Chronic Pain Cannot be Ignored in Depression and Anxiety

The majority of US adults living with unremitted depression and/or anxiety are also living with unaddressed chronic pain, according to a groundbreaking research paper published in Pain this month.

Psych Congress Network and Neurology Learning Network connected with study first author Jennifer S. De La Rosa, PhD, strategy director of the University of Arizona Health Sciences Comprehensive Center for Pain and Addiction and assistant research professor of family and community medicine in the College of Medicine at Tucson, to discuss the most significant findings from the study, important takeaways, and future pathways of research.

For more insights and resources, visit the Depression Topic Center on Psych Congress Network and the Pain Medicine Topic Center on Neurology Learning Network.

Interested readers can access the original journal article, titled "Co-occurrence of chronic pain and anxiety/depression symptoms in U.S. adults: prevalence, functional impacts, and opportunities," in-full here.

Editor’s note: This interview has been lightly edited for length and clarity.

Brionna Mendoza, Associate Digital Editor, Psych Congress Network and Neurology Learning Network: What led you and your colleagues to conduct this study? 

Jennifer S. De La Rosa, PhD: We were interested in understanding the co-occurrence of chronic pain and unremitted depression or anxiety a little more deeply than had been done before. Many studies of co-occurrence use samples of patients living with pain, or patients living with mental health challenges. We wanted to understand this co-occurrence “in the wild”, that is, in the US general adult population because, not everyone is a patient, particularly those that are disadvantaged and underserved

Mendoza, PCN and NLN: Please briefly describe the study method and your most significant finding(s).  

Dr De La Rosa: We first broke the US adult population into four categories and calculated the relative proportions of each: 1) those that had neither chronic pain nor unremitted anxiety or depression, 2) those that have chronic pain only, 3) those that have unremitted anxiety and depression only, and 4) those that have both. Then we looked at contingent prevalence: what proportion of those with unremitted anxiety and depression experienced chronic pain, and what proportion of those with chronic pain, experienced unremitted anxiety and depression. We calculated prevalence estimates in millions of people, to characterize how many U.S. adults experience co-occurrence in the population, compared with the prevalence of unremitted anxiety/depression or chronic pain alone. 

We found that co-occurrence of chronic pain with unremitted depression or anxiety affects nearly 5% of the population, or 1 in 20 U.S. adults. An estimated 12 million people are impacted, and of course their families as well. Unremitted anxiety and depression were 5 times as likely in those living with chronic pain compared to those who weren't.

Finally, this study showed that the majority (55.5%) of U.S. adults with unremitted anxiety or depression symptoms, are people who also live with co-occurring chronic pain. Here's why I think this is an important finding: policymakers, health researchers, and advocates often make reference to our national mental health crisis—that the amount of people living with clinically-elevated depression or anxiety symptoms is unacceptably high. So, when considering the “work ahead” in improving the mental health of the United States’ adult population, our study found that co-occurring chronic pain is not the exception, rather, it is the rule. In other words, chronic pain is more often present than not, in those with an unmet mental health need.  And yet, chronic pain is still very infrequently included in our national mental health conversation. My goal is to change that.

Mendoza, PCN and NLN: Your research highlights functional limitations experienced by individuals with co-occurring symptoms. What nonpharmacological strategies or interventions would you recommend to mental health care providers to help improve functional outcomes for these individuals? 

Dr De La Rosa: Biopsychosocial problems need biopsychosocial solutions. Maintaining sleep, nutrition, and daily movement of some kind can really help in preserving function. Mindfulness and meditation can have significant impact as well. In general, mental health care (whether pharmacological, non-pharmacological, or both) can be very helpful for anyone going through a distressing experience such as living with chronic pain. Perhaps the most important words any health care provider can say to someone experiencing pain are "I believe you", particularly for patients whose experience of pain or mental health challenges has been invalidated by other providers, employers, and family members.

It is important to try to manage expectations about chronic pain treatment, as follows: in most cases, no one treatment is going to be a panacea, and the optimal combination of chronic pain treatments or interventions can differ substantially from person to person. Also, quieting chronic pain is not a spectator sport—patients themselves need to take an active role in it. People living with chronic pain may need reassurance that a bit of a “journey” to treatment optimization is more common than not, but there is every reason to stay hopeful and keep exploring, in consultation with their healthcare team. 

Mendoza, PCN and NLN: Which misconceptions about chronic paid and A/D co-occurrence in the US adult population would you like to clarify for our audience?  

Dr De La Rosa: First, I would like to correct the perception of a strict dichotomy between pain—often seen as “physical”—and depression/anxiety—often seen as “mental”, or “emotional”. Both are biopsychosocial phenomena and emotions are really inextricable from the experience of physical pain. Think about the pain faces scale. It could as well have been titled “the pain emotions scale.”

Second, I would also like to help correct the perception that chronic pain in the context of anxiety or depression is “not real” or in some other way illegitimate. Besides being scientifically inaccurate, this attitude is harmful to people seeking care and may even prevent them from being open to discussing mental health care. I am passionate about addressing this problematic aspect of patient experience.   

Mendoza, PCN and NLN: What do you hope other researchers will explore further based on the insights gained from your study, and how might future studies build upon your findings to advance our understanding of this issue? 

Dr De La Rosa: I hope we will soon know more about the biopsychosocial mechanisms underlying the association between chronic pain and anxiety or depression, particularly to understand how we can intervene and help the quality of life of people affected by both.   

Mendoza, PCN and NLN: Is there anything I didn’t ask you about specifically that you’d like to mention in regard to this study and its findings? 

Dr De La Rosa: Many people reading this are living with both chronic pain and depression. I want to acknowledge their courage. I hope they continue to show up to their lives as much as possible: actively investigating physical, mental health, and integrative treatments, making small sustainable improvements in eating, sleeping, and moving, and incorporating mindfulness, stress reduction, and relaxation where possible.  

Jennifer Schultz De La Rosa, PhD, is a medical sociologist and data scientist specializing in treatment quality and utilization, workforce development, stigma, and health equity in the interrelated areas of chronic pain, substance use, and mental illness. Dr. De La Rosa is the Director of Strategy at the University of Arizona Health Sciences’ Comprehensive Center for Pain and Addiction. She is the Principal Investigator of PeerWORKS and the Director of Evaluation for Project FUTRE, HRSA-funded collaborations with the Department of Family and Community Medicine’s Workforce Development Program (College of Medicine- Tucson). These two programs train, certify, and place opioid-impacted individuals and family members in community provider roles, providing support to people with similar lived experiences. Dr. De La Rosa also directs evaluation of AzCANN, an Arizona Department of Health Services contract providing interprofessional and general public education events on safer adult use of cannabis.