INTRODUCTION
Depression may exist as a disease entity by itself1
or serve to complicate the disease spectrum of an already existing
chronic illness; it is commonly found in patients in association with a variety
of chronic infectious, metabolic, neoplastic and genetic
illnesses. 2-6 Perhaps the most common type of depression is the one
found in association with old age 7-9, pregnancy 10-12
and the post partum period in women. 13-15 Several
studies have even documented the role of depression as a primary or additional
risk factor for subsequent occurrence of diseases. 16-18 As a comorbid factor present in
the diseased state, it increases the disease burden of the patient and incurs
increased costs for health care. 19-25
The association of
depression with chronic illnesses has been a subject of research for many
years, without any clear cut plausible pathogenetic
mechanism being elucidated. Some authors favour a psychosomatic origin for
depression, terming it merely a depressed mental state of the patient who is
aware of the presence of a chronic disease in the body; 26,27 others try to find biochemical and neuronal
pathways linking the presence of depression in chronic disease to specific
organic lesions or pathways in the brain. 28,29
One of the associations
found more significantly with depression is that of the presence of pain. 30-32
Though some studies have claimed the presence of chronic fatigue and pain as a
consequence of depression in patients suffering from various states of chronic
mental depression, 33 it has also been found that states of chronic
pain (of whatever origin) by themselves bring about depression in patients. 31,
34, 35 Pain mediated depression has been linked to the findings of raised
serum cortisol and other corticoids 36 and
also to cytokine mediators such as TNF-alpha. 37-39 However the
probable biological plausibility is still to be worked out.
MATERIAL
AND METHODS
The
study was carried out at
Patients with musculoskeletal
pain of at least 4-24 weeks duration were included in the study group after
excluding people with history of injury, diabetes mellitus, renal disease,
chronic infection, neoplastic condition or any other
systemic disease, known cases of arthritic diseases and subjects testing
positive for rheumatoid arthritis factor, ANA, ASOT, with raised levels of CPK,
LDH, ALAT, AST, BUN, Creatinine, Glucose, and ESR.
Detailed history was taken on prescribed Proforma
assessing the patients’ disease status and history of musculoskeletal pain.
History was taken on prescribed proforma
assessing the patient's status and history of musculoskeletal pain and
depression.
Physical examination
of the subject was carried out for height, weight, temperature, blood pressure,
anaemia, joint swelling, localization of pain,
deformity and functional disability.
Documentation for pain
was accomplished by the Tender Point Scoring System derived by palpation of
nine tender points in the muscles, joints and other localities. The 18-point
sites (unilateral, bilateral) on palpation were used to derive the Tender
Points Score (TPS) for each patient complaining of chronic non-specific musculo-skeletal pain. 41
For assessing the
presence of depression a General Health Questionnaire (GHQ) for depression was
filled; a cut-off point >5 score for 28 items was taken to diagnose the accompanying
depression. 40
All data
were entered on SPSS version 8.0 software and were
analyzed for frequencies, means and SD; Chi-Square and Student’s t-test were
used for hypothesis testing. Pearson’s Correlation Coefficient (r) was used to determine numerical
associations. P £ 0.05 was maintained as
significant.
RESULTS
Of the 72 study subjects, 22 (30.6%) were males and 50
(69.4%) were females, giving a male to female ratio of 1:2.36. There were 12 (33.3%)
males and 24 (66.7%) females among controls and 10 males (27.8%) and 26 females
(72.2%) among patients. The ages of subjects ranged from 25 to 60 years with a
mean age of 38.08 ± 8.24 years. The ages of 36 controls ranged from 25 to 54
years with a mean age of 38.64 ± 6.74 years. The ages of 36 patients ranged
from 25 to 60 years with a mean age of 37.53 ± 9.57 years (Table 1).
Table 1: The age
characteristics of controls, patients and all subjects by gender.
|
Groups |
|
Mean Age (years) |
|
Controls (36) Males (12) Females (24) |
25 –
54 29 -
54 25 -
52 |
38.64
± 6.74 39.92
± 6.91 38.00
± 6.70 |
|
Patients (36) Males (10) Females (26) |
25 –
60 25 -
60 25 -
55 |
37.53
± 9.57 36.40
± 11.32 37.96
± 9.03 |
|
All Subjects (72) Males (22) Females (50) |
25 –
60 25 -
60 25 -
55 |
38.08
± 8.24 38.32
± 9.12 37.98
± 7.92 |
Pain duration in patients ranged
from
The GHQ scores of 36 controls
ranged from 0 to 8, with a mean score of 3.11 ± 1.89. The GHQ scores of 36
patients ranged from 9 to 31, with a mean score of 20.47 ± 7.19 (Table 2). This
difference was highly significant with p <0.001.
Table 2: Pain characteristics and depression index
in subjects.
|
Variables |
Range |
Means ± S.D. |
|
Duration of pain (weeks) |
4 –
24 |
16.17
± 7.07 |
|
Total Pain Score |
3 –
18 |
9.63 ±
4.25 |
|
GHQ Score Controls (36) Patients (36) |
0 - 8 9 –
31 |
3.11
± 1.89 20.47
± 7.19* |
* p < 0.001 as compared to
controls
Correlation analysis revealed a
significant positive linear association between the TPS and the GHQ scores in patients,
with r = 0.517 and p = 0.001 (Figure 1). In the
control group, no graph could be generated as there were an insufficient number
of cases for correlation analysis.
Figure 1: Scattergram
of patients’ TPS and GHQ scores showing a positive linear association which is
significant with r = 0.517 and p = 0.001.
DISCUSSION
Our
patients tended to fit into the category of chronic non-specific pain as
defined by ISAP 42 and belonged to an adult age group; they had all
other common causes of chronic pain excluded by relevant investigations.
The present study revealed a significant difference
between patients of chronic pain and normal subjects when tested by an index,
the General Health Questionnaire, used to monitor the level of depression in
people (Table 2).
When analysed further, the data indicated a
significant positive linear correlation between the patients’ GHQ scores and
their Total Pain Scores (TPS), indicating that the increased depression found
in patients with chronic pain was related to the magnitude of pain present in
their bodies. Such correlation could not be performed in controls as there were
an insufficient number of cases to correlate.
Pain mediated depression warrants recognition in the
general population as well as in patients undergoing treatment for a variety of
chronic painful conditions.35, Once depression ensues, it further
mediates a cycle of depression -based enhanced pain perception, so that the
psychosomatic component serves to maintain feelings of pain despite routine
pain medication.43 A vicious cycle thus ensues that not only
requires greater pain medication and longer treatment times, but may defy total
pain resolution unless the depression is recognized and treated as well.30,32
Several studies have pointed out that both chronic
pain syndromes and depression exist more commonly in females.44, 45
This is seen also in the present study, where the number of female patients
with pain (26, 72.2%) is more than twice the number of male patients (10,
27.8%); however the mean GHQ scores of male and female patients did not differ
significantly.
To conclude, the presence of depression must be sought
for actively in patients suffering from chronic non-specific painful
conditions, so that the additional psychosomatic or neurochemical
mechanisms that maintain a cycle of persistent pain in these patients can be
recognized and treated appropriately.
Acknowledgement
We would like to acknowledge the help of Dr. Iftikhar Qayum, Department
of Pathology, Ayub Medical College Abbottabad and Dr.Abdul
Waheed, Department of Biochemistry, Ayub Medical College Abbottabad for
literature search, data analysis and article writing.
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