Pain symptoms in Malay patients with major depression

Asian Journal of Psychiatry 5 (2012) 297–302

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Pain symptoms in Malay patients with major depression Salleh Mohd Razali *, Ahmad Qabil Khalib Department of Psychiatry, School of Medical Sciences, Universiti Sains Malaysia, Health Campus, 16150 Kota Bharu, Kelantan, Malaysia

A R T I C L E I N F O

A B S T R A C T

Article history: Received 1 January 2011 Received in revised form 12 February 2012 Accepted 21 February 2012

Objectives: There is a strong association between depression and pain, which is influenced by various biological and psychological mechanisms. The objectives of this study were to assess the prevalence and severity of pain symptoms among patients with major depression; and to determine the correlation between pain with clinical variables, neurotic pathology and severity of depression. Methods: Fifty-one Malay patients with major depressive disorder without psychotic feature enrolled for the study. They were assessed with the Hamilton Rating Scale for Depression (HAM-D), Brief Pain Inventory (BPI) and Crown Crisp Experiential Index (CCEI). Results: The majority (80.4%) of the subjects had experienced pain, but overall severity of the pain was mild (33.3%). There were no statistically significant differences in socio-demographic variables with the status of pain. The prevalence of pain was significantly higher in patients who were still depressed (p < 0.05), had anxious depression (p < 0.05) and those with prominent somatic symptoms of anxiety (SOM) (p < 0.05). The severity of pain was significantly correlated with neuroticism, the severity of depression (HAM-D total score) and high scores on SOM, DEP and FFA subscales of the CCEI. Among the three, the DEP subscale had the highest correlation with severity of pain. Conclusions: The somatising patients were heterogeneous group. The pain symptoms were common in severe mixed anxiety–depression, predisposed by the underlying neurotic pathology. Neuroticism and high scores on SOM, DEP and FFA subscales of the CCEI contributed significantly to the pathogenesis of depressed Malay patients with pain symptoms. ß 2012 Elsevier B.V. All rights reserved.

Keywords: Depression Pain Neuroticism Somatisation CCEI

1. Introduction The phenomenon of somatisation of psychological disorders is well known worldwide (Gureje, 2007), especially in Asia and Africa (Saxena et al., 1988; Ohaeri and Odejide, 1994). The psychopathologic aetiology of these patients ranged from psychotic illness to various neurotic disorders, such as somatoform disorder, depressive illness, anxiety disorders, conversion disorders and personality disorders. Many of these complaints were psychologically determined. Depressed patients for instance presented with predominantly somatic symptoms such as arches and pains; rather than presenting with low mood or anhedonia. Depressed patients are found to be four times more likely to have a painful condition (Ohayon and Schatzberg, 2003). On the other hand, pain is also strongly associated with anxiety and depression (Von Korff and Simon, 1996). Chronic pain problems are common worldwide and the association of chronic pain with mood disorders extends to the non-Western world (Gureje et al., 2008). The combination of chronic pain and depression, which affects 2% of the general population, is associated with high rates of disability, socioeco-

* Corresponding author. Tel.: +60 9 767 6710; fax: +60 9 765 9057. E-mail address: [email protected] (S.M. Razali). 1876-2018/$ – see front matter ß 2012 Elsevier B.V. All rights reserved. doi:10.1016/j.ajp.2012.02.015

nomic disadvantages and greater utilisation of healthcare resources (Currie and Wang, 2004). The experience of pain is believed to be influenced by a complex interplay of biological factors, personality traits, emotional, cognitive and socio-cultural factors (Mongini et al., 2009). Psychopathological trait such as neuroticism has the tendency to experience negative affect such as anxiety, sadness, embarrassment, anger, guilt and disgust (Quilty et al., 2008). Individuals high on neuroticism are emotional, insecure, impulsive, susceptible to psychological distress and vulnerable to stress. Some researchers believe that depression in itself may cause pain, potentially mediated through the neurochemical imbalance of neurotransmitters, including serotonin and norepinephrine. The chemical changes that occur as a consequence of depression are believed to increase sensitivity to painful stimuli and thus render individuals more vulnerable to pain (Delgado, 2004). Patients presenting with multiple pain symptoms are quite a challenge to the clinician. Somatising patients form a high proportion of patients with multiple unexplained physical symptoms attending various medical care settings (Bridge and Goldberg, 1985; Kesler et al., 1985). The presence of pain may contribute to delayed diagnosis and treatment of depression. Identifying the characteristic features of such patients may facilitate the diagnosis of depression, avoiding unnecessary delays

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in treatment. The general objective of this study was to assess the prevalence and severity of pain symptoms among depressed Malay patients. The specific objectives were to determine the correlation between pain symptoms with socio-demographic and clinical variables, severity of depression and psychoneurotic pathology. 2. Methods 2.1. Patient selection This was a cross-sectional study of consecutive Malay patients attending the psychiatric clinic of Hospital Universiti Sains Malaysia (USM) in the east coast of Peninsular Malaysia. The study protocol was approved by the Research and Ethical Committee (Human) of USM. Malay patients with the primary diagnosis of major depression without psychosis, aged 18 years and above, attending the psychiatric clinic during the study period were screened for the study. More than 90% of patients in the catchment areas were Malays. The selected patients were reassessed with the Structured Clinical Interview for DSM-IV Axis 1 Disorders (SCID-1) (First et al., 1997) to confirm the diagnosis of major depressive disorder without psychotic features (DSM-IV-TR) (American Psychiatric Association, 2000). Those who refused to give written informed consent; patients with co-morbid psychiatric diagnoses, e.g. psychoses, neuroses, personality disorder, mental retardation, substance abuse; and patients with medical or surgical conditions generally known to be associated with pain symptoms were excluded from the study. These include patients who had been treated or being treated for chronic pain and regular use of analgesics. 2.2. Research tools The selected cases were assessed with Hamilton Rating Scale for Depression (HAM-D) (Hamilton, 1960), Brief Pain Inventory (BPI)validated Malay version (Aisyaturridha et al., 2006) and Crown Crisp Experiential Index (CCEI) (Crown and Crisp, 1979). The CCEI, which was previously known as the Middlesex Hospital Questionnaire (MHQ), was designed to measure neurotic symptomatology (neuroticism) (Crown and Crisp, 1979). It consists of six scales of neurotic symptoms, each having eight items. The scales are: freefloating anxiety (FFA), phobic anxiety (PHO), obsession (OBS), somatic symptoms of anxiety (SOM), depression (DEP) and hysterical symptoms (HYS). The Malay version of the CCEI was validated by Kasmini and Kyaw (1988). 2.3. Statistical analysis The data were analysed using the Statistical Package for the Social Sciences (SPSS), version 12.01. Bivariate analysis using the chi-square test was carried out to compare the socio-demographic characteristics and clinical variables with the presence of pain. Fisher’s exact test was used if the assumptions of the chi-square test were not met. Appropriate correlation analysis was carried out to assess the relationship between neurotic symptomatology (CCEI scores) with depression score and the total pain scores. A post hoc analysis of sample size was performed in view of the small sample size. Logistic regression analysis was conducted to compute the odds ratios (OR) i.e., likelihood of having pain based on specific demographic and clinical characteristic, after adjusting for possible confounding factors. 3. Results A total of 58 patients fulfilled the inclusion criteria. However, 7 patients declined to participate in the study due to various reasons. Final data were available for 51 subjects (88% response rate).

3.1. Pain score 3.1.1. BPI pain intensity score The BPI intensity score ranged from 0 to 23, with a mean of 9.67 + 6.54. When the pain intensity score was averaged for the four items, the score was 2.42, which was in the range of mild pain (Mystakidou et al., 2009). 3.1.2. BPI pain interference score The BPI pain interference score ranged from 0 to 56, with a mean of 18.51 + 15.45. When the pain interference score was averaged for the seven items, the score was 2.64, which is in the range of mild pain (Serlin et al., 1995). 3.1.3. BPI total score The BPI total score was the sum of the pain intensity and pain interference scores. The BPI total score reflected the severity of pain. The BPI total score in the 51 patients ranged from 0 to 65, with a mean of 28.18 + 19.72. When the BPI total score was averaged for the 11 items, the score was 2.56, which is in the range of mild pain (Mystakidou et al., 2009). 3.1.4. Status of pain The presence of pain was assessed using the single item of ‘worst pain in the past 24 hours’ from the pain intensity scale (Dworkin et al., 2008). Forty-one (80.4%) subjects experienced pain. 3.2. Depression score 3.2.1. HAM-D total score The HAM-D total score ranged from 2 to 36, with a mean of 12.76 + 7.58, which was within the upper range of the mild depression category (Hamilton, 1960). Among the 51 patients, 17 (33.3%) had mild depression (score 8–13) while 15 (29.4%) were in remission (score 7 or less). Seven subjects had moderate (score 14– 18) and severe depression (score 19–22) respectively, while five had very severe depression (score 23 or more). 3.2.2. HAM-D anxiety/somatisation factor score Seven 7 items of the HAM-D anxiety/somatisation factor score are used to identify patients with anxious depression: (item no. 10, 11, 12, 13, 14, 15, 17). The anxiety/somatisation factor score ranged from 0 to 13, with a mean of 5.92 + 2.95. Using a cut-off score of 7 (Nierenberg et al., 2007), 30 (58.8%) of the subjects had a low anxiety/somatisation factor score while 21 (41.2%) had a high anxiety/somatisation factor score. 3.3. Psychoneurotic pathology 3.3.1. CCEI total score The CCEI total score ranged from 15 to 75, with a mean of 41.5 + 13.22. Patients with a CCEI total score above 42 are classified as neurosis (neuroticism) (Hamilton, 1960). The majority or 27 (52.9%) of the subjects scored in the normal range, while 24 (47.1%) scored above 42 and were categorised as neurotic. 3.4. The relationships between socio-demographic data and clinical variables with status of pain 3.4.1. Socio-demographic variables The mean age of the study population was 44.4 years, with a range of 18–68 years. The majority of them were female (52.9%). There were no statistically significant differences in sociodemographic variables such as marital status, employment, income and educational status with the status of pain.

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Table 1 Clinical characteristics of the subjects by status of pain. Total (N = 51)

Characteristics

Depression status In remission Depressed Anxiety/somatisation factor score Below 7 7 or more Neurosis Normal Neurotic Physical illness None Present

sample

With pain (N = 41)

Without (N = 10)

pain

N

%

N

%

N

%

15 36

29.4 70.6

9 32

60.0 88.9

6 4

40.0 11.1

30 21

58.8 41.2

21 20

70.0 95.2

9 1

30.0 4.8

27 24

52.9 47.1

19 22

70.4 91.7

8 2

29.6 8.3

35 16

68.6 31.4

28 13

80.0 81.3

7 3

20.0 18.8

F (df)

p

1

0.047a

1

0.034a

1

0.081

1

>0.95

F = Fisher’s exact test. a p < 0.05.

3.4.2. Clinical variables There was a statistically significant difference between subjects with depression and subjects in remission (p = 0.047) with the status of pain. Depressed patients were more susceptible to pain as compared to those in remission. Sixteen patients had medical problem; 10 of them were treated for hypertension and/or diabetic mellitus (type II), and the others were known to have allergic rhinitis, hypercholesterolemia, bronchial asthma and hypothyroidism. There was also a statistically significant difference for the HAM-D anxiety/somatisation factor score (p < 0.034) in relation to the status of pain. Subjects with high anxiety/somatisation factor scores (mixed anxiety–depression) were more likely to experience pain than those with low scores (Table 1). 3.5. The correlation between HAM-D item score with severity of pain Six HAM-D items were significantly correlated with the BPI total score at the 0.01 level. These items were depressed mood, work and interest, anxiety (psychic), anxiety (somatic), general somatic and genital symptoms. Six other items were correlated with pain at the 0.05 level: suicidal impulses, initial insomnia, terminal insomnia, agitation, gastro-intestinal and hypochondriasis. The correlations of the other HAM-D items with the severity of pain were not significant (Table 2).

Table 2 The correlation between HAM-D items score and BPI total score. HAM-D item 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 a b

Bivariate Spearman Depressed mood Self depreciation and guilt Suicidal impulses Initial insomnia Middle insomnia Terminal insomnia Work and interests Retardation (general) Agitation Anxiety (psychic) Anxiety (somatic) Gastro-intestinal General somatic Genital symptoms Hypochondriasis Weight loss Insight

Correlation significant at the 0.01 level (2-tailed). Correlation significant at the 0.05 level (2-tailed).

0.433a 0.236 0.341b 0.301b 0.212 0.284b 0.456a 0.271 0.283b 0.390a 0.476a 0.285b 0.548a 0.424a 0.348b 0.090 0.072

3.6. The correlation between HAM-D total score with severity of pain The HAM-D total score was significantly correlated with the severity of pain (BPI total score), with the correlation being significant at 0.01 level (two-tailed). There was a moderate Spearman’s correlation coefficient effect, with R2 linear = 0.332 and rho = 0.608 (p < 0.001). Therefore, HAM-D total score accounted for 33.2% of the variance of the BPI total score (Fig. 1). 3.7. The correlation between CCEI subscale scores with status of pain There were no statistically significant correlations between the six CCEI subscale scores with the presence of pain, except for the somatic concomitants of anxiety (SOM) subscale (p = 0.030). Although it did not reach the level of statistical significant (p = 0.081), the total CCEI score was strongly correlated with the presence of pain (Table 3). 3.8. The correlation between CCEI total score with severity of pain The CCEI total score is significantly positively correlated with BPI total score, with the correlation being significant at the 0.01 level (2-tailed). There is a low Pearson correlation coefficient effect, with r = 0.415 (p = 0.002). There is a relationship between CCEI total score and BPI total score (R2 linear = 0.172). Therefore, CCEI total score accounts for 17.2% of the variance of BPI total score. 3.9. The correlation between CCEI subscales scores with severity of pain Out of the six CCEI subscales, there were statistically significant positive correlations between three subscales with pain severity (BPI total score); FFA (r = 0.363, p = 0.009), SOM (rho = 0.394, p = 0.004) and DEP (r = 0.478, p < 0.001). Therefore FFA, SOM and DEP scores account for 13.2%, 13.5% and 22.9% of the variance of BPI total score respectively. However, the correlations are only of low effect with r between 0.26 and 0.49 (Munro and Connell, 2005). 3.10. Logistic regression analysis Simple binary logistic regression analysis was carried out, with presence of pain being the dependent variable. However, all relevant categorical and numerical independent variables such as socio-demographic factors, severity of depression, status of depression (in remission versus depressed), anxiety/somatisation factor score, neuroticism and the presence of medical illness did

S.M. Razali, A.Q. Khalib / Asian Journal of Psychiatry 5 (2012) 297–302

300

70

60

BPI total score

50

40

30

20

10

R Sq Linear = 0.332

0 0

10

20

30

40

HAM-D total score Fig. 1. Correlation between depressive symptoms and severity of pain.

Table 3 The correlation between CCEI subscales scores with status of pain. Characteristics

FFA Normal Anxious PHO Normal Phobic OBS Normal Obsessional SOM Normal Somatic DEP Normal Depressive HYS Normal Hysterical CCEI total Normal Neurotic

Entire (N = 51)

sample

With pain (N = 41)

Without pain (N = 10)

F

N

%

N

%

N

%

54.9 19

22 82.6

78.6 4

6 17.4

21.4

23

28 45.1

66.7 16

25 94.1

73.5 1

9 5.9

26.5

17

34 33.3

64.7 13

28 72.2

84.8 5

5 27.8

15.2

18

33 35.3

45.1 26

15 92.9

65.2 2

8 7.1

34.8

28

23 54.9

52.9 19

22 79.2

81.5 5

5 20.8

18.5

24

27 47.0

78.4 7

34 63.6

85.0 4

6 36.4

15.0

11

40 21.6

52.9 22

19 91.7

70.4 2

8 8.3

29.6

24

27 47.0

df

p

1

>0.95

1

0.135

1

0.296

1

0.030a

1

>0.95

1

0.193

1

0.081

F = Fisher’s exact test. a p < 0.05.

not reveal any statistically significant result. Therefore, multiple logistic regression analysis was not pursued. 4. Discussion We found that the prevalence of pain among depressed patients in this study was 80.4%, which is within the reported rates of 66% (Arnow et al., 2006) to 83% (Bair et al., 2007). However, the figures appear high when compared with two previous local studies by Razali and Hasanah (1999) and Ramli and Ariff (1994) of 42% and 34% respectively. The reported prevalence in other studies varied depending on the study population and methodology of the study.

We studied a group of depressed patients from a psychiatric clinic that included a mixture of new and old cases. The majority of the patients were old cases on regular follow-ups. This was reflected in the severity of depression where one third of the patients had mild depression, while 29% were in remission and only 10% had very severe depression. Although the prevalence and factors associated with depression among the Malay women are consistent with the findings in the west (Din and Nor, 2010), the relatively low attendance of women patients at the psychiatric clinic (52% female) as compared to male in this study is related to socio-cultural and economic factors. All the Malays are Muslim and majority of the population in this part

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of the country followed strict Islamic teaching; the women cannot go out alone without the permission from their husband. Majority of them are also full time house-wives; they are financially weak and cannot go to the hospital without the support from husband. Some of the husbands did not provide good support as they were busy with their work or even neglected their wives (Razali and Najib, 2000). Malaysia is a multi-racial society which comprises of three major ethnic group; Malay, Chinese and Indian. The somatisation of depression was not only confined to Malay society, but also found in other races in this country. In a recent study of 154 patients with post-natal depression (PND) by Grace et al. (2001) using Edinburg Post-Natal Depression Scale (EPNDS) (Cox et al., 1983) and Bradford Somatic Inventory (BDI) (Mumford et al., 1991), where the score of EPNDS and BSI was strongly correlated; they found that Indian women (8.5%) were significantly more likely to score higher on the EPNDS than Malay (3.0%) or Chinese women (0%). The authors concluded that socio-cultural variations between ethnic group; and the differences in individual coping mechanism and personality characteristics may explain some of the findings. Analysis of the socio-demographic variables of the study sample did not reveal any significant relationships with the status of pain. The lack of significant findings was partly related to the small sample size, and a small number of patients without pain (n = 10) further contributed to the low power. In contrast, previous studies have shown that women with depression (Marcus et al., 2008), and even without depression, have a higher prevalence of pain as compared to men, and also that the vulnerability to chronic pain increases as one grows older (Tsang et al., 2008). Furthermore, depressed patients with lower levels of education and a poorer quality of life were found to be more likely to have pain complaints (Husain et al., 2007). When looking into why some patients somatise their depressive symptoms, we found that the status of depression, anxiety/ somatisation factor scores and specific neurotic symptomatology had significant correlations with the status of pain. Although it was not statistically significant, there was a strong correlation between neuroticism and the status of pain. Regarding the severity of pain, it was significantly correlated with the CCEI total score, and three subscales of the CCEI (DEP, SOM and FFA). This meant that neuroticism also significantly correlated with the severity of pain. Among the three subscales, DEP was found to have the strongest correlations with pain severity. Patients who were still depressed were more likely to experience pain, which was consistent with the results of a larger study (Keogh et al., 2006; Bonnewyn et al., 2009). Patients with mixed anxiety–depression (anxiety/somatisation factor score 7 or more) had significantly higher tendencies to somatise than those with non-anxious depression. This finding was in line with recently reported evidence that those with anxious depression were likely to experience pain (Dworkin et al., 2008), while the STAR*D study revealed that they were two-and-a-half times more likely to experience pain (Husain et al., 2007). This was also in accordance with a previous local finding (Salleh, 1989) that somatic symptoms in the majority of these patients were the bodily manifestation of underlying anxiety. The findings of this study suggest a complex relationship between depression, neuroticism, anxiety with somatic and pain symptoms. The linear regression analysis could not elicit a significant correlation between pain symptoms and independent variables due to complexity of the problem and a small sample size. The socio-culture factors also play an important role in determining the expression of pain or other somatic symptoms. If it is accepted by the culture norm, it would encourage the expression of somatic symptoms and the psychological distress becomes less prominent. It seems that patients with pain

301

symptoms in this study were heterogeneous group. Three main groups were identified; one was depressed patients with prominent anxiety symptoms (mixed anxiety–depression), the second group was those with a specific neurotic pathology or neuroticism; and the third group was the combination of both. We conclude that patients with neuroticism, specific neurotic pathology and mixed anxiety–depression from certain ethnic group had a high risk for pain symptoms. The more severe the depressive symptoms are, the higher the prevalence of pain symptoms is. Role of funding source The study was self-sponsored for M. Med (Psychiatry) dissertation. Contribution The first author is responsible for planning of the study, preparing of research protocol and final writing of the article. The second author conducted the study with supervision from the first author. Conflict of interest None. Acknowledgement The authors thank Dr. Sarimah Abdullah from Statistic Unit, Department of Community Medicines, USM, for her guidance in statistical analysis. References Aisyaturridha, A., Naing, L., Nizar, A., 2006. Validation of the Malay brief pain inventory to measure cancer pain. J. Pain Symptom Manage. 31, 13–21. American Psychiatric Association, 2000. Diagnostic and Statistical Manual of Mental Disorders, Text Revision (DSM-IV-TR), fourth ed. American Psychiatric Association, Washington, DC. Arnow, B.A., Hunkeler, E.M., Blasey, C.M., Lee, J., Constantino, M.J., Fireman, B., Kraemer, H.C., Dea, R., Robinson, R., Hayward, C., 2006. Comorbid depression, chronic pain and disability in primary care. Psychosom. Med. 68, 262–268. Bair, M.J., Kroenke, K., Sutherland, J.M., McCoy, K.D., Harris, H., McHorney, C.A., 2007. Effects of depression and pain severity on satisfaction in medical outpatients: analysis of the medical outcome study. J. Rehab. Res. Dev. 44, 143–152. Bonnewyn, A., Katona, C., Bruffaerts, R., Haro, J.M., de Graaf, R., Alonso, J., Demyttenaere, K., 2009. Pain and depression in older people: comorbidity and patterns of help seeking. J. Affect. Disord. 117, 193–196. Bridge, K.W., Goldberg, D.P., 1985. Somatic presentation of DSM-III psychiatric disorders in primary care. J. Psychosom. Res. 29, 563–569. Cox, J.L., Connor, Y.M., Henderson, I., McGuire, R.J., Kendell, R.E., 1983. Prospective study of the psychiatric disorders of childbirth by self report questionnaires. J. Affect. Disord. 5, 1–7. Crown, S., Crisp, A.H., 1979. Manual of Crown-Crisp Experiential Index. Hodder and Stoughton, London. Currie, S.R., Wang, J., 2004. Chronic back pain and major depression in the general Canadian population. Pain 107, 54–60. Delgado, P.I., 2004. Common pathway of depression and pain. J. Clin. Psychiatry 65 (Suppl. 12), 16–19. Din, M.A., Nor, N.M., 2010. Prevalence and factors associated with depressive symptoms in Malay women. Women Health 8, 573–591. Dworkin, R.H., Turk, D.C., Wyrwich, K.W., Beaton, D., Cleeland, C.S., Farrar, J.T., Haythornthwaite, J.A., Jensen, M.P., Kerns, R.D., Ader, D.N., Brandenburg, N.A., Burke, L.B., Cella, D., Chandler, J., Cowan, P., Dimitrova, R., Dionne, R., Hertz, S., Jadad, A.R., Katz, N.P., kehlet, H., Kramer, L.D., Manning, D.C., MaCormick, C., Dermott, M.P., McQuay, H.J., Patel, S., Porter, L., Quessy, S., Rappaport, B.A., Rauschkold, C., Revicki, D.A., Rothman, M., Schmader, K.E., Stacey, B.R., Stauffer, J.W., Von Stein, T., White, R.E., Witter, J., Zavisi, S., 2008. Interpreting the clinical importance of treatment outcome in chronic pain clinical trial: IMMPACT recommendations. J. Pain 9, 105–121. First, M., Spitzer, R., Gibbon, M., William, J., 1997. Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I). American Psychiatric Association, Washington, DC. Grace, J., Lee, K.K., Ballard, C., Herbert, M., 2001. The relationship between post-natal depression, somatisation and behaviour in Malaysian women. Transcult. Psychiatry 38, 27–34.

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