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164]

Original Article

Prevalence of depression and its association with

sociodemographic factors in patients with chronic pain:
A cross‑sectional study in a tertiary care hospital in
Saudi Arabia
ABSTRACT
Introduction: Mental health issues, especially depression, are common in chronic pain patients. Depression affects these
patients negatively and could lead to poor control of their pain. Some risk factors for both chronic pain and depression are
known and need to be targeted as part of the management in a multidisciplinary approach. This study was conducted to
estimate the prevalence of depression among chronic pain patients attending a pain clinic and to explore the association
between depression in chronic pain patients and other factors such as sociodemographic features, number of pain sites,
severity of pain, and types of pain.
Methods: This is a cross‑sectional study that carried out in a chronic pain clinic in a tertiary care hospital in Riyadh, Saudi Arabia
(King Faisal Specialist Hospital and Research Centre). All chronic pain patients including cancer‑related pain, apart from acute
pain patients and children, were eligible to participate in the study. Association between depression and sociodemographic
factors was assessed with univariate and multivariate methods. Main outcome measures were the prevalence of depression
in chronic pain patients using the Patient Health Questionnaire‑9 (PHQ‑9) and the association with sociodemographic factors.
Results: A total of 200 chronic pain patients (128 females [64%]) participated in the study. The prevalence of depression was
71% (95% confidence interval: 64.7–77.3) based on the PHQ‑9 diagnostic criteria using a cutoff point of >5. Among those
patients who were depressed, 9 (4.5%) had severe depression as compared to 31 (15.5%), 41 (20.5%), and 61 (30.5%)
who had moderately severe, moderate, and mild depression, respectively. Depression (scored at the cutoff point of 5) in
chronic pain patients was significantly associated with age, financial status, medical history of depression, and pain severity.
Conclusion: Depression is common among chronic pain patients with several risk factors aggravating its presentation. Due
to their increased risk of depression, psychiatric counseling that offers mental health assistance should be prioritized and
made available as a multidisciplinary approach for the treatment of chronic pain patients.

Key words: Chronic pain; depression; mental health disorders; perceived health questionnaire; sociodemographic factors

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How to cite this article: Al-Maharbi S, Abolkhair AB, Al Ghamdi H,

Haddara M, Tolba Y, El Kabbani A, et al. Prevalence of depression and
DOI:
its association with sociodemographic factors in patients with chronic
10.4103/sja.SJA_771_17 pain: A cross-sectional study in a tertiary care hospital in Saudi Arabia.
Saudi J Anaesth 2018;12:419-25.

Sameeh Al-Maharbi1,2, Abdullah Bakr Abolkhair1,2, Hani Al Ghamdi1,2, Mamdouh Haddara1,2,

Yasser Tolba1,2, Ahmed El Kabbani3, Adwa Al Sadoun2, Evelyn Pangilinan2, Jaya Joy2, Shadi Abu Khait2,
May Wathiq Al-Khudhairy4
Department of Anesthesia, 2King Faisal Specialist Hospital and Research Centre, 3Al Faisal University, 4Riyadh Colleges of Dentistry
1

and Pharmacy, Riyadh, Saudi Arabia

Address for correspondence: Dr. Abdullah Bakr Abolkhair, Department of Anesthesia, King Faisal Specialist Hospital and Research Centre,
AC 11211, MBC 22, PO Box 3354, Riyadh, Saudi Arabia. E‑mail: [email protected]

© 2018 Saudi Journal of Anesthesia | Published by Wolters Kluwer - Medknow 419

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Al‑Maharbi, et al.: Chronic pain and depression

Introduction Inclusion/exclusion criteria

The study included a convenient sample of patients having
Chronic pain (also persistent pain) is defined as pain lasting chronic pain attending the chronic pain clinic at KFSH
for >3 months. Prevalence estimates for chronic pain range and RC. The study excluded patients with pain of <6 months,
from 9% to 33%.[1‑3] Mental health disorders commonly admitted patients, and children.
occur in patients with chronic pain. The reported 12‑month
prevalence rates in population‑based samples range anywhere Ethical statement
from 7% to 28% for depression, 4% to 17% for anxiety, and 0.8% The study was approved by the Institutional Review Board
to 5% for substance abuse disorders.[2‑4] Other studies have Ethics Committee at the Research Centre in KFSH and RC
shown that the prevalence of depression in patients with pain in October 2015 (Project number 2151179). Verbal consent
varies from 14% to 66% dependant on samples in retirement was attained from all study participants in lieu of respect and
homes, primary care settings, pain clinic, and community appreciation for their time in completing the questionnaire.
samples.[2,5‑8] One study mentioned that chronic pain increases The participants were provided with a written information
the risk of depression by 2‑ to‑5‑fold.[9] sheet attached to the questionnaire that explained the
importance and aims of the study.
However, the studies assessing chronic pain are inconsistent
Data collection
in terms of duration of pain considered as chronic. Few
The chronic pain questionnaire that was used included
studies have mentioned pain duration while others have
duration, severity, types, and sites of pain. Other
considered pain lasting for longer than 1 month as chronic.
sociodemographic factors in the questionnaire were included
Regardless of these limitations, some studies have assessed
to screen for risk factors. The Patient Health Questionnaire‑9
the risk factors in patients with co‑occurring pain and
(PHQ‑9) was used as a screening tool for depression. All the
depression. It was found that pain occurred more commonly
questionnaires were available in both English and Arabic
in females, unemployed, and those with lower education
language. The questionnaires were distributed to the study
levels.[10‑12] Common risk factors for depression included
participants attending their regular clinic appointment at the
gender, income, and education.[10‑12] Patients with two or
pain clinic. Those participants facing difficulty in completing
more pain complaints were far more likely to be depressed
the questionnaires due to illiteracy were aided by a single
than those with a single pain complaint. The greater the
investigator who assisted them by reading the questionnaire
number of pain conditions reported, the more likely that
clearly, ensuring their comprehension, and recording their
major depression was present rather than pain severity or
respective answers. The instructions were given clearly to
pain persistence.[13] There is a lack of data pertaining to ensure that study participants understood the contents of
pain, particularly in the Kingdom of Saudi Arabia where no the questionnaires. All questionnaires were given a study
previous studies have explored the relation of chronic pain number to ensure anonymity of the recruited participants;
to depression. thus, all measures were taken to keep the information
confidential.
Within the above‑mentioned background, more research
should be dedicated to explore the magnitude and the Instruments
associated factors, contributing to emotional disorders such Chronic pain questionnaire
as depression among chronic pain patients. This study aimed This questionnaire was designed based on the study by
to explore the prevalence of depression among chronic pain Mossey and Gallagher on chronic pain and depression in
patients attending the pain clinic. The study also examined retirement communities as well as the study by Howe et al.[6,9]
the association between depression in chronic pain patients To ensure that a participant had chronic pain for this study,
and other factors such as sociodemographic features, number he or she was asked two questions: “Do you currently have
of pain sites, severity, and types of pain. pain?” and “How long have you had the pain?” If the patient
answered, “yes” to the first question and “6 months or longer
Methods “to the following question, then the patient was considered
eligible in participating in the study. A duration of 6 months
Study design or longer was used as the cutoff for chronic pain based on the
The cross‑sectional study was conducted over a period of recommendation of the key articles which mentioned similar
6 months from November 2015 to April 2016 at King Faisal criteria.[6,9] The type of pain, location, as well as severity of
Specialist Hospital and Research Centre (KFSH and RC) in the pain were all included in the questionnaire. The latter
Riyadh, Saudi Arabia. was determined via use of the universal pain assessment

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Al‑Maharbi, et al.: Chronic pain and depression

tool  (mild  [1–2], moderate  [3–6], and severe  [≥7]), which Results
was attached with the questionnaire.
Prevalence of depression in chronic pain
Sociodemographic data A total of 200 chronic pain patients participated in the
From previous studies, a concoction of structured study. There were 72 males (36%) and 128 females (64%).
sociodemographic factors mostly associated with depression The prevalence of depression was 71% (95% confidence
were included in our study.[10‑13] These included age, gender, interval [CI]: 64.7–77.3) based on the PHQ‑9 diagnostic
marital status, level of education, work status, financial criteria using a cutoff point of >5. [Table 1]. Most of
status, family relations, past and family history of depression, chronic pain patents participating in the study were
and history of chronic disease. middle‑aged (40–59 years, n = 88; 44%) followed by
elderly (≥60 years, n = 65; 32.5%). Majority were married
Patient health questionnaire‑9 114 (75.5%) and almost half 81 (57%) had low education
The PHQ‑9 is a multipurpose instrument that has been level (high school or less). A total of 104 (52%) of chronic
validated and found reliable to be used for screening, pain patients reported severe pain (≥7 in universal pain
diagnosing, monitoring, and measuring the severity of assessment tool), 93 (46.5%) had moderate pain (3–6), and
depression. It incorporates the Diagnostic and Statistical 3 (1.5%) had mild pain (1–2) [Table 1].
Manual of Mental Disorders, Fourth Edition Text Revision
depression diagnostic criteria with other leading major Prevalence, types, and sites of chronic pain
depressive symptoms into a brief self‑report tool. The Spine problems (n = 139; 69.5%) accounted for the most
frequency of symptoms is rated which factors into the scoring common followed by osteoarthritis (n = 84; 42%) and
severity index. PHQ‑9 is brief and useful in clinical practice.[14] neuropathic pain (n = 67; 33.5%) [Table 2]. The most common
A PHQ‑9 score ≥10 has a sensitivity and specificity of 88% for site was the lower back (n = 139; 69.5%) followed by the
major depression.[15‑17] The calculated Cronbach’s alpha was knee (n = 84; 42) [Table 2]. However, when lower and upper
0.76, which showed an acceptable reliability level of the used back pain reports were combined creating a back‑pain
questionnaire. In our study, we also used the Arabic Version category, 85% of the study participants (n = 170) had chronic
of the PHQ‑9, which has been validated and found reliable pain reported as back pain.
to be used in an Arabic‑speaking population.[18]
Risk factors for depression in chronic pain
Depression scores were categorized based on PHQ‑9 into Univariate logistic analysis showed a significant association
five categories: no depression (0–4), mild depression (5–9), between depression and risk factors including age (P = 0.0045),
moderate depression (10–14), moderate–severe depression marital status (P = 0.0234), financial status (P = 0.0171),
(15–19), and severe depression (20–27).[19] medical history of depression (P = 0.0092), and pain severity
(P = 0.0138) [Table 3].
Statistical methods
Descriptive statistics for the continuous variables were However, multivariate logistic analysis showed [Table 4]
reported as mean ± standard deviation and categorical that marital status was not significantly associated with
variables were summarized as frequencies and percentages. All depression (P = 0.074). Hence, other factors including age,
the categorical variables were compared using Chi‑square test. financial status, medical history of depression, and pain
Univariate and multivariate logistic regression analysis was severity were significantly associated with depression.
used to define which demographic and clinical characteristics
were most likely to be associated with depression. All the Age had a statistically significant effect on depression, where
statistical analysis of this cross‑sectional study was done middle‑aged participants (n = 69, 78.4%) were more likely
using the software package SAS version 9.4 (SAS Institute to have depression than their younger or older age group
Inc., Cary, NC, USA). The level of statistical significance was counterparts (odds ratio [OR]: 0.529, 95% CI: 0.341–0.821;
set at P < 0.05. P  = 0.0033). A significant number of patients 31 (88.6%)

Table 1: Distribution of chronic pain patients according to depression severity and pain severity
Depression severity No Mild (5-9) Moderate (10-14) Moderately Severe Total patients
depression (<4) severe (15-19) (20-27) with depression
Number of patients, n (%) 58 (29) 61 (30.5) 41 (20.5) 31 (15.5) 9 (4.5) 142 (71)
Pain severity Mild pain (1-2) Moderate pain (3-6) Severe pain  (≥7)
Number of patients, n (%) 3 (1.5) 93 (46.5) 104 (52)

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Al‑Maharbi, et al.: Chronic pain and depression

Table 2: Prevalence of chronic pain types and by chronic pain which concurred to being five times more likely to have
site depression than those who did not report a medical history
Prevalence n (%) of depression 111 (66.8%) (OR: 5.12, 95% CI: 1.50–17.49;
Chronic pain types P = 0.0044). Regarding severity of pain and its association
Osteoarthritis 84 (42)
with depression, results showed that patients who had severe
Spine or disc problems 139 (69.5)
pain were more likely to be depressed 85 (81.7%) than those
Neuropathic pain 67 (33.5)
Autoimmune syndromes 6 (3) who had mild to moderate pain (2 [66.7%] and 55 [59.1%],
Fibromyalgia 7 (3.5) respectively) (OR: 1.22, 95% CI: 1.036–1.44; P = 0.001).
Abdominal conditions 16 (8)
Cancer 9 (4.5) Discussion
Blood‑related disorders 3.5 (7)
Skin diseases 2.5 (5) The prevalence of depression observed in our study was
Other 16 (8)
consistent with a previous study[20] but not comparable to the
Unknown 10 (5)
majority of studies.[2,5,6] This may be explained by the use of
Chronic pain site
Lower back 139 (69.5) different screening tools, environmental factors, population
Knee 84 (42) sample, as well as the lower cutoff limit of 5 used in our
Hip 62 (31) study versus a higher cutoff limit of 10 and more used in
Ankle/foot 42 (21) different populations to diagnose depression.[21‑23] Choi et al.
Shoulder 66 (33) have championed the use of PHQ‑9 as a screening tool for
Neck 72 (36) depression with cutoffs of 5 and have validated, studied, and
Wrist or hand 11 (5.5)
compared with other screening tools in pain patients with
Upper back 31 (15.5)
fair enough sensitivity and specificity.[19] To reiterate, this
Elbow 12 (6)
Leg 43 (21.5) variation in prevalence of depression can be explained due
Head 20 (10) to differences in culture, health‑care system, and population,
Abdomen/pelvis 24 (12) in addition to the tools used in the study. Other reasons
Other 14 (7) to consider are the heterogeneous sample of chronic pain
patients used in our study versus other studies published
Table 3: Univariate logistic regression analysis in the literature that target a specific pain problem such as
sociodemographic factor back pain.[24,25] Chronic pain may have an effect on mood as
OR (95% CI) P it is a chronic stressor that frustrates its target. It has been
Age 0.53 (0.341-0.821) 0.0045* reported that approximately 90% of patients with chronic
Gender 0.818 (0.429-1.560) 0.5419 pain develop depressive symptoms at the same time or after
Marital status 0.724 (0.548-0.957) 0.0234*
the chronic pain diagnosis.[26] In the study by Magni et al. on
Education level 0.964 (0.708-1.313) 0.8160
the general population in the United States, they found that
Financial status 3.769 (1.27-11.22) 0.0171*
Family history relations 3.306 (0.73-14.94) 0.1202 around 18% of those diagnosed with chronic pain ultimately
Medical history of depression 5.120 (1.50-17.49) 0.0092* developed depressive symptoms as compared to a mere 8%
Family history of depression 1.556 (0.633-3.829) 0.3355 of the population not having chronic pain.[10] However, the
History of chronic disease 1.035 (0.559-1.919) 0.9121 temporal relationship and causality between chronic pain and
Pain types 1.322 (0.717-2.439) 0.3714 depression were not investigated in the current study, and
Pain sites 1.551 (0.76-3.15) 0.2248 this relation cannot be made by the cross‑sectional study.
Pain severity 1.213 (1.04-1.41) 0.0138*
*Refers to significant P values. OR: Odds ratio; CI: Confidence interval
Most of the chronic pain conditions mentioned here were
musculoskeletal, predominantly including the lower back,
who were unsatisfied with their financial status, reported
knee, hip, and ankle/foot in consistence with the published
depressive symptoms compared to 111 (67.2%) of those who
literature.[7] These pain sites that have been reported by the
were satisfied (OR: 3.77, 95% CI: 1.27–11.22; P = 0.01). Hence,
participants were typically associated with less mobility,
financially discontented participants were more than three which in turn affects their physiologic well‑being and their
times as likely to elicit signs of depression as compared to supply of endorphins.
their financially content chronic pain‑matched participants.
Prevalence of depression in participants with a positive A number of sociodemographic risk factors in chronic pain
medical history of depression reached to almost 31 (91.2%) patients were investigated as correlates of comorbid chronic

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Al‑Maharbi, et al.: Chronic pain and depression

Table 4: Multivariate logistic regression and cross tabling pain showed that patients with comorbid pain and depression
analysis of sociodemographic risk factors in chronic pain were younger than patients with pain and no depression.[24]
patients and its association with depression
The reason could be that these middle agers had an age
Sociodemographic Prevalence of OR (95% CI) P range of 40–59 years of age and are still engrossed with
factor depression (%) (significant)
Age
family, at the peak of their work career, and amid plenty of
18-39 37 (78.7) 0.529 (0.34-0.82) 0.0033 other life stressors which might make them more vulnerable
40-59 69 (78.4) to depression when experiencing unremitting pain that
≥60 36 (55.3) becomes chronic. Both the studies by Currie and Wang[24] and
Marital status Kessler et al.[26] were published nearly a decade ago and their
Married 114 (75.5) 0.797 (0.59- 0.074 age group of child‑bearing years’ participants were younger
Unmarried 9 (56.3) 1.081)
than todays. Nowadays, people are investing more in their
Divorced 6 (66.7)
education and starting their families at an older age.
Widow 13 (54.2)
Financial status 31 (88.6) 3.77 (1.27-11.22) 0.01
discontent In addition, low socioeconomic status is well known to
Medical history of 31 (91.2) 5.12 (1.50-17.49) 0.0044 be associated with depression,[28] possibly because of the
depression
financial strain and burden. A person experiencing pain
Pain severity
and depression could find it more challenging to keep
Mild 2 (66.7) 1.22 (1.036- 0.001
Moderate 55 (59.1) 1.44) their job due to their volatile temperament, making one’s
Severe 85 (81.7) socioeconomic status, depression, and pain a vicious cycle.
OR: Odds ratio; CI: Confidence interval Another risk factors for depression, emphasized in the
current study, was the medical history of depression. The
pain and depression. Surprisingly in this study, gender didn’t risk of depression recurrence was studied recently in chronic
have any effect on the risk of depression. This is in contrast noncancer pain patients who were on opioids and compared
to a study conducted in Pakistan where those having chronic with those who were not on opioids, which found a higher
low back pain were at a higher risk of depression and more risk of depression recurrence, especially in those who were
so in females.[27] on opioids.[29] This elaborates the importance of obtaining
a good history of perceived depression in any medical
Univariate analysis showed a positive association between consultation for chronic pain patients as opioids are more
marital status (P = 0.0234) and risk of depression. This is likely to be prescribed in those with pain, especially at the
of interest since it is well known that there is congruence pain clinic when all other avenues have been explored.
between male patients and their spouses as opposed
to female patients and their spouses, where there is In this study, depression in chronic pain patients was not
incongruence. That is, the wife of a male patient is more found to be related with any specific type of pain. The type
sympathetic to her husband’s needs and perceptive of even of pain or the site was not related to depression. This is
his nonverbal behavior. Sadly, this is not true in the case of unusual as it would make sense that activity‑restricting pain
husbands of female patients. This may indeed be the reason would increase the risk of depression.[30] It could be that
for the significant association found in this study between chronic pain generally affects social activities, which might
chronic pain and depression with marital status as a risk lead to solitude and a state of “unhappiness.” Pain severity
factor. Keeping in mind that the majority of the participants was another associated risk factor for depression found in our
were females,[5] however, this was not so on the multivariate study but was not related to depression in one other study.[7]
analysis.
There are some limitations to this research. Although PHQ‑9
In this study, only four risk factors were significantly has been proven as a reliable screening tool, it should be used
associated with depression which were middle‑aged group in conjunction with a clinical assessment to provide a better
in terms of age, discontented financial status, medical history management of the patients’ condition.[31]
of depression, and those reporting severe pain
There is a need to have a multidisciplinary approach for
Middle‑aged participants in our study were more likely to detecting and managing depression in chronic pain patients
experience comorbid chronic pain and depression than other in hospitals. In addition, the results suggest the need for
age groups. This contradicts Kessler et al. “depression tends mental health promotion activities targeting chronic pain
to decrease with age.”[26] Similarly, a study of chronic back patients.
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Al‑Maharbi, et al.: Chronic pain and depression

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