Abstract
Purpose
Nationally representative longitudinal evidence on the association of chronic pain and pain-related activity limitation with newly reported frequent feelings of depression remains limited. We examined the association using the 2019–2020 National Health Interview Survey follow-back cohort.
Methods
The longitudinal cohort used nationally representative data from the 2019–2020 National Health Interview Survey to examine the relationship between chronic pain and newly reported frequent feelings of depression among US adults. The primary outcome was newly reported frequent feelings of depression in 2020. Weighted modified Poisson regression models with robust standard errors were used to estimate risk ratios, adjusting for demographic and health-related covariates.
Results
Among adults with chronic pain and nonchronic pain in 2019, the cumulative incidence of newly reported frequent feelings of depression in 2020 was 9.0% (95% CI, 7.3–10.7%) and 5.5% (95% CI, 4.4–6.5%), respectively. Chronic pain was associated with a higher likelihood of newly reported frequent feelings of depression after adjusting for demographic and health-related characteristics (adjusted risk ratio, 2.32 [95% CI, 1.71–3.15]). A similar association was observed between high-impact chronic pain and increased likelihood of newly reported frequent feelings of depression (adjusted risk ratio, 2.86 [95% CI, 1.96–4.16]).
Conclusion
We found that chronic pain exposure was associated with a higher likelihood of newly reported frequent feelings of depression. These findings suggest that psychological treatment should also be considered in the management of chronic pain.
Keywords: chronic pain, high-impact chronic pain, newly reported frequent feelings of depression, co-occurrence
Introduction
Chronic pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, persisting for more than 3 months.1 It has become a prevalent and growing public health concern, affecting approximately 20% of US adults.2,3 Chronic pain is often accompanied by psychological disorders, social dysfunction, and increased risk of substance use, contributing to a heavy burden on individuals and health systems.4–6 Depression is a leading cause of mental and physical disability worldwide and is associated with reduced quality of life, increased mortality, and more economic costs.7–9 The co-occurrence of chronic pain and depression is common. Previous studies have reported that approximately 23.9–39.3% of US adults with chronic pain experienced depression and/or anxiety.10,11 Individuals experiencing both conditions incurred higher health care costs compared with those with pain alone, and comorbid depression has been recognized as a major barrier to effective pain management.12
Extensive literature has documented the association between chronic pain and depression, but the mechanisms underlying the co-occurrence of pain and depression have not been fully clarified. Previous research on the relationship between chronic pain and depression has been limited to smaller sample sizes or cross-sectional data.4,10 Chronic pain can affect physical activity, social participation, and interpersonal relationships. Whether these aspects of pain-related burden contribute differently to depression remains unclear. High-impact chronic pain (HICP) is commonly defined by activity limitations in work or daily life, representing a key component of pain-related burden. An estimated 17.1 million (6.9%) individuals suffered from HICP.2 In addition to activity limitation, pain may affect family members and significant others through caregiving needs and changes in family responsibilities. Recent research has indicated that negative family function could elevate the risk of poor health and depression.13,14 Reported family impact of chronic pain refers to the self-reported impact of chronic pain on family members and significant others, which has rarely been examined in population-based longitudinal studies.
To address this, we used data from the 2019–2020 National Health Interview Survey (NHIS) Longitudinal Cohort to examine the association between chronic pain and newly reported frequent feelings of depression over a one-year follow-up. We further evaluated chronic pain accompanied by life or work activity limitation and conducted an exploratory analysis of whether reported pain-impact on family identified individuals with a greater likelihood of newly frequent feelings of depression. This study aimed to highlight the mental health problems arising from chronic pain, emphasizing the importance of combining pain management with mental health care, which may help reduce the burden of chronic pain and depression.
Methods
Study Population
The data used for this cohort study were from the 2019–2020 National Health Interview Survey (NHIS). NHIS is a nationally representative cross-sectional household survey, comprising the US noninstitutionalized civilian population living in the 50 states and the District of Columbia, administered annually by the National Center for Health Statistics, Centers for Disease Control and Prevention.15 The use of geographically stratified clustered sampling and weights ensures representativeness of the sample, allowing the findings to be generalized to the national population. It aims to estimate the prevalence and trend of health topics in the United States, with a stratified population by various demographic and socioeconomic characteristics.
Due to the impact of the COVID-19 pandemic on data collection, the 2020 survey included sample adults who had participated in the 2019 NHIS, allowing for a longitudinal cohort with approximately 1 year of follow-up on health outcomes. Of the 31,997 sample adults interviewed in 2019, 21,161 were selected for the 2019–2020 longitudinal follow-up. Among those selected, 1746 were proxy respondents or lacked contact information, and 334 died or became institutionalized. Among the remaining 19,081 adults, 8666 did not participate in the 2020 follow-up interview, while 10,415 completed the 2020 follow-up interview and constituted the longitudinal analytic cohort. In accordance with NCHS guidance, all longitudinal analyses incorporated the longitudinal sample adult weight (WTSA_L), which was derived from the 2019 sample adult weight and adjusted for panel subsampling, nonrecontact, and reinterview nonresponse, with calibration to the 2019 population.16 A total of 10,415 follow-up interviews were conducted between August and December in 2020 and all interviews were completed by telephone.
The NHIS study was reviewed and approved by the National Center for Health Statistics Research Ethics Review Board, and informed consent was obtained from all the participants. The present study was a secondary analysis of publicly available, de-identified data and was approved by the Institutional Review Board of the Peking Union Medical College Hospital (Ethics Approval Number: I-26ZM0072). The study was conducted according to the guidelines of the Declaration of Helsinki and followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for reporting cohort studies.17,18
Exposure and Outcome Measures
Chronic pain was assessed based on the following question: “In the past 3 months, how often did you have pain? Would you say never, some days, most days, or every day?” Respondents who reported pain on most days or every day were considered to have chronic pain, while those who reported pain on some days were classified as having nonchronic pain. High-impact chronic pain (HICP) was defined as chronic pain occurring in the past 3 months, limiting life or work activities on most days or every day, based on responses to the question: “Over the past 3 months, how often did pain limit your life or work activities? Would you say never, some days, most days, or every day?”. Reported family impact of chronic pain was characterized as having chronic pain in the past 3 months, affecting family and significant others on most days or every day, based on responses to the question: “Over the past 3 months, how often did your pain affect family and significant others? Would you say never, some days, most days, or every day?”. The definition of chronic pain was consistent with the International Classification of Diseases-11 (ICD-11) by the International Association for the Study of Pain (IASP) and previously published.1,10,19–21
In this cohort study, newly reported frequent feelings of depression were measured using the following question: “How often do you feel depressed? Would you say daily, weekly, monthly, a few times a year, or never?” Respondents who answered daily or weekly were coded as newly reported frequent feelings of depression.
Covariates
We collected covariates that were considered potential confounders in the association between chronic pain and newly reported frequent feelings of depression based on previous studies and existing knowledge. All the covariates were assessed at baseline in 2019. Demographic characteristics included age, sex (male or female), race and ethnicity (Hispanic, non-Hispanic white, non-Hispanic black or others), education (below high school, high school graduate or some college or higher), and region (large central metro, large fringe metro, medium and small metro or nonmetropolitan). Health-related behaviors included body mass index (BMI) (underweight, BMI < 18.5 kg/m2; normal weight, 18.5 ≤ BMI < 25 kg/m2; overweight, 25 ≤ BMI < 30 kg/m2 or obese, BMI ≥ 30 kg/m2) and smoking status (never, former or current). Comorbidities included general health status (good or above, or fair or poor) and self-reported hypertension, diabetes, coronary artery disease (CAD), stroke, chronic obstructive pulmonary disease (COPD), cancer, and arthritis history. Socioeconomic factors included marital status (married/living with partner, divorced/separated/widowed or single/never married), employment status, poverty status (< 100% federal poverty level, 100% ≤ and < 200% federal poverty level, 200% ≤ and < 400% federal poverty level, or ≥ 400% federal poverty level), and health insurance coverage.
Statistical Analysis
The raw and weighted frequencies were calculated to present the prevalence of chronic pain across the population. Unadjusted and adjusted survey-weighted modified Poisson regression models with robust sandwich standard errors (SEs) were performed to examine the association between chronic pain and the 1-year cumulative incidence of newly reported frequent feelings of depression in 2020. Risk ratios (RRs) with 95% confidence intervals (CIs) were estimated, with the pain-free group serving as the reference group. All weighted RR estimates used longitudinal sample weights provided by the 2019–2020 NHIS cohort. The statistical significance was set at two-sided P <0.05. All statistical analyses accounted for the complex survey design of NHIS and were performed in R, version 4.4.3, using the survey package.
Four models were constructed. Model 1 was an unadjusted model. Model 2 adjusted for demographic characteristics, including age, sex, race and ethnicity, education, and region. Model 3, considered the primary adjusted model, additionally included BMI and comorbidities. Model 4 further adjusted for behavioral and socioeconomic factors, including smoking status, marital status, employment status, poverty level, and health insurance coverage. General health status was excluded because of potential overadjustment.
The primary analysis was constructed using the complete-case analysis, excluding participants with missing data. In addition, we conducted exploratory analyses to evaluate the association between different domains of pain-related impact and newly reported frequent feelings of depression, and the same regression models were applied to two sets of exposure classifications: (1) pain-free, nonchronic pain, and chronic pain stratified by activity limitation (non-HICP and HICP); (2) pain-free, nonchronic pain, and chronic pain stratified by reported family impact (non-reported family impact of chronic pain and reported family impact of chronic pain), with the pain-free group serving as the reference.
Sensitivity analyses were conducted to assess the robustness of the findings. First, we compared participants with and without observed follow-up depressive-feeling frequency, as well as complete cases and participants who had missing covariate data using unweighted and weighted estimates. Second, missing covariate values were addressed using multiple imputation and the primary survey-weighted modified Poisson models were performed in the imputed datasets. In addition, the analysis was repeated in which missing values were retained as a separate category. Third, to evaluate the potential influence of interview timing during the COVID-19 pandemic, we compared baseline pain status and cumulative incidence of outcome across interview months, adjusted the primary model for interview month, and tested the interaction between pain status and interview month. Last, the primary analysis was performed using different definitions of pain status and frequent depressed feelings to assess the robustness of the findings.
Results
Baseline Characteristics
Among the 10,415 participants who completed the 2020 follow-up, 965 were excluded because they reported feelings of depression daily or weekly in 2019. We further excluded 8 participants with missing pain status information in 2019, 41 with missing feelings of depression frequency in 2019, and 118 with missing feelings of depression frequency in 2020. Of the remaining 9283 participants, 360 had missing data for one or more covariates, leaving 8923 participants in the primary complete-case analysis (Figure 1). Among the weighted analytic sample, 54.1% (95% CI, 52.6–55.7%) were aged 18–49 years, 24.6% (95% CI, 23.4–25.8%) were 50–64 years, and 21.3% (95% CI, 20.3–22.4%) were 65 years or older. Overall, 49.4% (95% CI, 47.9–50.8%) were male, and 50.6% (95% CI, 49.2–52.1%) were female. Additional demographic details were presented in Table S1 (Supplementary materials).
Figure 1.
Flowchart of Participants in the Study.
Abbreviation: NHIS, National Health Interview Survey.
Pain and Newly Reported Frequent Feelings of Depression
At baseline in 2019, 17.4% (95% CI, 16.3–18.5%) of the weighted sample reported chronic pain, 40.0% (95% CI, 38.5–41.5%) reported nonchronic pain, and 42.6% (95% CI, 41.0–44.2%) did not report pain (Supplementary materials: Table S1). Weighted and unweighted comparisons of baseline characteristics according to pain status were presented in Table 1. In 2020, 5.2% (95% CI, 4.6–5.9%) of the weighted sample reported newly frequent feelings of depression. Among individuals who reported no pain in 2019, the cumulative incidence of newly reported frequent feelings of depression in 2020 was 3.5% (95% CI, 2.7–4.3%), while the cumulative incidence among participants with nonchronic pain was 5.5% (95% CI, 4.4–6.5%) and 9.0% (95% CI, 7.3–10.7%) with chronic pain (Table 2). As shown in Figure 2, the cumulative incidence of newly reported frequent feelings of depression was significantly higher in the chronic pain group than in the pain-free group or nonchronic pain group. In the unadjusted model, chronic pain was associated with a higher likelihood of newly reported frequent feelings of depression (unadjusted RR, 2.58 [95% CI, 1.91–3.49]). The association remained significant after adjusting for demographic and health-related characteristics (adjusted RR, 2.32 [95% CI, 1.71–3.15]). Nonchronic pain was also associated with newly reported frequent feelings of depression compared with those without pain (adjusted RR, 1.51 [95% CI, 1.16–1.96]) (Table 2 and Figure 3). Estimates remained consistent after further adjustment for behavioral and socioeconomic covariates (Supplementary materials: Table S2).
Table 1.
Baseline Characteristics of Study Population by Pain Status in the Longitudinal Cohort
| Variable | Pain Free | Nonchronic Pain | Chronic Pain | |||
|---|---|---|---|---|---|---|
| Raw Frequency (n=3412) |
Weighted Frequency, Thousands (%) (n = 90561) |
Raw Frequency (n = 3703) |
Weighted Frequency, Thousands (%) (n = 84985) |
Raw Frequency (n = 1808) |
Weighted Frequency, Thousands (%) (n = 36,939) |
|
| Age group | ||||||
| 18-49 | 1756 | 59,041 (65.2%) | 1423 | 43,262 (50.9%) | 407 | 12,677 (34.3%) |
| 50-64 | 784 | 18,310 (20.2%) | 1048 | 22,670 (26.7%) | 560 | 11,233 (30.4%) |
| 65+ | 872 | 13,211 (14.6%) | 1232 | 19,053 (22.4%) | 841 | 13,028 (35.3%) |
| Sex | ||||||
| Male | 1716 | 46,304 (51.1%) | 1691 | 40,582 (47.8%) | 812 | 18,021 (48.8%) |
| Female | 1696 | 44,257 (48.9%) | 2012 | 44,403 (52.2%) | 996 | 18,918 (51.2%) |
| Race and ethnicity | ||||||
| Hispanic | 479 | 17,724 (19.6%) | 358 | 12,820 (15.1%) | 132 | 3900 (10.6%) |
| White, non-Hispanic | 2288 | 52,501 (58.0%) | 2723 | 55,565 (65.4%) | 1442 | 27,004 (73.1%) |
| Black, non-Hispanic | 308 | 10,638 (11.7%) | 380 | 10,191 (12.0%) | 149 | 3872 (10.5%) |
| Other, non-Hispanic | 337 | 9698 (10.7%) | 242 | 6409 (7.5%) | 85 | 2163 (5.9%) |
| Education | ||||||
| Below high school | 169 | 7103 (7.8%) | 200 | 7822 (9.2%) | 144 | 4667 (12.6%) |
| High school graduate | 746 | 26,890 (29.7%) | 783 | 22,257 (26.2%) | 467 | 11,595 (31.4%) |
| Some college or higher | 2497 | 56,568 (62.5%) | 2720 | 54,905 (64.6%) | 1197 | 20,677 (56.0%) |
| Region | ||||||
| Large central metro | 1124 | 30,380 (33.5%) | 1119 | 27,481 (32.3%) | 403 | 9106 (24.7%) |
| Large fringe metro | 772 | 22,695 (25.1%) | 865 | 20,972 (24.7%) | 367 | 7909 (21.4%) |
| Medium and small metro | 1048 | 26,452 (29.2%) | 1128 | 24,866 (29.3%) | 647 | 12,602 (34.1%) |
| Nonmetropolitan | 468 | 11,034 (12.2%) | 591 | 11,665 (13.7%) | 391 | 7322 (19.8%) |
| BMI | ||||||
| Underweight | 57 | 1356 (1.5%) | 36 | 639 (0.8%) | 19 | 483 (1.3%) |
| Normal weight | 1253 | 33,935 (37.5%) | 1131 | 24,904 (29.3%) | 423 | 8320 (22.5%) |
| Overweight | 1243 | 31,800 (35.1%) | 1297 | 29,603 (34.8%) | 571 | 11,296 (30.6%) |
| Obese | 859 | 23,470 (25.9%) | 1239 | 29,838 (35.1%) | 795 | 16,840 (45.6%) |
| Smoking status | ||||||
| Never | 2368 | 66,723 (73.7%) | 2303 | 54,768 (64.4%) | 905 | 18,404 (49.8%) |
| Former | 745 | 15,668 (17.3%) | 1002 | 20,229 (23.8%) | 624 | 11,867 (32.1%) |
| Current | 299 | 8171 (9.0%) | 398 | 9988 (11.8%) | 279 | 6668 (18.1%) |
| General health status | ||||||
| Good or above | 3257 | 86,305 (95.3%) | 3364 | 76,641 (90.2%) | 1303 | 26,142 (70.8%) |
| Fair or poor | 155 | 4256 (4.7%) | 339 | 8344 (9.8%) | 505 | 10,797 (29.2%) |
| Hypertension history | ||||||
| No | 2480 | 70,427 (77.8%) | 2299 | 56,930 (67.0%) | 849 | 19,036 (51.5%) |
| Yes | 932 | 20,134 (22.2%) | 1404 | 28,055 (33.0%) | 959 | 17,902 (48.5%) |
| Diabetes history | ||||||
| No | 3205 | 86,202 (95.2%) | 3316 | 77,137 (90.8%) | 1503 | 30,796 (83.4%) |
| Yes | 207 | 4360 (4.8%) | 387 | 7848 (9.2%) | 305 | 6143 (16.6%) |
| CAD history | ||||||
| No | 3286 | 88,445 (97.7%) | 3518 | 81,840 (96.3%) | 1623 | 33,744 (91.4%) |
| Yes | 126 | 2116 (2.3%) | 185 | 3144 (3.7%) | 185 | 3195 (8.6%) |
| Stroke history | ||||||
| No | 3344 | 89,211 (98.5%) | 3596 | 82,675 (97.3%) | 1700 | 34,789 (94.2%) |
| Yes | 68 | 1350 (1.5%) | 107 | 2310 (2.7%) | 108 | 2149 (5.8%) |
| COPD history | ||||||
| No | 3328 | 88,896 (98.2%) | 3546 | 82,412 (97.0%) | 1607 | 33,456 (90.6%) |
| Yes | 84 | 1665 (1.8%) | 157 | 2573 (3.0%) | 201 | 3483 (9.4%) |
| Cancer history | ||||||
| No | 3079 | 84,866 (93.7%) | 3198 | 76,150 (89.6%) | 1449 | 30,803 (83.4%) |
| Yes | 333 | 5695 (6.3%) | 505 | 8834 (10.4%) | 359 | 6136 (16.6%) |
| Arthritis history | ||||||
| No | 3080 | 84,553 (93.4%) | 2750 | 68,268 (80.3%) | 767 | 17,778 (48.1%) |
| Yes | 332 | 6009 (6.6%) | 953 | 16,716 (19.7%) | 1041 | 19,160 (51.9%) |
| Marital status | ||||||
| Married/Living with partner | 1946 | 55,134 (60.9%) | 2179 | 56,078 (66.0%) | 959 | 22,586 (61.1%) |
| Divorced/Separated/Widowed | 706 | 10,991 (12.1%) | 925 | 13,119 (15.4%) | 636 | 9702 (26.3%) |
| Single/Never married | 760 | 24,436 (27.0%) | 599 | 15,788 (18.6%) | 213 | 4651 (12.6%) |
| Employment status | ||||||
| Employed | 2377 | 65,679 (72.5%) | 2323 | 58,232 (68.5%) | 781 | 17,936 (48.6%) |
| Unemployed | 1035 | 24,882 (27.5%) | 1380 | 26,753 (31.5%) | 1027 | 19,003 (51.4%) |
| Poverty status | ||||||
| <1 FPL | 242 | 7747 (8.6%) | 252 | 6743 (7.9%) | 210 | 5014 (13.6%) |
| [1FPL, 2FPL) | 483 | 15,953 (17.6%) | 497 | 13,767 (16.2%) | 349 | 7685 (20.8%) |
| [2FPL, 4FPL) | 964 | 27,889 (30.8%) | 1091 | 26,414 (31.1%) | 558 | 11,620 (31.5%) |
| ≥ 4FPL | 1723 | 38,971 (43.0%) | 1863 | 38,062 (44.8%) | 691 | 12,619 (34.2%) |
| Health insurance coverage | ||||||
| Yes | 3129 | 79,154 (87.4%) | 3481 | 77,108 (90.7%) | 1720 | 33,804 (91.5%) |
| No | 283 | 11,407 (12.6%) | 222 | 7877 (9.3%) | 88 | 3135 (8.5%) |
Notes: Other Race and ethnicity includes American Indian, Alaska Native, Native Hawaiian, Other Pacific Islanders, and individuals of mixed races.
Abbreviations: BMI, body mass index; CAD, coronary artery disease; COPD, chronic obstructive pulmonary disease; FPL, federal poverty level.
Table 2.
Number of Events, Cumulative Incidences, and Risk Ratios for Association Between Chronic Pain and Newly Reported Frequent Feelings of Depression in 2020 Among Study Population in the Longitudinal Cohort
| Weighted Data | ||||||
|---|---|---|---|---|---|---|
| Pain status | Raw No. of Events | No. of Events, Thousands |
Cumulative Incidence (%) (95% CI) |
RR (95% CI) | ||
| Model 1 | Model 2 | Model 3 | ||||
| Pain free | 123 | 3144 | 3.5 (2.7–4.3) | 1 [Reference] | 1 [Reference] | 1 [Reference] |
| Nonchronic pain | 203 | 4635 | 5.5 (4.4–6.5) | 1.57 (1.19–2.07) | 1.61 (1.23–2.11) | 1.51 (1.16–1.96) |
| Chronic pain | 167 | 3315 | 9.0 (7.3–10.7) | 2.58 (1.91–3.49) | 2.73 (2.04–3.67) | 2.32 (1.71–3.15) |
| Pain free | 123 | 3144 | 3.5 (2.7–4.3) | 1 [Reference] | 1 [Reference] | 1 [Reference] |
| Nonchronic pain | 203 | 4635 | 5.5 (4.4–6.5) | 1.57 (1.19–2.07) | 1.61 (1.23–2.11) | 1.51 (1.16–1.96) |
| Non-HICP | 100 | 2006 | 7.8 (6.0–9.6) | 2.25 (1.62–3.13) | 2.40 (1.74–3.31) | 2.10 (1.50–2.94) |
| HICP | 67 | 1309 | 11.6 (8.1–15.2) | 3.35 (2.30–4.90) | 3.52 (2.41–5.14) | 2.86 (1.96–4.16) |
| Pain free | 123 | 3144 | 3.5 (2.7–4.3) | 1 [Reference] | 1 [Reference] | 1 [Reference] |
| Nonchronic pain | 203 | 4635 | 5.5 (4.4–6.5) | 1.57 (1.19–2.07) | 1.62 (1.24–2.11) | 1.51 (1.16–1.97) |
| Non-reported family impact of chronic pain | 131 | 2579 | 8.0 (6.3–9.8) | 2.32 (1.69–3.19) | 2.45 (1.79–3.35) | 2.13 (1.53–2.94) |
| Reported family impact of chronic pain | 35 | 721 | 15.2 (9.1–21.3) | 4.38 (2.76–6.94) | 4.81 (3.09–7.48) | 3.87 (2.52–5.94) |
Notes: Model 1 was an unadjusted model. Model 2 adjusted for age, sex, race and ethnicity, education and region. Model 3 additionally adjusted for body mass index (BMI), hypertension history, diabetes history, coronary artery disease (CAD) history, stroke history, chronic obstructive pulmonary disease (COPD) history, cancer history and arthritis history.
Abbreviations: RR, risk ratio; CI, confidence interval.
Figure 2.
Cumulative Incidences of Newly Reported Frequent Feelings of Depression in 2020 among Study Population in the Longitudinal Cohort.
Abbreviations: CI, cumulative incidence; BMI, body mass index; CAD, coronary artery disease; COPD, chronic obstructive pulmonary disease; FPL, federal poverty level.
Figure 3.
Risk Ratios between Chronic Pain and Newly Reported Frequent Feelings of Depression in 2020 among Study Population in the Longitudinal Cohort. Model 1 was an unadjusted model. Model 2 adjusted for age, sex, race and ethnicity, education and region. Model 3 additionally adjusted for body mass index (BMI), hypertension history, diabetes history, coronary artery disease (CAD) history, stroke history, chronic obstructive pulmonary disease (COPD) history, cancer history and arthritis history.
Abbreviations: RR, risk ratio; CI, confidence interval.
High-Impact Chronic Pain and Reported Family Impact of Chronic Pain
High-impact chronic pain (HICP) was associated with a higher likelihood of newly reported frequent feelings of depression (adjusted RR, 2.86 [95% CI, 1.96–4.16]). Non-HICP was also associated with an increased likelihood of newly reported frequent feelings of depression (adjusted RR, 2.10 [95% CI, 1.50–2.94]) (Table 2 and Supplementary materials: Figure S1A).
In the exploratory analysis, both reported family impact of chronic pain and non-reported family impact of chronic pain were also associated with elevated likelihood of newly reported frequent feelings of depression (adjusted RR, 3.87 [95% CI, 2.52–5.94]; adjusted RR, 2.13 [95% CI, 1.53–2.94]) (Table 2 and Supplementary materials: Figure S1B).
Sensitivity Analyses
Participants with and without depressive-feeling data in 2020 had similar baseline characteristics in 2019, including pain status (Supplementary materials: Table S3). Baseline characteristics in 2019 were generally comparable between the 8923 complete cases and excluded 360 participants with missing covariates (Supplementary materials: Table S4). Estimates after multiple imputation confirmed the results of the complete case analysis, indicating that the exclusion of participants with missing data did not significantly affect the findings (Supplementary materials: Table S5). Results were also consistent when missing values were retained as a separate category (Supplementary materials: Table S6). In addition, the distribution of baseline pain status across the 2020 follow-up interview months was presented in Supplementary Table S7. There was no strong evidence that the association differed by interview month (Supplementary materials: Table S8 and Figure S2). In addition, the findings were consistent across different definitions of pain status and newly reported frequent feelings of depression (Supplementary materials: Figure S3, Tables S9 and S10).
Discussion
In this nationally representative longitudinal cohort, chronic pain reported at baseline in 2019 was associated with a higher likelihood of newly reported frequent feelings of depression at the 2020 follow-up. The association was also observed when chronic pain was further characterized according to activity limitation and reported impact on family members and significant others. The findings persisted after adjustment for interview time during the pandemic.
The co-occurrence of chronic pain and newly reported frequent feelings of depression was consistent with previous studies.10,11 Although the pathophysiological mechanisms underlying the association remained incompletely understood, several shared pathways might be considered, such as neuroinflammation and neural alterations.22–24 Existing research suggested that several brain regions engaged in chronic pain were shared with those implicated in depression, which served an essential role in regulating emotion and nociceptive processes.25,26 Additionally, pain-related disruptions in daily life may further predispose individuals to depressive symptoms. Several longitudinal studies have indicated that sleep impairment was associated with an increased risk of depression.27–29
Our study further examined activity limitation and the reported impact of chronic pain on family members and significant others. Persistent limitations in daily activities may reduce physical activity and social participation.30,31 The family-impact analysis provided exploratory findings on the interpersonal burden of chronic pain, which has received less attention in population-based longitudinal studies. Among individuals experiencing these conditions, the lack of interpersonal relationships and inadequate emotional support may further exacerbate psychological vulnerability, thereby increasing the likelihood of developing depressive symptoms.32,33 These findings suggest that the association between chronic pain and newly reported frequent feelings of depression might be driven not only by nociceptive intensity but also by interference with functional capacity and social roles.
These findings emphasized the importance of incorporating psychological assessment and social support into the management of chronic pain. Recent studies have suggested that psychological interventions, such as cognitive-behavioral therapy, may improve both pain and mood outcomes.34–36 Some antidepressants, including serotonin-norepinephrine reuptake inhibitors (SNRIs) and tricyclic antidepressants, have demonstrated benefits in managing both pain and depression.37,38 Importantly, our findings supported that pain management should consider both physical symptoms and interpersonal factors, as combined psychological and behavioral interventions may provide greater overall benefit.
The timing of the follow-up should also be considered. The 2020 NHIS interviews were conducted during the COVID-19 pandemic, a period characterized by changes in social contact, employment, healthcare access, family responsibilities, and daily routines that may have influenced both depressive feelings and the experience of living with chronic pain. The sensitivity analyses indicated that the association was relatively consistent across the August–December 2020 interview period.
Limitations
Nevertheless, several limitations should be noted. First, the Patient Health Questionnaire-8 (PHQ-8), recognized as a reliable and validated tool to assess depression, was not included in the 2020 survey.39 The depressive symptoms were assessed with self-reported frequencies. Some participants with a previous history of depression, including subthreshold, treated, remitted or recurrent cases might be not identified. Potential outcome misclassification may introduce some bias, therefore, the reported feeling depressed daily and weekly should be interpreted as newly reported frequent feelings of depression rather than incident depression. Second, the self-reported measures on chronic pain and feelings of depression in the NHIS may suffer from some potential bias, such as recall bias. Third, although we have adjusted for demographic, health-related, and socioeconomic factors, some potential confounders may not be fully explored. Fourth, although sensitivity analyses have confirmed the robustness of our results, potential bias arising from missing data could not be excluded. Last, the 2019 baseline interview was conducted primarily in person, however, the 2020 follow-up was completed by telephone during the COVID-19 pandemic. The changes in interview and the effect of the COVID-19 pandemic could have confounded or modified the observed association.
Conclusions
In this nationally representative cohort study, chronic pain was associated with a higher likelihood of newly reported frequent feelings of depression. These findings highlight the importance of integrating psychological assessment and family support into chronic pain management.
Acknowledgment
Han Zang and Tianchun Li contributed to the work equally and should be regarded as co-first authors.
Funding Statement
The study was funded by the National Natural Science Foundation of China (82271262).
Abbreviations
NHIS, National Health Interview Survey; HICP, high-impact chronic pain; ICD-11, International Classification of Diseases-11; IASP, International Association for the Study of Pain; BMI, body mass index; CAD, coronary artery disease; COPD, chronic obstructive pulmonary disease; RR, risk ratio; CI, confidence interval; SNRI, serotonin-norepinephrine reuptake inhibitor; PHQ-8, Patient Health Questionnaire-8; FPL, federal poverty level.
Data Sharing Statement
The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request.
Ethics Approval and Consent to Participate
The NHIS study was reviewed and approved by the National Center for Health Statistics Research Ethics Review Board, and informed consent was obtained from all the participants. The present study was a secondary analysis of publicly available, de-identified data and was approved by the Institutional Review Board of the Peking Union Medical College Hospital (Ethics Approval Number: I-26ZM0072). The study was conducted according to the guidelines of the Declaration of Helsinki and followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for reporting cohort studies.
Consent for Publication
Consent for publication was deemed not applicable.
Disclosure
The authors declare that they have no competing interests. Data for this study were obtained from the National Health Interview Survey, conducted by the National Center for Health Statistics, Centers for Disease Control and Prevention. The analyses, interpretations, and conclusions presented in this study are those of the authors and do not represent the views of the National Center for Health Statistics, which is responsible only for the initial data.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request.