Depression and anxiety as major determinants of neck pain: a cross-sectional study in general practice
From: BMC Musculoskelet Disord. 2009 Jan 26;10(1):13. [Epub ahead of print]
Neck pain is a highly prevalent condition with about two thirds of the adult population affected at some time in their lives. Unspecific neck pain usually resolves within days, but in 10% neck pain recurs or persists.
Recent Cochrane reviews have investigated the effects of therapeutic options such as exercise, manipulation and mobilisation, acupuncture, medicinal and injection therapies. The authors conclude that there is too little evidence to recommend for or against these non-psychosocial therapeutic options focusing on somatic symptoms. However, these therapies have recently been recommended by the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders and are widely used in primary care. Albeit, their availability might lead to medicalisation which carries the dangers of unnecessary labelling, iatrogenic illness and economic waste. Key mechanisms of medicalisation are patients’ fears about the condition or disease as well as drawing attention on somatically based therapeutic options and possibly disregard of any psychosocial causes behind the musculoskeletal pain. Moreover, somatically based therapies may be associated with adverse events and, if ever possible, patients must be preserved from unnecessary harm.
A large body of evidence shows that patient characteristics such as psychosocial factors are determinants, risk factors and prognostic factors of neck pain. However, this knowledge has not yet been integrated in recommendations to primary care physicians on how to handle their patients with common neck pain. Given the unclear benefit of the existing neck pain therapies and given the inadequate consideration of psychosocial patient characteristics in clinical guidelines, further research is needed on which patients might rather benefit from psychosocial interventions than from immediate somatically based therapies such as medicinal or manipulatory therapy. Therefore, it is essential to identify patients with psychosocial distress such as anxiety or depression, with particular regard to the possible influence of patients’ fears on physicians’ prescription behaviour. This study aims to identify socio-demographic, psychosocial, medical history and health promoting lifestyle factors which might interact with neck pain.
This study suggests that various non-medical factors are closely linked to recurrent or persistent neck pain in a general practice population. Of these, psychosocial distress, specifically depression and anxiety, play a major role. These results emphasise the importance of expanding assessment of especially psychosocial factors for management of neck pain in general practice.
Crude analyses indicated markers for those patients with relevant levels of neck pain. Basic education, depression, anxiety, deficits in social support and infrequent physical exercise were linked to higher levels of neck pain, representing characteristics relatively easy to assess in general practice. Furthermore, the adjusted model suggested depression and anxiety being major determinants of neck pain. Deficits in social support, basic education and infrequent exercise, in contrast, were not linked with neck pain in the adjusted model. This may indicate that social support and exercise are confounding factors and that variability in neck pain levels is intrinsically explained by psychosocial characteristics.
In fact, results from this study are coherent with what is known from previous research. A recent systematic review investigated determinants and risk factors for neck pain in the general population and found consistent evidence only for psychological health factors and for other health problems like musculoskeletal complaints and poorer self-rated health. This indicates that high-level evidence was reproduced by this study, and that results derived in a general practice setting using practical self-administered instruments are very likely to be valid.
The present findings have research implications relevant for developing improved clinical guidelines for the assessment and management of neck pain in general practice. Future research into the effects of interventions to improve neck pain in general practice settings should include differentiated measures of psychosocial factors such as those used in this study. Future research should focus on targeted interventions for the differing subgroups of neck pain patients. Of course, not only somatically based therapies but also psychosocial interventions have their drawbacks. Upcoming studies should therefore evaluate not only efficiency but also risks and harms of both types of interventions. The scientific basis of decision trees for general practitioners to guide them in choosing psychosocial and/or somatically based therapies for their patients is certainly needed. This will further our understanding of the nature of psychosocial determinants of neck pain, and guide future strategies for relief or cure of neck pain.
The present study suggests that the degree of neck pain was gradually related to psychosocial distress and that different levels of neck pain might discriminate patients with different degrees of psychological distress. To put it in other words: the higher the pain level in patients with cervical problems, the more attention should be paid to psychosocial distress as an additional burden. Moreover, the instruments used to operationalise depression and anxiety and neck pain are suitable for assessment in general practice populations. These are self-administered instruments easy-to-score and to interpret so that application in busy general practice settings is not timeconsuming. All instruments are validated for the use in general practice patients. By using these instruments for example, general practitioners are able to identify these groups of patients, e.g. those identified as depressive or anxious, for whom psychosocial factors play an obvious role in their neck pain condition and in whom somatically based therapies only are very unlikely to be effective.
Findings of this study underline the need for further research that determines whether neck pain therapies are more likely to be efficient if care for patients is not only symptom oriented but focuses on psychosocial factors.
