Research reportPresence and predictors of pain in depression: Results from the FINDER study
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)
- et al.
Prescribing patterns of antidepressants in Europe: results from the Factors Influencing Depression Endpoints Research (FINDER) study
European Psychiatry
(2008) - et al.
The visual analogue pain intensity scale: what is moderate pain in millimetres?
Pain
(1997) - et al.
Comorbid painful physical symptoms and depression: prevalence, work loss, and help seeking
Journal of Affective Disorders
(2006) - et al.
Comorbid painful physical symptoms and anxiety: prevalence, work loss and help-seeking
Journal of Affective Disorders
(2008) - et al.
Pharmacological management of neuropathic pain: evidence-based recommendations
Pain
(2007) - et al.
A European longitudinal study of factors influencing outcomes of depression (FINDER): design and characteristics of study population
European Psychiatry
(2008) - et al.
Depression, anxiety and somatisation in primary care: syndrome overlap and functional impairment
General Hospital Psychiatry
(2008) - et al.
Depression and pain comorbidity. A literature review
Archives of Internal Medicine
(2003) - et al.
Impact of pain on depression treatment response in primary care
Psychosomatic Medicine
(2004)
Cited by (38)
Relationship between the tryptophan-kynurenine pathway and painful physical symptoms in patients with major depressive disorder
2022, Journal of Psychosomatic ResearchImpact of mind–body intervention on proinflammatory cytokines interleukin 6 and 1β: A three-arm randomized controlled trial for persons with sleep disturbance and depression
2022, Brain, Behavior, and ImmunityCitation Excerpt :It is suggested that sleep disturbances and depression should be treated together to prevent recurrence of either disorder (Fang et al., 2019). Depressed patients and persons having poor sleep quality are prone to pain and somatic symptoms (Demyttenaere et al., 2010; Zhang et al., 2012), as well as low psychological well-being (Chu and Richdale, 2009). Therefore, it seems important that interventions for depressed persons should also consider sleep disturbance, and vice versa.
When it hurts even more: The neural dynamics of pain and interpersonal emotions
2020, Journal of Psychosomatic ResearchCitation Excerpt :They may be particularly relevant for patients who have heightened rejection sensitivity and expectations that others will reject, hurt, or abandon them - a perception of others previously shown to be the dominant relational schema in 90% of patients with chronic somatoform pain compared with 10% of healthy controls [44]. These findings may also help explain why 50–75% of patients with depression [45–48], 45% with anxiety, and up to 80% with borderline personality disorder suffer from pain that is unexplained by another medical condition [49,50]. Brain imaging studies of feelings of rejection and pain interaction in clinical populations are needed to investigate these hypotheses further.
Somatic symptoms vary in major depressive disorder in China
2018, Comprehensive PsychiatryWhat is important in being cured from depression? Discordance between physicians and patients (1)
2015, Journal of Affective DisordersCitation Excerpt :This picture seems to be far different from what regulatory bodies or physicians expect from outcome and from what the HDRS or MADRS assess and suggests that a broader perspective should be considered when assessing outcome. Moreover, real life patients often have comorbid anxious and somatic symptoms, have excessive negative affect and lack of positive affect, present with functional impairment in their occupational, social and family life and report a low quality of life (Demyttenaere et al., 2010; Demyttenaere et al., 2009; Watson et al., 1988a, 1988b; De Fruyt and Demyttenaere, 2009). The two standard scales show some differences here: the HDRS covers a somewhat broader spectrum of symptoms including anxiety and neurovegetative (somatic) symptoms while the MADRS is more focused on the depressive symptomatology but neither scale covers the whole range of issues/symptoms mentioned above.
Comparison of the effects of escitalopram and nortriptyline on painful symptoms in patients with major depression
2015, General Hospital PsychiatryCitation Excerpt :The high prevalence of pain in depression was confirmed in the prospective FINDER (Factors Influencing Depression Endpoints Research) study, and moderate to severe pain was detected in 56% of the patients before initiation of treatment with an antidepressant. One third of the patients continued to experience moderate to severe pain at 6-month follow- up [4]. Several implications of painful symptoms in depression have been suggested.