Chronic pain and the psyche: 4 in 10 have clinical depression or anxiety

The largest review to date found that among adults with chronic pain, ~40% have clinically significant symptoms of depression (39.3%) and anxiety (40.2%). Risks are particularly high in women, younger people, and those with so-called nociplastic pain (eg, fibromyalgia). Compared with people without chronic pain, depression and anxiety are significantly more common. The implications for practice are clear: all pain care settings should routinely screen for mental health symptoms and ensure access to treatment. The study is published in JAMA Network Open.

What kind of research is this?

• Type: Systematic review and meta-analysis.
• Size: 376 studies, 347,468 adults with chronic pain from 50 countries (excluding chronic headaches - these are analyzed separately).
• How it was calculated: the proportions of patients with clinical symptoms (according to validated scales) and with diagnoses according to DSM-5 were combined; additional comparisons were made with clinical and “healthy” control groups.

Key figures

• Depressive symptoms: 39.3% (95% CI 37.3–41.1).
• Anxiety symptoms: 40.2% (95% CI 38.0–42.4).
• Diagnoses:
  • Major depressive disorder (MDD): 36.7% (95% CI 29.0–45.1).
  • Generalized anxiety disorder (GAD): 16.7% (95% CI 11.8–23.2).
  • Panic disorder - 7.5%; persistent depressive disorder - 6.3%; social anxiety - 2.2%.

Comparison with controls. In groups without chronic pain, depression and anxiety were significantly less common (e.g., symptomatic depression ~14%, anxiety ~16%). The difference persisted when compared with “clinical” controls (people with other diseases).

Who is having a particularly hard time?

• Pain type: maximum in conditions with a nociplastic mechanism - when pain is maintained by altered signal processing without obvious tissue damage.
  • Fibromyalgia: depression 54%, anxiety 55.5%.
  • Complex regional pain syndrome, temporomandibular disorders - also high.
  • Arthritis (osteo-, rheumatoid, spondyloarthritis) - the lowest scores (for example, with osteoarthritis, depression ~29%, anxiety ~18%).
• Gender and age: Women and younger patients are more likely to have depression/anxiety.
• Duration of pain: longer pain → more frequent anxiety (no such connection was found for depression).

Why is this? In nociplastic pain, emotional distress, stressors, and adverse experiences are more tightly woven into the chronification of pain, and sensory networks and pain threat/anticipation systems operate differently, which reinforces both pain and anxiety-depressive symptoms.

What does this change in practice?

1) Screening by default.
In all pain services, from primary care to specialist centres, include short validated depression and anxiety scales (e.g. PHQ-9, GAD-7) as part of the standard routine, and repeat them over time.

2) Don't be "kicked out" because of psychiatry.
People with comorbid depression/anxiety are often excluded from pain programs or clinical trials - and they are the ones who need help the most. Access to specialized care should be equal.

3) Team approach.
Interdisciplinary programs (pain doctor/family doctor + psychologist/psychiatrist + physiotherapist) remain the gold standard, but are not available to everyone. Minimum:

• referral to psychotherapy with proven effectiveness for pain (CBT, ACT, behavioral sleep/activity protocols);
• distance and short formats (online CBT, “mobile” modules) – to expand coverage;
• if necessary - pharmacotherapy for depression/anxiety according to guidelines, taking into account interactions and effects on sleep/pain.

4) Assess two anxieties.
Standardized scales of general anxiety do not always capture pain-specific phenomena (catastrophizing, kinesiophobia). It is better to assess both - these are different therapeutic goals.

For the patient - what can be done now

• Ask your doctor for short questionnaires on depression and anxiety; track the scores together.
• Discuss a realistic “package”: sleep, paced activity, pain management training, psychotherapy, and medication if indicated.
• If you are not accepted because of psychiatry, this is not normal: ask for an alternative route or a remote module; seek a second opinion.

Important Disclaimers

• Heterogeneity between studies is very high (I²≈99%): different countries, scales, samples.
• The quality of the papers varied (many with incomplete descriptions of samples and procedures).
• Design is not causal: meta-analysis captures the extent of the problem and the factors, but does not prove “which came first.”

Summary

Chronic pain is rarely “just pain.” About 40% of adult patients also have clinical depression or anxiety — especially women, young people, and people with nociplastic pain. If we are to truly reduce the burden of chronic pain, mental health must be an integral part of the journey — from screening to accessible treatment.