Visual analog scale and beck depression inventory assessing the clinical correlation of backache with depression

Muhammad Nadeem; Salman Mansoor; Shoab Saadat; Nadia Mehboob; Hamza Hassan Khan; Salman Assad; Bazeela Saeed; Anam Saleem; Anam Zehra; Ahmed Shah Bukhari

doi:10.4103/ts.ts_6_18

ORIGINAL ARTICLE

Year : 2018 | Volume : 3 | Issue : 2 | Page : 38-41

Visual analog scale and beck depression inventory assessing the clinical correlation of backache with depression

Muhammad Nadeem¹, Salman Mansoor², Shoab Saadat³, Nadia Mehboob³, Hamza Hassan Khan³, Salman Assad³, Bazeela Saeed⁴, Anam Saleem⁴, Anam Zehra⁴, Ahmed Shah Bukhari³
¹ Department of Neurosurgery, Shifa International Hospital, Islamabad, Pakistan
² Department of Neurology, Cork University Hospital, Wilton, Cork, Ireland
³ Department of Medicine, Shifa International Hospital, Islamabad, Pakistan
⁴ Department of Medicine, Islamabad Medical and Dental College, Islamabad, Pakistan

Date of Submission	23-Mar-2018
Date of Acceptance	06-Jun-2018
Date of Web Publication	27-Jun-2018

Correspondence Address:
Dr. Salman Mansoor
Cork University Hospital, Wilton, Cork
Ireland

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/ts.ts_6_18

Abstract

Aim: Patients with chronic pain mostly suffer from additional psychiatric condition especially depression. The aim of this study is to determine a relation between depression and backache. Methods: We conducted a study between January 2015 and November 2015 at a tertiary care hospital in Islamabad, Pakistan. The study included 165 adult patients (≥20 years) with backache and were interviewed at the neurosurgery clinic. Visual analog scale (VAS) and Beck depression inventory (BDI) scores were analyzed. Results: According to VAS, 11.5% patients had mild, 67.2% patients had moderate, and 21.8% patients had severe backache. A striking difference in the frequency of depression was observed between the genders, 67.8% in females compared to 32.2% in males. BDI scores showed 12.1% normal, 13.9% mild, 3% borderline, 26% moderate, 24.8% severe, and 19.3% extreme depression. A statistically significant correlation was observed between severity of backache and depression (P < 0.003). Conclusion: A high number of patients suffering from backache also demonstrated mild to extreme depression. We recommend screening for depression among these patients to achieve a better treatment outcome.

Keywords: Backache, beck depression inventory, depression, visual analog scale

How to cite this article:
Nadeem M, Mansoor S, Saadat S, Mehboob N, Khan HH, Assad S, Saeed B, Saleem A, Zehra A, Bukhari AS. Visual analog scale and beck depression inventory assessing the clinical correlation of backache with depression. Transl Surg 2018;3:38-41

How to cite this URL:
Nadeem M, Mansoor S, Saadat S, Mehboob N, Khan HH, Assad S, Saeed B, Saleem A, Zehra A, Bukhari AS. Visual analog scale and beck depression inventory assessing the clinical correlation of backache with depression. Transl Surg [serial online] 2018 [cited 2018 Jul 22];3:38-41. Available from: http://www.translsurg.com/text.asp?2018/3/2/38/235395

Introduction

Backache is a symptom with which patients commonly visit healthcare facilities.^[1],[2] It is one of the most common presenting symptoms in an outpatient setting and is usually under-treated and underestimated.^[3],[4] Approximately 65%-85% of people suffer from severe backache at least once in their lifetime.^{[1],[2],[5],[6]} The impact of backache ranges from a temporary disability to persistent symptoms and major disability, which pose significant economic consequences in work and seeking healthcare.^{[2],[5],[7],[8],[9],[10]} Prolonged backache is said to be associated with a number of psychiatric symptoms, of which depression is among the most commonly reported problem (30%-60%).^{[1],[3],[4],[5],[6],[8],[9],[10],[11],[12]} Depression is the second most common cause of disability-adjusted life years in the age category of 15-44 years, affecting about 120 million people.^[13] Cost of medical treatment for chronic lower backache with depression is found to be 2.8 times higher than those without depression.^[14] Therefore, early screening for depression is to be employed in patients with backache for a better treatment outcome.^{[8],[9],[12],[15],[16]} The current study was conducted to find a correlation of backache with depression in the local population.

Methods

This is a 6-month cross-sectional survey conducted from June 2015 to December 2015 at a tertiary care hospital in Islamabad, Pakistan. The study included 165 adult patients (age ≥20 years) with complaints of backache presenting to neurosurgery, neurology, and orthopedics out-patient departments. Patients with other comorbid diseases such as diabetes mellitus, liver diseases, ischemic heart diseases, renal diseases, and malignancies were excluded based on history and investigation. Patients with previous history of psychiatric disorders were also excluded from the study.

All procedures performed in the present study, involving human participants, were in accordance with the ethical standards of the Institutional and/or National Research Committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.

According to the published literature, the prevalence of depression was 30% among backache patients. Thus, the sample size was calculated to be 165 using WHO sample size calculator, with a 95% confidence interval and precision of ±7%. Assuming that depression would be 60% among severe backache patients and 30% among mild backache patients, the sample size was determined to be 54. After obtaining informed consent, the study was carried out till the required number of patients was surveyed. Pain score was calculated through visual analog pain scale (VAS) as shown in [Table 1]. Depression score was calculated through Beck depression inventory (BDI) as shown in [Table 2]. Data were analyzed using the SPSS 20 (IBM, Armonk, NY, USA).

Table 1: Visual analog scale

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Table 2: Beck depression inventory scores

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Results were mostly presented in frequencies and percentages. Descriptive statistics, Chi-square analysis, and ordinal regression analysis were used to determine whether there was statistically significant correlation between severity of a backache and severity of depression.

Results

Out of 165 patients, 116/165 (70%) patients had moderate-to-severe depression. Gender bias was observed where females were more prone to backache with depression - 112/165 (67.8%), than males - 53/165 (32.2%). Younger age group (21-35 years) had more backache complaints (BDI scores in severe and extreme range) associated depression - 31/71 (43.6%), compared to older age groups (36-50 years) - 26/67 (38.8%), as shown in [Table 3]. On visual analog scale, 19/165 (11.5%) patients had mild, 111/165 (67.2%) patients had moderate, and 36/165 (21.8%) patients had severe backaches, data shown in [Table 4]. BDI scores showed that 21/165 (12.1%) normal, 23/165 (13.9%) mild, 5/165 (3%) borderline, 43/165 (26%) moderate, 41/165 (24.8%) severe, and 32/165 (19.3%) extreme depression [Table 4]. A statistically significant correlation was established between severity of backache and severity of depression (P< 0.003).

Table 3: Age - Beck Depression Inventory scores

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Table 4: Visual analog scale - Beck Depression Inventory scores

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Ordinal regression analysis was done on the data to evaluate the relationship between backache as an explanatory variable and depression as the response variable and vice versa [Table 5]. Age and gender were treated as control variables to assess their impacts on the estimation model. When backache was treated as the explanatory variable, model fitting was significant with an insignificant goodness of fit. Test of parallel lines was also insignificant. With the Nagelkarke Pseudo R² of 0.117, this model was able to predict only 11% of the variation in response variable. Low BDI scores were found associated with mild VAS scores while controlling for all other variables, and this relationship was significant (P = 0.002). Males were also less likely to have backache compared to females (P = 0.03). Backache patients aged 21 years and above were more likely to have depression with increasing age (P = 0.03) after adjusting for all other variables. A counter-analysis with depression as explanatory variable and backache as response variable was also performed that showed significant relationship at normal, mild, moderate, and severe depression levels, inferring that depression may itself be a cause of backache in a subset of population and may contribute up to 18% of backache among people with depression (Nagelkerke Pseudo R² = 0.186). In addition, it showed no significant relationship of age as a covariate with depression.

Table 5: Parameter estimates of backache and depression

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Discussion

Pain is a subjective feeling or experience mediated by an individual's own psychological state whenever he or she receives a painful stimulus.^[1] Chronic backache is a problem that is experienced by a large number of people and depression accompanies backache very frequently.^[3],[4],[5] The prevalence of depression in patients with backache is approximately three to four times higher as compared to general population.^[17] Pain-induced depression is responsible for long-term disability in patients with backache.^[3] Several studies have investigated the correlation between these two entities and have assessed the impact of depression on pain outcomes.^[18],[19]

Studies have revealed that the added morbidity of depression in combination with backache is associated with more severe pain, more pain sites, increased duration of pain, and cause more disability than either depression or chronic backache alone.^[9] There are only a few studies on chronic pain and depression conducted in general population using the same methodology as in our study.^{[20],[21],[22]} Consistent with population-based studies in other countries, our study showed that a significant impact of age and gender on depression in person with or without backache.^{[23],[24],[25]}

Chronic backache patients often do not realize that they are suffering from depression. It is important for patient as well as physician to get detailed history to not miss the diagnosis of depression. It is accepted almost worldwide that the pain and the depression should be treated side-by-side in a multidisciplinary fashion.^[26] When the diagnosis of depression is missed in the chronic backache patients, treatments targeting pain are much more likely to fail. It has been proved by the studies that combined treatment of both conditions showed better outcomes than either of the interventions alone.^[27] Our study results showed that, in the local population, an increase in backache was found associated with increase in depression.

Wang et al.^[28] reported that the risk of depression increases in a linear fashion with pain severity. Our data showed similar results; 21/165 (12.1%) normal, 23/165 (13.9%) mild, 5/165 (3%) borderline, 43/165 (26%) moderate, 41/165 (24.8%) severe, and 32/165 (19.3%) extreme depression as depicted in [Table 3]; 116/165 (70.3%) patients with moderate-to-extreme depression had mild-to-severe pain on VAS. On the other hand, 28/165 (16.9%) patients with mild-to-borderline clinical depression had mild-to-severe backache on VAS; 36/165 (21.8%) patients had both depression and pain of moderate intensity; 21/165 (12.7%) patients had mild-to-severe backache but no depression afterward.

Ordinal/logistic regression analysis showed that there can be a mutual possible cause-effect relationship between backache and depression. When treating backache as the predictor variable, it was found that lower scores of backache were significantly associated with less depression; however, the relationship between higher backache scores and more depression were not statistically significant. Females were more likely to get depressed than males, and older people were also more likely to be depressed than younger people, while controlling for other covariates.

Our study had few limitations. First, it was a cross-sectional survey, and it was difficult to correlate backache and depression as a simple cause-effect relationship. The data were also skewed in favor of a larger female population 119/165 (72.1%) which may also be a reason contributing to a greater prevalence of depression in the female patients. There were also not enough covariates to explain 89% of the variation in the model. There was also a greater population (83.6%) in the range of 21-50 years of age, again contributing to the skewness, thus limiting generalizability to the older population in particular. A low R² (11%) meant that there are other covariates that could have been added for a better fit of the model. The application of the results to the whole population needs to be further studied through large population-based studies with the representation of people from different backgrounds. Factors such as socioeconomic status, diet, living conditions, history of psychiatric disease, drug abuse, education, daily exercise, duration of sleep, quality of life, and recent loss of a relative and many other covariates can be assessed along with the ones studied in this study to obtain a more realistic picture of how well backache can explain presence of depression in a person.

In conclusion, depression is highly prevalent in patients with backache; however, cause-effect relationship is yet to be established. This study points toward how backache can be an important factor leading to depression especially in female population and need to be specially screened. Associated depression in patients with backache should be recognized early to get an optimal response to treatment.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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