Depression in Chronic Pain Patients: Relation to Pain ...

337

Puin, 23 (1985) 337-343

Elsevier

PA1 00821

Depression in Chronic Pain Patients: Relation to Pain, Activity, and Sex Differences William E. Haley I-*, Judith A. Turner * Department of Psychology, University of Alabama at * * Department

of Psychiatry

and Behavioral

Birmrngham,

Sciences RP - IO, Unrversit_y of Washington

Seattle,

(Received

** and Joan M. Roman0 Birmmghom,

**

AL 35294, and School of Medicine.

WA 98195 (U.S.A.)

11 March 1985. accepted

21 June 1985)

Summary Depression is commonly reported among chronic pain patients and receiving increased attention from clinicians and researchers. There is, however, little empirical evidence concerning variables that differentiate depressed from non-depressed chronic pain patients, and whether depression is related to factors such as gender, pain report, and activity. As part of a study to address these questions, 63 chronic pain patients completed daily diaries of activity, pain levels, and medication intake, and completed questionnaires and interviews assessing depression, medical history, and demographic variables. Male and female depressed and non-depressed chronic pain patients did not differ on demographic and medical history data, but sex differences were found in patterns of the relationships of depression, activity, and pain. For women, depression was closely related to pain report, whereas for men depression was more strongly related to impairment of activity. Pain report was related only minimally to activity for male and female patients. Implications of the results of behavioral research on depression in chronic pain patients are discussed. Researchers are urged to carefully consider sex differences in future research with chronic pain patients.

Introduction A number of studies have found depression to be common in chronic pain patient populations, and researchers and clinicians are increasingly attending to this syndrome in the study and treatment of chronic pain problems [16,18]. Depression and

’ To whom correspondence

0304-3959/85/$03.30

should be sent.

0 1985 Elsevier Science

Publishers

B.V. (Biomedical

Division)

33X

chronic pain seem to influence one another in a number of important ways. For example. depression appears to be a significant risk factor for poor response to treatment for chronic pain [2.3.8]. and antidepressant medication has been shown to decrease pain in many patients [4]. However. little is known about the way.4 in which depression influences the clinical presentation of chronic pain problems, e.g.. how it relates to pain report. inactivity and physical disability. The few investigations that have examined such issues have yielded mixed results. In a study of predominantly female facial pain patients. Marbach and Lund [13] found a significant but low correlation between self-reported depression and pain levels. However. in a later study of facial and back pain patients with a \omewhat lower proportion of females. no significant relationship was found between these variables [14]. Timmermans and Sternbach 117). in a predominately male sample. found that patients’ ratings of their average pain intensity were not significantly related to depression. but were related stronglv to a measure of preoccupation with pain and disability in daily activities. Two studies (6.151 of chronic pain patients l’ound no significant relationship between self-reported depression meaburc scores and words chosen to describe pain. On the cjther hand. an inverse relationship between activity level and depreasion among chronic pain patients has been reported in two investigations [6,9]. These findings suggest that the interrelationships among activity level. depression, and pain report may be complex and require further examination and clarification. One theoretical formulation posed by Fordyce [5] is that depression may develop and persist when the patient’s customary reinforcing activities are disrupted because of pain. Such a formulation is consistent with the work of Lewinsohn and his colleagues [IO,1 1,21J which has stressed the role of decreased positive reinforcement and pleasant activities in the development and maintenance of depression. Loeser [ 121 has hypothesized that depression increases the suffering of patients with chronic pain. However. as noted above. empirical data supporting these theoretical perspectives in chronic pain populationa are inconsistent. The studies reviewed above also suggest that the sex distribution of samples may be an influential factor in determining findings. and indicate a need for study of sex differences in relationships among pain levels. depression, and activity. Sex differences in depression have been found repeatedly in psychiatric and community samples [20]. The present study is a preliminary exptoration of the relationships among depression, pain report, and activity in chronic pain patients. Specifically, we sought to examine whether: (a) there were demographic and medical history differences between depressed and non-depressed pain patients. (b) depression was related to level. and (d) there were sex pain report. (c) depression w;~s related to activit\ differences in relationships among depression. pain- report. and activity levels.

Methods Subjec.t.c

Sixty-three patients seen consecutively als in the Pain Clinic at the University

who completed of Washington

all standard intake materiwere studied. Fifty-seven

339

percent of the sample were female, consistent with the typical percentage seen in the setting. The sample had an average age of 45.2 years (SD. = 14.7, range = 25-76) an average of 7.1 years of pain (S.D+ = 7.9, range = l-42) and had received an average of 1.2 surgeries for their pain (S.D. = 2.1, range = O-13). Patients were heterogenous in site of pain and often had multiple pain complaints. Sites of pain complaint included back (48%) face or head (22%) knee, leg, or hip (19%) neck or shoulder (17%) and other (17%). Most patients were seen in the Pain Clinic because physical findings were insufficient to explain their pain and disability. Procedure

As part of a comprehensive evaluation, all patients received a semi-structured psychological interview by an experienced Ph.D. level clinical psychologist and completed the Minnesota Multiphasic Personality Inventory (MMPI). Each patient was diagnosed as to the presence or absence of a major depressive disorder according to the American Psychiatric Association Diagnostic and Statistical Manual, third edition (DSM-III) [l]. In a prior study, Turner and Roman0 found good interrater reliability of diagnosis of major depression in a similar pain clinic sample [19]. Each patient completed 2 weeks of pain diaries [5], which included medications taken, pain intensity ratings, and activity (sitting, standing/walking, or reclining) monitored hourly around the clock. Demographic data and medical history information were also collected.

Results Demographic

and medical history variables

Forty-nine percent of the sample (52% of males, 47% of females) met DSM-III criteria for major depression. A chi-square analysis indicated that depressed patients as diagnosed by DSM-III criteria did not differ significantly from non-depressed patients in proportion of males versus females. Six additional chi-square analyses showed that depressed and non-depressed patients, and male versus female patients, did not differ significantly in percentage using narcotic, sedative-hypnotic, or antidepressant medications at the time of initial evaluation. No significant differences were found between male and female depressed and non-depressed patients on age, number of years of chronic pain, or number of surgeries when assessed by 2 x 2 analyses of variance (sex x DSM-III depression). Pain and activity levels

Pain diary measures of average pain, and hours sitting, standing, and reclining, scored separately for daytime and nighttime, were analyzed by 2 X 2 analyses of variance (sex x DSM-III depression). Significant main effects for depression were found on activity diary daytime (8 a.m. to 8 p.m.) pain ratings (F = 12.34, df = 1, 59, P < 0.001) and nighttime (8 p.m. to 8 a.m.) pain ratings (F= 4.61, df = 1, 59, P < 0.05). Significant sex x depression interactions were also found on patients’ average nighttime (F = 11.63, df = 1, 59, P -C 0.001) and daytime (F = 10.80, df 1,

340 II

Depressed

@ Non-depressed

'r---

Daytime /

Nightime

---7

6 Average Pain Diary RatbIg

1

5

4 3 2

Males

Females

Males

Females

Sex

Fig. 1. Interaction

of sex and depression

in pam report

59,P CC0.002) pain levels. Examination

of these interactions indicated that, for both the daytime and nighttime data, depressed women showed higher pain levels than non-depressed women, but depressed and non-depressed men showed no difference in pain ratings. These data are shown in Fig. 1. Further, main effects for sex indicated that women showed significantly higher levels of standing (F= 6.57, df= 1, 59, P < 0.05)and lower levels of reclining (F = 11.29, df= 1, 59, P < 0.001) during the day than did men. Men and women did not differ on the daytime sitting. or nighttime sitting, standing, or reclining measures. and no significant depression or interaction effects were found on these measures. Correlational analyses were undertaken to assess the relationships among depression severity as assessed by the MMPI Depression Scale, pain ratings. and activity. Pearson product-moment correlations were computed separately for male and female patients, as shown in Table I.

1

TABLE

CORRELATIONS

Note:

AMONG

MMPI D = Minnesota

DEPRESSION. Multiphasic

PAIN AND ACTlVlTY

Personality

MMPI

Night pain 0.15

D

Night sit

-- O.UR

- 0.03

Night stand

- 0.25

- 0.07

Night recline

0.16

0.04

Day sit Day stand Day recline * P < 0.05. ** P < 0.01.

- 0.46 ** -0.17 0.45 **

Depression

Scale,

Females (N ==36)

Males (N = 27) MMPI D

Inventory

Day pain

MMPI D .~

~ 0.03

Night pain O.?‘) **

0.17 --O.l?

-0.15 -0.04

~ 0.05

0.29 -0.13

- 0.23 0.35 *

Da). pain 0.50 * *

o.ux 0.22

-0.17 -0.11 --0.16 0.35 *

341

Pain ratings were significantly correlated with depression for females, with more depressed women reporting higher levels of pain during daytime and nighttime. No significant correlation was found between pain ratings and depression for males during either time period. For males, depression was significantly correlated with daytime activity. Men with higher levels of depression recorded higher levels of reclining and lower levels of sitting during the day. Increased depression in women was also associated with more reclining during the day. Depression was not significantly related to nighttime activity for male or female patients. Generally, levels of pain were not related to daytime or nighttime activity for either sex, although women who reported higher levels of daytime pain did recline more during the day.

Discussion The results suggest important sex differences in the relationships among depression, activity, and chronic pain. In female patients, depression was significantly related to self-reported pain severity. This relationship held up whether depression was assessed via clinical syndrome diagnosis or by a measure of severity of symptoms. For males, analyses revealed no significant relationship between pain report and depression. Behavioral formulations about the relationship between depression and inactivity received greater support from data of male patients, with more depressed men reporting higher levels of daytime reclining, and lower levels of daytime sitting. Daytime reclining is obviously an indication of inactivity. Daytime sitting, however, is an indicant of activity among these patients, given that sitting tolerance is typically reduced in patients with chronic pain disorders [5]. More depressed women also reclined more during the day. Depression did not correlate significantly with activity patterns at ni~ttime for either men or women. The results suggest little relationship between self-reported pain and activity levels assessed by diary data, consistent with previous research by Fordyce et al. [7]. However, for women, increased daytime pain report was associated with more daytime reclining. In addition, female patients were more active during the day than male patients. These sex differences are especially interesting because of the lack of sex differences on other clinical variables which were assessed. Contrary to findings reported in community and psychiatric populations, male and female chronic pain patients seen in this Pain Clinic setting were equally likely to meet criteria for major depression. Male and female patients also did not differ in age, duration of pain, number of surgeries, or types of medications used. Depression was also not related to these clinical variables. Sex differences may account for some of the inconsistent findings in past research in this area. Perhaps depression in male patients is more influenced by the processes described in Fordyce’s activity level hypothesis, while pain and depression in females are each indications of suffering, consistent with Loeser’s model. Several limitations of the current study should be noted. The data are correla-

342

tional and provide no information about causality. For example, it is possible that depressed male patients are less active secondary to their depression. or that female patients’ depression is secondary to higher pain levels. The issue of how treatment affects depression, activity and pain in male and female patients begs further study. Findings in the present study also suffer from the limitations of exclusive reliance on self-report measures, and future research utilizing direct observation of activity would be useful. The finding that sex differences may exist in the interrelationships among pain, activity and depression requires replication, but provides preliminary evidence for the importance of examining gender as a variable in further research in this area.

References 1 American Psychiatrtc American

Psychiatric

Assocratron. Association,

DSM-III: Diagnostic and Statrstrcal Washington, DC. 1980.

Manual

of Mental

Disorders.

2 Blanchard, E.B.. Andrasik, F., Neff. D., Arena, J.G.. Ahlea. T.A., Jurish. SE.. Pallmeyer. T.P.. Saunders, N.L.. Teders. S.J., Barron, K.D. and Rodichok, L.D., Biofeedback and relaxation training with three kinds of headache: treatment effects and their prediction. J. consult. elm. Psychol.. 50 (1982) 5622575. 3 Blanchard, E.G., Andrasik, F.. Neff, D.F., Teders, S.J., Pallmeyer. T.P., Arena, J.G.. Jurrsh. SE.. Saunders, N.L.. Ahles, T.A. and Rodichok, L.D.. Sequential comparisons of relaxatton training and biofeedback in the treatment of three kinds of chronic headache, or, the machines may he necessary some of the time, Behav. Res. Ther.. 20 (1982) 469-481. 4 Butler, S., Present status of tricyclic antidepressants in chronic pain therapy. In: C. Benedetti. C.R. Chapman and G. Moricca (Eds.), Advances in Pain Research and Therapy. Vol. 7. Recent Advances in the Management of Pain, Raven Press, New York, 1984. pp. 173-197. 5 Fordyce. W.E., Behavioral Methods for Chronic Pain and Illness. Mosby. St. Lotus. MO. 1976, 236 PP. 6 Fordyce. W.E., Brena, S.F., Holcomb, R.J., Delateur. B.J. and Loeser. J.D.. Relatmnship of patient semantic pain descriptions to physician diagnostic judgments, activity level measure and MMPI, Pain. 5 (1978) 293-303. 7 Fordyce. W.E., Lansky, D., Calsyn. D.A., Shelton J.L.. Stolov, W.C. and Rock, D.L.. Pain measurement and pain behavior. Pain. 18 (1984) 53-69. B.H., Predicting outcome of relaxation X Jacob, R.G., Turner, SM., Szekely, B.C. and Eidelman. therapy in headaches: the role of ‘depression.’ Behav. Ther., I4 (1983) 4566465. 9 Kerns, R.D., Holzman, A.D. and Turk, D.C., A cognitive behavioral analysis of depression among chronic pain patients, Paper presented at the Association for the Advancement of Behavror Therapy. Los Angeles. CA. November, 1982. 10 Lewinsohn, P.M. and Libet. J.. Pleasant events, activity schedules. and depression, .I. abnorm. Psychol., 79 (1972) 291-295. 11 Lewinsohn. P.M., Sullivan, J.M. and Grosscup, S.J., Behavioral therapy: clinical applications. In: A.J. Rush (Ed.), Short-Term Psychotherapies for Depression, Guilford Press. New York. 1982, pp. 50-88. 12 Loeser, J.D.. Perspectives on pain. In: Proc. 1st World Conference on Clinical Pharmacology and Therapeutics, MacMillan. London, pp. 313-316. 13 Marbach, J.J. and Lund. P., Depression, anhedonia. and anxiety rn temporomandibular joint and other facial pain, Pain. 11 (1981) 73-84. depression and anhedonia in 14 Marbach, J.J., Richlin, D.M. and Lipton, J.A., Illness behavior, myofascial face and back pain patients. Psychother. Psychosom., 39 (1983) 47-54. 15 Parker, J.C.. Doerfler, L.A.. Tatten, H.A. and Hewett, J.E., Psychological factors self-reported pain. J. clin. Psychol., 39 (1983) 22-25.

that

influence

343 16 Romano, J.M. and Turner, J.A., Chronic pain and depression: does the evidence support a relationship?, Psychol. Bull., 97 (1985) 18-34. 17 Timmermans, G. and Sternbach, R.A., Human chronic pain and personality: a canonical correlation analysis. In: J.J. Bonica and D. Albe-Fessard (Eds.), Advances in Pain Research and Therapy, Vol. 1, Raven Press. New York, 1976, pp. 307-310. 18 Turner, J.A. and Romano. J.M., Review of prevalence of coexisting chronic pain and depression. In: C. Benedetti, C.R. Chapman and G. Moricca (Eds.), Advances in Pain Research and Therapy, Vol. 7, Recent Advances in the Management of Pain. Raven Press, New York. 1984, pp. 123-130. 19 Turner, J.A. and Romano, J.M., Self-report screening measures for depression in chronic pain patients, J. clin. Psychol., 40 (1984) 909-913. 20 Weissman, M.M. and Klerman. G., Sex differences and the epidemiology of depression, Arch. gen. Psychiat., 34 (1977) 98-109. 21 Youngren, M.A. and Lewinsohn, P.M., The functional relation between depression and problematic interpersonal behavior, J. abnorm. Psychol., 89 (1980) 333-341.