LInks between Chronic Pain, Anxiety, and Depression

Association of Depression and Anxiety Alone and in Combination with Chronic Musculoskeletal Pain in Primary Care Patients – Psychosom Med. 2008 Oct; – free full-text PMC article

To assess the relationship between depression and anxiety comorbidity on pain intensity, pain-related disability, and health-related quality of life (HRQL).


Pain is a significant public health problem, with a third (1) to more than half (2) of adults in population-based surveys suffering from chronic or recurrent pain.  

Pain is the most pervasive symptom reported in the community and primary care setting (3–5) and accounts for nearly 20% of all ambulatory visits in the US (6).  

Chronic pain is one of the most common reasons for temporary and permanent work disability (8) and is frequently accompanied by psychiatric comorbidity (e.g. depressive and anxiety disorders) (9).

Depression and anxiety symptoms often present together with chronic pain in primary care.

Depression is one of the most common mental health problems in the general medical setting (10, 11); present in 10% to15% of patients. Depression produces substantial disability and decrements in health-related quality of life, often exceeding the impairment seen in patients with chronic medical disorders such as heart disease, diabetes, arthritis, and low back pain (12).

Major depression is the fourth leading cause of disease burden worldwide and projected to move into second place by 2020 (13). Depression costs an estimated $83 billion annually in the US (14), of which more than half represents lost work productivity (15).

Anxiety disorders afflict more than 30 million Americans in their lifetime (16), and cost the US an estimated $42 billion dollars per year in direct and indirect costs (17). Anxiety disorders often impair work, social, and physical functioning (18). Anxiety and depression frequently co-exist; complicating management and adding to health care utilization and costs (19).

The linkage between chronic pain and its affective components (i.e. depression and anxiety) has been known since the ancient Greeks (20).

Recent reviews report a 30 to 60% co-occurrence rate for pain and depression (9, 21). McWilliams et al. found in a nationally representative sample that anxiety disorder was present in 35% of persons with chronic pain versus 18% of the general population (22).

Additionally, studies have shown that anxiety and depression frequently coexist in patients with chronic pain (23, 24).

Pain, depression, and anxiety symptoms often overlap in general medical inpatients (25). Among 1,000 enrollees of a large health maintenance organization, those with at least one pain condition had more depression and anxiety symptoms than persons without a pain condition (26).

Both serotonin and norepinephrine may dampen peripheral pain signals.

This may explain how depression and anxiety, which are associated with dysregulation of these modulating neurotransmitters along shared neuroanatomical pathways, may contribute to the frequent presence of painful symptoms.

Thus the decrease or dysregulation in one or both of these neurotransmitters may increase peripheral pain signals and affect how antidepressants that increase these neurotransmitters reduce pain signals

While the link between chronic pain, depression, and anxiety has been established, less is known how having all three disorders concurrently may adversely impact pain outcomes.

We hypothesized that individuals with the triad of chronic pain, depression, and anxiety would have poorer pain outcomes, compared to individuals with either chronic pain and depression or chronic pain and anxiety. In other words, those with all three conditions (pain, depression, and anxiety) would be associated with

  • more intense pain,
  • greater pain interference,
  • more functional limitations,
  • more days “disabled” because of pain, and
  • greater decrements in HRQL.

In summary, among primary care patients with chronic musculoskeletal pain, depression and anxiety have independent as well as additive adverse effects on

  • pain severity,
  • pain interference,
  • functional limitations,
  • disability days, and
  • HRQL.

Because depression and anxiety further complicate the management of patients with pain and are associated with poorer outcomes, future studies are needed to test integrated and comprehensive approaches to the assessment and treatment of these common conditions (73, 74).  

Here is a similar study investigating the connections between pain, anxiety, and depression:

The incremental burden of pain in patients with depression: results of a Japanese surveyBMC Psychiatry. 2015; – free full-text PMC article

Major depressive disorder (MDD) is a chronic mental illness which affects an estimated 3% of the Japanese population.

Many patients with MDD report painful physical symptoms, and research outside of Japan suggests such patients may represent a subtype of depression which is more severe and difficult to treat.

There is no evidence available about the characteristics or incremental burden of these patients in Japan. The objective of this study was to quantify the incremental burden of physical pain among individuals in Japan diagnosed with depression.

Individuals whose depression is accompanied by physical pain have a higher burden of illness than those whose depression does not include physical pain. Clinicians should take the presence of pain into account and consider treating both the physical and emotional symptoms of these patients.


In conclusion, the presence of physical pain among depression patients in Japan appears to have an effect similar to that seen in other countries, where it is associated with

  • more-severe depression,
  • treatment resistance,
  • worse health outcomes,
  • greater use of health care resources, and
  • lower productivity.

Clinicians caring for these patients should take the presence of physical pain into account and consider treating both the physical and emotional symptoms of depression.  

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