Quality of life in major depressive disorder: the role of pain and pain catastrophizing cognition
Introduction
Major depressive disorder (MDD) is currently the leading cause of disability in developed countries and the fourth leading cause of disability worldwide. Projections estimate that MDD will rise to be the second leading cause of disability worldwide by the year 2020 [1], [2]. One of the most disabling aspects of MDD is its adverse impact on quality of life (QOL). Previous studies have shown that patients with MDD have significantly impaired QOL compared with healthy individuals and people with chronic medical conditions [3], [4]. Multiple factors are associated with the QOL in patients with MDD, including the age of onset and severity of depression, psychiatric and medical comorbidity, pain and somatic symptoms, and sociodemographic characteristics [5], [6], [7], [8]. Acute pharmacotherapy of depression can improve psychosocial functioning and QOL, but a significant disability persists despite symptom improvement [9].
Pain symptoms are frequent complaints in patients with MDD. A recent review reported an average 65% co-occurrence rate for pain and depression [10]. The severity of pain complaints in MDD was found to predict a longer time to remission, poorer clinical outcome, greater functional impairment, worse QOL, and higher associated health care costs [11]. Clinical studies suggest that pain symptoms in MDD could be a somewhat separate entity from depressive symptoms [12], [13]. Whereas depressive symptoms continued to improve over time, pain symptoms had minimal change after some initial improvements [14].
Psychological factors are important in shaping the experience of chronic pain; in particular, the manner in which one copes with pain is a consistent predictor of clinical outcome. Of the pain-related coping variables that have been studied, pain catastrophizing has been found to have one of the strongest associations with negative pain outcomes [15], [16]. The construct of catastrophizing incorporates magnification of pain symptoms, rumination about pain, feelings of helplessness, and pessimism about pain-related outcomes [17]. It is proposed that pain catastrophizing promotes fear of movement and injury, in turn, leads to avoidance behavior, disuse, disability, and depression. Recent studies have found that pain catastrophizing has significant associations with disability and QOL in patients with chronic pain, even after controlling for levels of anxiety, depression, and pain [18], [19], [20], [21].
Understanding pain catastrophizing's contribution to QOL is important for developing and improving treatments in patients with MDD associated with pain symptoms. Previous studies have shown that after remission of depression, functioning levels in patients with a previous depressive episode are still substantially lower than those in healthy controls [22], [23]. If pain catastrophizing is found to contribute significantly to physical and psychosocial functioning, we would expect that treatments targeting depressive symptoms alone might be insufficient for improving QOL in patients with MDD and that interventions specifically designed to target pain catastrophizing would be beneficial. The present study was designed to determine the relationship of pain catastrophizing with QOL in patients with MDD after accounting for the impact of pain, depression, and anxiety. We also examined if the effects of pain catastrophizing differed across domains of QOL.
Section snippets
Design
This was a local extension of a multicenter, prospective, noninterventional, observational study of Asian patients with acute MDD [24]. We systematically collected pain and psychiatric symptoms twice during a 3-month period. Baseline assessment was conducted after written informed consent was obtained from the participants. All procedures used in the present study were reviewed and approved by the local institutional review board.
Subjects
Either outpatients or inpatients of Chinese ethnicity aged from
Results
The 91 participants included 18 men and 73 women. Ages ranged from 20 to 62 years, with a mean ± SD of 48.3 ± 9.5 years. Almost half of the subjects were married or cohabiting, 23 (25.3%) were single, and 24 (26.4%) were divorced or widowed. The patients' occupation was as follows: 18.7% (n = 17) were professionals, associate professionals, or clerical or service workers; 25.3% (n = 23) were manual workers; 5.5% (n = 5) were retired; 1.1% (n = 1) were student; and 49.5% (n = 45) were unemployed
Discussion
Recently, there has been a growing focus on the role of pain in the outcome of MDD. We found that not only pain but also pain-related cognition explained a significant proportion of the variance in physical and psychosocial functioning. After controlling for sociodemographic, clinical, pain, anxiety, and depression variables, pain catastrophizing was independently associated with QOL in patients with an acute episode of MDD and after 3 months of pharmacotherapy for depression and was predictive
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Conflict of interest: None.