Depression and chronic pain.

A paper in this issue of the Saudi Journal of Anesthesia addresses for the first time the prevalence of depression and its association with a range of sociodemographic factors in patients with chronic pain in Saudi Arabia.[1] In our opinion, this article is highly relevant in its specific national and regional setting but also on an international level.

Chronic pain is one of the biggest challenges of modern medicine, and it represents one of the most serious health burdens in the modern world.[2] By its very nature, pain always involves perceptual, emotional, and cognitive factors.[3] The clear recognition and acknowledgment of these multiple factors, going beyond tokenism, are essential in its successful management. The so-called “psychosocial” factors are often conceptualized and understood as epiphenomena and as “separate” diagnostic entities from the psychological field. However, these psychological factors are an integral part of the complex experience of pain, including on a biomedical level. Not long ago, the psychological changes accompanying depression were thought to be a result of mainly psychological rather than biological factors. More recent research has shown that pain shares to a significant degree the same or similar biological mechanisms with psychological conditions such as anxiety and depression.[4] They require assessment of the pain condition in its cultural milieu and context, including broadly defined socioeducational-psychological background. The relevance of these factors in the setting of chronic pain has been recently highlighted by Dan Carr, who suggested to “flip the curriculum” from the old term “bio-psycho-social” to the more appropriate “socio-psycho-biomedical.”[5] Understanding of pain in this way will determine the true and effective application of an integrated multidisciplinary approach to its management. This approach will help to negotiate the apparent conflict between the “cure” expected by the patient and the reality of successful management of a chronic condition.

First and foremost, the paper discussed here identifies the prevalence of depression in the studied population in Saudi Arabia and through this mirrors comparable international studies in other social and ethnic settings. Furthermore, it raises issues about important sociodemographic factors; in particular, the correlation of low socioeconomic status with higher incidence of depression. It also confirms studies done in other cultural contexts describing the elevated risk of development of an effective condition, i.e., depression, among people who have a previous psychiatric history. As a result, it emphasizes the importance of these psychosocial factors for developing depression, respectively, the indivisible interplay between “somatic” and “psychological” factors in the manifestation of chronic pain. This understanding makes obvious that management of chronic pain necessarily requires addressing the emotional and cognitive components of the pain experience and not preferentially the perceptual ones as it happens so often in clinical practice. Only then, the authors’ appeal for multidisciplinary management will result in management that goes beyond the nominal tokenistic practices. A real multidisciplinary and interdisciplinary approach requires integration and coordination of the skills of the various health-care professionals to address chronic pain comprehensively.[6]

This study also raises questions, which require further studies in this field. These include more comprehensive studies regarding the assessment of these factors on a transcultural level as many of the tools used are not specifically standardized for particular cultural groups. The cultural inferences on mental health issues are well recognized, and the pitfalls of transferring instruments from one culture to another have been well documented, although often ignored.[7]

Furthermore, depression is only one of the conditions that are present along with chronic pain and influence its course. In fact, a much more common, and one could dare to say ubiquitous, condition in any ill health, is anxiety. Anxiety in its manifestations often leads to an extreme focus on biomedical symptoms and diseases, which in its own right, further adversely affects chronic pain.[8] This of course also requires further studies with a particular emphasis and attention on cultural factors, but also involving some more universal factors such as “cyberchondria” or the “Dr Google phenomenon.”[9]

We welcome and recommend this paper, notwithstanding certain limitations, clearly identified by the authors. We value this study not only for what it gives us now but also appreciate it for its potential to generate further research in the “complex experience” of chronic pain, addressing not only its perceptual side but also reaching for the emotional-cognitive dimensions and ultimately, human meaning and significance.