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Post injury chronic low back pain and depression: comparative study between early and late post-injury sufferers shows significant difference.


Depression in spinal cord injured patients is frequently undiagnosed and untreated despite its frequency and negative effect on mental health. However, it is clear that apathy, fatigue, sleep disturbance, and an adverse effect on life are common outcomes. The experience of sadness is a normal, expectable response to the spinal cord injury due to changes in bodily appearance and functioning, pain and physical distress, limitations in the capacity to work and to engage in pleasurable activities, a perceived alteration in the anticipated life trajectory, fears of disability and dependency, alterations in intimate relationship, family life, social relationships and activities.

Chronic low back pain is usually defined as a complex state in which the pain symptoms have persisted long after the original injury or trauma onset (often described as longer than 6 months). The symptoms are viewed as exceeding the typical expected time course for healing of the acute injury, and the symptoms intensity and duration are also viewed as in excess of what would be predicted by the medical condition alone. Patients with chronic low back pain suffer dramatic reductions in physical, social, and psychological well-being with lowered health-related quality of life.

Some researchers have noted that the patient's pain symptoms move beyond the initial acute injury to a point where the pain symptoms themselves become the disease. Chronic pain is usually associated with a broad array of functional impairments, psychological symptoms, disability, and a high rate of medical service utilization. Patients with this type of chronic pain are often referred for psychological or psychiatric services and compose significant subgroup. Pincus (1) stated that psychological factors such as depressed mood, distress, and somatisation are highly correlated with low back pain, which predict the transition from acute into the chronic condition of depression.

Patients with chronic low back pain exemplify the complexity of treatment. However, it is common that a multidisciplinary treatment plan for chronic low back pain is not implemented, and is based only on unidimensional biomedical models with emphasis on the correct diagnosis and treatment using procedures such as nerve blocks, massage, pharmacological approaches, and surgery, without consideration of coexisting psychosocial factors. Furthermore, physical symptoms alone are often poorly associated with predictive value in return to work or functional outcomes. There is no doubt that severe low back injury is a stressful experience, which impacts as a psychological condition.

Stressful events have subjective meanings such as loss and fear, which are important in the etiology of depression, anxiety, specific phobias, substance abuse, and personality disorders. Trauma with physical injuries is largely focused on focused on Post-Traumatic Stress Disorder (PTSD). However, the other psychiatric outcomes after the trauma are less investigated; specifically, the trauma experienced by subjects who attended the emergency department as victims of a motor vehicle or work related accident. As outcomes they have shown immediate onset of a variety of psychiatric complications--general anxiety, depression, cognitive impairment, specific phobias.

Symptoms of depression associated with chronic low back pain are generally defined to include depressed mood, crying spells, depleted self-esteem, lack of self-confidence, thoughts of death and suicide, disturbance in sleep, appetite, energy and activity levels, anhedonia (inability to experience pleasure), concentration, short-term memory problems, and social withdrawal. Such symptoms are frequently seen with chronic low back patients and lead to question about the incidence of clinical depression in chronic pain. In a review of rates of depression in chronic pain there is a reported prevalence range from 10% to 100% across the study, which likely reflects methodological problems in diagnostic and assessment technique in assessing the impact on a mental health of injured people.

There is considerable controversy in how to diagnose depression or other psychiatric disorders with patients who have sustained a chronic low back injury. The most common dilemmas are: (1) depressive symptoms are often 'appropriate' to stress and disabling, (2) many symptoms of depression are similar to medical illness itself, (3) symptoms of depression often overlap with other psychiatric disorders. Over the past decade, there have been numerous investigations of affective aspects of the pain experience and to see the role of emotional distress, catastrophic, coping strategies, self-efficacy and motivational factors in persistent pain.

Clinical experience shows considerable overlap of PTSD symptoms and other psychiatric disorders with victims of the accident who, nevertheless, present significant distress and disabling. The relationship between stressful life events and risk of a major depression is largely presented. In this study, we used a measure to find the cause between the long-term disabling adversity and depression. There is growing evidence that people with chronic low back pain avoid a variety of stimuli, including those directly (physical activities) or indirectly (social activities), due to pain. The low back pain is conceptualized as a complex, subjective, perceptual phenomenon that involves a number of dimensions such as intensity, quality, time course and personal meaning. Pain of this nature often leads to significant distress, suffering, and functional disability.

Using standardized diagnostic criteria, Atkinson et al2 in a study of depression prevalence among men with chronic low back pain, compared with a control group without back pain history, found significantly elevated depression (32% versus 16%), alcohol abuse (65% versus 39%), and major anxiety disorder (31% versus 14%). Further, they also concluded that more major depressive episodes developed after the onset of pain than as a preexisting condition. Work-related low back injuries pose different subjective psychological demands than other conditions, such as gradual-onset pain disorders.

Severity and character of the pain, response to pain relief measures, functional limitation in daily activities, and changes in marital, family, or employment roles, may all affect perceptions and affective status. Individuals whose pain appraisal involves negative thought patterns and coping mechanisms have been found to increase rates of depression.

Unrealistic expectations and unawareness of a condition caused by low back injury play a major role in exaggerated fear and avoidance. Avoidance refers to a pattern of behaviour that delays, or puts off, an undesirable situation or experience. Avoidance is an important factor in the maintenance of disability in patients with a chronic low back pain. Although avoidance behaviour may be adaptive in response to acute pain, its longterm effects are deleterious.

Social avoidance behaviour due to discomfort caused by chronic low back pain is related to accurate expectations (as in phobic patients), that an activity is more painful than is actually the case. This in turn is related to fearing and avoidance of the particular day-to-day activities, like climbing a few stairs or using a support stick to assist in walking. Furthermore, due to avoidance as a secondary outcome, the patients suffered from muscle tightening and wasting, supporting patient's further reinforcement for avoidance of activity. Fear-avoidance of physical activities usually leads to self-isolation and withdrawal. Patient who behaves anxiously in the context of chronic pain entails a number of unhelpful responses such as: (1) reduced range of motions, and (2) decreased coping with pain.

During a clinical interview, questions that may be helpful for generating a diagnosis of depression with chronic low back pain would be What are you able to enjoy these days? What interests you now? When did you last have a good time? Patients who report a loss of interest and pleasure for at least two weeks should be considered as those suffering symptoms of depression, and they are likely candidates for the diagnosis of depression. It is also helpful to investigate the presence of other psychological symptoms of depression such as inability to concentrate, the sense of lowered self-esteem or feelings of guilt, and thoughts about death. As a part of mental status examination it is important to evaluate the levels of memory deficits. Severity of symptoms should be judged based on the degree of distress and functional disability and also to reassure absence of psychotic features.

It is common that chronic low back pain and discomfort cause either loss of pleasure in all, or most, activities or lack of reactivity to usual pleasurable stimuli. Melancholic features are accompanied by three or more of the following: (1) distinct quality of depressed mood different from bereavement, (2) depression is regularly worse in the morning, (3) insomnia with early morning awakening, (4) hypoactive sexual desire, (5) marked psychomotor retardation or agitation, (6) interpersonal rejection sensitivity, (7) significant changes in appetite.

In this study, we tried to find a relationship between chronic pain and depression using objective psychometric testing. Three major factors were targeted to evaluate the pain-depression relationship:

1. perceived interference (adverse effects of pain on activities);

2. measures of cognitive distortion (negative self-statement, de pleted self-valuation, catastrophic, over generalizing);); and

3. perceived level of self-control (perceptions of control and adjustment versus hopelessness).

The chronic pain-depression relationship demands characteristics of living with chronic pain that produces negative cognitive, behavioural, and personality changes, which often leads to depression. Chronic pain is itself a stressor which can lead to sufficient changes causing symptoms of major depression or, if depressive symptoms persist more than two years, to dysthymic disorder. We predict that measuring depression symptoms would provide more information about the pain and disability, than would relay on measures of single pain presentation.



Subjects for this study were 47 patients with low back injury referred to our Clinic for treatment of chronic pain. About half the patients were female (46.8%). Most of the referred patients were married (85%) and middle-aged (M= 45.3; SD=12.4), and most had completed secondary education (82.98%). Subjects complained mostly of low back pain (76.59%) followed by lower extremity pain (19.15%), and other locations (4.24%). The median reported duration of pain was 9 months (range 1-27 months). Subjects were divided into two groups: 21 who sustained injury on low back between 6 and 12 months prior to the assessment, and 26 who had an injury more than 12 months before referral was made.

All patients have previously been diagnosed as having a spinal cord injury (disc bulge, herniation, or disruption) confirmed by CT scan or MRI test. Before proceeding with the examination, informed consent was obtained from all participants.


The Beck Depression Inventory (BDI) is a 21-item measure of depression in adolescents and adults. It is designed to standardize the assessment of depression severity in order to monitor change over time or to simply describe the depression. Attitudes and symptoms, which appeared to be specific to this group of patients, were described by a series of statements, and a numerical value was assigned to each statement. Each of 21 areas to measure the behavioural manifestations of depression is represented by four or five statements describing symptom severity from low to high.

The Montgomery-Asberg Depression Rating Scale (MADRS) was designed to be used in patients with major depressive disorder to measure the overall severity of depressive symptoms. This is a 10-item checklist, which is rated on a scale of 0-6 with anchors at 2-point intervals. MADRS is a useful instrument to assess the degree of symptom severity in depressed patients and to evaluate changes in symptom severity.

The General Health Questionnaire-28 (GHQ-28) was designed to assess for the presence of psychiatric distress related to general medical condition. This measure was not designed for psychiatric diagnosis but rather as a screening device, which produces results that could lead to a formal psychiatric interview to determine a diagnosis. The GHQ was used as a complement to formal psychiatric interview conducted with each referred patient in this study. The GHQ was developed to evaluate the psychological components and assess an individual's ability to carry out daily functioning typical with low back injury patients.

Clinical interview was used to assess the severity of symptoms, changes over time, and the efficacy of medication, taking into account the patient's clinical condition and the severity of side effects (particularly the long use of painkillers). It was designed to assist the clinician in obtaining an impression of the patient's current illness state, and assessing the patient's improvement or worsening over time. In general, questions during the interview were almost the same addressed to all patients, in particular the statement about how the current condition interferes with patient's functioning. During the interview time, it was also important to note the presence of posturing, grimacing, or other gestures that occurred.


Despite some criticism, that measurement of depression using BDI in people with physical disabilities can be problematic because of items about work, tiredness, and weight loss, the BDI has been reported to be a valid and sensitive instrument. We used four recommended points in assessing the severity of depression with low back pain patients for both instruments (BDI and MADRS) between two groups of patients:

We found that both groups of patients reported symptoms of depression. However, patients who had the injury for a period of less than 12 months before the assessment were categorized as having 'mild-to-moderate' depression. However, those who had the injury for more than 12 months before the examination, placed at a 'moderate' level of depression. When this group was divided into two sub-groups (those who had received treatment regarding psychological symptoms and those who did not prior to evaluation), we found very interesting and significant differences:

Above results revealed that patients who did not have any treatment regarding depressive symptoms scored a result, which placed them in the category of severe depression. The results also confirmed that despite having treatment, patients who had the injury for more than 12 months prior to evaluation, presented a higher level of depressive symptoms than those who had the injury less than 12 months before the evaluation.

When compared two instruments (BDI and MADRS), we have also found some discrepancy and a higher level of depression assessed by MADRS than BDI. Our supposition is that this probably occurred because the items of MADRS cover 'pure' symptoms of depression but not work or physical symptoms like BDI.

In the evaluation GHQ-28 was used as complementary to psychiatric interview to assess the psychological components of chronic low back pain. We divided the scores into four sub scales (A-somatic symptoms, B-anxiety/insomnia, C-social dysfunction and D-severe depression) to evaluate the chronicity of reported symptoms:

We found an interesting difference between three groups: patients who had the injury less than 12 months before the examination scored 'consistent' results on all four scales. However, patients who had the injury more that 12 months before the examination and had received therapy due to a psychological condition, showed 'inconsistent' scores. They have higher scores on scale A (somatic symptoms) and scale C (social dysfunction) than patients who did not have any treatment.

These results revealed their disappointment with therapy provided and that no progress was achieved, confirming the chronicity of the pain and accompanied problems (depressive symptoms). On further evaluation, they reported that their physical condition and depression are much worse than after the injury, they feel run down, more incapable of making decisions, cannot enjoy their normal day-to day activities, and are unsatisfied with the progress of work carried out regarding their condition.

High score on scale D (severe depression) confirmed severity of psychological distress caused by chronic pain condition associated with feelings that life is not worth living, they feel worthless, hopeless, and that things are not on their side.


Chronic low back pain is a cardinal manifestation of spinal injury, and the relief of pain is probably the most common demand made by the patient upon presentation to a physician. Patients who experience chronic low back pain often have a host of related symptoms. Some of these individuals are chronically depressive, pessimistic and gloomy, whose guilty, self-depreciating attitudes are readily apparent to the moment they walk into our office. They seem to have no joy or enthusiasm for life and, indeed, some seem to have suffered the most extraordinary number and variety of defeats, humiliations and unpleasant experiences.

Chronic pain causes important changes in patients' physical and emotional relationship with their environment, and it is likely to require significant adaptation in self-care, leisure and vocational activities, and increased risk of developing psychological problems. The pain causes difficulties in sleep (inability to find a comfortable position), worries about financial situation, and even gastrointestinal stress caused by anti-inflammatory medication.

Pain is distracting and often leading to memory and concentration difficulties. Due to physical restrictions patients usually spend most of their time at home and away from others and from activities they previously enjoyed (prior to the accident or injury). Sexual activity is often the last thing on their minds, with significant hypoactive sexual desire evident. In general, patients with chronic low back pain often experience a loss of control over many aspects of life. All above factors are significantly pre-morbid to potentially develop the symptoms of clinical depression (feelings of despair, hopelessness, sadness, and even suicidal ideation).

Levels of depression with examined subjects have been found to be significantly higher in those who suffered an injury for 12 or more months before the evaluation. The study confirmed significantly increased levels of depression, hopelessness, and depleted self-esteem with patients after one year of injury despite having medical treatment. This finding confirmed that psychological adjustment to chronic low back injury does not improve with time and that psychological difficulties remain years after the injury.

The clinical interview was designed, among other things, to identify how and in what degree the injury and chronic low back pain caused psychological distress. All patients scored above 150, which confirmed that they suffered from accumulative stress, as injury caused marital problems, sexual difficulties, changes in finances, changes in living conditions, retirement, business readjustment, changes in a number of arguments with a partner or separation, and changes in sleeping habits.

The severity and complexity of the pain show that it is not a uniform entity in its etiology or treatment. Results in this study confirm that with chronic low back pain, the patient's depression symptoms should be examined. It is important to discuss the details of the patient's complaints at the beginning of the interview, in order to reassure the patient of the examiner's belief about stated complaints.

Obtaining subjective estimates of walking, sitting, and standing tolerances, allows comparison to be made with imposed limits and subjective estimates. Therefore, psychological data, whether collected by interview, testing, or both, should help to render statements referring to all five axes included in DSM-IV multiaxial classification. Just as depression is a frequent and somewhat natural reaction to chronic pain, the effects of depression may make it more difficult to recover from pain.

The general principles that may be summarized from our research are as follows:

1. chronic low back pain is also a psychological phenomenon, which gives rise to identifiable qualities that permit its perception;

2. chronic low back pain plays a significant role in the development of depressive symptoms and accompanied problems;

3. the severity of depressive symptoms is related to time since the onset of chronic low back pain, and may not be initially evident.

Although more interview time is required in attempting to evaluate the psychological condition of patients with chronic low back pain, we cannot rule out this problem. A proper evaluation of the patient's physical condition should be structured to permit the patient to spontaneously reveal personal and psychological data along with physical symptoms, and thus more information for appropriate multi-dimensional treatment modalities/ options.

Conflict of interest: None declared.


(1.) Pincus T, Burton AK, Vogel S, Field AP. A systematic review of psychological factors as predictors of chronicity/disability in prospective cohorts of low back pain. Spine (Phila Pa 1976). 2002;27(5):E109-20.

(2.) Atkinson JH, Slater MA, Patterson TL, Grant I, Garfin SR.Prevalence, onset, and risk of psychiatric disorders in man with chronic low back pain, Pain 1991(45); 11-121.

Corresponding author: Dr Vito Zepinic, PhD

Unit for Social and Community Psychiatry

Bart's and the London School of Medicine

Queen Mary University of London

London E13 8SP, UK


Dr Vito Zepinic, PhD

Unit for Social and Community Psychiatry

Bart's and the London School of Medicine

Queen Mary University of London, London, UK
                        BDI   MADRS

<12 months of injury   17.6   21.3
>12 months of injury   25.3   31.2

                          BDI    MADRS

With treatment (15)       21.2   20.4
Without tre atment (11)   36.4   42.3

           <1 year    >1 year of injury  >1 year of injury
          of injury     with therapy      without therapy

Scale A     14.3            24.3               22.1
Scale B     13.7            17.4               21.3
Scale C     16.1            25.1               24.3
Scale D     15.2            24.5               26.1
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Title Annotation:original article
Author:Zepinic, Vito
Publication:International Journal of Health Science
Article Type:Report
Geographic Code:4EUUK
Date:Jul 1, 2009
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