Welcome back to Spine IQ’s BackBlog! Last week, we discussed the relationship between stress and pain. This week, we will continue the discussion surrounding psychological comorbidities and their clinically relevant association with pain, which is often overlooked by clinicians dealing with the physical aspect, by focusing on depression and anxiety. The current prevalence of depression globally is about 280 million adults or 5% of all adults.1 Approximately 31% of people are expected to have an anxiety disorder at some point during their life time.2 Adding in the high prevalence of musculoskeletal pain and there is a lot of overlap between depression, anxiety, and pain. In fact, pain is commonly found in about 70% of people with depression or anxiety disorders.3,4

The relationship between pain and anxiety/depression is likely to be bidirectional. People with pain can become fear avoidant leading to more social isolation and work loss that can develop into depression or anxiety. Additionally, people with depression or anxiety may develop poor coping strategies or behaviors that can increase their likelihood of experiencing pain. This makes depression and anxiety important conditions to be aware of when treating people with pain. In this blog, we will discuss the evidence and clinical implications for conservative spine clinicians surrounding the relationship between anxiety, depression, and pain.

Depression and/or anxiety leading to pain

Depression and anxiety can lead people to being hyperaware of potential threat and subsequent avoidance of activities. This fear avoidance due to depression and anxiety is a risk factor for pain. When people with depression or anxiety report having comorbid pain, clinicians tend to focus more on the physical symptoms (pain) and focus less on psychological symptoms (depression and anxiety). This leads to people presenting with comorbid depression/anxiety and pain having a lower likelihood to have an accurate recognition and diagnosis of their psychological conditions. It is important for clinicians to always remember Hickam’s dictum, which states “patients can have as many diseases as they please.” Clinicians should rigorously assess patients presenting with pain for psychological symptoms (depression and anxiety and be prepared for patients to be able to present with both physical (pain) and psychological (depression and anxiety) conditions. In a previous blog we described yellow flag screening tools that clinicians can use in their office to screen for psychological conditions. People with depression and/or anxiety are more likely to have disabling pain. Specifically, a study found that compared to people with no depression or anxiety, people with remitted depression/anxiety are 3.53 times more likely to have disabling pain, people with depression are 6.67 times more likely to have disabling pain, people with anxiety are 4.84 times more likely to have to have disabling pain, and people with depression and anxiety are 30.26x more likely to have disabling pain.5 People with comorbid depression/anxiety and pain that are being treated for their depression and/or anxiety are less likely to benefit from the treatment compared to people with depression and/or anxiety without pain.

Pain leading to depression and/or anxiety

Pain has a unique way of being detrimental and burdensome to people’s lived experiences. Pain can become disabling, which leads to people not being able to do the things that they love. This can lead to higher likelihood of experiencing depression or anxiety. In fact, compared to people without pain, people with pain are 2.28 more likely to have remitted anxiety, 2.64 times more likely to have depression, 2.29 more likely to have anxiety, and 3.88 times more likely to have depression and anxiety.5


Conservative spine clinicians must begin to acknowledge the high likelihood that patients with pain are likely to have depression and/or anxiety that may be undiagnosed. Decreasing pain with conservative care may help depression and anxiety symptoms. However, clinicians can discuss with their patients when depression and/or anxiety symptoms may need referral or co-management with psychological clinicians. Having relationship(s) with psychological clinicians is equally as important as relationships with Orthopedic, cardiologists, neurologists, etc. not just for potential referral/co-management of patients seeking care for pain presenting with comorbid depression and/or anxiety but also for patients seeking care for depression/anxiety presenting with comorbid pain. Discussing with psychological clinicians that treatment for depression and/or anxiety is less effective when patient has comorbid pain can lead to referrals and co-management of these patients, which will lead to greater value and treatment effect both for the physical (pain) and psychological (depression and anxiety) conditions.


  1. Depression. Accessed May 1, 2022. https://www.who.int/news-room/fact-sheets/detail/depression
  2. Bandelow B, Michaelis S. Epidemiology of anxiety disorders in the 21st century. Dialogues Clin Neurosci. 2015;17(3):327-335.
  3. Bair MJ, Robinson RL, Katon W, Kroenke K. Depression and Pain Comorbidity: A Literature Review. Arch Intern Med. 2003;163(20):2433-2445. doi:10.1001/archinte.163.20.2433
  4. Impact of pain on the course of depressive and anxiety disorders – PubMed. Accessed July 20, 2021. https://pubmed-ncbi-nlm-nih-gov.palmer.idm.oclc.org/22154919/
  5. de Heer EW, Gerrits MMJG, Beekman ATF, et al. The Association of Depression and Anxiety with Pain: A Study from NESDA. PLoS ONE. 2014;9(10):e106907. doi:10.1371/journal.pone.0106907