Anxiety and depression in chronic back pain

Marc Darrow, MD, JD

Research has recognized that the anxiety that low back pain patients suffer from was influenced by the intensity of the pain they had, the level of disability it was causing level, and the  subsequent feeling of helplessness that back pain can spiral the patient into.  These factors were summarized in a November 2022 paper (1)  which suggested: “Quality of life is a very important outcome of low back pain patients, which is affected by multiple dimensions, primarily mobility, followed by anxiety or depression. . . The patients who have chronic musculoskeletal pain combined with psychosomatic factors (anxiety and depression) were correlated with more severe pain and greater daily activities (a greater need to work or be a caregiver themselves for example) than those who experienced pain alone. Previous studies . . . have shown that chronic low back pain patients with psychological disorders (mood and/or anxiety disorders) are highly associated with more severe pain and disability and dysfunctional management.”

These findings are considered controversial as other research points out that it is not clear whether anxiety and depression cause or worsen back pain. Nevertheless, patients can suffer from back pain, anxiety and depression at the same time. This is pointed out in the conclusion of the above paper.

“Although the relationship between symptoms of low back pain and anxiety is very weak in addition to the quality of life and quality of sleep, the problem still commonly exists in patients with low back pain; in view of this, psychotherapy should be an integral part of a multidisciplinary rehabilitation training strategies, psychological consultant for patients with anxiety, and other negative emotions control strategy of education to improve their psychological state.”

A December 2022 paper (2) writes: “Across virtually all orthopedic subspecialties, symptoms of depression, anxiety, and unhelpful thinking are associated with worse patient-reported satisfaction with orthopedic treatment and increased postoperative complications. In the orthopedic community, there is growing interest in patients’ mental health in the orthopedic care setting, but addressing mental health is still not a focus of orthopedic clinical training. In contrast to the perceptions of some orthopedic clinicians, most patients with orthopedic conditions expressed they would like their mental well-being to be acknowledged, if not addressed, as part of a thoughtful orthopedic care plan.”

A December 2022 paper (3) discusses the accumulating evidence suggesting that mood changes are reported by about one in ten osteoarthritis patients and that inflammation has something to do with it. In this paper the authors describe that about one in five patients with osteoarthritis are diagnosed with depression and or anxiety disorder. Further, “Greater pain scores, joint dysfunction, stiffness, and two or more comorbidities are associated with a higher incidence of depression among osteoarthritis patients.” Osteoarthritis is associated with greater suicidal ideation and suicide attempts. There is a greater risk of developing osteoarthritis-associated dementia. The authors write: “it is evident that there is a tendency for the coupling of the pathologic processes of osteoarthritis and neuropsychiatric disease. A higher prevalence of mood disorders in osteoarthritis patients that experience more pain, suggests chronic pain as the mediating mechanism of pathogenesis. Indeed, chronic pain itself has been shown to promote higher risks of developing depression, anxiety, and dementia.” What is causing this? According to the paper: “molecular and cellular changes in the brain, recognized in the presence of chronic peripheral inflammation.” Chronic-low grade inflammation.


1 Jiang Y, Wang Y, Wang R, Zhang X, Wang X. Differences in pain, disability, and psychological function in low back pain patients with and without anxiety. Frontiers in Physiology. 2022:2328.
2 Cheng AL, Leo AJ, Calfee RP, Dy CJ, Armbrecht MA, Abraham J. What Are Orthopaedic Patients’ and Clinical Team Members’ Perspectives Regarding Whether and How to Address Mental Health in the Orthopaedic Care Setting? A Qualitative Investigation of Patients With Neck or Back Pain. Clinical Orthopaedics and Related Research®. 2022 May 10:10-97.
3 Naumovs V, Groma V, Mednieks J. From Low-Grade Inflammation in Osteoarthritis to Neuropsychiatric Sequelae: A Narrative Review. International Journal of Molecular Sciences. 2022 Dec 16;23(24):16031.


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