Pain and the onset of depressive and anxiety disorders Marloes M.J.G. Gerrits a,b,⇑ , Patricia van Oppen a,b , Harm W.J. van Marwijk b , Brenda W.J.H. Penninx a,c,d , Henriëtte E. van der Horst b a Department of Psychiatry, EMGO Institute for Health and Care Research, VU University Medical Center and Academic Outpatient Clinic for Affective Disorders, GGZ inGeest, Amsterdam, The Netherlands b Department of General Practice and Elderly Care Medicine, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands c Department of Psychiatry, Leiden University Medical Center, The Netherlands d Department of Psychiatry, University Medical Center Groningen, The Netherlands Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article. article info Article history: Received 25 April 2013 Received in revised form 23 August 2013 Accepted 3 September 2013 Keywords: Anxiety disorder Depressive disorder Incidence Pain Self-report abstract Patients with pain may be at increased risk of developing a first episode of depressive or anxiety disorder. Insight into possible associations between specific pain characteristics and such a development could help clinicians to improve prevention and treatment strategies. The objectives of this study were to examine the impact of pain symptomatology on depression and anxiety onset and to determine whether these associations are independent of subthreshold depressive and anxiety symptoms. Data from the Netherlands Study of Depression and Anxiety, collected between 2004 and 2011, were used. A total of 614 participants with no previous history and no current depression or anxiety at baseline were followed up for 4 years. Onset of depressive or anxiety disorder was assessed at 2- and 4-year follow-up by Com- posite International Diagnostic Interview. Baseline pain characteristics were location, duration, and severity, as assessed by chronic pain grade. Onset of depressive or anxiety disorder occurred in 15.5% of participants. Using Cox survival analyses, onset of depression and anxiety was associated with 6 pain locations (neck, back, head, orofacial area, abdomen, and joints; hazard ratio [HR] = 1.96 to 4.02; P < .05), increasing number of pain locations (HR = 1.29; P < .001), and higher severity of pain (HR = 1.57; P < .001). By contrast, there was no association with duration of pain symptoms (HR = 1.47; P = .12). Independent of subthreshold affective symptoms, only joint pain and increasing number of pain locations were still sig- nificantly associated with depression and anxiety onset. Clinicians should be aware that regardless of affective symptoms, pain, particularly at multiple locations, is a risk indicator for developing depressive and anxiety disorders. Ó 2013 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved. 1. Introduction Pain is usually defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage [43]. Pain is associated with functional impairment, (social) disability [44], pain-related anxiety, and even anxiety sensitivity, the tendency to catastrophically misinterpret anxiety sensations [38], which have all been linked to an increased development of depres- sive as well as anxiety disorders [12]. Data from epidemiological studies also suggest that pain could be a risk indicator for depres- sive and anxiety disorder onset [5,18,24], but we know little about the specifics of such a relationship. The emotional, economic, and societal burden of pain and depressive and anxiety disorders, separately and conjointly, is high [6,8,21,54]. An estimate of the contribution of pain to the onset of depressive and anxiety disorders could support the development of new management strategies in clinical practice. There are several methodological issues that hamper a sound estimation of this relationship. Firstly, most current studies are based on the onset of depressive or anxiety symptoms [4,13,22,24,33,34], but not all individuals with symptoms will ultimately develop a disorder [2,15,26]. Pain was found to be associated with increased risk of depressive and anxiety symp- tom onset in these studies, with 1 exception [33]. Secondly, most of these studies use a single determinant of pain, such as location (joints [34], neck, back [13], unspecified [22]) or interference with daily life [4,24], to examine the impact on depression and anxiety onset. Two studies showed that having pain at a particu- 0304-3959/$36.00 Ó 2013 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.pain.2013.09.005 ⇑ Corresponding author. Address: Department of General Practice, VU University Medical Center and EMGO+ Institute for Health and Care Research, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands. Tel.: +31 20 4446116; fax: +31 20 4448361. E-mail addresses: m.gerrits@ggzingeest.nl, mj.gerrits@vumc.nl (M.M.J.G. Ger- rits). PAIN Ò 155 (2014) 53–59 www.elsevier.com/locate/pain