Double Trouble: Decoding the Pain-Depression Feedback Loop

Pain Sadness Depression Painting Concept Art

A commentary in JAMA Network Open discusses the intertwined nature of pain, depression, and anxiety, highlighting the importance of addressing both physical and psychological symptoms for effective patient care. Credit:

JAMA Network Open commentary focuses on the relationship of pain, depression, and anxiety.

Chronic pain is often accompanied by depression and anxiety. In an invited commentary published in JAMA Network Open, Kurt Kroenke, M.D., of Regenstrief Institute and Indiana University School of Medicine, discusses the relationship between pain, the most common symptom for which individuals visit a physician, and depression and anxiety, the two most prevalent mental health conditions worldwide. He highlights the importance of not neglecting psychological symptoms in patients experiencing pain.

Understanding the Connection

“One of the reasons for the bi-directional linkage between pain and depression, as well as anxiety, is the existence of a feedback loop. Individuals with pain don’t sleep well and their resulting tiredness affects their mood, making them vulnerable to depression and anxiety. Having problems with depression or anxiety can increase susceptibility to pain.

“Also, areas in the brain that affect the pain that people experience are connected with areas that regulate mood, making physical and mental symptoms closely associated,” Dr. Kroenke said.

The Importance of Treating Both Symptoms

Noting that successfully addressing depression and anxiety is associated with improvement in pain, he observes that treating pain may not improve depression and anxiety to the same degree but does not negate the benefit of identifying and treating both physical and psychological symptoms.

“Symptoms of the body and the mind are frequent fellow travelers,” said Dr. Kroenke. “But patients seeing their primary care physician for a headache, back or muscle or leg pain or stomachache often neglect to mention the symptoms commonly associated with depression and anxiety that they are also experiencing such as fatigue, lack of motivation, nervousness and moodiness.  And physicians don’t always ask about symptoms beyond the ones which brought the patient into the office.

“Un- or under-treated, these emotional symptoms can cause long-term suffering and impaired quality of life. If clinicians measure and monitor both physical and mental symptoms they will be more able and likely to treat them. But there is no blood pressure cuff, lab test or X-ray for symptoms. We don’t have a way to measure symptoms other than from what the patient tells us, yet screening and diagnosis are crucial to improving patient outcomes.”

Symptomology and Measurement Tools

Dr. Kroenke is one of the fathers and leaders of the growing field of symptomology and the developer of several validated and widely used scales that enable clinicians to use feedback from patients to measure type and severity of pain (PEG), depression (PHQ-9), anxiety (GAD-7) and other symptoms including cancer fatigue (FSI-3) and risk of suicide (P-4). These brief measurement tools have been translated into more than 100 languages. 

Symptoms account for half of all outpatient primary care visits. In a review article published in 2014, Dr. Kroenke and colleagues reported that one in three common symptoms do not have a clear-cut disease-based explanation. That percentage is now thought to be more than one in two, he says.

The need to address both physical and psychological symptoms has long been recognized, says Dr. Kroenke, whose measurement tools are helping physicians to do so. He concludes his JAMA Network Open commentary with an illustrative quote from Ovid [born 43 B.C.], “I am no better in mind than in body; both alike are sick and I suffer double hurt.”

“Improvements in Pain or Physical Function and Changes in Depression and Anxiety Symptoms” is published in JAMA Network Open.

Reference: “Improvements in Pain or Physical Function and Changes in Depression and Anxiety Symptoms” by Kurt Kroenke, 28 June 2023, JAMA Network Open.
DOI: 10.1001/jamanetworkopen.2023.20474

In addition to his role as a research scientist with the William M. Tierney Center for Health Services Research at Regenstrief Institute, Dr. Kroenke, is also an IUPUI Chancellor’s professor and a professor of medicine at Indiana University School of Medicine.

1 Comment on "Double Trouble: Decoding the Pain-Depression Feedback Loop"

  1. As a chronic pain sufferer, I have found meditation good at alleviating the psychological affects.

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