The Link Between Depression, Stress, and Back Pain

The CDC states that about 8% of America adults had depression and that it was almost twice as common amongst women as among men. Vague aches and pain are often the presenting symptoms of depression, including chronic joint pain, limb pain, back pain, GI problems, tiredness and sleep disturbances.

Depression is also associated with psychogenic pain - psychological pain without a physiologic cause. Psychogenic pain is not always without a physiologic correlate, it can be related to real pathology. In other words, a depressed person complaining of unbearable back pain might have real lumbar spine pathology and real back pain, the perception of which is made worse by depression. Patients with depression who complain of back pain, should first undergo adequate assessment and treatment for their depression before considering back surgery.

Pain perception is complicated and is clearly affected by the emotional state of the patient. This relationship between emotions and the perception of pain is the basis of a vicious cycle:

1. Pain induces stress and reduces the quality of life, inciting or worsening depression.

2. Depression can lead to perception of pain as more severe.

3. Pain caused by back pathology can lead to increased stress and worsening depression.

The effect of depression is evident in the result of treatment. Antidepressants have the secondary effect of reducing pain levels. Treating depression reduces pain.

Likewise for anti-anxiety medications. Anxietolytics reduce anxiety due to short-term stressors and can reduce the “burden” of pain even when the patient reports that they are still aware of having severe pain.

Surgery, when successful, can dramatically reduce pain. When this happens, patients often reduce or eliminate their need for antidepressant medications.

Reducing pain reduces stress and, if it improves the quality of life, increases the likelihood of enhancing reactive depression. Pain, stress/anxiety, and depression are all part of a vicious cycle. Breaking any portion of this cycle can dramatically improve a patient’s quality of life.

This cycle is particular evident in patients with failed back syndrome. In a study published in the European Spine Journal in 2022, Stanton et al, found that depression was present in upwards of 20% of patients with FBS.

The bottom line is that emotional factors can often complicate the assessment and treatment of low back pain. Treatment of depression can favorably reduce pain levels.