IndianJPain_2014_28_3_166_138453 (1)

ISSN: 0970-5333
VOL. 28 | Issue 3 | September-December 2014
INDIAN Journal of
PAINPAINPAIN
Indian Society for Study of Pain
IndianJournalofPain•Volume28•Issue3•September-December2014•Pages125-***
www.indianjpain.org

166 Indian Journal of Pain | September-December 2014 | Vol 28 | Issue 3
Chronic pain and depression: An online survey
on Indian experiences
Introduction
Depression and chronic pain are two contrast ailments
which affect different parts of a human body. Depression
isapsychiatricconditionwhilepain isadistinctlyphysical
conditionwith manyphysicallypresentablesymptoms. Itis
now well — established that chronic pain and depression
are related but the reasons for this association remain
unclear.[1]
According to studies 2-4% of persons in the
community, 5-10% of primary care patients, and 10-14%
of medical inpatients suffer from major depression.[2]
Studies done in primary care set up in India, however,
have estimated the prevalence rate of depression as high
as 21-40%.[3]
Depression is more prevalent in chronic
pain patients (CPPs) than in the general population as a
consequence of the presence of chronic pain.[4]
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DOI:
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ABSTRACT
Background: It is now well-established that chronic pain and depression are interrelated but the exact reasons for this association remain
unclear. Although, in the majority, chronic pain is the source of depression; in a few, chronic pain is a manifestation of depression. The
objective of this survey was to study the pattern of socio-demographic characteristics of persons with depression and chronic pain carried
out by online survey. Materials and Methods: Two-hundred and ten psychiatrist from all over India were selected randomly from those
who were registered with the Indian Psychiatry Society. Online survey was conducted with these psychiatrists. Survey questionnaire
included 16 questions on depression with chronic pain. Results: One hundred and fourteen psychiatrist responded on online survey.
The data was compiled and analyzed. The results showed that 201 patients/week visit psychiatric clinics.47% psychiatrist say 15-30%
present with chronic pain, 35% say depression with chronic pain is present in 20-40% patients. Eighty-four percent psychiatrist say pain
and depression are related to each other. Forty-one say 25-50% patients of chronic pain have depression. Conclusion: The results of this
survey showed that chronic pain and depression co-exist commonly.
Key words: Chronic pain, depression, online survey, socio-demographic
Santosh K. Chaturvedi, G. Prasad Rao1
, Kushal D. Sarda2
, Sachin Y. Suryawanshi2
Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, 1
Department of Schizophrenia,
Asha Psychiatric Hospital and Research Center, Hyderabad, Andhra Pradesh, 2
Department of Medical Services, Ranbaxy Labs Ltd., Mumbai,
Maharashtra, India
Prevalence estimates for chronic pain (that is, pain
lasting 3-6 months or longer) range from 9-33%. A review
of the literature revealed that depression is present in
31% to 100% of people with pain. Other studies have
shown that the prevalence of depression in pain ranges
from 4-66% across retirement community, primary
care, pain clinic, and community samples.[5]
In terms
of depression risk factors, Magni and colleagues found
that various demographic factors (e.g., sex, income,
education) and the presence of pain predicted high
levels of depressive symptoms.[6]
However, differential
correlates of chronic pain versus comorbid illness were
not explored. The findings on gender as a correlate of
comorbid depression are mixed. Women with pain
may be at a higher risk for depression,[7]
whereas other
research fails to show an association. Furthermore,
in a study of depressed outpatients, younger, African
Original Article
Address for correspondence:
Dr. Kushal D. Sarda,
Medical Advisor, Ranbaxy Laboratories Ltd, Western Edge-I,
Unit no. 201-204, 2nd
Floor, Western Express Highway, Borivali (E),
Mumbai - 400 066, Maharashtra, India.
E-mail: kushal.sarda@ranbaxy.com

Chaturvedi, et al.: Chronic pain and depression: An online survey on Indian experiences
Indian Journal of Pain | September-December 2014 | Vol 28 | Issue 3 167
American, Hispanic, or less educated people were more
likely to report pain.[8]
Pain has been reported from India in patients suffering
from such psychological illnesses as depression and
hysteria. On the other hand certain authors reported
seeing very few patients with a depressive illness in the
pain clinics.[9]
Although, in the majority, chronic pain is the source
of depression; in a few, chronic pain is a manifestation
of depression. Certain other factors such as financial
burdenduetochronicityof thedisease, restricted physical
movements, dependence on others, sleep disturbances,
occupational issues, reduced sexual activities, social
isolation, are also responsible for depression in these
patients.[10]
To our knowledge the prevalence of depression in Indian
populationwithchronic facetpain is notwell studied. The
objective of this study was to study socio-demographic
characteristics of depression in persons with chronic
pain in Indian clinical practice through online survey
questionnaire.
Materials and Methods
The online survey was carried out for period of 3 months
(from February 2013 to April 2013). Twenty questions
based on chronic pain and depression was prepared. They
were validated by doing a pilot study at five Psychiatrists.
After corrections, additions and deletions of questions
from pilot study, the questionnaire was finalized with 16
questions. Two-hundred and ten psychiatrist fromall over
India were selected randomly who were registered with
Indian Psychiatry Society. There email ids were obtained
from the list and questionnaire link was shared with these
psychiatrists to respond. The questions were related to:
1. Onanaverage how manypatientsdoyou seeperweek?
2. In your clinic, what percentage of your patients report
‘Chronic Pain’ as a main problem/symptom?
3. In your clinic, what percentage of your patients with
depressive disorder report ‘Chronic Pain’ as a main
problem?
4. In context of ‘Chronic Pain and Depression’, which of
the following statements is appropriate?
a. Pain as a cause of depression
b. Depression as a cause of pain
c. Bothdepressionand painarerelated toeachother
d. Both depression and pain are not related to
each other
e. Cannot comment
5. According to you, what percentage of ‘Chronic Pain’
patients suffers from Depression?
6. Whatarethemajorchallengesindiagnosingdepression
among ‘Chronic Pain’ patients?
7. Furthermore, what is the percentage distribution of
‘Pain intensity’ in these patients?
8. Apart from Depression, which other psychiatric
disorders co-exist with chronic pain?
9. What are the most common manifestations of
‘Depression with chronic pain’?
10. Whatpercentageof thesepatientsexpress impairment
that is ‘in excess of’ their physical findings?
11. Doesdepression decrease theeffectivenessof ‘Chronic
Pain’ treatment?
12. What is the gender wise distribution of ‘Chronic Pain
with Depression” patients?
13. What is the religion-wise distribution of such patients
in your practice (in percentage)?
14. Whatistheage-groupwisedistributionof suchpatients
15. In your practice, most patients of ‘Chronic Pain and
Depression’ fall into which of the following socio-
economic class?
16. What is the education wise distribution of these
patients (in percentage)?
Psychiatrists were requested to visit link and respond in
3 months duration, if they consented to this survey. After
obtaining theresponseof doctorsonsurveyquestionnaire,
data was entered in Microsoft Excel sheets and analysis
was done.
Results
Out of 210 Psychiatrist approached for survey, 114 (54%)
responded on online survey. We included the Psychiatrist
who responded within 3 months of duration.
From the first question it was shown that on an average
a psychiatrist see 201 patients per week. Around 47%
psychiatrists reported that 15-30% patients have chronic
pain as their main problem/symptom presenting to
their clinic [Figure 1]. Whereas 35% Psychiatrists say
that there are around 20-40% patients of depressive
disorder who report chronic pain as their main problem
[Figure 2].
Nextquestionwasasked related towhatpsychiatristthinks
about association of ‘Chronic Pain and Depression’, 84%
Psychiatrists believethatbothdepressionandchronicpain
arerelated toeachotherwhereasonly1% believesthatboth
are not related [Figure 3].

According to response, 41.23% of psychiatrist says that 25-
50%patientssufferfromdepressionduetochronicpainand
37.72% psychiatrist feel that 50-75% patients suffer from
depression due to chronic pain [Figure 4].
Questionnumber6wasasubjective,whatmajorchallenges
does a psychiatrist face while diagnosing depression in
chronic pain patients. 30.91% psychiatrists say social
stigma towards psychiatry and patients’ unwillingness
to accept depression as a cause for pain was a major
challenge followed by 28.36% saying unawareness among
the population. Others included lack of diagnostic tools,
comorbid conditions such as arthritis, obesity, lack of
compliance etc [Figure 5].
Furthermore, we asked psychiatrist what is the intensity
of pain reported by these patients, 22.40% psychiatrist
said that patient have severe pain, whereas 39.72%
psychiatrist said moderate pain and 37.86% psychiatrist
said have mild pain which needs treatment [Figure 6].
Apart from depression, 29.87% psychiatrist said that
patientscomplainof somatoformdisorderco-existing with
chronic pain, followed by 26.58% for generalized anxiety
disorder, 22.28% for substance abuse. Others included
stressdisorder,conversiondisorders,schizophrenia,chronic
fatiguesyndrome,disturbedsleep,panicdisorder[Figure7].
Twenty-four percent psychiatrists say patients complain
of disturbed sleep followed by irritability and sadness
respectively seen as manifestations of depression with
chronic pain [Figure 8].
Out of these patients, 51.36% express impairment that is
in excess of their physical findings as per psychiatrists.
Seventy-nine percent psychiatrist says that depression
decreasestheeffectivenessof chronicpaintreatmentwhere
as 6% say it does not affect the treatment of chronic pain.
Coming to gender wise distribution, 64% female patients
reportchronicpainwithdepressioncomparedto36% male.
Figure 1: Q 2. In your clinic, what percentage of your patients report
‘Chronic Pain’ as a main problem/symptom?
Figure 2: Q 3. In your clinic, what percentage of your patients with
depressive disorder report ‘Chronic Pain’ as a main problem/symptom?
Figure 3: Q 4. In context of ‘Chronic Pain & Depression’, which of the
following statements is appropriate?
Figure 4: Q 5. According to you, what percentage of ‘Chronic Pain’
patients suffer from Depression?

Figure 9 shows religion wise distribution of patients,
43.93% are Hindu followed 33.18% are Muslims. Figure 10
shows age wise distribution of such patients, 36.97%
patients are in 35-50 years of age has maximum chronic
painwithdepressioncomplaints followed byalmostequal
in age group of 20-34 years and 51-64 years respectively.
We also asked psychiatrist about the socioeconomic
classiﬁcation of their patients, for which we followed
Modified Kuppuswamy’s socioeconomic scale. In
response 46% psychiatrist say patients were from lower
middle class followed by 30% from upper middle class.[11]
[Figure 11].
Lastly, education wise distribution of these patients was
asked to psychiatrist who said that 37.76% patients have
done higher school secondary education followed by
36.67% done primary education [Figure 12].
Discussion
The range of pain experiences is wide and varied. An
individual’sresponsetochronicpainreﬂectscharacteristics
of the pain and the person’s thoughts and behavior
developedduringthecourseof theillness,whicharesubject
topositiveand negativereinforcement.[12]
Majordepression
is the mostcommon mental illnessassociated withchronic
pain.[13]
So the present study was carried out using online
survey in psychiatrist doctors to see the relation between
chronic pain and depression among their patients.
In our study, it was observed that on an average a
psychiatrist see 201 patients per week. Out of this, 47.37%
psychiatrist says 15-30% patients come with chronic pain
as main problem whereas more than 16% psychiatrist says
it is more than 30%. One study found that prevalence
rates of pain patients were 38% in psychiatric clinics.[14]
Stengel et al., had reported pain as a presenting symptom
Figure 5: Q 6. What are the major challenges in diagnosing depression
among ‘Chronic Pain’ patients?
Figure 6: Q 7. What is the percentage distribution of ‘Pain intensity’
in these patients?
Figure 7: Q 8. Apart from Depression, which other psychiatric disorders
co-exist with Chronic pain?
Figure 8: Q 9. What are the most common manifestations of
‘Depression with chronic pain’?

in 45-60% of cases in psychiatric clinics.[15]
In Figure 2, we
can see that 35.09% psychiatrist says 20-40% depressive
patients visiting their clinic have chronic pain as main
problem other 30% psychiatrist says it is more than in
40% of patients. A study based on interviews by skilled
clinicians determined that according to standardized
criteria, depression aﬄicted 87% of 300 patients with
chronic pain.[16]
The co-occurrence of pain and depression is common.
Depression is more prevalent in CPPs than in the
general population as a consequence of the presence of
chronic pain.[10]
In our study, 84% psychiatrist says pain
and depression are related to each other, whereas 12%
doctors feel it is the pain which causes depression. Bair
et al., reviewed the literatures on prevalence rate of major
depression among CPPs and found the prevalence rate to
bevarying within awide rangeof 1.5-100% which included
studies from pain clinic, psychiatric clinic, orthopedic
clinic, dental clinic, gynecologic clinic, surgical patients,
andprimarycaresettings.Theyfound themeanprevalence
rate of major depression in CPPs from pain clinics to be
52% which included 15 studies.[17]
Ourstudydemonstrated
50% of psychiatrist saying that more than 50% of patients
having chronic pain suffer from depression, 41.23%
psychiatrist says it falls between 25-50% of range.
Furtherweasked whatarechallenges faced bypsychiatrist
in diagnosing depression in chronic pain [Figure 5]. Few
psychiatrists (30.91%) saysocial stigmatowardspsychiatry
and patients unwillingness toacceptdepressionasacause
for pain was a major challenge followed by 28.36% saying
unawarenessamong thepopulation. Others included lack
of diagnostic tools, comorbid conditions such as arthritis,
obesity, lack of compliance etc. Several studies report
that depression is associated with more pain complaints,
greater pain intensity, longer duration of pain and greater
likelihood of non-recovery.[17]
So we included question
Figure 9: Q 13. What is the religion-wise distribution of such patients
Figure 10: Q 14. What is the age-group wise distribution of such
patients in your practice (in percentage)?
Figure 11: Q 15. In your practice, most patients of ‘Chronic Pain &
Depression’ fall into which of the following Socio-economic class?
Figure 12: Q 16. What is the education wise distribution of these
patients (in percentage)?

regarding the pain intensity, 22.40% psychiatrist said
patientscomplainof severepainwhereas 39.72% said have
moderate pain and 37.86% said patients have mild pain
but require treatment which was contrary to the study
which reported 66% patients complaining of mild pain
intensity.[18]
Recently,aworldwidestudyexaminingapopulation-based
sample from 18 developed and developing countries, has
carefullyexamined the relationship between chronic pain
and mental disorders. They have concluded that chronic
pain is associated with mood and anxiety disorders.[19]
In
our study we also wanted to see what other psychiatric
disorders are presented by chronic pain patient. Patients
complaining some form of somatoform disorder was
observed by 29.87% Psychiatrist, followed by 26.58% for
generalized anxiety disorder, 22.28% for substance abuse.
Others included stress disorder, conversion disorders,
schizophrenia, chronic fatiguesyndrome, disturbed sleep,
and panic disorder.
We also asked psychiatrist what are the clinical features
with which a patient of depression with chronic pain
present to your clinic, 24% says have disturbed sleep,
18.35% irritability, 17.65% sadness, 13.88% weakness,
13.18% loss of appetite, others included decreased
concentration, stress, headache. 51.36% of psychiatrist
said these patients express impairment that is ‘in
excess of’ their physical findings as per psychiatrists.
Presence of depression in a patient with chronic pain is
associated with decreased function, poorer treatment
response and increased health care costs.[20]
In our
study, 79% psychiatrist says that depression decreases
the effectiveness of chronic pain treatment, where as
6% say it does not affects the treatment of chronic pain.
Coming togenderwisedistribution, 64% psychiatristsaid
female patients report chronic pain with depression in
OPD compared to 36% psychiatrist males. The finding
that female patients and those with higher education
present with chronic pain significantly more often has
already been observed by other researchers. There is no
sound explanationoffered forthis predilectionof the pain
problem in female patients.[21]
Considering the socio-demographic characteristics, we
did not find any much difference when it came to religion
wise distribution of patients. Hindu, Muslims, and all
othercaste had almost same distribution. Age-group wise
distribution of patients having depression with chronic
painwashigh in 35-50yearsagewhichwas36.97% followed
byalmostequal inage-groupof 20-34 yearsand 51-64years
respectively. Socio-economic classification of patients
revealed that 46% belong to middle class and 30% belong
to upper class, this is contrary to studies done which says
depressionwithchronicpain isseen in lowsocioeconomic
status.[18,22]
Lastly, it was estimated that more than 70% of
patients is from lower level of education.
The present study has some limitations. Sample size
of psychiatrist was low, so we cannot apt for whole
population. In conclusion, this study demonstrated that
psychiatrists are aware of chronic pain and depression
co-existence. Demographic characteristics are also
important when it comes to treating patients of chronic
pain with depression.
Acknowledgement
TheAuthorsaregrateful toMr. GovindarajanDorairajan, business
unit head, Mr. Mukesh Sehgal, senior manager—marketing
and Solus and Solus Care team, Ranbaxy Laboratories Limited,
Mumbai for their support and constant encouragement.
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How to cite this article: Chaturvedi SK, Rao GP, Sarda KD,
Suryawanshi SY. Chronic pain and depression: An online survey on
Indian experiences. Indian J Pain 2014;28:166-72.
Source of Support: Nil. Conﬂict of Interest: None declared.

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