Abstract
Chronic body pain and depression, two major global health concerns, frequently co‐occur and collectively impair individuals' well‐being, compromising their ability to maintain an independent lifestyle and social relationships [1]. A global study of pain prevalence among 52 countries indicated the overall prevalence of pain was estimated to be 27.5% [2], with significant variation across countries (9.9%–50.3%). In China, a study used China Suboptimal Health Survey data showed the prevalence of pain in women was 39.92%, and the prevalence of chronic pain in men was 32.17%, and the prevalence increased with age [3].
In recent years, depression have also attracted attention among public health professionals worldwide. The date published by the Global Burden of Disease Study indicated that depression is now recognized as a leading contributor to disability‐adjusted life years globally, affecting individuals across all age groups [4]. According to data released by the World Health Organization in 2023, approximately 280 million people in the world have depression, with the incidence rate of 3.8% [5]. These diseases make great health risks to populations while creating a crushing economic burden on societies.
The relationship between pain and depression has been recognized for more than 25 years. For example, a systematic review and meta‐analysis of depression and anxiety in chronic pain patients revealed that approximately 40% of adults exhibit significant depressive symptoms [6]. Depression and chronic pain co‐occur so frequently that they have been labeled as the depression‐pain syndrome [7] or depression‐pain dyad [8], which may share biological pathways and neurotransmitters [9].
Despite previous research that documents the connection between pain and depression, further research is still necessary to elucidate the causal links between pain and depression. Most of the previous studies on the association between pain and depression used cross‐sectional data [10]. Furthermore, there is limited longitudinal research examining the association between pain and depressive symptoms among Chinese adults, an important population at risk for increased pain complaints and psychiatric morbidity [3].
In summary, the present study aimed to clarify the longitudinal relationship between pain and depressive symptoms in Chinese adults using data collected from the China Health and Retirement Longitudinal Study (CHARLS), a national random sample of the Chinese population.
CHARLS is a biennial nationwide longitudinal study for Chinese middle‐aged and older population. 17,422 residents age 45 years and older were interviewed. At visit one in 2011 and visit five in 2020, blood samples were collected. Details of CHARLS were published previously [11]. The surveys included information regarding demographic characteristics, biomarker date, health status and functioning information, physical examinations, diagnostic date, etc.
In this study, 17,422 individuals with body pain information at visit one were included. The exclusion criteria were as follows: (1) No CESD‐10 score at visit five (n = 6002); (2) Having depressive symptoms at visit 1 (n = 3809); (3) Having memory‐related diseases, emotional problems, nervous problems or psychiatric problems at visit one (n = 155); Abnormal or missing data for depression symptoms, pain severity, memory‐related diseases, emotional problems, nervous problems or psychiatric problems and covariates (n = 1110). Finally, a total of 6346 individuals were included in this study (Figure S1). CHARLS was approved by the Ethical Review Committee of Peking University (IRB00001052–11,015), and all participants signed informed consent forms.
Participants responded to the question “Are you often troubled with any body pain?” in the questionnaire and were answered with no or yes. If the participant responded “yes,” they were presented with the question “On what part of your body do you feel pain? (list all body pains).” Fifteen specific common pain locations were included: head, shoulder, arm, wrist, fingers, chest, stomach, back, waist, buttocks, legs, knees, ankle, toes, neck, and others. Then, they were presented with the question “How bad is your pain (if more than one type of pain, ask about the most severe one among them)? Mild, Moderate or Severe?”. The baseline pain intensity was categorized into three groups: no pain, mild to moderate pain, and severe pain.
In CHARLS study, CES‐D (10‐item version) which has been validated and widely used to measure depressive symptoms in Chinese adults was used to measure depressive symptoms [12, 13, 14]. This scale contains 10 items regarding major components of depressive symptoms. Three points were given for each item. Thus, the scores were ranged from 0 to 30. A total CESD‐10 score ≥ 10 was used to identify patients with depressive symptoms [14].
Covariates that were selected in our study include gender(male, female), age (years), education (illiterate, primary school, middle school, high school and higher), marital status (married, widowed, single/Other), smoking status (current/former, never), alcohol consumption (current/former, never), residence type (urban, rural), and relevant clinical characteristics (self‐reported hypertension, diabetes, coronary heart disease, stroke, cancer, chronic lung disease, and asthma) [15]. Additionally adjusted for all other body pain locations (head, shoulder, arm, wrist, fingers, chest, stomach, back, waist, buttocks, leg, knees, ankle, toes, neck) when analyzing each specific pain location.
Diabetes was defined by meeting any of the following criteria: (1) physician‐diagnosed diabetes, (2) nonfasting plasma glucose ≥ 200 mg/dL (11.1 mmol/L), (3) fasting plasma glucose ≥ 126 mg/dL (7.0 mmol/L), (4) glycated hemoglobin (HbA1c) ≥ 6.5%, (5) current use antidiabetic drugs. Hypertension was diagnosed based on (1) clinician‐confirmed hypertension, (2) systolic/diastolic blood pressure ≥ 140/90 mmHg, (3) current use antihypertensive drugs.
Data are presented as percentages for categorical variables and means ± standard deviation (SD) for continuous variables. Differences were assessed by Student's t‐test for continuous variables and by the chi‐squared test for categorical variables. Multivariable logistic regression was performed to obtain adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for the association of depressive symptoms with body pain. The model was adjusted for gender, age, education, marital status, smoking status, alcohol consumption, residence type, and relevant clinical characteristics (self‐reported hypertension, diabetes, coronary heart disease, stroke, cancer, chronic lung disease, and asthma). When examining the association between pain at specific body locations and depressive symptoms, we adjusted for all of the other body pain locations (head, shoulder, arm, wrist, fingers, chest, stomach, back, waist, buttocks, leg, knees, ankle, toes, neck).
A total of 6346 individuals without depressive symptoms at baseline were included in the analysis of the association between body pain and incident depressive symptoms. The individuals with and without pain were found to differ in most of characteristics except for age, marital status and alcohol consumption status. The individuals with pain were more likely to be female, less educated, nonsmokers, rural area dwellers (Table S1).
As shown in Table S2, the main locations of body pain were waist, leg, knees, head and shoulder.
As shown in Table 1, compared with individuals who reported no pain at baseline, the unadjusted OR of incident depressive symptoms for participants with mild to moderate pain and for those with severe pain was 1.76 (95% CI: 1.52–2.05, p < 0.001) and 2.44 (95% CI: 1.98–3.02, p < 0.001), respectively. After adjusted the potential confounders, the association between body pain and incident depressive symptoms was still existed. The adjusted OR of incident depressive symptoms for participants with mild to moderate pain and for those with severe pain was 1.40 (95% CI: 1.20–1.64, p < 0.001) and 1.85 (95% CI: 1.49–2.31, p < 0.001), respectively. Additionally, we examined the association between pain in different pain locations and depressive symptoms. As shown in Table S3, significant associations were observed between each individual pain location and depressive symptoms before covariate adjustment; however, after adjustment for covariates, only the association between headache and depressive symptoms remained statistically significant (Adjusted OR 1.33 [1.03–1.74] p = 0.029).
Table 1.
Association between baseline body pain severity and incident depressive symptoms.
| Pain severity | n | Unadjusted OR (95% CI) | p value | Adjusted OR (95% CI) | p value |
|---|---|---|---|---|---|
| No | 5111 | — | — | — | — |
| Mild to middle | 857 | 1.76 (1.52–2.05) | < 0.001 | 1.40 (1.20–1.64) | < 0.001 |
| Severe | 378 | 2.44 (1.98–3.02) | < 0.001 | 1.85 (1.49–2.31) | < 0.001 |
Note: Adjusting for baseline CESD‐10 scores, gender, age, education, marital status, smoking, alcohol consumption, self‐reported hypertension, diabetes, coronary heart disease, stroke, cancer, chronic lung disease, and asthma.
Stratified by age, significant associations were observed between body pain and depressive symptoms in people under 60. In the population over 60 years, the association between pain and depression symptoms was only observed before adjusting for covariates. The adjusted OR for participants with mild to middle pain (Adjusted OR = 1.11, 95% CI: 0.84–1.46, p = 0.470) or sever pain (Adjusted OR = 1.41, 95% CI: 0.96–2.07, p = 0.079) failed to reach significance after adjusted the potential confounders (Table 2).
Table 2.
Association between baseline body pain severity and incident depressive symptoms by age and sex.
| Pain severity | n | Unadjusted OR (95% CI) | p value | Adjusted OR (95% CI) | p value |
|---|---|---|---|---|---|
| By age | |||||
| < 60 years | 4267 | ||||
| No | 3418 | — | — | — | — |
| Mild to middle | 593 | 2.01 (1.68–2.41) | < 0.001 | 1.55 (1.28–1.88) | < 0.001 |
| Severe | 256 | 2.79 (2.16–3.61) | < 0.001 | 2.12 (1.62–2.77) | < 0.001 |
| ≥ 60 years | 2079 | ||||
| No | 1693 | — | — | — | — |
| Mild to middle | 264 | 1.38 (1.06–1.79) | 0.017 | 1.11 (0.84–1.46) | 0.470 |
| Severe | 122 | 1.90 (1.32–2.75) | 0.001 | 1.41 (0.96–2.07) | 0.079 |
| By sex | |||||
| Male | 3266 | ||||
| No | 2748 | — | — | — | — |
| Mild to middle | 357 | 1.58 (1.25–2.00) | < 0.001 | 1.31 (1.02–1.68) | 0.036 |
| Severe | 161 | 2.16 (1.56–3.00) | < 0.001 | 1.67 (1.18–2.35) | 0.004 |
| Female | 3080 | ||||
| No | 2363 | — | — | — | — |
| Mild to middle | 500 | 1.72 (1.42–2.10) | < 0.001 | 1.49 (1.22–1.83) | < 0.001 |
| Severe | 217 | 2.46 (1.86–3.27) | < 0.001 | 2.02 (1.51–2.71) | < 0.001 |
Note: By age: Adjusting for baseline CESD‐10 scores, gender, education, marital status, smoking status, alcohol consumption, self‐reported hypertension, diabetes, coronary heart disease, stroke, cancer, chronic lung disease, and asthma. By sex: Adjusting for baseline CESD‐10 scores, age, education, marital status, smoking status, alcohol consumption, self‐reported hypertension, diabetes, coronary heart disease, stroke, cancer, chronic lung disease, and asthma.
In addition, the population was stratified by sex, the significant associations were observed between body pain and depressive symptoms in both male and female groups, even after adjusted the potential confounders. Furthermore, compared to males, there is a stronger association between body pain and depressive symptoms in females (Table 2).
In this study, using the data from a nationally representative Chinese population‐based survey, we investigated the association of chronic body pain with the risk of depressive symptoms. The results demonstrated that chronic body pain is a dependent risk factor for depressive symptoms in Chinese population, which is an important population at risk for increased pain complaints and psychiatric morbidity.
In our study, we provided additional evidence for the association between chronic body pain and depression from longitudinal population‐based study in Chinese middle‐aged and elderly people. As previous studies have revealed, depression and pain often exhibit comorbidity [1, 7, 8]. A common theory for the association between depression and body pain is that they follow the same pathways of the central nervous system [8]. For example, a domestic animal study in demonstrated that the paraventricular thalamic nucleus serves as a central hub regulating sensory pain and depressive‐like behaviors through the 5‐hydroxytryptamine receptor 1D [16]. Furthermore, the changes in dopamine system function had also been used to explain the comorbidity of pain and depression [17].
Some studies reported that female depression patients were more likely to be affected by chronic pain and depressive symptoms than male [18, 19]. Biological, cultural, psychological, and social factors are all hypothesized to contribute to these disparities [20]. In our study, we also found that the percentage of female affected by pain and depressive symptoms was higher than male. Previous studies have shown that male are more susceptible to depression [4, 21] and body pain [2] than female, which may depend on physiological differences [21]. Furthermore, the majority of female participants in this study were in the perimenopausal or postmenopausal stages with lower estrogen levels. The imbalance of estrogen levels may affect the availability of neurotransmitters, which may induce dysregulation of central nervous system function and make female more susceptible to the effects of chronic pain and depression symptoms [14, 22].
In the age subgroup analysis, we found the population over 60 years, the association between pain and depression symptoms was only observed before adjusting for covariates. After adjusting for confounding factors, this association was no longer statistically significant. A possible explanation for this is our age classification is based on the age of 60, previous studies indicated that chronic disorders among individuals aged ≥ 60 years account for 23% of the global disease burden [23]. Cardiovascular diseases, malignancies, chronic respiratory conditions, musculoskeletal disorders, and neuropsychiatric conditions contribute to elevate per capita burden in this population [23]. that depression is one of the most common comorbidities of chronic disease [24]. The prevalence of depression is significantly higher in these populations with chronic disease compared to the general population [24]. Therefore, in our study, there are multiple factors contributing to depression, and pain may mediate rather than directly cause depression in the elderly population. This phenomenon deserves further research to elucidate its potential mechanisms.
The major strength of our study is the large community‐based cohorts. And this longitudinal study can establish the temporal direction of the association between chronic body pain and depressive symptoms in Chinese population. However, there were still several limitations in this study. First, body pain, depressive symptoms and some disease history in CHARLS study were self‐reported, which might bias our results, although such self‐reported data are widely accepted in published studies [14, 25, 26, 27]. Second, although a longitudinal design was employed in this study, this study remains an observational study and unable to fully exclude unobserved confounding factors, which limited the ability to demonstrate the causal association. Further mechanisms or experimental studies are needed. Third, as body pain in this study population was distributed across diverse locations while the spectrum of pain location extends beyond the 15 common locations captured in CHARLS, we could not fully adjust for all potential pain‐related confounding effects, which may affect our results.
In conclusion, our study suggested that individuals with chronic body pain tended to be more susceptible to depressive symptoms. Further work is needed to explore the potential mechanisms of the specific associations between body pain and depressive symptoms. The results from our study suggested that people should pay more attention to the management of chronic body pain which may have a positive effect on the prevention of depression.
Author Contributions
Jiaying Wang conceived and designed the study. Kai Wang and Wenchang Xu acquired the data. Jiaying Wang, Kai Wang, and Jiaying Wang interpreted and analyzed the data. Kai Wang and Jiaying Wang drafted the manuscript. Gongchang Yu, Qingxia Gao, and Bin Shi reviewed the manuscript. All authors approved the version submitted.
Ethics Statement
CHARLS was approved by the Ethical Review Committee of Peking University (IRB00001052‐11,015), and all participants signed informed consent forms.
Conflicts of Interest
The authors declare no conflicts of interest.
Supporting information
Figure S1: Flowchart of the study.
Table S1: The baseline characteristics of participants in CHARLS study (2011).
Table S2: The location of body pain in CHARLS study (2011).
Table S3: Association between different baseline body pain locations and incident depressive symptoms.
Acknowledgments
This study was supported by Shandong Province Traditional Chinese Medicine Science and Technology Program (M‐2022254), Shandong First Medical University (Shandong Academy of Medical Sciences) Youth Science Fund Cultivation and Support Program (202201‐127), High Level Key Discipline Construction Project of the State Administration of Traditional Chinese Medicine (zyyzdxk‐2023123), and the Major Science and Technology Innovation Project of Shandong Province (2022CXGC020510, 2024CXGC010609).
Jiaying Wang and Kai Wang contributed equally to this study.
Data Availability Statement
The data that support the findings of this study are available in China Health and Retirement Longitudinal Study, CHARLS at http://charls.pku.edu.cn/gy/gyxm.htm. These data were derived from the following resources available in the public domain: ‐ CHARLS, https://charls.charlsdata.com/pages/data/111/zh-cn.html.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Figure S1: Flowchart of the study.
Table S1: The baseline characteristics of participants in CHARLS study (2011).
Table S2: The location of body pain in CHARLS study (2011).
Table S3: Association between different baseline body pain locations and incident depressive symptoms.
Data Availability Statement
The data that support the findings of this study are available in China Health and Retirement Longitudinal Study, CHARLS at http://charls.pku.edu.cn/gy/gyxm.htm. These data were derived from the following resources available in the public domain: ‐ CHARLS, https://charls.charlsdata.com/pages/data/111/zh-cn.html.