinic with chief complaints of chronic pain (backache, neck pain, leg pain, joint paints and widespread muscle pain etc) from June to December 2012 were enrolled in this prospective study. Chronic pain was defined as pain persisting for more than 3 months. Exclusion criteria included patients on anti-depressants or already diagnosed with any psychiatric disorder prior to onset of painful symptoms, patients with cancer and pregnant females. Patients refusing to participate in the study were also excluded. Written and informed consent in the patient's own language was taken from all the patients. Demographic characteristics like age, sex and marital status (married/unmarried/others) were noted and statistically analyzed. Duration and intensity of pain were assessed from patient's recollection of the "time of first appearance of symptoms0" and "Numerical rating scale", a validated measure of intensity of pain respectively. The patients were assessed for depression and sleep disturbance by using preformed questionnaires. Depression was evaluated by a self-administered and validated measure known as 'Patient Health Questionnaire 9 (PHQ-9) depression scale' [Table 1], a self-administered version of mental disorder assessing tool PRIME-MD. [7],[8] PHQ-9 is a preformed questionnaire consisting of nine questions. The response to each of the nine questions is evaluated by frequency of the symptoms over the last 2 weeks and is categorized as 'Not at all', 'several days', 'more than half the days' and 'nearly every day'. The above response categories are scored as 0, 1, 2 and 3 respectively, giving a total score of 0-27. The severity of depression was assessed by PHQ-9 depression severity score: 0-no depression, 1-4- minimal depression, 5-9- mild depression, 10-14- moderate depression, 15-19- moderately severe depression and 20-27- severe depression. Patients were further classified into those suffering from no depression (0), minimal mild depression (1-9) and moderate-severe depression (10-14). The patients were questioned regarding their sleep pattern and self-reported descriptors like 'waking up refreshed', 'waking up fatigued', 'can't find a comfortable position' and 'toss and turn frequently' to assess sleep quality and disturbance. The patients were accordingly classified into those with good (waking up refreshed) and poor (waking up fatigued, cannot find a comfortable position and toss and turn frequently) sleep quality.
Table 1: PHQ-9

Click here to view


Statistical analysis was performed by the SPSS program for Windows, version 17.0. Data were checked for normality before statistical analysis using Shaipro-Wilk test. Continuous variables are presented as mean ± SD and categorical variables are presented as absolute numbers and percentage. Normally distributed continuous variables were compared using ANOVA. The Kruskal-Wallis test was used for those variables that were not normally distributed and further comparisons were done using Mann-Whitney U test. Categorical variables were analyzed using the chi-square test. For all statistical tests, a P value less than 0.05 was taken to indicate a significant difference.


  Results Top


Out of 512 patients enrolled, 471 patients who filled the pain questionnaires completely and satisfied all the inclusion criteria were included in the study. There were a total of 278 (59%) females and 143 (41%) males in the studied sample. The average age of patients was 47.53 years, with a range of 20-82 years. The maximum number of patients (71.8%) was in the age group of 31-60 years. The mean duration of pain complaint was 47.3 months with a range of 3 months to 30 years. The demographic profile of the patients is shown in [Table 2].
Table 2: Demographic profi le of the patients

Click here to view


Depression severity assessment according to PHQ-9 DSS revealed that 124 (26.3%) had minimal depression, 142 patients (30.1%) had mild depression, 83 (17.6%) had moderate depression, 42 (8.9%) had moderately severe and 22 (4.7%) had severe depression. Therefore, minimal-mild and moderate-severe depression was present in 56.4% and 31.2% of patients suffering from pain for more than 3 months, respectively [Figure 1]. The demographic profile of patients suffering from 'no', 'minimal-mild' and 'moderate-severe depression' is depicted in [Table 3].
Table 3: Demographic characteristics and duration of pain

Click here to view
Figure 1: Severity of depression

Click here to view


Demographic characteristics other than gender were found to be comparable among patients with or without depression. Average duration of pain was 51.39 years compared with 44.18 years in patients suffering from moderate-severe depression and those without depression, respectively; however, the results did not reach statistical significance. Depression was found to be more prevalent among female patients suffering from chronic pain with F:M of 1:1.76, 1:0.73 and 1: 0.43 among those suffering from 'no', 'minimal-mild' and 'moderate-severe depression', respectively [Figure 2].
Figure 2: Sex distribution

Click here to view


Chronic pain patients suffering with moderate-severe depression reported greater intensity of pain compared to those suffering from 'no' and 'minimal-mild' depression, P = 0.006* and 0.009*, respectively [Figure 3].
Figure 3: Relationship of sleep quality with pain intensity

Click here to view


A total of 324 patients (68.8%) reported having poor sleep quality. Demographic characteristics other than gender were found to be comparable among those with 'good' and 'poor' sleep quality [Table 4]. Female patients with chronic pain reported more frequently to be suffering from poor sleep quality compared to their male counterparts; P = 0.001*.
Table 4: Demographic characteristics

Click here to view


Patients suffering from poor sleep quality and waking up fatigued reported greater perceived intensity of pain compared with those with good sleep quality and waking up refreshed [Figure 4]. Depression was found in 305 and 105 patients suffering from good and poor sleep quality respectively; P < 0.001 [Figure 5].
Figure 4: Relationship of depression severity with pain intensity

Click here to view
Figure 5: Depression and sleep quality

Click here to view



  Discussion Top


The biopsychosocial model of chronic pain emphasizes a link between physical, emotional, behavioral and affective components of pain. A number of prospective and longitudinal studies have shown a strong mutually reinforcing relationship between chronic pain and depression. [9],[10],[11],[12] The inability to elucidate the organic cause of various chronic pain syndromes, its existence been questioned by the relatives, friends, employers and primary care physicians, as well as the increasing frustration due to piling financial burdens and exhausting treatment options, can initiate or augment a premorbid psychosocial affliction in these patients. Rapidly emerging new insights into the neurophysiology and neuroanatomy of pain and depression have revealed that both of these co-morbidities share common descending modulatory neural circuits employing the same neurotransmitters namely the monoamines serotonin, norepinephrine and dopamine. [4],[13]

The supraspinal system of pain modulation exerts tonic descending nociceptive inhibition at the level of spinal dorsal horn. The midbrain periaquiductal gray (PAG), medullary nucleus raphe magnus (NRM)/rostral ventromedial medulla (RVM), locus coerulus, dorsolateral pontine tegmentum (DLPT) and nucleus tractus solitaries are the prominent brainstem areas involved in this endogenous descending modulation of nociception. [14] These relay systems contain both serotonergic and noradrenergic neurons. The RVM which has 'on cells' (facilitating nociceptive transmission) and 'off cells' (inhibiting nociceptive transmission), send direct serotonergic projections to the dorsal horn whereas DLPT send noradrenergic projections to the dorsal horn both directly and indirectly via the RVM. [15],[16],[17] The limbic system which control emotions also contain the same neurotransmitters. Normally, this descending modulation dampens the peripheral nociceptive signals. However, continued stimulation as is the case with chronic pain and presence of depression causes increased turnover and depletion of serotonin and norepinephrine resulting in amplification of pain symptoms. [18],[19] This 'top-down' nociceptive control serves the basis for efficacy of antidepressants in alleviating these pain conditions by inhibiting reuptake of serotonin and norepinephrine, thereby restoring the descending inhibitory modulation.

The prevalence of depression in patients with chronic pain varies from 1.5-100%, depending upon the study population, type of pain studied and the assessment method. [5] Psychosocial factors such as depression play a significant part in prolonging the pain and associated distress. [20],[21] A number of self report scales to screen depression, e.g. Hospital anxiety and depression scale, [22] beck depression inventory (BDI), [23] Zung self reporting depression scale [24] and Patient Health Questionnaire 9 (PHQ-9) [7],[8] are available and have been validated in both clinical and research settings. We used PHQ-9 as the depression assessment tool because it is quick, does not require specialist training to administer, has positive predictive value and informs about the severity of depression. [25],[26] PHQ-9 uses diagnostic criteria from diagnostic and statistical manual of mental disorders and has been validated against the same. PHQ-9 can be repeated over time to monitor change and response to treatment. [7],[27],[28] It is the best available tool to assess depression in primary care setup and has been translated in Hindi and validated for diagnosis of depression in Indian patients. [29],[30]

The prevalence of depression has been found to vary between 20-61% among specific chronic pain syndromes. [31],[32],[33],[34],[35] Depression was present in 87.6% of chronic pain patients, in our study. The prevalence rate of depression and moderate-severe depression was 87.6% and 56.4% respectively. The higher prevalence of depression in Indian chronic pain patients found in our study can be attributed to a number of socio-demographic factors. The majority of patients in our study belonged to lower middle class and the female sex (59%). These subgroups of population have been found to be more predisposed to depression due to a number of social, hormonal and psychological factors. [36],[37],[38],[39],[40] Studies indicate that women are twice as likely to suffer from major depression compared to males. There is lack of consensus about the true scientific definition of chronic pain with definitions such as pain persisting more than three months or six months or pain persisting beyond the usual course of injury been proposed and used in both clinical and research settings. [41],[42],[43] We used the former definition of chronic pain i.e. pain persisting more than three months since the time of onset in this study.

We identified a number of risk factors catalyzing the development of depression in our study. Females outnumbered males both in terms of prevalence as well as severity of depression. Females were almost twice more likely to suffer from moderate-severe depression compared to males. A similar preponderance of depression among females suffering from chronic pain has been proposed by other authors as well. Secondly, the severity of depression was found to increase with increased severity of perceived pain intensity. The prevalence and severity of depression was found to increase with increased duration of symptoms, however the results did not reach statistical significance. No association however could be elicited between depression with other demographic characteristics such as age or marital status. This indicates that the perceived severity of pain is more important a risk factor rather than duration of pain for the development of depression in this patient population.

Poor sleep quality or not feeling rested after a habitual sleep episode, is also a subjective phenomenon just like pain. [44] Meneffee and colleagues reviewed sleep disturbance among different types of pain and found it to be most prevalent among patients with chronic non-malignant pain. [45] A high percentage, i.e. 68.8% of Indian patients with chronic pain were found to be suffering from poor sleep quality and waking up fatigued in the morning. Our results are similar to those of Morin et al., who found that more than 65% of chronic pain patients attending a pain management center identify themselves as poor sleepers. This phenomenon of non-restorative sleep i.e. waking up fatigued was observed particularly in patients with widespread body pain and satisfying criteria for fibromyalgia. However, the present authors did not evaluate the actual prevalence of either fibromyalgia or depression among patients with fibromyalgia as this was not the primary aim of the study. Like other authors, a statistically significant association of poor sleep quality was found with the female sex and higher perceived intensity of pain. [46] However, no relationship was found between poor sleep quality and other demographic characteristics or duration of pain. A strong association between poor sleep quality and depression emerged out of the present study such that patients with moderate to severe depression suffered more from poor sleep quality as a co-morbidity compared to those without depression. Our results are in agreement with previous literature suggesting that relationship between pain and poor sleep quality is bidirectional, that is presence of one exacerbates another. [47],[48] This may be due to the neurobiological areas of brain involved in pain perception are also the sites of sleep generation and mantainence.

Patients suffering from chronic pain frequently suffer from poor sleep quality and depression particularly moderate-severe depression. There may create a vicious circle of increasing pain, depression and poor sleep quality, often one amplifying another. Therefore, these co-morbidities should be routinely assessed and treated simultaneously for the pain physician's management of chronic pain patients to be complete and effective. The successful pain management strategy should be targeted against 'total pain' and not just the 'pain'.

 
  References Top

1.Lorenz KA, Sherbourne CD, Shugarman LR, Rubenstein LV, Wen L, Cohen A, et al. How reliable is pain as the fifth vital sign? J Am Board Fam Med 2009;22:291-8.  Back to cited text no. 1
    
2.Bowsher D, Rigge M, Sopp L. Prevalence of chronic pain in the British population: A telephone survey of 1037 households. Pain Clin 1991;4 : 223-30.  Back to cited text no. 2
    
3.Andersson HI, Ejlertsson G, Leden I, Rosenberg C. Chronic pain in a geographically defined general population: Studies of differences in age, gender, social class, and pain localization. Clin J Pain 1993;9:174-82.  Back to cited text no. 3
    
4.Blier P, Abbott FV. Putative mechanisms of action of antidepressant drugs in affective and anxiety disorders and pain. J Psychiatry Neurosci 2001;26:37-43.  Back to cited text no. 4
    
5.Bair MJ, Robinson RL, Katon W, Kroenke K. Depression and pain comorbidity: A literature review. Arch Intern Med 2003;163:2433-45.  Back to cited text no. 5
    
6.Breivik H, Collett B, Ventafridda V, Cohen R, Gallacher D. Survey of chronic pain in Europe: Prevalence, impact on daily life, and treatment. Eur J Pain 2006;10:287-333.  Back to cited text no. 6
    
7.Kroenke K, Spitzer RL. The PHQ-9: A new depression diagnostic and severity measure. Psychiatr Ann 2002;32:509-21.  Back to cited text no. 7
    
8.Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: The PHQ primary care study. Primary care evaluation of mental disorders. Patient Health Questionnaire. JAMA 1999;282:1737-44.  Back to cited text no. 8
    
9.Romano JM, Turner JA. Chronic pain and depression: Does the evidence support a relationship? Psychol Bull 1985;97:18-34.  Back to cited text no. 9
[PUBMED]    
10.Sullivan MJ, Reesor K, Mikail S, Fisher R. The treatment of depression in chronic low back pain: review and recommendations. Pain 1992;50:5-13.  Back to cited text no. 10
    
11.Magni G. On the relationship between chronic pain and depression when there is no organic lesion. Pain 1987;31:1-21.  Back to cited text no. 11
[PUBMED]    
12.Turk DC, Okifuji A, Scharff L. Chronic pain and depression: Role of perceived impact and perceived control in different age cohorts. Pain 1995;61:93-101.  Back to cited text no. 12
    
13.Evans DL, Staab JP, Petitto JM, Morrison MF, Szuba MP, Ward HE, et al. Depression in the medical setting: Biopsychological interactions and treatment considerations. J Clin Psychiatry 1999;60:40-55.  Back to cited text no. 13
    
14.Fields HL. Pain modulation: Expectation, opioid analgesia and virtual pain. Prog Brain Res 2000;122:245-53.  Back to cited text no. 14
[PUBMED]    
15.Fields HL, Heinricher MM, Mason P. Neurotransmitters in nociceptive modulatory circuits. Annu Rev Neurosci 1991;14:219-45.  Back to cited text no. 15
    
16.Okada K, Murase K, Kawakita K. Effects of electrical stimulation of thalamic nucleus submedius and periaqueductal gray on the visceral nociceptive responses of spinal cord dorsal horn neurons in the rat. Brain Res 1999;834:112-21.  Back to cited text no. 16
    
17.Hirakawa N, Tershrer SA, Fields HL. Highly delta selective antagonists in the RVM attenuate the antinociceptive effect of PAG DAMGO. Neuroreport 1999;10:3125-9.  Back to cited text no. 17
    
18.Johansson F, von Knorring L, Sedvall G, Terenius L. Changes in endorphins and 5-hydroxyindoleacetic acid in cerebrospinal fluid as a result of treatment with serotonin reuptake inhibitor (zimelidine) in chronic pain patients. Psychiatry Res 1980;2:167-72.  Back to cited text no. 18
[PUBMED]    
19.von Knorring L, Perris F, Oreland L, Eisemann M, Eriksson U, Perris H. Pain as a symptom in depressive disorders and its relationship to platelet monoamine oxidase activity. J Neural Transm 1984;60:1-9.  Back to cited text no. 19
    
20.Gatchel RJ. Psychological disorders and chronic pain: Cause and effect relationships. In: Gatchel RJ, Turk DC, editors. Psychological Approaches to Pain Management: A Practitioner's Handbook. New York: Guilford Publications; 1996. p. 33-54.  Back to cited text no. 20
    
21.Geisser ME, Roth RS, Robinson ME. Assessing depression among persons with chronic pain using the Center for Epidemiological Studies-Depression Scale and the Beck Depression Inventory: A comparative analysis. Clin J Pain 1997;13:163-70.  Back to cited text no. 21
    
22.Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983;67:361-70.  Back to cited text no. 22
[PUBMED]    
23.Beck AT, Ward CH, Mendelson M, Mock N, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry 1961;4:561-71.  Back to cited text no. 23
    
24.Zung WW. A self rating depression scale. Arch Gen Psychiatry 1965;12:63-70.  Back to cited text no. 24
[PUBMED]    
25.Nease DE Jr, Maloin JM. Depression screening: A practical strategy. J Fam Pract 2003;52:118-24.  Back to cited text no. 25
    
26.Witkampf KA, Naeije L, Schene AH, Huyser J, van Weert HC. Diagnostic accuracy of the mood module of the patient health questionnaire: A systematic review. Gen Hosp Psychiatry 2007;29:388-95.  Back to cited text no. 26
    
27.Avasthi A, Varma SC, Kulhara P, Nehra R, Grover S, Sharma S. Diagnosis of common mental disorders by using PRIME-MD patient health questionnaire. Indian J Med Res 2008;127:159-64.  Back to cited text no. 27
[PUBMED]  Medknow Journal  
28.Kochar PH, Rajadhyaksha SS, Suvarna VR. Translation and validation of brief patient health questionnaire against DSM-IV as a tool to diagnose major depressive disorder in Indian patients. J Postgrad Med 2007;53:102-7.  Back to cited text no. 28
    
29.Grover S, Dutt A, Avasthi A. An overview of Indian research in depression. Indian J Psychiatry 2010;52:S178-88.  Back to cited text no. 29
    
30.Löwe B, Unutzer J, Callahan CM, Perkins AJ, Kroenke K. Monitoring depression treatment outcomes with the Patient Health Questionnaire-9. Med Care 2004;42:1194-201.  Back to cited text no. 30
    
31.Cohen H, Neumann L, Haiman Y, Matar MA, Press J, Buskila D. Prevalence of post-traumatic stress disorder in fibromyalgia patients: Overlapping syndromes or post-traumatic fibromyalgia syndrome? Semin Arthritis Rheum 2002;32:38-50.  Back to cited text no. 31
    
32.Walker EA, Boy-Byrne PP, Katon WJ, Li L, Amos D, Jiranek G. Psychiatric illness and irritable bowel syndrome: A comparison with inflammatory bowel disease. Am J Psychiatry 1990;147:1656-61.  Back to cited text no. 32
    
33.Katon W, Egan K, Meller D. Chronic pain: Lifetime psychiatric diagnoses and family history. Am J Psychiatry 1985;142:1156-60.  Back to cited text no. 33
    
34.Yap AU, Tan KB, Chua EK, Tan HH. Depression and somatization patients with temporomandibular disorders. J Prosthet Dent 2002;88:479-84.  Back to cited text no. 34
    
35.Korszun A. Facial pain, depression and stress-connections and directions. J Oral Pathol Med 2002;31:615-9.  Back to cited text no. 35
[PUBMED]    
36.Sethi BB, Prakash R. Depression in industrial population. Indian J Psychiatry 1979;21:359-61.  Back to cited text no. 36
  Medknow Journal  
37.Nandi DN, Banerjee G, Boral GC, Ganguli H, Ajmany(Sachdev) S, Ghosh A, et al. Socio-economic status and prevalence of mental disorders in certain rural communities in India. Acta Psychiatr Scand 1979;59:276-93.  Back to cited text no. 37
[PUBMED]    
38.Bagadia VN, Jeste DV, Doshi SU, Shah LP. Depression: A clinical study of 233 cases. Indian J Psychiatry 1973;15:224-30.  Back to cited text no. 38
  Medknow Journal  
39.Ramachandran V, Menon MS, Arunagiri S. Socio-cultural factors in late onset depression. Indian J Psychiatry 1982;24:268-73.  Back to cited text no. 39
[PUBMED]  Medknow Journal  
40.Mohandas E. Roadmap to Indian psychiatry. Indian J Psychiatry 2009;51:173-9.  Back to cited text no. 40
[PUBMED]  Medknow Journal  
41.Classification of chronic pain. Descriptions of chronic pain syndromes and definitions of pain terms. Prepared by the International Association for the Study of Pain, Subcommittee on Taxonomy. Pain Suppl 1986;3:S1-226.  Back to cited text no. 41
[PUBMED]    
42.Bonica JJ. Importance of` the problem. In: Anderson S, Bond M, Mehta M, Swerdlow M, editors. Chronic Non-Cancer Pain: Assessment and Practical Management. Norwell: MTP Press Limited; 1987.  Back to cited text no. 42
    
43.Marcus DA. Treatment of nonmalignant chronic pain. Am Fam Physician 2000;61:1331-8.  Back to cited text no. 43
[PUBMED]    
44.International Classification of Sleep Disorders: Diagnostic and Coding Manual. Diagnostic Classification Steering Committee; Thorpy MJ, Chairman. Rochester, Minn: American Sleep Disorders Association; 1990.  Back to cited text no. 44
    
45.Menefee LA, Cohen MJ, Anderson WR, Doghramji K, Frank ED, Lee H. Sleep disturbance and nonmalignant pain: A comprehensive review of the literature. Pain Med 2000;1:156-72.  Back to cited text no. 45
    
46.Smith MT, Perlis ML, Carmody TP, Smith MS, Giles DE. Pre sleep cognitions in patients with insomnia secondary to chronic pain. J Behav Med 2001;24:93-114.  Back to cited text no. 46
    
47.Smith MT, Haythornwaite JA. How do sleep disturbance and chronic pain inter-relate? Insights from the longitudinal and cognitive-behavioral clinical trials literature. Sleep Med Rev 2000;8:119-32.  Back to cited text no. 47
    
48.Morin CM, Gibson D, Wade J. Self-reported sleep and mood disturbance in chronic pain patients. Clin J Pain 1998;14:311-4.  Back to cited text no. 48
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]


This article has been cited by
1 Determinants of chronic pain among adults in urban area of Udupi, Karnataka, India
Paramjot Panda,Navya Vyas,Sushma Marita Dsouza,Vamsi Krishna Boyanagari
Clinical Epidemiology and Global Health. 2018;
[Pubmed] | [DOI]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Materials and Me...
Results
Discussion
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed2034    
    Printed64    
    Emailed0    
    PDF Downloaded252    
    Comments [Add]    
    Cited by others 1    

Recommend this journal