Musculoskeletal (MSK) conditions are among the most common causes of disability in the UK, with estimates indicating that they account for 30.5% of all years lived with disability. Such conditions are not only associated with pain and disability but can also have a significant impact on well-being and quality of life. In fact, estimates suggest that depression is around 3-4 times more prevalent in people with MSK conditions when compared with the general population.
Some studies have found distress and depression to be a predictor of the transition to persistent pain. Patients with persistent pain and mental health symptoms, including depression, are most commonly managed in primary care settings. Yet, evidence suggests that in some circumstances it may be difficult to distinguish between depression and distress.
It is unclear how GPs currently work with and support people with pain and distinguish between pain-related distress and depression. Care practitioners should be aware of this distinction to better detect mental health problems (especially depression) while avoiding the over-treatment of distress with antidepressants and/or other unacceptable or inappropriate interventions.
For people living with persistent pain, the effective management of psychological and social symptoms arising from their condition is often considered equally important as pain management itself. It is, therefore, essential that primary care providers can distinguish between depression and pain-related distress in order to identify the most suitable treatment. A recent qualitative study aimed to understand pain-related distress and depression from the perspectives of people with persistent musculoskeletal pain and GPs.
Design and Methods of the Study
This study employed semi-structured interviews with both patients and GPs. The design and analysis of the study were developed with input from a patient advisory group (PAG) and a GP stakeholder group also contributed to the study design. People with persistent pain were recruited using advertisements in public areas, social media posts, local radio, and identification through general practice registers. GPs were recruited using social media and professional networks, as well as through local clinical research networks (CRNs).
Eligible participants were provided with participant information leaflets about the study before consenting to participate. Interviews were then held either via telephone or using virtual software (such as Microsoft Teams). Interviews were conducted by two experienced health services researchers with expertise in qualitative methods.
Results of the Study
A total of 21 interviews were carried out with people with persistent pain, and 21 more with GPs. The interviewers and researchers identified three main themes throughout the data collected: ‘pain and distress are interlinked’, ‘being stuck’, and ‘moving forwards’. An overarching thread of ‘recognising and dealing with uncertainty’ was also found to underpin all the themes.
Distress and Pain are Interlinked
All participants noted how distress and pain are inseparable from one another: “distress was seen as a reaction to, and impact of, persistent pain.” Participants with persistent pain reflected how pain impacted every aspect of their lives, from being unable to perform daily chores or pleasurable activities to becoming dependent on others.
Persistent pain was also seen to have an impact on mood – as one participant explained: “If I have a bad day and all of it hurts, I can get quite upset. It does affect my mood. It irritates me that I can’t cut my toenails properly and when I’m in the shower. Like I say, it’s putting socks on and things like that. It just makes you so fed up.”
Pain, Distress, and Depression
GPs also recognised the impact of persistent pain on mood and physical ability. One GP noted: “They have very restricted lives quite often, they are very limited, they become very deconditioned, they are often having others in the family playing a caring role, even children. And there’s an overlap with fatigue and its quite severe emotional distress and they know we can’t make it better…”
Participants acknowledged the difficulty in distinguishing between distress and depression, with both people with persistent pain and GPs likening the link between persistent pain, distress, and depression to a “cycle” or “spectrum”. For example, one GP stated: “I don’t think there is a clear distinction. I think it’s a spectrum. So, distress merges into depression. There’s not a hard and fast distinction.”
Patients recruited from primary care considered their emotional experience to be different to their perceived notions of ‘actual’ depression or mental illness.
This finding supports previous evidence that has established the difficulties that GPs face in distinguishing between pain-related distress and depression. Some GPs conceptualised pain-related distress as a medical disorder needing treatment while others suggested that distress was a normal response to pain. Both GPs and patients expressed having limited expectations of what could be done to help patients manage their pain and deal with distress, tying in with the identified themes of ‘being stuck’ and ‘moving forwards’.
Some GPs described how identifying the cause of low mood might help them to distinguish between distress and depression. For example, distress can be categorised as emotional upset that is linked to a specific thing, while depression may apply to a more generalised feeling of low mood. Some GPs also used severity scales, such as the Patient Health Questionnaire-9 (PHQ-9) to help them make this distinction.
Participating GPs expressed an understanding of the importance of making sure patients felt heard and understood, with many illustrating how “listening could be used as one of the strategies to manage patients with persistent pain.” However, patient experiences contrasted between feeling “brushed off by my GP” and experiencing positive consultations and feeling understood by GPs.
The insights gathered through patient and GP interviews in this study offer a framework for primary care consultations for patients presenting with pain-related distress. The authors conclude that this framework “incorporates hearing the patient’s story, recognising and empathising with the impact of pain on the patient, supporting the person in coming to terms with their pain, exploring how the person feels about the future and encouraging optimism and engagement with self-management strategies.”
They also note that the key to this is for GPs to recognise and manage their own and their patient’s uncertainty regarding the cause of their pain, in addition to trying to distinguish between distress and depression. The authors of this study conclude with the hope that “this framework, developed with a PAG, will support GPs in managing this group of patients, leading to improved satisfaction for both GPs and patients.”