Anxiety, Depression, and Chronic Pain

In the mental health field, discussions of co-occurring disorders typically focus on people who have two mental illnesses, or one mental illness along with a substance use disorder n(DUD), a.k.a. addiction, but they rarely include discussions about co-occurring anxiety, depression, and chronic pain.

A recent study calls attention to the impact of this category of co-occurring disorders: the simultaneous presence of a physical health condition and a mental health concern.

Published in September 2023 in the journal Pain, the study shows nearly 5% of the adult population in the United States – that’s one in every 20 people age 18+) is affected by chronic pain and co-occurring anxiety or depression.

The cumulative impact of these conditions, the study authors report, includes diminished functioning and decreased quality of life.

The Prevalence of Anxiety and Depression

Anxiety and depression are two of the most common mental health disorders in the U.S. They’re linked with profound distress and severe impairments, as well as a staggering economic impact.

The National Institute of Mental Health (NIMH) reports the following statistics about anxiety:

• Experts estimate that about 1% of U.S. adults had symptoms of an anxiety disorder in the past 12 months.
• The estimated lifetime prevalence of anxiety among U.S. adults is 31.1%.
• With a current adult population of 258.3 million people in the U.S., this means that more than 87 million adults will struggle with anxiety at some point in their lives.
• Among adults who develop anxiety, 22.8% experience severe impairment and 33.7% experience moderate impairment as scored on the Sheehan Disability Scale.

The NIMH has also reports the following about major depressive disorder (MDD) among adults in the United States:

• About 3% of U.S. adults (or about 21 million people) had at least one major depressive episode in the previous 12 months.
• Major depressive disorder is most common among young adults ages 18-25. In 2021, 18.6% of people in this age range had at least one major depressive episode.
• About 69% of adults who had depression in the previous year (or about 14.5 million people) experienced severe impairment as scored on the Sheehan Disability Scale.

Economists have estimated that the global economic impact of anxiety and depression may be as high as $1 trillion per year. This number includes direct healthcare costs, absenteeism, and lost productivity.

Chronic Pain in the U.S.

The term chronic pain refers to persistent discomfort that lasts for months or years. In some cases, chronic pain is a lifelong condition. Diseases such as arthritis and fibromyalgia can cause chronic pain, as can injuries, nerve damage, and certain genetic factors.

The U.S. Centers for Disease Control and Prevention (CDC) defines chronic pain as pain that occurs every day or just about every day for more than three months. In April 2023, the CDC reported the following about chronic pain among adults in the United States:

• In 2021, about 9% of the adult population in the U.S. (or about 51.6 million people) suffered with chronic pain.
• An additional 17.1 million people experienced what the CDC called high-impact chronic pain, which means that their pain was severe enough to limit their participation in typical activities, including work, on a daily or near-daily basis.
• Among adults with long-term medical conditions, the rate of chronic pain is highest among those who have myalgic encephalomyelitis/chronic fatigue syndrome (70%).

Various sources estimate that chronic pain costs the U.S. as much as $635 billion per year due to healthcare costs, lowered productivity, and missed work.

Anxiety, Depression, and Chronic Pain

There is little question that, when they occur on their own, anxiety, depression, and chronic pain can have a devastating effect.

But what is the impact on people who are living with two or all three of these conditions? And how many people experience this?

These are among the questions that a team led by Jennifer S. De La Rosa, PhD, of the University of Arizona’s Health Sciences Comprehensive Pain and Addiction Center, set out to answer.

De La Rosa and her team analyzed data from 31,997 U.S. adults. They collected their data from the 2019 National Health Interview Survey (NHIS).

The researchers evaluated pain and mental illness with a variety of well-established assessment tools, including:

• International Association for the Study of Pain (IASP) classification system
• Generalized Anxiety Disorder 7-Item questionnaire (GAD-7)
• Patient Health Questionnaire-8 (PHQ-8)

The tools helped the research team determine the following about co-occurring chronic pain, anxiety, and depression in the United States.

Prevalence of Co-Occurring Chronic Pain, Anxiety, and Depression

• About 4.9% of the U.S. adult population (or about 12 million adults) have chronic pain as well as symptoms of anxiety or depression.
• Among people who have chronic pain, about 23.9% also have co-occurring anxiety or depression.
• Among adults with anxiety or depression, about 55.6% also have chronic pain.

Study subjects with both chronic pain and either anxiety or depression reported being the following consequences.

Impact of Co-Occurring Chronic Pain, Anxiety, and Depression

• 69.4% said their ability to work was negatively affected by their health struggles.
• 55.7% said they had problems participating in social activities as a result of their poor health.
• 43.7% said their health concerns made it difficult for them to run errands on their own.

These statistics indicate that impairments among people with both types of disorders are significantly higher than among those who only had a chronic pain or a mental health concern.

For example, reports of limited ability to work were 1.9 times higher among people with both conditions than among those who only had anxiety or depression, and 1.6 times higher than among those who only had chronic pain.

Given the prevalence of anxiety, depression, and chronic pain in the U.S., these prevalence rates should not surprise us. However, lead study author Dr.  Jennifer S. De La Rosa told ScienceDaily she was caught off-guard by the degree of disruption these simultaneously occurring conditions can cause.

“I was surprised by the magnitude of the effect with functional limitations. Across all domains of functional activity in life, we saw an enormous jump among people who are living with both conditions. These are people who are at a high risk for functional limitation, which will disturb their quality of life.”

Potential Causes & Possible Solutions

Chronic pain can be a source of persistent physical anguish. It can also undermine a person’s ability to achieve success at work, participate in enjoyable social activities, and otherwise engage in a full, productive, and satisfying life.

Clearly, then, among people who have both chronic pain and a co-occurring mental health disorder, the chronic pain must be the causative factor, right?

Not so fast.

While the impact of chronic pain can absolutely have a negative effect on a person’s psychological well-being, the cause-effect relationship between pain and either anxiety or depression can be bidirectional.

Mental Health and Chronic Pain: Connections

• Studies that employed functional magnetic resonance imaging (fMRI) have found that certain areas of the brain are involved in both chronic pain and mental illnesses. According to the American Psychiatric Association (APA), this type of research indicates that depressive disorders can make people more sensitive to pain.
• Writing on the Mayo Clinic website, psychiatrist Daniel Hall-Flavin, M.D. notes that depression can cause people to experience headaches and back pain. As this pain intensifies and has a more intrusive impact on a person’s life, this can lead to a worsening of their depression symptoms.
• The Anxiety and Depression Association of America (ADAA) has identified various forms of physical pain (including muscle tension, headaches, and general body soreness) as possible symptoms of anxiety disorders. The ADAA has also reported that, like depression, anxiety can make a person more sensitive to pain.

Regardless of which disorder occurred first, it’s essential that treatment for someone with chronic pain and a co-occurring mental health concern addresses both physical and psychological distress. Treating one affliction while ignoring the other can prevent a person from making sustained progress toward a healthier and more satisfying future.

Treating Co-Occurring Chronic Pain and Mental Health Disorders

Depending on the full scope of a person’s needs, treatment for anxiety, depression, and co-occurring chronic pain may include both medication and therapy.

Various medications can ease the symptoms of anxiety and depressive disorders. If chronic pain is intertwined with mental health challenges, the appropriate use of these medications may reduce the need for opioids or other prescription painkillers, which can cause serious problems themselves.

Therapy can also help people learn to manage the symptoms of all the disorders that have been impacting their life, including their chronic pain.

Cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT) are effective, evidence-based interventions for people living with chronic pain, as well as people with anxiety and/or depression.

• CBT is a goal-directed type of therapy that can help people identify maladaptive thought and behavior patterns and replace them with healthier ways of thinking and acting.
• DBT can help people develop skills in several areas, including mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness.

Of course, no single medication, type of therapy, or course of treatment is universally effective. This is why it’s important to find a provider who can assess the full scope of your needs, then develop a truly personalized plan.

When you get the focused care that reflects your unique circumstances, you can achieve improved health and better overall quality of life.

To learn more about treatment options for people with acute symptoms of anxiety, depression, and other complex mental health conditions, please visit our Contact page or call Crownview Psychiatric Institute today.