|Year : 2018 | Volume
| 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|
Dr. Salman Mansoor
Cork University Hospital, Wilton, Cork
Source of Support: None, Conflict of Interest: None
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 Nov 17];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., It is one of the most common presenting symptoms in an outpatient setting and is usually under-treated and underestimated., Approximately 65%-85% of people suffer from severe backache at least once in their lifetime.,,, 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.,,,,, 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%).,,,,,,,,, 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. Cost of medical treatment for chronic lower backache with depression is found to be 2.8 times higher than those without depression. Therefore, early screening for depression is to be employed in patients with backache for a better treatment outcome.,,,, 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).
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).
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.
| Discussion|| |
Pain is a subjective feeling or experience mediated by an individual's own psychological state whenever he or she receives a painful stimulus. Chronic backache is a problem that is experienced by a large number of people and depression accompanies backache very frequently.,, The prevalence of depression in patients with backache is approximately three to four times higher as compared to general population. Pain-induced depression is responsible for long-term disability in patients with backache. Several studies have investigated the correlation between these two entities and have assessed the impact of depression on pain outcomes.,
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. There are only a few studies on chronic pain and depression conducted in general population using the same methodology as in our study.,, 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.,,
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. 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. Our study results showed that, in the local population, an increase in backache was found associated with increase in depression.
Wang et al. 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
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ehrlich GE. Low back pain. Bull World Health Organ
Hincapié CA, Cassidy JD, Côté P. Is a history of work-related low back injury associated with prevalent low back pain and depression in the general population? BMC Musculoskelet Disord
Shuchang H, Mingwei H, Hongxiao J, Si W, Xing Y, Antonius D, Opler M. Emotional and neurobehavioural status in chronic pain patients. Pain Res Manag
Kroenke K, Bair MJ, Damush TM, Wu J, Hoke S, Sutherland J, Tu W. Optimized antidepressant therapy and pain self-management in primary care patients with depression and musculoskeletal pain: A randomized controlled trial. JAMA
Dunn KM, Jordan KP, Croft PR. Contributions of prognostic factors for poor outcome in primary care low back pain patients. Eur J Pain
Ha JY, Kim ES, Kim HJ, Park SJ. Factors associated with depressive symptoms in patients with chronic low back pain. Ann Rehabil Med
Walid MS, Zaytseva N. The relationship of unemployment and depression with history of spine surgery. Perm J
Wang H, Ahrens C, Rief W, Schiltenwolf M. Influence of comorbidity with depression on interdisciplinary therapy: Outcomes in patients with chronic low back pain. Arthritis Res Ther
Bair MJ, Wu J, Damush TM, Sutherland JM, Kroenke K. Association of depression and anxiety alone and in combination with chronic musculoskeletal pain in primary care patients. Psychosom Med
Mngoma N, Corbière M, Stevenson J. Pain profiles and psychosocial distress symptoms in workers with low back pain. Physiother Can
Wang H, Ahrens C, Rief W, Gantz S, Schiltenwolf M, Richter W. Influence of depression symptoms on serum tumor necrosis factor-α of patients with chronic low back pain. Arthritis Res Ther
Trivedi MH. The link between depression and physical symptoms. Prim Care Companion J Clin Psychiatry
2004;6 (Suppl 1):12-6.
Reddy MS. Depression: The disorder and the burden. Indian J Psychol Med
Sheehan DV. Establishing the real cost of depression. Manag Care
2002;11 8 Suppl: 7-10.
Airaksinen E, Wahlin A, Larsson M, Forsell Y. Cognitive and social functioning in recovery from depression: Results from a population-based three-year follow-up. J Affect Disord
Pfingsten M, Schöps P. Low back pain: from symptom to chronic disease. Z Orthop Ihre Grenzgeb
Middleton P, Pollard H. Are chronic low back pain outcomes improved with co-management of concurrent depression? Chiropr Osteopat
Sullivan MJ, Reesor K, Mikail S, Fisher R. The treatment of depression in chronic low back pain: Review and recommendations. Pain
Patten SB. Long-term medical conditions and major depression in the Canadian population. Can J Psychiatry
Currie SR, Wang J. Chronic back pain and major depression in the general Canadian population. Pain
Magni G, Caldieron C, Rigatti-Luchini S, Merskey H. Chronic musculoskeletal pain and depressive symptoms in the general population. An analysis of the 1st
National Health and Nutrition Examination Survey data. Pain
Wilson KG, Mikail SF, D'Eon JL, Minns JE. Alternative diagnostic criteria for major depressive disorder in patients with chronic pain. Pain
Blazer DG, Kessler RC, McGonagle KA, Swartz MS. The prevalence and distribution of major depression in a national community sample: The National Comorbidity Survey. Am J Psychiatry
De Marco RR. The epidemiology of major depression: Implications of occurrence, recurrence, and stress in a Canadian community sample. Can J Psychiatry
Kessler RC, Berglund P, Demler O, Jin R, Koretz D, Merikangas KR, Rush AJ, Walters EE, Wang PS; National Comorbidity Survey Replication. The epidemiology of major depressive disorder: Results from the National Comorbidity Survey Replication (NCS-R). J Am Med Assoc
Pampallona S, Bollini P, Tibaldi G, Kupelnick B, Munizza C. Combined pharmacotherapy and psychological treatment for depression: A systematic review. Arch Gen Psychiatry
Von Korff M, Simon G. The relationship between pain and depression. Br J Psychiatry
Tang NK, Salkovskis PM, Hodges A, Wright KJ, Hanna M, Hester J. Effects of mood on pain responses and pain tolerance: An experimental study in chronic back pain patients. Pain
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]