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Depression symptoms and chronic pain in the community population in Beijing, China
Psychiatry Research 200 (2012) 313–317
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Depression symptoms and chronic pain in the community population in Beijing, China Xi Chen, Hui Green Cheng, Yueqin Huang n, Zhaorui Liu, Xiaomin Luo Institute of Mental Health, Peking University, Key Laboratory of Mental Health, Ministry of Health (Peking University), Beijing 100191, PR China
a r t i c l e i n f o
abstract
Article history: Received 27 January 2011 Received in revised form 8 April 2012 Accepted 13 April 2012
We explore the association of depressive symptoms and chronic pain (arthritis, back or neck pain, headache, or other pain) in a community population of Beijing, China. Two thousand four hundred and sixty nine residents aged 16 years and older were investigated in 2010. Data were collected from faceto-face interviews using the Composite International Diagnostic Interview-3rd version. The presence of chronic pain condition and depressive symptoms were analyzed using univariate and multivariate analysis methods. We found a 12-month prevalence of MDD (Major depressive disorder) at 3.28%. Nearly half (41.01%) of respondents with depressive symptoms also had at least one chronic pain condition, and 64.20% of subjects with MDD (Major depressive disorder) experienced at least one chronic pain. After adjusting for selected demographic variables, it was found by multivariate logistic regression analysis that depressive symptom without MDD was significantly associated with backor neck pain (Adjusted odds ratio (AOR) ¼ 1.97, 95% CI, 1.34–2.90), headache (AOR ¼ 3.17, 95% CI, 1.81–5.58), and other chronic pain (AOR ¼ 2.21, 95% CI, 1.07–4.49). MDD was significantly associated with arthritis (AOR ¼2.23) back or neck pain (AOR ¼ 4.17), headache (AOR ¼ 3.16), and other chronic pain (AOR ¼ 3.51). Multiple types of chronic pain are associated with depressive symptoms and MDD. Future studies are needed to infer causality. & 2012 Elsevier Ireland Ltd. All rights reserved.
Keywords: Depressive symptoms Major depressive disorder Pain Epidemiology
1. Introduction As one of the most prevalent mental disorders (Kessler et al., 2007; Oakley Browne et al., 2006; Shen et al., 2006; Williams et al., 2008), major depressive disorder (MDD) diagnosed by the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) often co-occurs with pain in various sites (Ohayon, 2004). The data from studies in adult populations showed that the likelihood of chronic pain was found to be twice as high as in people with depression (Demyttenaere et al., 2006; Ohayon and Schatzberg, 2003). Another study further illustrates that depression and chronic pain can be considered to be closely linked (Geerlings et al., 2002). An epidemiological study in Europe reported MDD subjects with chronic pain had more severe symptoms of insomnia, fatigue, impaired concentration and psychomotor retardation than MDD subjects without pain (Ohayon and Schatzberg, 2003). Some studies showed that the number of people with depressive symptoms was at least one time greater than people with MDD by DSM-IV. This was due to the fact that the duration or number of symptoms did not meet DSM-IV criterion. Very few
n Corresponding author. Tel./fax: þ86 10 82802836. E-mail address: [email protected] (Y. Huang).
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studies have been reported with a focus on only those with depressive symptoms. Illuminating specific features associated with co-morbid pain conditions may help increase physician’s recognition of these psychiatric syndromes. A longitudinal study in the elderly persons found that chronic pain conditions increased the risk for depressive symptoms (Chou and Chi, 2005). Another study showed that depressive symptoms predicted future episodes of low back pain, neck–shoulder pain and musculoskeletal symptoms compared with those patients without depressive symptoms (Leino and Magni, 1993). An additional study showed that lower back pain reported by individuals with depressive symptoms were more than 2 times more likely to be reported by those without depressive symptoms (Croft et al., 1995). Although the association between pain and depressive symptom has been extensively and systematically investigated in Western countries (Currie and Wang, 2004; Ohayon and Schatzberg, 2003), there have been few studies on similar issues in China. In the past few years, there have been several studies of the co-morbidity between pain and depression in China (Lee and Tsang, 2009; Ng et al., 2002; Wang et al., 1999). Nonetheless, little research has focussed on the relationship between specific pain sites and depressive symptoms. In order to fill the gaps in knowledge, this study explores the relationship between four common kinds of pain (arthritis, back or neck pain, headache and other pain) and depressive symptom using standardised diagnostic criteria in a community
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sample in Beijing. Furthermore, this study evaluates the association between chronic pain and frequency and severity of depressive symptoms in subjects with and without MDD.
was self-reported. Socio-demographic information included age, gender, marital status, rural or urban residence, education, occupation and financial situation.
2. Methods
The Chi-square test was used to compare demographic variables across groups. Spearman correlation was used to calculate the correlation coefficient for the number of pain and the number of depressive symptoms. Logistic regression was used to calculate odds ratio for the relationship between chronic pain and depressive symptom with and without MDD. Depressive symptoms with and without MDD were coded as dichotomous variable. In the statistical analysis, a P-value o0.05 (two-sided) was considered as statistically significant. SAS 9.1.3 was used for analyses.
2.1. Subjects and procedures Multi-stage sampling methods were used to select household dwelling individuals of at least 16 years old. First, a total of six districts (three rural and three urban areas) in Beijing were selected. Second, two neighbourhoods were selected from each of the six districts. Lastly, 200 people from each neighbourhood were selected as participants using a systematic sampling method. Individuals who had insufficient fluency in Mandarin, hearing or speech impairment, or an illness that precluded the feasibility of an interview were excluded. A total of 2469 subjects completed the interview, and the average participation level was 72.88%. The field managers of the Institute of Mental Health at Peking University were in charge of training the interviewers and data collection following the standard onsite training procedures. Face-to-face interviews were conducted by 70 medical students from a medical university. All the interviewers were thoroughly trained before the fieldwork. This included seven main sessions: introduction, sampling design and procedures, review of the questionnaire, methods and techniques of field interviewing, briefing on field conditions, potential difficulties in different neighbourhoods and in-and-out classroom exercises for interviewers. Adequate instruction notes were provided and briefing and debriefing sessions were conducted. Through the Computer Assisted Personal Interviewing System, each interviewer read each question appearing on the monitor and entered the respondents’ answers directly into the computer, thereby bypassing the timeconsuming process of data coding, editing and entry. The average interview time was 1.2 hour. All subjects provided written consent, and the Institutional Review Board of the participating organisations approved the survey protocol. 2.2. Assessment The Composite International Diagnostic Interview (CIDI) has been used in major epidemiological surveys in the US, Australia and some counties. The Composite International Diagnostic Interview version 3.0 (CIDI-3.0) was being used by the World Mental Health Surveys (World Health Organization, 1990). CIDI-3.0 is a fully structured face-to-face interview designed to be administered by trained lay interviewers, generated both International Classification of Diseases Tenth edition (ICD-10) and DSM-IV diagnoses. DSM-IV criteria were used in this survey. The CIDI-3.0 was translated into Chinese using the standard WHO protocol in which a team of survey experts completed the initial translation and a separate team then carried out an independent back-translation to confirm preservation of the meaning of the original English version. Diagnostic test found good to excellent validity and reliability of CIDI-3.0 (Huang Yueqin et al., 2010), (Haro et al., 2006). 2.2.1. Depressive symptoms and MDD In this study, three comparison groups were formed based on the occurrence of depressive symptoms during the 12 months prior to the assessment. They were (1) no depressive symptom, (2) any depressive symptom but not MDD and (3) MDD based on criteria of DSM-IV. The assessment of depressive symptoms and MDD included two core symptoms: (1) depressed mood or (2) loss of interest or pleasure, and seven other symptoms including changes in appetite or weight, insomnia or hypersomnia symptoms, psychomotor agitation or retardation, fatigue or loss of energy, feeling of worthlessness or guilt, difficulties in concentration, thinking or making decisions, and suicidal thoughts, plan and attempt. Additionally, duration criteria were applied. That is, depressive symptoms had to be present for most of the day and nearly every day during the same 2 weeks in the past year. A standard CIDI3.0 diagnostic algorithm was used to generate DSM-IV MDD diagnosis. Essentially, DSM-IV requires four other symptoms besides at least one of the core symptoms to diagnose MDD. The ‘depressive symptom without MDD’ group consisted of individuals with at least one of the two core symptoms and less than four other symptoms. 2.2.2. Pain and demographic variables The participants were questioned regarding four chronic pain conditions as well as four chronic physical diseases. Considering the pain conditions, the respondents were asked about whether they experienced chronic back/neck problems, arthritis/rheumatism, frequent or severe headaches or any other pain problem in the previous 12 months. For example, for back and neck pain: ‘‘Have you had chronic back or neck problems in the past 12 months?’’ Chronic physical diseases included cancer, cardiovascular (hypertension, other heart disease), diabetes and ulcers. Data collection of chronic pain and chronic physical diseases
2.3. Statistical analysis
3. Results The sample included 2469 respondents aged 16–97 years; 967 (39.17%) were male and 1502 (60.83%) were female; 787(31.88%) were employed; 1954 (79.14%) were married or cohabiting; 1220 (49.21%) were rural residents; 677 (27.42%) had education of less than 6 years; 326 (13.20%) were aged 18–29 years, 449 (18.19%) 30–45 years, 901 (36.49%) 46–60 years and 793 (32.12%) 60 years and older; 1335 (54.07%) had no financial income; and 1133 (45.89%) had chronic physical diseases. The respondents with only depressive symptoms had a mean age of 44.68 years (S.D.¼17.58), being significantly younger than those with MDD with a mean age of 52.11 years (S.D.¼15.08). Chronic diseases were higher in those with MDD than respondents with depressive symptoms but no MDD (49.38% vs. 32.37%; P¼0.02).No statistical differences had been found amongst the other variables. 3.1. Association between pain and depressive symptoms Two-hundred and twenty (8.91%) respondents reported at least one of the two core symptoms of depression (including non-MDD (5.63%) and MDD (3.28%)) during the 12 months prior to the assessment. The prevalence of chronic pain was the highest for the ‘MDD’ group (64.20%), followed by the ‘depressive symptom without MDD’ group (41.01%), with the lowest for the ‘no depressive symptom’ group (34.19%). Chi-square tests revealed significant differences across these three groups (x2 ¼32.62, Po0.0001). Nearly half of subjects (49.32%) with at least one of the two key depressive symptoms also had at least one chronic pain. Some differences emerged when looking at the categorical composition of types of pains across three groups. For back and/or neck pain and other chronic pain, the prevalence was the highest for the ‘MDD’ group and lowest for the ‘no depressive symptom’ group with the ‘depressive symptom without MDD’ group in between. For arthritis pain, the prevalence was approximately the same for the ‘no depressive symptom’ group and the ‘depressive symptom without MDD’ group. For headache, the prevalence was approximately the same for the ‘no depressive symptom’ group and the ‘MDD’ group (Table 1). The frequency of pain was positively correlated with the number of depressive symptoms (r ¼0.16; Po0.0001). More than one-third (34.29%) of the respondents with two to four depressive symptoms also had at least one chronic pain. This proportion increased to 35.29% for respondents with five depressive symptoms and 56.82% for those with at least six depressive symptoms (Po 0.001). The proportion of chronic pain increased with the number of depressive symptoms. 3.2. Factors associated with depressive symptoms and MDD Table 2 shows the association between depressive symptoms and pain. Multivariate analyses were used to explore differences among three groups. After adjusting for age, gender, marital status,
X. Chen et al. / Psychiatry Research 200 (2012) 313–317
education, occupation, residence and chronic diseases, variables that ceased to be significant in the multivariate model were eliminated, yielding four final models in which all four pain variables were independently associated with depressive symptoms. After adjusting the corresponding variables, logistic regression found that depression symptoms were significantly associated with back or neck pain (AOR, 1.97, 95% CI, 1.34–2.90, Cox Snell R2 ¼0.03, Nagelkerke R2 ¼0.10), headache (AOR, 3.17, 95% CI, 1.81–5.58,Cox Snell R2 ¼0.02, Nagelkerke R2 ¼0.06) and other chronic pain (AOR,
Table 1 Distribution of depressive symptoms by demographic variables. Factor
Total N ¼ 2469 N (%)
Gender Male Female Age 18 29 30 45 46 60 460 Residence urban rural
No depressive symptoms N ¼ 2249 N (%)
967 (39.17) 890 (39.57) 1502 (60.83) 1359 (60.43) 326 449 901 793
(13.20) (18.19) (36.49) (32.12)
280 404 824 741
(12.45) (17.96) (36.64) (32.95)
1248 (50.55) 1125 (50.02) 1221 (49.45) 1124 (49.98)
Depressive symptoms without MDD N ¼139 N (%)
MDD N ¼ 81 N (%)
47 (33.81) 92 (66.19)
30 (37.04) 51 (62.96)
37 30 43 29
9 15 34 23
(26.62) (21.58) (30.94) (20.86)
(11.11) (18.52) (41.98) (28.40)
71 (51.08) 68 (48.92)
52 (64.20) 29 (35.80)
Education o6 6–9 9–12 412
677 821 513 458
(27.42) (33.25) (20.78) (14.77)
623 752 461 413
(27.70) (33.44) (20.50) (18.36)
27 44 33 35
(19.42) (31.65) (23.74) (25.18)
26 25 19 10
(33.33) (30.86) (23.46) (12.35)
Occupation Employed Homemaker Retired Other
787 460 436 786
(31.88) (18.63) (17.66) (31.83)
730 424 417 678
(32.46) (18.85) (18.54) (30.15)
43 20 9 67
(30.94) (14.39) (6.47) (48.20)
14 16 10 41
(17.28) (19.75) (12.35) (50.62)
Marital status Married 1954 (79.14) 1808 (80.39) Unmarried 515 (20.86) 414 (19.61)
89 (64.03) 50 (35.97)
57 (70.37) 24 (29.63)
Chronic diseases Yes 960 (38.88) 875 (38.91) No 1509 (61.12) 1374 (61.09)
45 (32.37) 94 (67.63)
40 (49.38) 41 ( 50.62)
339 (15.07) 472 (20.99)
20 (14.39) 44 (31.65)
24 (29.63) 42 (51.85)
98 (4.36) 79 (3.51)
17 (12.23) 9 (6.47)
11 (13.58) 10 (12.35)
587 (26.10)
34 (24.46)
29 (35.80)
182 (8.09)
23 (16.55)
23 (28.40)
Past year chronic pain Arthritis 383 (15.51) Back and/or 558 (22.60) neck pain Headache 126 (5.10) 98 (3.97) Other chronic pain One chronic 650 (26.33) pain Two or 238 (9.23) more pain
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2.21, 95% CI, 1.07–4.49, Cox Snell R2 ¼0.02, Nagelkerke R2 ¼0.06). MDD was significantly associated with arthritis (AOR, 2.23, 95% CI, 1.33–3.72, Cox Snell R2 ¼0.02, Nagelkerke R2 ¼0.05) back or neck pain (AOR, 4.17, 95% CI, 2.63–6.61, Cox Snell R2 ¼0.02, Nagelkerke R2 ¼0.06), headache (AOR, 3.16, 95% CI, 1.60–6.26, Cox Snell R2 ¼0.02, Nagelkerke R2 ¼0.06) and other chronic pain (AOR, 3.51, 95% CI, 1.71–7.20, Cox Snell R2 ¼0.02, Nagelkerke R2 ¼0.05). That is, the respondents with only depressive symptoms reported more back and/or neck pain, headache and other chronic pain than the respondents who had no depressive symptoms. On the other hand, the MDD group reported more arthritis, back and/or neck pain, headache and other chronic pain than the respondents who had no depressive symptoms. Smaller AORs were found for back/neck pain and other chronic pain when comparing the ‘symptom without MDD’ group and the ‘MDD’ group, while approximately the same AORs were found for headache.
4. Discussion In this study, we found a 12-month prevalence of MDD at 3.28%, which is higher than similar prevalence surveys reported in other China surveys (Lee et al., 2009; Lu et al., 2008; Phillips et al., 2009; Shen et al., 2006), and is lower than that in American and Western European surveys (Kessler et al., 2003). It is assumed that the main reasons for the higher rates in our study are economic development, social change and methodological issues such as sampling, instrument, interview and so on. However, it can be seen that the prevalence of MDD remains in the low-average range of worldwide estimates (Demyttenaere et al., 2004). The relationship of chronic pain and depression symptoms in a community sample was estimated. In the recent 30 years through a literature search, this is the first study to examine the co-morbidity of multiple types of pain and depressive symptoms in a Chinese community sample. The results are in line with previous findings in Western countries, and, more importantly, offer new insight by focussing on respondents who had depressive symptoms but did not meet DSM-IV criteria for MDD. In this study sample, it was found that the majority (64.6%) of respondents who experienced at least one of the two key symptoms of depression did not meet DSM-IV MDD criteria. These respondents may or may not proceed to become MDD cases. Previous studies found that the vast majority of MDD cases had never sought professional treatment in psychiatry or mental health (Shen et al., 2006). Mental disorders were often undetected by primary care physicians (Kessler et al., 1985). It was reasonable to believe that the proportion of undetected people is higher among people who had depressive symptom but did not meet DSM-IV criteria. According to the results of this study, these respondents had considerably higher prevalence of pain compared to respondents with no depressive symptom. Furthermore, the number of types of pain increased with the number of
Table 2 Association between depressive symptoms and pain. Factors
Arthritis Back and/or neck pain Headache Other chronic pain
No depressive symptoms
1.00 1.00 1.00 1.00
Depressive symptoms without MDD
MDD
Crude OR (95% CI)
Adjusted OR (95% CI)
Crude OR (95% CI)
Adjusted OR (95% CI)
0.95 1.74 3.06 1.90
1.12 1.98 3.17 2.22
2.38 4.05 3.45 3.87
2.22 4.16 3.16 3.50
(0.58, (1.20, (1.77, (0.93,
1.54) 2.53) 5.28) 3.88)
(0.68, (1.35, (1.80, (1.08,
1.87) 2.90) 5.57) 4.62)
(1.45, (2.59, (1.77, (1.92,
3.88) 6.34) 6.72) 7.78)
Adjusted for age, gender, marital status, education, occupation, residence, and chronic diseases OR ¼ odds ratio, CI ¼confidence interval.
(1.33, (2.63, (1.60, (1.71,
3.72) 6.60) 6.26) 7.19)
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depressive symptoms. This is in line with findings from other studies; that is, as the severity and probability of pain increase, depressive symptoms and depression diagnoses become more prevalent (Carroll et al., 2000a; Von Korff et al., 1988). The information regarding specific patterns of co-morbidity between pain conditions and mental disorders may help the detection and treatment of psychiatric disorders (Arola et al., 2010; Geerlings et al., 2002). In this study, it was found that, as expected, the pain–depressive symptom association was stronger for the ‘MDD’ group compared to the ‘depressive symptoms without MDD’ group. The only exception was that the estimates were the same for headaches. In Western studies, migraine headache had the highest co-morbidity with major depression in the senior population (Fiest et al., 2011). The association between depression and pain is complex: longitudinal studies have shown that depressed individuals were more likely to develop multiple physical symptoms than non-depressed subjects. Conversely, the presence of pain was predictive of a new onset of depression (Benjamin et al., 2000; Larson et al., 2004). More research is needed to determine how alleviation of pain helps the patients’ depressive symptoms and, likewise, whether relief of depressive symptoms improves pain and its related morbidity. Due to the cross-sectional nature of this study, no temporal sequence for depressive symptoms and pain can be confirmed. Nonetheless, it may shed some new light on the depression–pain association. Among all four types of pain under study, the weakest association was found for arthritis, and there was a lack of association between arthritis and ‘depressive symptom without MDD’. Limited studies have found that pain intensity and pain-related cognition predict quality of life (QOL) in MDD with chronic pain. After controlling for the severity of pain, anxiety and depression, score of Pain Catastrophizing Scale was independently associated with QOL in MDD (Chung et al., 2011). This suggested that some other variables might account for the link between arthritis and depression. On the other hand, strong associations were found for headache and back/neck pain. Along with a large literature about the co-morbidities of depression and back–neck pain in developed and developing countries (Carroll et al., 2000b; Currie and Wang, 2004; Demyttenaere et al., 2007; Elliott et al., 1999; Von Korff et al., 2005), the results argue for a more likely genuine link between headache or back/neck pain and depression. Existing research indicates significant positive correlations between self-reports of depression and chronic pain condition (Robinson, 2010). The findings do suggest that the relationship between depression and chronic pain is likely more complex than can be determined with the use of self-report measures of chronic pain. Unavoidably, this study had several limitations. First, the current study was cross-sectional and observational in nature. Thus, results cannot be used to infer causal relationship between depressive symptoms and chronic pain. Second, ascertainment of all chronic conditions including pain, chronic physical disease and depression symptoms were based on current self-report without longitudinal observation. Additionally, information regarding the duration of the pain was not available. Therefore, there might be some variation in terms of the duration of pain across respondents. Also, variables used to define pain and physical conditions in this study are different from those in some previous studies. This made it difficult to compare results from different studies, despite that methodological research showed moderate to high agreement between self-reported data and medical record data regarding chronic physical conditions (Levav et al., 1993). Third, the possibility of residual confounding, for example, the frequency of underlying physical illnesses and social interaction, poverty, isolation in the survey, cannot be excluded, and the intensity of depression was not assessed. Finally, although the
overall response rate in this survey was reasonably high (72.88%), non-respondents might have differed with regard to characteristics that were related to chronic pain or depressive symptoms. The present study had several strengths, which were not commonly found in the literature regarding chronic pain, including a community sample and the use of a structured interview to assess MDD and depressive symptoms. Furthermore, the current study added to the growing literature on the chronic pain– depressive symptom relationship and laid a foundation for future experimental studies in China to determine if the alleviation of pain helps the patients’ depressive symptoms and, likewise, whether relief of depressive symptoms improves pain and its related morbidity. In conclusion, we have presented data showing that the multiple types of chronic pain are associated with depressive symptoms and MDD. Further research is needed to infer the causality of these relationships. Primary and secondary prevention efforts should target persons who exhibit symptoms of depression or highly prevalent chronic pain conditions.
Conflict of interest None of the authors has any competing interest in connection with this work.
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Depression symptoms and chronic pain in the community population in Beijing, China Xi Chen, Hui Green Cheng, Yueqin Huang n, Zhaorui Liu, Xiaomin Luo Institute of Mental Health, Peking University, Key Laboratory of Mental Health, Ministry of Health (Peking University), Beijing 100191, PR China
a r t i c l e i n f o
abstract
Article history: Received 27 January 2011 Received in revised form 8 April 2012 Accepted 13 April 2012
We explore the association of depressive symptoms and chronic pain (arthritis, back or neck pain, headache, or other pain) in a community population of Beijing, China. Two thousand four hundred and sixty nine residents aged 16 years and older were investigated in 2010. Data were collected from faceto-face interviews using the Composite International Diagnostic Interview-3rd version. The presence of chronic pain condition and depressive symptoms were analyzed using univariate and multivariate analysis methods. We found a 12-month prevalence of MDD (Major depressive disorder) at 3.28%. Nearly half (41.01%) of respondents with depressive symptoms also had at least one chronic pain condition, and 64.20% of subjects with MDD (Major depressive disorder) experienced at least one chronic pain. After adjusting for selected demographic variables, it was found by multivariate logistic regression analysis that depressive symptom without MDD was significantly associated with backor neck pain (Adjusted odds ratio (AOR) ¼ 1.97, 95% CI, 1.34–2.90), headache (AOR ¼ 3.17, 95% CI, 1.81–5.58), and other chronic pain (AOR ¼ 2.21, 95% CI, 1.07–4.49). MDD was significantly associated with arthritis (AOR ¼2.23) back or neck pain (AOR ¼ 4.17), headache (AOR ¼ 3.16), and other chronic pain (AOR ¼ 3.51). Multiple types of chronic pain are associated with depressive symptoms and MDD. Future studies are needed to infer causality. & 2012 Elsevier Ireland Ltd. All rights reserved.
Keywords: Depressive symptoms Major depressive disorder Pain Epidemiology
1. Introduction As one of the most prevalent mental disorders (Kessler et al., 2007; Oakley Browne et al., 2006; Shen et al., 2006; Williams et al., 2008), major depressive disorder (MDD) diagnosed by the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) often co-occurs with pain in various sites (Ohayon, 2004). The data from studies in adult populations showed that the likelihood of chronic pain was found to be twice as high as in people with depression (Demyttenaere et al., 2006; Ohayon and Schatzberg, 2003). Another study further illustrates that depression and chronic pain can be considered to be closely linked (Geerlings et al., 2002). An epidemiological study in Europe reported MDD subjects with chronic pain had more severe symptoms of insomnia, fatigue, impaired concentration and psychomotor retardation than MDD subjects without pain (Ohayon and Schatzberg, 2003). Some studies showed that the number of people with depressive symptoms was at least one time greater than people with MDD by DSM-IV. This was due to the fact that the duration or number of symptoms did not meet DSM-IV criterion. Very few
n Corresponding author. Tel./fax: þ86 10 82802836. E-mail address: [email protected] (Y. Huang).
0165-1781/$ - see front matter & 2012 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.psychres.2012.04.013
studies have been reported with a focus on only those with depressive symptoms. Illuminating specific features associated with co-morbid pain conditions may help increase physician’s recognition of these psychiatric syndromes. A longitudinal study in the elderly persons found that chronic pain conditions increased the risk for depressive symptoms (Chou and Chi, 2005). Another study showed that depressive symptoms predicted future episodes of low back pain, neck–shoulder pain and musculoskeletal symptoms compared with those patients without depressive symptoms (Leino and Magni, 1993). An additional study showed that lower back pain reported by individuals with depressive symptoms were more than 2 times more likely to be reported by those without depressive symptoms (Croft et al., 1995). Although the association between pain and depressive symptom has been extensively and systematically investigated in Western countries (Currie and Wang, 2004; Ohayon and Schatzberg, 2003), there have been few studies on similar issues in China. In the past few years, there have been several studies of the co-morbidity between pain and depression in China (Lee and Tsang, 2009; Ng et al., 2002; Wang et al., 1999). Nonetheless, little research has focussed on the relationship between specific pain sites and depressive symptoms. In order to fill the gaps in knowledge, this study explores the relationship between four common kinds of pain (arthritis, back or neck pain, headache and other pain) and depressive symptom using standardised diagnostic criteria in a community
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sample in Beijing. Furthermore, this study evaluates the association between chronic pain and frequency and severity of depressive symptoms in subjects with and without MDD.
was self-reported. Socio-demographic information included age, gender, marital status, rural or urban residence, education, occupation and financial situation.
2. Methods
The Chi-square test was used to compare demographic variables across groups. Spearman correlation was used to calculate the correlation coefficient for the number of pain and the number of depressive symptoms. Logistic regression was used to calculate odds ratio for the relationship between chronic pain and depressive symptom with and without MDD. Depressive symptoms with and without MDD were coded as dichotomous variable. In the statistical analysis, a P-value o0.05 (two-sided) was considered as statistically significant. SAS 9.1.3 was used for analyses.
2.1. Subjects and procedures Multi-stage sampling methods were used to select household dwelling individuals of at least 16 years old. First, a total of six districts (three rural and three urban areas) in Beijing were selected. Second, two neighbourhoods were selected from each of the six districts. Lastly, 200 people from each neighbourhood were selected as participants using a systematic sampling method. Individuals who had insufficient fluency in Mandarin, hearing or speech impairment, or an illness that precluded the feasibility of an interview were excluded. A total of 2469 subjects completed the interview, and the average participation level was 72.88%. The field managers of the Institute of Mental Health at Peking University were in charge of training the interviewers and data collection following the standard onsite training procedures. Face-to-face interviews were conducted by 70 medical students from a medical university. All the interviewers were thoroughly trained before the fieldwork. This included seven main sessions: introduction, sampling design and procedures, review of the questionnaire, methods and techniques of field interviewing, briefing on field conditions, potential difficulties in different neighbourhoods and in-and-out classroom exercises for interviewers. Adequate instruction notes were provided and briefing and debriefing sessions were conducted. Through the Computer Assisted Personal Interviewing System, each interviewer read each question appearing on the monitor and entered the respondents’ answers directly into the computer, thereby bypassing the timeconsuming process of data coding, editing and entry. The average interview time was 1.2 hour. All subjects provided written consent, and the Institutional Review Board of the participating organisations approved the survey protocol. 2.2. Assessment The Composite International Diagnostic Interview (CIDI) has been used in major epidemiological surveys in the US, Australia and some counties. The Composite International Diagnostic Interview version 3.0 (CIDI-3.0) was being used by the World Mental Health Surveys (World Health Organization, 1990). CIDI-3.0 is a fully structured face-to-face interview designed to be administered by trained lay interviewers, generated both International Classification of Diseases Tenth edition (ICD-10) and DSM-IV diagnoses. DSM-IV criteria were used in this survey. The CIDI-3.0 was translated into Chinese using the standard WHO protocol in which a team of survey experts completed the initial translation and a separate team then carried out an independent back-translation to confirm preservation of the meaning of the original English version. Diagnostic test found good to excellent validity and reliability of CIDI-3.0 (Huang Yueqin et al., 2010), (Haro et al., 2006). 2.2.1. Depressive symptoms and MDD In this study, three comparison groups were formed based on the occurrence of depressive symptoms during the 12 months prior to the assessment. They were (1) no depressive symptom, (2) any depressive symptom but not MDD and (3) MDD based on criteria of DSM-IV. The assessment of depressive symptoms and MDD included two core symptoms: (1) depressed mood or (2) loss of interest or pleasure, and seven other symptoms including changes in appetite or weight, insomnia or hypersomnia symptoms, psychomotor agitation or retardation, fatigue or loss of energy, feeling of worthlessness or guilt, difficulties in concentration, thinking or making decisions, and suicidal thoughts, plan and attempt. Additionally, duration criteria were applied. That is, depressive symptoms had to be present for most of the day and nearly every day during the same 2 weeks in the past year. A standard CIDI3.0 diagnostic algorithm was used to generate DSM-IV MDD diagnosis. Essentially, DSM-IV requires four other symptoms besides at least one of the core symptoms to diagnose MDD. The ‘depressive symptom without MDD’ group consisted of individuals with at least one of the two core symptoms and less than four other symptoms. 2.2.2. Pain and demographic variables The participants were questioned regarding four chronic pain conditions as well as four chronic physical diseases. Considering the pain conditions, the respondents were asked about whether they experienced chronic back/neck problems, arthritis/rheumatism, frequent or severe headaches or any other pain problem in the previous 12 months. For example, for back and neck pain: ‘‘Have you had chronic back or neck problems in the past 12 months?’’ Chronic physical diseases included cancer, cardiovascular (hypertension, other heart disease), diabetes and ulcers. Data collection of chronic pain and chronic physical diseases
2.3. Statistical analysis
3. Results The sample included 2469 respondents aged 16–97 years; 967 (39.17%) were male and 1502 (60.83%) were female; 787(31.88%) were employed; 1954 (79.14%) were married or cohabiting; 1220 (49.21%) were rural residents; 677 (27.42%) had education of less than 6 years; 326 (13.20%) were aged 18–29 years, 449 (18.19%) 30–45 years, 901 (36.49%) 46–60 years and 793 (32.12%) 60 years and older; 1335 (54.07%) had no financial income; and 1133 (45.89%) had chronic physical diseases. The respondents with only depressive symptoms had a mean age of 44.68 years (S.D.¼17.58), being significantly younger than those with MDD with a mean age of 52.11 years (S.D.¼15.08). Chronic diseases were higher in those with MDD than respondents with depressive symptoms but no MDD (49.38% vs. 32.37%; P¼0.02).No statistical differences had been found amongst the other variables. 3.1. Association between pain and depressive symptoms Two-hundred and twenty (8.91%) respondents reported at least one of the two core symptoms of depression (including non-MDD (5.63%) and MDD (3.28%)) during the 12 months prior to the assessment. The prevalence of chronic pain was the highest for the ‘MDD’ group (64.20%), followed by the ‘depressive symptom without MDD’ group (41.01%), with the lowest for the ‘no depressive symptom’ group (34.19%). Chi-square tests revealed significant differences across these three groups (x2 ¼32.62, Po0.0001). Nearly half of subjects (49.32%) with at least one of the two key depressive symptoms also had at least one chronic pain. Some differences emerged when looking at the categorical composition of types of pains across three groups. For back and/or neck pain and other chronic pain, the prevalence was the highest for the ‘MDD’ group and lowest for the ‘no depressive symptom’ group with the ‘depressive symptom without MDD’ group in between. For arthritis pain, the prevalence was approximately the same for the ‘no depressive symptom’ group and the ‘depressive symptom without MDD’ group. For headache, the prevalence was approximately the same for the ‘no depressive symptom’ group and the ‘MDD’ group (Table 1). The frequency of pain was positively correlated with the number of depressive symptoms (r ¼0.16; Po0.0001). More than one-third (34.29%) of the respondents with two to four depressive symptoms also had at least one chronic pain. This proportion increased to 35.29% for respondents with five depressive symptoms and 56.82% for those with at least six depressive symptoms (Po 0.001). The proportion of chronic pain increased with the number of depressive symptoms. 3.2. Factors associated with depressive symptoms and MDD Table 2 shows the association between depressive symptoms and pain. Multivariate analyses were used to explore differences among three groups. After adjusting for age, gender, marital status,
X. Chen et al. / Psychiatry Research 200 (2012) 313–317
education, occupation, residence and chronic diseases, variables that ceased to be significant in the multivariate model were eliminated, yielding four final models in which all four pain variables were independently associated with depressive symptoms. After adjusting the corresponding variables, logistic regression found that depression symptoms were significantly associated with back or neck pain (AOR, 1.97, 95% CI, 1.34–2.90, Cox Snell R2 ¼0.03, Nagelkerke R2 ¼0.10), headache (AOR, 3.17, 95% CI, 1.81–5.58,Cox Snell R2 ¼0.02, Nagelkerke R2 ¼0.06) and other chronic pain (AOR,
Table 1 Distribution of depressive symptoms by demographic variables. Factor
Total N ¼ 2469 N (%)
Gender Male Female Age 18 29 30 45 46 60 460 Residence urban rural
No depressive symptoms N ¼ 2249 N (%)
967 (39.17) 890 (39.57) 1502 (60.83) 1359 (60.43) 326 449 901 793
(13.20) (18.19) (36.49) (32.12)
280 404 824 741
(12.45) (17.96) (36.64) (32.95)
1248 (50.55) 1125 (50.02) 1221 (49.45) 1124 (49.98)
Depressive symptoms without MDD N ¼139 N (%)
MDD N ¼ 81 N (%)
47 (33.81) 92 (66.19)
30 (37.04) 51 (62.96)
37 30 43 29
9 15 34 23
(26.62) (21.58) (30.94) (20.86)
(11.11) (18.52) (41.98) (28.40)
71 (51.08) 68 (48.92)
52 (64.20) 29 (35.80)
Education o6 6–9 9–12 412
677 821 513 458
(27.42) (33.25) (20.78) (14.77)
623 752 461 413
(27.70) (33.44) (20.50) (18.36)
27 44 33 35
(19.42) (31.65) (23.74) (25.18)
26 25 19 10
(33.33) (30.86) (23.46) (12.35)
Occupation Employed Homemaker Retired Other
787 460 436 786
(31.88) (18.63) (17.66) (31.83)
730 424 417 678
(32.46) (18.85) (18.54) (30.15)
43 20 9 67
(30.94) (14.39) (6.47) (48.20)
14 16 10 41
(17.28) (19.75) (12.35) (50.62)
Marital status Married 1954 (79.14) 1808 (80.39) Unmarried 515 (20.86) 414 (19.61)
89 (64.03) 50 (35.97)
57 (70.37) 24 (29.63)
Chronic diseases Yes 960 (38.88) 875 (38.91) No 1509 (61.12) 1374 (61.09)
45 (32.37) 94 (67.63)
40 (49.38) 41 ( 50.62)
339 (15.07) 472 (20.99)
20 (14.39) 44 (31.65)
24 (29.63) 42 (51.85)
98 (4.36) 79 (3.51)
17 (12.23) 9 (6.47)
11 (13.58) 10 (12.35)
587 (26.10)
34 (24.46)
29 (35.80)
182 (8.09)
23 (16.55)
23 (28.40)
Past year chronic pain Arthritis 383 (15.51) Back and/or 558 (22.60) neck pain Headache 126 (5.10) 98 (3.97) Other chronic pain One chronic 650 (26.33) pain Two or 238 (9.23) more pain
315
2.21, 95% CI, 1.07–4.49, Cox Snell R2 ¼0.02, Nagelkerke R2 ¼0.06). MDD was significantly associated with arthritis (AOR, 2.23, 95% CI, 1.33–3.72, Cox Snell R2 ¼0.02, Nagelkerke R2 ¼0.05) back or neck pain (AOR, 4.17, 95% CI, 2.63–6.61, Cox Snell R2 ¼0.02, Nagelkerke R2 ¼0.06), headache (AOR, 3.16, 95% CI, 1.60–6.26, Cox Snell R2 ¼0.02, Nagelkerke R2 ¼0.06) and other chronic pain (AOR, 3.51, 95% CI, 1.71–7.20, Cox Snell R2 ¼0.02, Nagelkerke R2 ¼0.05). That is, the respondents with only depressive symptoms reported more back and/or neck pain, headache and other chronic pain than the respondents who had no depressive symptoms. On the other hand, the MDD group reported more arthritis, back and/or neck pain, headache and other chronic pain than the respondents who had no depressive symptoms. Smaller AORs were found for back/neck pain and other chronic pain when comparing the ‘symptom without MDD’ group and the ‘MDD’ group, while approximately the same AORs were found for headache.
4. Discussion In this study, we found a 12-month prevalence of MDD at 3.28%, which is higher than similar prevalence surveys reported in other China surveys (Lee et al., 2009; Lu et al., 2008; Phillips et al., 2009; Shen et al., 2006), and is lower than that in American and Western European surveys (Kessler et al., 2003). It is assumed that the main reasons for the higher rates in our study are economic development, social change and methodological issues such as sampling, instrument, interview and so on. However, it can be seen that the prevalence of MDD remains in the low-average range of worldwide estimates (Demyttenaere et al., 2004). The relationship of chronic pain and depression symptoms in a community sample was estimated. In the recent 30 years through a literature search, this is the first study to examine the co-morbidity of multiple types of pain and depressive symptoms in a Chinese community sample. The results are in line with previous findings in Western countries, and, more importantly, offer new insight by focussing on respondents who had depressive symptoms but did not meet DSM-IV criteria for MDD. In this study sample, it was found that the majority (64.6%) of respondents who experienced at least one of the two key symptoms of depression did not meet DSM-IV MDD criteria. These respondents may or may not proceed to become MDD cases. Previous studies found that the vast majority of MDD cases had never sought professional treatment in psychiatry or mental health (Shen et al., 2006). Mental disorders were often undetected by primary care physicians (Kessler et al., 1985). It was reasonable to believe that the proportion of undetected people is higher among people who had depressive symptom but did not meet DSM-IV criteria. According to the results of this study, these respondents had considerably higher prevalence of pain compared to respondents with no depressive symptom. Furthermore, the number of types of pain increased with the number of
Table 2 Association between depressive symptoms and pain. Factors
Arthritis Back and/or neck pain Headache Other chronic pain
No depressive symptoms
1.00 1.00 1.00 1.00
Depressive symptoms without MDD
MDD
Crude OR (95% CI)
Adjusted OR (95% CI)
Crude OR (95% CI)
Adjusted OR (95% CI)
0.95 1.74 3.06 1.90
1.12 1.98 3.17 2.22
2.38 4.05 3.45 3.87
2.22 4.16 3.16 3.50
(0.58, (1.20, (1.77, (0.93,
1.54) 2.53) 5.28) 3.88)
(0.68, (1.35, (1.80, (1.08,
1.87) 2.90) 5.57) 4.62)
(1.45, (2.59, (1.77, (1.92,
3.88) 6.34) 6.72) 7.78)
Adjusted for age, gender, marital status, education, occupation, residence, and chronic diseases OR ¼ odds ratio, CI ¼confidence interval.
(1.33, (2.63, (1.60, (1.71,
3.72) 6.60) 6.26) 7.19)
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depressive symptoms. This is in line with findings from other studies; that is, as the severity and probability of pain increase, depressive symptoms and depression diagnoses become more prevalent (Carroll et al., 2000a; Von Korff et al., 1988). The information regarding specific patterns of co-morbidity between pain conditions and mental disorders may help the detection and treatment of psychiatric disorders (Arola et al., 2010; Geerlings et al., 2002). In this study, it was found that, as expected, the pain–depressive symptom association was stronger for the ‘MDD’ group compared to the ‘depressive symptoms without MDD’ group. The only exception was that the estimates were the same for headaches. In Western studies, migraine headache had the highest co-morbidity with major depression in the senior population (Fiest et al., 2011). The association between depression and pain is complex: longitudinal studies have shown that depressed individuals were more likely to develop multiple physical symptoms than non-depressed subjects. Conversely, the presence of pain was predictive of a new onset of depression (Benjamin et al., 2000; Larson et al., 2004). More research is needed to determine how alleviation of pain helps the patients’ depressive symptoms and, likewise, whether relief of depressive symptoms improves pain and its related morbidity. Due to the cross-sectional nature of this study, no temporal sequence for depressive symptoms and pain can be confirmed. Nonetheless, it may shed some new light on the depression–pain association. Among all four types of pain under study, the weakest association was found for arthritis, and there was a lack of association between arthritis and ‘depressive symptom without MDD’. Limited studies have found that pain intensity and pain-related cognition predict quality of life (QOL) in MDD with chronic pain. After controlling for the severity of pain, anxiety and depression, score of Pain Catastrophizing Scale was independently associated with QOL in MDD (Chung et al., 2011). This suggested that some other variables might account for the link between arthritis and depression. On the other hand, strong associations were found for headache and back/neck pain. Along with a large literature about the co-morbidities of depression and back–neck pain in developed and developing countries (Carroll et al., 2000b; Currie and Wang, 2004; Demyttenaere et al., 2007; Elliott et al., 1999; Von Korff et al., 2005), the results argue for a more likely genuine link between headache or back/neck pain and depression. Existing research indicates significant positive correlations between self-reports of depression and chronic pain condition (Robinson, 2010). The findings do suggest that the relationship between depression and chronic pain is likely more complex than can be determined with the use of self-report measures of chronic pain. Unavoidably, this study had several limitations. First, the current study was cross-sectional and observational in nature. Thus, results cannot be used to infer causal relationship between depressive symptoms and chronic pain. Second, ascertainment of all chronic conditions including pain, chronic physical disease and depression symptoms were based on current self-report without longitudinal observation. Additionally, information regarding the duration of the pain was not available. Therefore, there might be some variation in terms of the duration of pain across respondents. Also, variables used to define pain and physical conditions in this study are different from those in some previous studies. This made it difficult to compare results from different studies, despite that methodological research showed moderate to high agreement between self-reported data and medical record data regarding chronic physical conditions (Levav et al., 1993). Third, the possibility of residual confounding, for example, the frequency of underlying physical illnesses and social interaction, poverty, isolation in the survey, cannot be excluded, and the intensity of depression was not assessed. Finally, although the
overall response rate in this survey was reasonably high (72.88%), non-respondents might have differed with regard to characteristics that were related to chronic pain or depressive symptoms. The present study had several strengths, which were not commonly found in the literature regarding chronic pain, including a community sample and the use of a structured interview to assess MDD and depressive symptoms. Furthermore, the current study added to the growing literature on the chronic pain– depressive symptom relationship and laid a foundation for future experimental studies in China to determine if the alleviation of pain helps the patients’ depressive symptoms and, likewise, whether relief of depressive symptoms improves pain and its related morbidity. In conclusion, we have presented data showing that the multiple types of chronic pain are associated with depressive symptoms and MDD. Further research is needed to infer the causality of these relationships. Primary and secondary prevention efforts should target persons who exhibit symptoms of depression or highly prevalent chronic pain conditions.
Conflict of interest None of the authors has any competing interest in connection with this work.
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