Chronic Pain and Mental Health: A Compounding Relationship

Mental health has become a prominent issue in the United States due to skyrocketing rates of illness that were exacerbated by the COVID-19 pandemic. According to data from the Substance Abuse and Mental Health Services Administration, more than 1 in 5 Americans—nearly 58 million people—now live with a mental illness.¹ This has led the Biden administration to urge insurance companies to increase coverage of mental health treatments, as well as to boost funding for various behavioral health services.

Man experiencing chronic pain - sebra / stock.adobe.com

Like the mental health crisis, chronic pain has gained recognition among public health experts as a significant issue in the country. Defined as any pain lasting longer than 3 months, chronic pain occurs more often among adults than other common conditions, such as diabetes and high blood pressure. A study conducted by the National Institutes of Health found that 23% of US adults experience chronic pain, with two-thirds suffering from it after a year.² Chronic pain can be a debilitating condition that limits an individual’s life and work activities on most days or even daily.

Compounding these issues is the fact that they frequently occur together, with much research pointing to a bidirectional relationship between them. A study published in the journal Pain by De La Rosa et al found that 12 million US adults deal with co-occurring chronic pain and anxiety or depression.³ The investigators concluded that research to address unmet needs and improve outcomes must be prioritized to mitigate the “profound functional impacts” associated with the cooccurring conditions.

“The symptoms of either chronic pain or mental health disorders can worsen the symptoms of the other and cause a cyclic escalation of the two over time,” said Madison Irwin, PharmD, clinical and translational sciences postdoctoral fellow at University of Michigan’s College of Pharmacy. “There’s a lot of stigma associated with chronic pain and mental health disorders and that 100% influences someone’s access to care. There can be a lot of discrimination associated with that. It can quickly become a snowball effect that has far-reaching consequences.”

The bidirectional relationship between chronic pain and mental health disorders, in which the two tend to promote each other, has been well documented. There are many reasons for why this may occur, including that pain and common mental health disorders—such as anxiety and depression—are connected biologically. Certain regions in the brain (eg, the insular and prefrontal cortices) have been associated with processing and modulating pain, anxiety, and depression.³

Living with chronic pain can also result in maladaptive cognition and behaviors, which increases psychological stress and creates a mutually reinforcing effect. Individuals dealing with sustained pain and anxiety or depression may invalidate interactions with family or friends and experience social exclusion, both of which serve to weaken functional resilience. Furthermore, anxiety and depression can intensify the perception of pain and lower a patient’s willingness to engage with treatment.³

Pain catastrophizing, in which an individual believes pain will eventually result in the worst possible outcome, is another important factor that impacts those with chronic pain and mental health conditions. Research has shown that patients with chronic pain and pain catastrophizing experience higher rates of depression, anxiety, and suicidal ideation.⁴ It is also highly predictive of quality of life among individuals dealing with chronic pain and mental health conditions.

“I think it’s hard to overstate the role that [pain catastrophizing] plays,” Irwin said. “The presence of pain catastrophizing at baseline, even in someone who doesn’t have chronic pain, is either a risk factor or predictor for the development or transition to chronic pain. It impacts how individuals respond to interventions for chronic pain. Oftentimes, patients with higher elevated pain catastrophizing are less likely to respond to things like physical therapy, or even things like cognitive behavioral therapy.”

Although the co-occurrence of chronic pain and mental health conditions is a serious threat to patients, there are many ways to foster better health outcomes in this population. The erasing of stigmas, better patient education, tailored interventions, and improved collaboration between health care providers can all help those who are suffering. As medication experts who develop close relationships with patients, community pharmacists are well positioned to play a key role in combating this debilitating condition.

“In my experience, people dealing with chronic pain and living with mental health disorders are often pretty disenfranchised,” Irwin said. “They’re used to people handing down commands to them and that [can] feel really bad. I think one of the most important things is just listening and letting people know that they’re being heard. Unfortunately, health care professionals are often limited in the amount of time they have to spend with [patients] and these are not quick, simple, easy things for people to convey.”

READ MORE: Mental and Behavioral Health Resource Center

References

1. Key Substance Use and Mental Health Indicators in the United States: Results from the 2021 National Survey on Drug Use and Health (HHS Publication No. PEP22-07-01-005, NSDUH Series H-57). Substance Abuse and Mental Health Services Administration. 2022 .Accessed March 20, 2024. https://www.samhsa.gov/data/sites/default/files/reports/rpt39443/2021NSDUHNNR122322/2021NSDUHNNR122322.htm 

2. Nahin RL, Feinberg T, Kapos FP, Terman GW. Estimated rates of incident and persistent chronic pain among US adults, 2019-2020. JAMA Netw Open. 2023;6(5):e2313563. doi:10.1001/jamanetworkopen.2023.13563

3. De La Rosa JS, Brady BR, Ibrahim MM, et al. Co-occurrence of chronic pain and anxiety/depression symptoms in U.S. adults: prevalence, functional impacts, and opportunities. Pain. 2024;165(3):666-673. doi:10.1097/j.pain.0000000000003056

4. Slawek DE, Syed M, Cunningham CO, et al. Pain catastrophizing and mental health phenotypes in adults with refractory chronic pain: a latent class analysis. J Psychiatr Res. Published online December 2, 2021. doi:10.1016/j.jpsychires.2021.12.001