Research report
Presence and predictors of pain in depression: Results from the FINDER study

https://doi.org/10.1016/j.jad.2010.02.106Get rights and content

Abstract

Background

Patients with depression often experience pain. There is limited understanding of the relation between pain and other symptoms (depressive, anxious and non-painful somatic symptoms). This exploratory study assesses pain severity and interference of pain with functioning in a clinically depressed population and investigates the relation between the different groups of symptoms.

Methods

FINDER was a 6-month prospective, observational study investigating health-related quality of life of outpatients with depression initiating antidepressant treatment. Patients completed ratings on the Hospital Anxiety and Depression Scale (HADS), Somatic Symptom Inventory (SSI-28), and overall pain severity and interference of pain with functioning using Visual Analogue Scales (VAS) at baseline and at 3 and 6 months. Regression analyses identified factors associated with overall pain severity and interference of pain with functioning, at baseline and over the observation period.

Results

Of 3468 eligible patients at baseline, 56.3% experienced moderate to severe pain and 53.6% had moderate to severe pain-related interference with functioning. At 6 months of follow-up, these proportions decreased to 32.5% and 28.1%, respectively. Higher baseline SSI-somatic scores (non-painful) were strongly associated with greater pain severity and greater pain-related interference with functioning at baseline and over 6 months. Certain socio-demographic (increasing age, being unemployed) and depression-related factors (more previous episodes, longer duration of current episode) were also significantly associated with greater pain severity and interference over 6 months, while higher baseline severity of depression (HADS-D) and further education were associated with less severe pain or pain-related interference with functioning over 6 months.

Conclusions

Over half of depressed patients in this study experienced moderate to severe pain. Painful somatic symptoms appear to be closely related to non-painful somatic symptoms, more than to depressive or anxious symptoms suggesting that painful and non-painful somatic symptoms can be considered as one group of ‘somatic symptoms,’ all of them associated with depressive and anxious symptoms.

Introduction

Epidemiological studies show that the prevalence of chronic painful physical symptoms is increased in patients with mood disorders and in patients with anxiety disorders, suggesting they are not specific to depressive disorders (Ohayon and Schatzberg, 2003, Demyttenaere et al., 2006, Demyttenaere et al., 2008). The question whether these painful physical symptoms are also associated with the non-painful physical symptoms found in depressed patients is not fully understood.

Co-morbid chronic painful (and non-painful) physical symptoms result in poorer recognition of depression (Kirmayer et al., 1993) and in poorer outcomes of depression (Ohayon and Schatzberg, 2003), and this may be due to several factors, including lower rates of help-seeking and longer delays before help-seeking when pain accompanies depression (Demyttenaere et al., 2006), or lower efficacy of antidepressant treatment on painful physical symptoms. Indeed, the effect size measured after 9 months of treatment with antidepressants has been shown to be lower for painful (and non-painful) physical symptoms than for non somatic depressive symptoms and for positive well-being (Greco et al., 2004). During antidepressant treatment, remitters and non-remitted responders had significantly more change than non-responders in both pain and non-pain physical symptoms suggesting that the changes in the latter two groups of symptoms occurs in parallel (Greco et al., 2004).

Moreover, the somatic symptoms being part of or associated with depression are not only influencing the outcome of depression. Indeed, several recently published papers even suggest that (in patients with myocardial infarction or with chronic heart failure) the so-called somatic/affective symptoms of depression are more predictive of overall mortality than the cognitive/affective symptoms of depression (De Jonge et al., 2006, Schiffer et al., 2009).

Although the recent literature focused on the ‘comorbidity’ of depression and anxiety and of depression (and anxiety) and painful physical symptoms, the relation between these different symptom clusters (including the non-painful physical symptoms) is not fully understood. The specificity of the comorbidity between somatoform clusters and other mental disorders should indeed be further clarified (Lieb et al., 2007).

Pain, like many other somatic symptoms, is always a subjective experience (from sensory to affective to cognitive to behavioural aspects); therefore, it is important to investigate not only pain severity and changes in pain severity but also interference of pain with functioning and changes in pain interference with functioning when presented with depression.

Factors Influencing Depression Endpoints Research (FINDER) is a multinational, longitudinal, observational study designed to increase understanding of the factors that influence health-related quality of life outcomes for clinically depressed outpatients receiving antidepressant (AD) medication in routine primary and secondary care. In this study, pain as well as its impact on functioning and factors associated with pain was assessed using patient-reported measures.

The aims of the present exploratory analyses were to examine the severity of overall pain and the interference of pain with ability to undertake normal activities both at baseline (untreated) and over the 6-month observation period in clinically depressed outpatients. We also investigated the relation between pain severity and interference of pain with functioning with other symptom clusters (non-painful somatic symptoms, anxious and depressive symptoms) and socio-demographic and clinical variables at baseline and over 6 months.

Section snippets

Study design

FINDER was a 6-month, observational, multi-centre, multinational study conducted in 12 European countries: Austria, Belgium, France, Germany, Ireland, Italy, the Netherlands, Norway, Portugal, Sweden, Switzerland and the UK. Recruitment commenced in May 2004 and was completed in September 2005. The study had a non-interventional design which means that all treatment decisions were at the discretion of the participating physician. The study was approved in all countries according to local

Results

There were 3468 patients with a clinical diagnosis of depression in the study, of whom, 3308 had a non-missing overall pain rating at baseline and were, thus, eligible for inclusion in the current analysis. Of these patients, 1861 (56.3%) had moderate to severe pain (based on overall pain VAS > 30 mm) at baseline, and 1447 (43.7%) had no/mild pain. Of the 1861 patients with moderate to severe pain, 1311 (70.4%) had no recorded physical explanation for the pain. Table 1 summarises the baseline

Discussion

A first important finding of this naturalistic study is the presence of pain in a high proportion of patients in this population of help-seeking patients with clinically diagnosed depression. Indeed, more than half of the patients had moderate to severe pain (during the past week), which is consistent with previously published data on the relation between depression and more chronic pain (Ohayon and Schatzberg, 2003, Bair et al., 2003, Bair et al., 2004, Demyttenaere et al., 2006). One-third of

Role of funding source

FINDER was funded by Eli Lilly and Company Limited, Windlesham, UK and Boehringer Ingelheim International GmbH, Ingelheim, Germany.

Conflict of interest

Catherine Reed, David Perahia and Deborah Quail are Lilly employees and Brigitta Monz is a Boehringer Ingelheim employee. Michael Bauer, Nicolas Danchev, Koen Demyttenaere, Luigi Grassi, Angel Luis Montejo and Andre Tylee have received economic compensation for participation in the FINDER Advisory Board.

Acknowledgements

We would like to thank all investigators and patients who participated in FINDER.

The authors take full responsibility for the content of the paper but thank Deirdre Elmhirst, PhD, for her assistance in preparing the first draft of the manuscript and collating the comments of the authors and other named contributors and Nicole Yurgin for reviewing the draft manuscript.

References (19)

There are more references available in the full text version of this article.

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