The role of catastrophizing in the pain–depression relationship
-
Silje Endresen Reme
In this issue of the Scandinavian Journal of Pain, Wood and coworkers [1] investigate the mediating role of catastrophizing in the relationship between changes in pain intensity and changes in depression in older adults. The study has a prospective design, thereby strengthening the same findings that were previously found by the authors in a cross-sectional design. The article addresses a fairly well studied topic, but in an understudied population. Few previous studies have specifically targeted the elderly population when trying to understand chronic pain mechanisms, despite the fact that there appears to be a difference between younger and older adults when it comes to the prevalence and characterization of comorbid depression in chronic pain [2,3]. The study therefore provides much needed knowledge about a topic with obvious clinical implications. More insight into the mechanisms of pain chronification could contribute to intervention development by guiding which elements to target specifically in treatment.
1 The unknown nature of the pain-depression relationship
It has long been known that depression commonly co-occur in patients suffering from chronic pain, but the nature of this relationship is still largely unknown [4]. When it comes to directionality and mediating variables, the scarce literature in study populations of older adults points in different directions. While one study suggests a direct relationship between pain and depression in older adults [5], another study suggests that cognitive-behavioural variables, such as catastrophizing, play a significant role in differentiating between older pain patients with and without comorbid depression [6]. The need for more studies, with robust designs, is therefore much needed. The current study by Wood et al. takes us one step further by replicating their own previous findings with a stronger set of longitudinal data. Still, their current study suffers some of the same shortcomings as their previous study. In fact, these shortcomings are shared by most studies within this particular area, and concern the lack of intermediate measurement points demonstrating that the change in the proposed mediator precedes the outcome in time.
2 What is mediation?
Mediation is a hypothesized causal chain in which one independent variable X affects a mediating variable Y, which in turn, affects the outcome variable Z. If the intervening mediator Y explains the correlation betweenX andZ, we are talking about a full mediational model [7]. However, in orderto establish a mediational relationship and make any firm conclusions about causality or directionality, the mediator must precede the outcome in time [8]. In the study by Wood et al., this is not the case. Their dependent and mediating variables are all measured at the same two time points, thereby making it impossible to ascertain the role of catastrophizing as a mediator of the pain-depression relationship. This is, indeed, a limitation also acknowledged by the authors, who themselves suggests that future studies should aim to overcome this shortcoming in their study designs in order to disentangle the causal nature of catastrophizing in the pain-depression relationship.
By learning more about potential mediators of change, better and more targeted interventions can be developed and assessed. If, in fact, catastrophizing is a significant mediator of the relationship between pain intensity and depression, this is important to know when intervening on the patient group of elderly pain patients. Pain intensity is in itself often difficult to modify directly in patients suffering from chronic pain, but catastrophizing is a modifiable risk factor that could easily be targeted in treatment. Whether a reduction in catastrophizing could cause a reduction in comorbid depression remains to be seen in this patient group, but the current finding of catastrophizing as a possible mediator of the relationship is promising.
3 Chronic pain and ageing
With the continuous and rapid increase in people living to experience an old age, chronic pain and depression will become increasingly prevalent and important to address in this particular population. Living with pain bears consequences for both functioning and overall life quality, which again highlights the need for effective and feasible interventions. Older adults are, as previously mentioned, an understudied population when it comes to chronic pain, and so is also true when it comes to the literature on effective pain management interventions. There is, however, increasing evidence that cognitive and behavioural interventions are effective and helpful in the elderly, at least on self-reported pain experience [9]. And the lack of convincing effects on depression and medication use only serves to strengthen the rationale for the study aims provided by Wood et al., namely to investigate the mediators of the relationship between pain intensity and depressed mood.
In conclusion, the study by Wood et al. addresses an important topic in an understudied population, namely the role of catastrophizing as a possible mediator of the pain-depression relationship in elderly adults. As the authors themselves emphasize, future studies should continue to pursue the causal nature of catastrophizing in the pain-depression relationship, ideally with stronger study designs. More specifically, such studies should assess, on multiple occasions during treatment, both symptoms and proposed mediator (s) in order to establish with more certainty the presence of cognitive-behavioural variables, e.g. catastrophizing, as mediators of change in CBT treatment programmes.
DOI of refers to article: http://dx.doi.org/10.1016/j.sjpain.2015.12.009.
References
[1] Wood BM, Nicholas M, Asghari A, Blyth F, Gibson SJ. The mediating role of catastrophizing in the relationship between pain intensity and depressed mood in older adults with persistent pain: a longitudinal analysis. Scand J Pain 2016;11:157–62.Search in Google Scholar
[2] Corran TM, Farrell MJ, Helme RD, Gibson SJ. The classification of patients with chronic pain: age as a contributing factor. Clin J Pain 1997;13:207–14.Search in Google Scholar
[3] Riley JL, Wade JB, Robinson ME, Price DD. The stages of pain processing across the adult lifespan. J Pain 2000;1:162–70.Search in Google Scholar
[4] Fishbain DA, Cutler R, Rosomoff HL, Rosomoff RS. Chronic pain-associated depression: antecedent or consequence of chronic pain? A review. Clin J Pain 1997;13:116–37.Search in Google Scholar
[5] Turk DC, Okifuji A, Scharff L. Chronic pain and depression: role of perceived impact and perceived control in different age cohorts. Pain 1995;61: 93–101.Search in Google Scholar
[6] Lopez-Lopez A, Montorio I, Izal M, Velasco L. The role of psychological variables in explaining depression in older people with chronic pain. Aging Ment Health 2008;12:735–45.Search in Google Scholar
[7] Kraemer HC, Wilson GT, Fairburn CG, Agras WS. Mediators and moderators of treatment effects in randomized clinical trials. Arch Gen Psychiatry 2002;59:877–83.Search in Google Scholar
[8] Kazdin AE. Mediators and mechanisms of change in psychotherapy research. Annu Rev Clin Psychol 2007;3:1–27.Search in Google Scholar
[9] Lunde L-H, Nordhus IH, Pallesen S. The effectiveness of cognitive and behavioural treatment of chronic pain in the elderly: a quantitative review. J Clin Psychol Med Settings 2009;16:254–62.Search in Google Scholar
© 2016 Scandinavian Association for the Study of Pain
Articles in the same Issue
- Editorial comment
- Psychophysiological effects of threatening a rubber hand that is perceptually embodied in healthy human subjects
- Original experimental
- A preliminary investigation into psychophysiological effects of threatening a perceptually embodied rubber hand in healthy human participants
- Editorial comment
- Analysis of C-reactive protein (CRP) levels in pain patients – Can biomarker studies lead to better understanding of the pathophysiology of pain?
- Clinical pain research
- Serum C-reactive protein levels predict regional brain responses to noxious cold stimulation of the hand in chronic whiplash associated disorders
- Editorial comment
- Importance of early diagnosis of complex regional pain syndrome (CRPS-1 and CRPS-2): Delayed diagnosis of CRPS is a major problem
- Clinical pain research
- Delayed diagnosis and worsening of pain following orthopedic surgery in patients with complex regional pain syndrome (CRPS)
- Editorial comment
- Associative learning mechanisms may trigger increased burden of chronic pain; unlearning and extinguishing learned maladaptive responses should help chronic pain patients
- Original experimental
- When touch predicts pain: predictive tactile cues modulate perceived intensity of painful stimulation independent of expectancy
- Editorial comment
- Low back pain among nurses: Common cause of lost days at work and contributing to the worldwide shortage of nurses
- Observational study
- Pain-related factors associated with lost work days in nurses with low back pain: A cross-sectional study
- Editorial comment
- Assessment of persistent pelvic pain after hysterectomy: Neuropathic or nociceptive?
- Clinical pain research
- Characterization of persistent pain after hysterectomy based on gynaecological and sensory examination
- Editorial comment
- Transmucosal fentanyl for severe cancer pain: Nasal mucosa superior to oral mucosa?
- Original experimental
- Facilitation of accurate and effective radiation therapy using fentanyl pectin nasal spray (FPNS) to reduce incidental breakthrough pain due to procedure positioning
- Editorial comment
- Why do we have opioid-receptors in peripheral tissues? Not for relief of pain by opioids
- Clinical pain research
- Peripheral morphine reduces acute pain in inflamed tissue after third molar extraction: A double-blind, randomized, active-controlled clinical trial
- Editorial comment
- Chronic pain and psychological distress among long-term social assistance recipients – An intolerable burden on those on the lowest steps of the socioeconomic ladder
- Clinical pain research
- The co-occurrence of chronic pain and psychological distress and its associations with salient socio-demographic characteristics among long-term social assistance recipients in Norway
- Editorial comment
- Fifty years on the Visual Analogue Scale (VAS) for pain-intensity is still good for acute pain. But multidimensional assessment is needed for chronic pain
- Clinical pain research
- Patient reported outcome measures of pain intensity: Do they tell us what we need to know?
- Editorial comment
- Postoperative pain documentation 30 years after
- Topical review
- Postoperative pain documentation in a hospital setting: A topical review
- Editorial comment
- Aspects of pain attitudes and pain beliefs in children: Clinical importance and validity
- Observational study
- The Survey of Pain Attitudes: A revised version of its pediatric form
- Editorial comment
- The role of social anxiety in chronic pain and the return-to-work process
- Clinical pain research
- Social Anxiety, Pain Catastrophizing and Return-To-Work Self-Efficacy in chronic pain: a cross-sectional study
- Editorial comment
- Advances in understanding and treatment of opioid-induced-bowel-dysfunction, opioid-induced-constipation in particular Nordic recommendations based on multi-specialist input
- Topical review
- Definition, diagnosis and treatment strategies for opioid-induced bowel dysfunction–Recommendations of the Nordic Working Group
- Observational study
- Opioid-induced constipation, use of laxatives, and health-related quality of life
- Editorial comment
- Migraine headache and bipolar disorders: Common comorbidities
- Systematic review
- Migraine headache and bipolar disorder comorbidity: A systematic review of the literature and clinical implications
- Editorial comment
- The role of catastrophizing in the pain–depression relationship
- Clinical pain research
- The mediating role of catastrophizing in the relationship between pain intensity and depressed mood in older adults with persistent pain: A longitudinal analysis
- Announcement
- May 26-27, 2016 Scandinavian Association for the Study of Pain, Reykjavik, Iceland May 25, 2016 PhD course
Articles in the same Issue
- Editorial comment
- Psychophysiological effects of threatening a rubber hand that is perceptually embodied in healthy human subjects
- Original experimental
- A preliminary investigation into psychophysiological effects of threatening a perceptually embodied rubber hand in healthy human participants
- Editorial comment
- Analysis of C-reactive protein (CRP) levels in pain patients – Can biomarker studies lead to better understanding of the pathophysiology of pain?
- Clinical pain research
- Serum C-reactive protein levels predict regional brain responses to noxious cold stimulation of the hand in chronic whiplash associated disorders
- Editorial comment
- Importance of early diagnosis of complex regional pain syndrome (CRPS-1 and CRPS-2): Delayed diagnosis of CRPS is a major problem
- Clinical pain research
- Delayed diagnosis and worsening of pain following orthopedic surgery in patients with complex regional pain syndrome (CRPS)
- Editorial comment
- Associative learning mechanisms may trigger increased burden of chronic pain; unlearning and extinguishing learned maladaptive responses should help chronic pain patients
- Original experimental
- When touch predicts pain: predictive tactile cues modulate perceived intensity of painful stimulation independent of expectancy
- Editorial comment
- Low back pain among nurses: Common cause of lost days at work and contributing to the worldwide shortage of nurses
- Observational study
- Pain-related factors associated with lost work days in nurses with low back pain: A cross-sectional study
- Editorial comment
- Assessment of persistent pelvic pain after hysterectomy: Neuropathic or nociceptive?
- Clinical pain research
- Characterization of persistent pain after hysterectomy based on gynaecological and sensory examination
- Editorial comment
- Transmucosal fentanyl for severe cancer pain: Nasal mucosa superior to oral mucosa?
- Original experimental
- Facilitation of accurate and effective radiation therapy using fentanyl pectin nasal spray (FPNS) to reduce incidental breakthrough pain due to procedure positioning
- Editorial comment
- Why do we have opioid-receptors in peripheral tissues? Not for relief of pain by opioids
- Clinical pain research
- Peripheral morphine reduces acute pain in inflamed tissue after third molar extraction: A double-blind, randomized, active-controlled clinical trial
- Editorial comment
- Chronic pain and psychological distress among long-term social assistance recipients – An intolerable burden on those on the lowest steps of the socioeconomic ladder
- Clinical pain research
- The co-occurrence of chronic pain and psychological distress and its associations with salient socio-demographic characteristics among long-term social assistance recipients in Norway
- Editorial comment
- Fifty years on the Visual Analogue Scale (VAS) for pain-intensity is still good for acute pain. But multidimensional assessment is needed for chronic pain
- Clinical pain research
- Patient reported outcome measures of pain intensity: Do they tell us what we need to know?
- Editorial comment
- Postoperative pain documentation 30 years after
- Topical review
- Postoperative pain documentation in a hospital setting: A topical review
- Editorial comment
- Aspects of pain attitudes and pain beliefs in children: Clinical importance and validity
- Observational study
- The Survey of Pain Attitudes: A revised version of its pediatric form
- Editorial comment
- The role of social anxiety in chronic pain and the return-to-work process
- Clinical pain research
- Social Anxiety, Pain Catastrophizing and Return-To-Work Self-Efficacy in chronic pain: a cross-sectional study
- Editorial comment
- Advances in understanding and treatment of opioid-induced-bowel-dysfunction, opioid-induced-constipation in particular Nordic recommendations based on multi-specialist input
- Topical review
- Definition, diagnosis and treatment strategies for opioid-induced bowel dysfunction–Recommendations of the Nordic Working Group
- Observational study
- Opioid-induced constipation, use of laxatives, and health-related quality of life
- Editorial comment
- Migraine headache and bipolar disorders: Common comorbidities
- Systematic review
- Migraine headache and bipolar disorder comorbidity: A systematic review of the literature and clinical implications
- Editorial comment
- The role of catastrophizing in the pain–depression relationship
- Clinical pain research
- The mediating role of catastrophizing in the relationship between pain intensity and depressed mood in older adults with persistent pain: A longitudinal analysis
- Announcement
- May 26-27, 2016 Scandinavian Association for the Study of Pain, Reykjavik, Iceland May 25, 2016 PhD course
