Research reportReciprocal relationship between pain and depression in older adults: Evidence from the English Longitudinal Study of Ageing
Introduction
Pain and depression are two major health concerns in community-dwelling older adults due to both their commonness and their adverse health consequences. Specifically, depending on the investigated variables and the methodology used, between 45% and 80% of the older adults report having painful symptoms (Ferrell et al., 1990, Gaston-Johansson et al., 1996), whereas the prevalence rates of depression in old age have been reported to be between 9% and 18% (Beekman et al., 1999, Mulsnt and Ganguli, 1999). Due to the dualistic perspective, pain symptoms reported by depressed people receive far less attention from researchers and practitioners than depression among people with chronic pain (Bair et al., 2003, Katona et al., 2005, Peveler et al., 2006) and this is unfortunate, because evidence show that pain in depressed patients detrimentally affects their responses to treatment (Bair et al., 2004, Fava et al., 2004). Obviously, it is essential to explore the “chicken and egg” question about pain and depression.
The association between pain and depressive symptoms, known as the depression–pain dyad, has been established consistently in community-dwelling elderly adults (Calabrese et al., 2006, Onder et al., 2005, Williamson and Schultz, 1995) and has been shown to contribute to elevated health care costs and high prevalence of functional disability (Greden, 2003, Greenberg et al., 2003). Although the causal direction between pain and depression has been extensively and systematically investigated in the general population (Currie and Wang, 2004, Ohayon and Schatzberg, 2003), the temporal relationship between these syndromes in the aged population is still unclear and cannot be resolved through using the cross-sectional data (Calabrese et al., 2006, Onder et al., 2005) or involving clinical samples or health service recipients (Arnow et al., 2006, Chou and Chi, 2005).
It is certainly plausible that either syndrome may lead to the other. Namely, an individual who feels pain may subsequently become depressed and depressed patients are more likely to develop pain symptoms. Depression has been demonstrated as an immediate consequence of pain and in studies that have been examined prospectively (Chou and Chi, 2005, Geerlings et al., 2002). Some investigators have proposed a diathesis stress model for understanding the development of depression among individuals with chronic pain (Banks and Kerns, 1996, Dersh et al., 2002, Dworkin et al., 1999) and skill deficits or a maladaptive attributional style leading to helplessness are a potential diathesis for the onset of depression among people with pain (Keefe et al., 2002, Williams, 1996). In other words, these psychological characteristics may be activated because of the stress due to chronic pain, which may consequently lead to depression.
Conversely, depression may in turn cause pain. This could potentially be mediated through the neurochemical imbalance of neurotransmitters (Bair et al., 2003, Fava, 2003) including serotonin, norepinephrine, and dopamine (Andrews and Pinder, 2000, Blackburn-Munro and Blackburn-Munro, 2001). The chemical changes in serotonergic or noradrenergic function 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). Emotionally negative mood states may also reduce tolerance to aversive stimuli that cause pain (Meagher et al., 2001, Zelman et al., 1991). The data supporting this direction of association are mixed (Chou and Chi, 2005, Geerlings et al., 2002).
A final explanation for the cross-sectional correlation between pain and depression is that these outcomes are not directly related but result from common underlying risk factors such as chronic medical conditions and functional disability (Geerlings et al., 2002, Onder et al., 2005) that increase the risk of both outcomes. Therefore, understanding the causal relationship between pain and depression as well as the identification of common risk factors leading to both outcomes, is critical in the development of prevention and treatment for these two common syndromes. This study uses longitudinal data from the English Longitudinal Study of Ageing (Waves 1 and 2), a population-based, prospective, observation study in the United Kingdom, to investigate whether: a) pain is an independent predictor for becoming depressed, and conversely, depression is an independent predictor of the onset of pain; b) which factors are the independent risk factors for the new onset of pain and for the new onset of depression in individuals who do not report these syndromes at baselines and which factors are common predictors for developing these two outcomes; and c) which factors are predictors of pain and depression after baseline pain and depression are included in the model and which factors are shared risk factors for both outcomes.
Section snippets
Data-set
This prospective analysis used data from the first and second waves of the English Longitudinal Study of Ageing (ELSA) conducted in 2002–2003 and 2004–2005. The ELSA is a national, on-going longitudinal study designed to investigate the experiences of community-dwelling older persons in health, economic, psychological, and social aspects. The survey included older persons aged 50 and above living in England in 2002. The ELSA was well fitted for this research because of its large sample size,
Results
The population was 57.1% female and subjects had a mean age of 74.2 with a standard deviation of 7.3 (Table 1). Overall, 1125 subjects (30.1%) reported pain (from moderate to severe) and 366 of them reported severe pain whereas 927 (24.8%) reported depression at their baseline evaluation. Characteristics of the study population according to the presence of pain and the status of depression at baseline assessment are presented in Table 2, Table 3, respectively.
Chi-square analyses were performed
Discussion
In this population-based longitudinal study of 3741 older adults aged 65 and above at baseline, depression at baseline is an independent predictor for the onset of pain after two years, and pain at baseline independently predicts becoming depressed. Because each is a predictor of the other, an individual who develops one of these outcomes is at greater risk of developing the other. These data provide evidence of a spiraling effect of increasing pain and depression. The findings are important
Conclusions
In summary, pain and depression are common, serious, potentially preventable conditions in older community-dwelling adults. Because each is a risk factor for the other, an individual who has one of these factors is at risk for developing the other. This in turn may set off a “vicious cycle” of pain and depression; and many adverse outcomes can result, such as functional decline, a decrease in quality of life, and increase in health care service cost. Further studies are needed to determine
Acknowledgments
Preparation of this article was supported in part by the Research Grant Council (HKU 7220/03H, HKU 7295-04H, and HKU 7004-PPR20051). The data was made available by the Institute of Fiscal Studies, United Kingdom. The data collector of the original data bears no responsibility for the analyses and interpretations presented here. The author also would like to thank two anonymous reviewers for their comments on earlier drafts of this article.
References (46)
- et al.
Personality and the association of pain and depression
Am. J. Geriatr. Psychiatry
(2006) - et al.
Chronic back pain and major depression in the general Canadian population
Pain
(2004) - et al.
One- and two-item measures of pain beliefs and coping strategies
Pain
(2003) - et al.
Pain symptoms in depression: definition and clinical significance
Clin. Med.
(2005) - et al.
Impact of pain on self-rated health in the community-dwelling older adults
Pain
(2002) - et al.
Depression impairs self-reported vision function in age-related macular degeneration
Arch. Ophthalmol.
(2002) - et al.
The effects of induced mood on laboratory pain
Pain
(1991) - et al.
Antidepressants of the future — a critical assessment of the chemistry and pharmacology of novel antidepressants in development
- et al.
Comorbid depression, chronic pain, and disability in primary care
Psychosom. Med.
(2006) - et al.
Depression and pain comorbidity: a literature review
Arch. Intern. Med.
(2003)
Impact of pain on depression treatment response in primary care
Psychosom. Med.
Explaining high rates of depression in chronic pain: a diatheseis–stress framework
Psychol. Bull.
Disease and disadvantage in the United States and in England
JAMA
Review of community prevalence of depression in later life
Br. J. Psychiatry
Management of pain in elderly cancer patients
JAMA
Chronic pain, chronic stress and depression: coincidence or consequence?
J. Neuroendocrinol.
Methodology
Reciprocal relationship between pain and depression in elderly Chinese Primary Care Patients
Int. J. Geriatr. Psychiatry
Common pathways of depression and pain
J. Clin. Psychiatry
Chronic pain and psychopathology: research findings and theoretical considerations
Psychosom. Med.
Toward a model of the pathogenesis of chronic pain
Semin. Clin. Neuropsychiatry
Depression and comborbid pain as predictors of disability, employment, insurance status, and health care costs
Psychiatr. Serv.
The role of the serotonergic and noradrenergic neurotransmitter systems in the treatment of psychological and physical symptoms of depression
J. Clin. Psychiatry
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