Indian Journal of Pain

: 2014  |  Volume : 28  |  Issue : 3  |  Page : 177--183

Depression-sleep disturbance-chronic pain syndrome

Mayank Gupta1, Gautam Das1, Priyanka2, Anand G.S. Kumar1,  
1 Daradia: The Pain Clinic, Kolkata, India
2 Department of Anaesthesia, Chacha Nehru Bal Chikitsalya, New Delhi, India

Correspondence Address:
Mayank Gupta
14, Himvihar Apartment, Plot No. 8, I.P. Extension, New Delhi - 110 092


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 «SQ»Patient Health Questionnaire 9 (PHQ-9) depression scale«SQ», a self-administered version of mental disorder assessing tool PRIME-MD. Self-reported descriptors like «SQ»waking up refreshed«SQ», «SQ»waking up fatigued«SQ», «SQ»can«SQ»t find a comfortable position«SQ» and «SQ»toss and turn frequently«SQ» 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.

How to cite this article:
Gupta M, Das G, Priyanka, Kumar AG. Depression-sleep disturbance-chronic pain syndrome .Indian J Pain 2014;28:177-183

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Gupta M, Das G, Priyanka, Kumar AG. Depression-sleep disturbance-chronic pain syndrome . Indian J Pain [serial online] 2014 [cited 2021 Jan 20 ];28:177-183
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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

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}

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.


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}

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}{Figure 1}

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}

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}

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}

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}{Figure 5}


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'.


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