Back pain with symptoms of anxiety and depression

Ross Hauser, MD and Danielle Matias, PA-C

It is hard to imagine that there is limited research and sometimes a debate as to whether depression and anxiety play an important role in back pain. But there is. For decades researchers have not been able to say with convincing evidence that depression and anxiety make back pain worse. Or for that matter, vice versa, that back pain makes depression and anxiety worse. The influences of back pain, anxiety, and depression however can certainly be suggested. As you a reading this article, it probably will not take a lot of convincing to suggest when you are depressed, yoru back pain get can worse, and when your back pain is worse, you have anxiety. The problem then can be in what your doctor understands about you and the treatments you may need. The debate we just mentioned comes from a “lack of evidence” connecting all three of these problems. This is why there may be treatment confusion in the medical community in how to go about treating low back pain patients who exhibit depression and anxiety. The question is, is there back pain making their anxiety worse or is the anxiety making the back pain worse? Do you treat one or the other or all three at the same time? Let’s see if we can work together to find some answers on this question.

Before we move on, we invited you to also explore our companion articles on neck pain and emotional duress.

This article’s learning points:

  • Depression and anxiety often exist among patients with lower back pain.
  • Anxiety’s role in chronic pain

Depression and anxiety often exist among patients with lower back pain

At our center we see many people with low back pain and they do suffer emotionally.  To someone who suffers from back  pain, anxiety and depression, it can be very difficult to explain or convey to a family member, a friend, even a medical professional how profound their symptoms are. In simplest form, treating the back pain should then alleviate the problems of emotional distress. But it is not that simple. Despite the controversies, there is research that suggests the problems of back pain, anxiety and depression goes deeper than simply a problem of back pain. It is a whole body, physical problem. It therefore becomes a situation of what is the right treatments for some. For some it may be treatments that act as an anti-inflammatory. We are going to discuss this further later in this article, for now let’s look at recent studies.

A March 2022 paper in the International journal of psychiatry in medicine (1) writes: “Chronic lower back pain induced by lumbar disc degeneration or herniation exerts a great impact on patients’ daily lives. Depression and anxiety often exist among patients with lower back pain. Some studies mentioned about mechanisms, such as inflammatory biomarkers, which are commonly seen in herniated intervertebral disc and major depressive disorder (MDD). Patients with herniated intervertebral disc were at high risk of developing major depressive disorder.”

What is being said here?

What has been suggested in many recent papers is that depression is an inflammatory disease, just like back pain. Then does the inflammation of back pain cause depression? Or does the depression related inflammation cause back pain and body pain? Do they cause each other? Below we will try to answer that question and provide treatments guidelines as it relates to fixing the back pain.

As studies show, depression and anxiety and their relationship to back pain can be a complicated subject for health care providers. A group of researchers from the University of Sydney published their findings (2) that health care providers should be on the lookout for future episodes of back pain in depressed patients:

  • “Individuals with symptoms of depression have an increased risk of developing an episode of low back pain in the future, with the risk being higher in patients with more severe levels of depression.”

Simply, the more depression, the more back pain.

Anxiety’s role in chronic pain

Anxiety is a common byproduct of chronic pain. A 2013 study suggested that patients coping with chronic pain should be evaluated for anxiety disorders. (3) Researchers evaluated 250 patients with moderate to severe chronic joint or back pain for which pain medications were not helping. They tested for the following conditions:

  • generalized anxiety, characterized by persistent worry;
  • panic, or sudden, repeated attacks of fear;
  • social anxiety, characterized by overwhelming anxiety in everyday social interactions; post-traumatic stress, or a repeated feeling of danger after a stressful event;
  • obsessive-compulsive disorder, characterized by repeated thoughts or rituals that interfere with daily life.

They also evaluated health-related quality of life issues, i.e. fatigue, sleep habits, and work productivity. The results showed that 45% of the patients tested positive for at least one or more of these common anxiety disorders. Many of these were present in combination with depression. Patients with anxiety disorders also presented with more pain and worse quality of life issues.

It did not matter which symptom made which symptom worse. The patient needs to be treated.

To continue with the theme of how to best manage anxiety and depression in back pain patients, let’s move forward to doctors writing in a 2017 paper published in the medical journal Spine, (4) suggested it did not matter which symptom made which symptom worse. The patient needs to be treated. This paper showed the results of a multi-national study led by the University of Sydney in finding a significant association between chronic low back pain and increased risk of depression and/or anxiety. However the questioned remained whether back pain caused symptoms of anxiety and depression or if depression and anxiety caused symptoms of back pain.  So what came first? They suggest that no matter which one came first, when combined, anxiety, depression, and back pain acted on each other and caused accelerated worsening of symptoms. As more research shows, there is no answer to this question other than, anxiety and depression can make back pain worse, and back pain can make anxiety and depression worse.

Is it then a matter of drugs for anxiety and depression or coping skills?

Bringing this 2017 research forward to July 2022 doctors writing in the Frontiers in aging neuroscience (5) suggested that the brain regions where chronic back pain is perceived may share components with the perception of depression. BUT, while simultaneous depressive and chronic low back pain symptoms do have an affect on each other, “depression does not aggravate pain intensity by directly affecting the function of the pain matrix (the brain region where pain is sensed).  Here again the doctors are saying the emphasis is not if one symptom worsens the other, but rather treat the symptoms in what they say is a “more humanistic care” paying more attention to the recovery of psychosocial function. In other words while back pain is being treated offer patients coping skills. What is the focus of treatment then?

Antidepressants have no meaningful clinical benefit, opioids are not recommended: Twelve years of research

As we know, chronic back pain under conservative care may mean pain medications for as long as possible until such time that back surgery will be recommended because pain medications for your back pain are no longer effective. Let’s start a quick decades long look at the research in the treatments offered patients with low back pain and depressive/anxious symptoms.

In October 2011, doctors at Harvard Medical School wrote in the medical journal Spine (6) “Opioids and NSAIDs are effective for chronic low back pain, while antidepressants have no meaningful clinical benefit. Based on the significant rate of side effects with opioids and the lack of convincing superiority over NSAIDs, opioids are not recommended as a treatment for chronic chronic low back pain.”

In addition to assessing the effectiveness of these drugs, they also evaluated whether certain people respond more favorably to pharmacological management.

The researchers acknowledged that medications are a mainstay of low back pain management, but there is uncertainty as to the optimal use of commonly prescribed medications such as opioids, antidepressants, and NSAIDS.

After examining the medical literature, these are the conclusions they reached:

 1. Opioids and NSAIDs are effective for chronic low back pain, while antidepressants have no meaningful clinical benefit.

2. Based on the significant rate of side effects with opioids and the lack of convincing superiority over NSAIDs, opioids are not recommended as a treatment for chronic low back pain.

Here are their recommendations:

1: NSAIDs should be considered as a treatment of chronic low back pain. There is evidence demonstrating favorable effectiveness, but also significant side effects that may have meaningful clinical consequences.

2: Opioids may be considered in the treatment of chronic low back pain but should be avoided if possible. There is evidence demonstrating favorable effectiveness compared to placebo, similar effectiveness compared to NSAIDs, and with significant side effects including decreasing effectiveness related to habituation when used long-term.

3: Antidepressants should not be routinely used for the treatment of chronic low back pain. There is evidence that they are not more effective than placebo with respect to pain, functional status, or depression.

As we read through the article, we basically see a lot of contradiction. Use NSAIDs but only if necessary because the side effects are great. Opioids and painkillers: consider them, but in reality avoid them if you can. The one thing that is not contradictory is antidepressants – don’t use them.

Researchers ask then: “are pain killers effective for patients with depression and anxiety?”

That was 2011. Let’s bring this research up to 2015. Further along this line of research is a study from Brigham and Women’s Hospital and Harvard Medical School (7)  that questions if opioid pain killers are effective for patients with depression and anxiety. Here the researchers found in patients with chronic low back pain psychiatric comorbidity (specifically,  high levels of depression and anxiety) was a significant predictor of poor opioid treatment outcomes compared with chronic low back pain patients with low  levels of depression and anxiety, including almost 50% less improvement in pain, increased side effects, and 75% more opioid misuse. 

Anxiety and depression may cause need for opioids, a study of cue-reactivity and addiction

Now let’s get to 2022. First a definition of cue-reactivity. As it sounds, cue-reactivity is a reaction to a cue. In April 2022, researchers at the University of Utah, University of Oslo in Norway,  and the University of Missouri wrote in the journal Drug and alcohol dependence (x) that the cue that patient’s react to is a past (painful or emotional) experience that suggests to the patient that they must have opioids to deaden the sensation of impending pain. Cue-reactivity is part of addiction. Here the researchers explored the cue-elicited craving and autonomic (unconscious – the body is acting on its own) cue-reactivity “phenomenon among chronic pain patients on long-term opioid therapy.” They write:

  • “Negative cognitive-emotional reactivity in general (e.g., distress) and cognitive-emotional reactivity specific to pain (e.g., pain catastrophizing) might drive cue-reactivity independent of pain severity.”

The person will crave opioids even when they are not in pain but rather when they have emotional distress. Here are the summary findings:

  • There were 243 patients receiving long-term opioid therapy were classified as exhibiting aberrant behavior consistent with opioid misuse (145 of the 243 patients) or as using opioids as prescribed (97 patients).

Of note: Autonomic cue-reactivity (unconscious addiction) were measured with craving ratings and high-frequency heart rate variability (HRV). A high heart rate variable demonstrates the resiliency to cope with “fight-flight”  or danger, stress and anxiety and have the ability to calm down afterwards. A high heart rate variable indicates an ability to manage stressful situations. In general, low heart rate variability is considered a sign of current or future health problems because it shows your body is less resilient and struggles to handle conditions of distress and catastrophizing. In this paper the researchers found “Distress and catastrophizing predicted cue-elicited craving and HRV, whereas pain severity did not. . . Findings suggest that although opioids are prescribed for analgesia, the exacerbating influence of negative cognitive-emotional reactivity, both in general and specific to pain, on cue-elicited opioid craving extends beyond the effects of pain severity alone.” The opioids have made themselves part of your coping mechanisms and this is how addiction may occur.

Stress and anxiety during Covid-19 on low back pain patients. Perceptions of self-management helped.

To suggest that some patients underwent significant anxiety and stress during the Covid-19 reduction in ability to get healthcare would of course be considered a gross understatement. In March 2022 doctors from the Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine wrote in the North American Spine Society journal (8) how patients may be able to help themselves manage their conditions. “Patients with pre-existing psychological distress experienced greater worsening of pain and Quality of Life. High patient activation (the patient took on a more involved role in self-care) appeared to mitigate worsening of physical function. Providers should screen for psychological distress and patient activation and enhance supports to manage pain and maintain Quality of Life in at-risk patients.” Through self-help guidelines “healthcare providers and systems can better support these patients through times of difficulty.”

“Spine surgery in chronic low back pain patients after multidisciplinary pain program including cognitive – behavioral therapy cannot be recommended due to its questionable success.”

With the problems documented above, it would seem that the answer to anxiety, depression and back pain may be surgery. Surely if back pain can be resolved with surgery, wouldn’t the problems of anxiety and depression? For many people the answer would be yes. For others, doctors will need to closely examine the situation to make sure that a they do not make a bad problem worse. In 2016, in a study published in the International journal of rehabilitation research doctors made these observations about the risks of sending patients with anxiety and depression to back surgery. (9)

  • Depressive symptoms are very common in chronic pain patients.
  • Studies have reported prevalence of 30-80% of patients with some depressive symptoms and 20% of patients who fulfill the criteria for a true major depressive disorder.
  • There is increasing evidence that the fear of pain, along with the fear of hurt or harm, are major influences. They note that  “yellow flags” indicating diverse psychosocial prognostic factors for the development of disability following the onset of musculoskeletal pain are often present.
  • Additionally, depression and psychosomatic disorders are common in patients receiving multidisciplinary pain programs.
  • Therefore, with the existence of these risk factors, surgical intervention is not recommended due to the increased incidence of developing postoperative pain and chronic problems.

Spine surgery in chronic low back pain patients after multidisciplinary pain program including cognitive – behavioral therapy cannot be recommended due to its questionable success.

The role of depression and anxiety in patients undergoing spinal surgery is conflicting

Let’s now move this research into February 2022 (10) where doctors at the University of Zurich looked at how depression and anxiety impacted symptom and function after surgery for lumbar spinal stenosis. The authors write: “Evidence on the role of depression and anxiety in patients undergoing surgical treatment for symptomatic degenerative lumbar spinal stenosis is conflicting. . .” In this study of 401 patients undergoing surgery for symptomatic lumbar spinal stenosis, the researchers found a “robust” association between baseline depression with more severe symptoms and worse function after surgery. The also write: “Although the effect of anxiety alone was clinically not relevant, baseline depression and anxiety combined were associated with a clinically relevant increase in the severity of symptoms over the 24 month study period.”

However, Canadian university researchers writing in The spine journal (11) wrote: “Depressed patients have similar or better relative improvements in disability, quality of life, and pain, when compared to non-depressed patients, although their preoperative and postoperative levels of disability are higher. Surgeons should not be concerned that depression will reduce the patient-reported beneficial response to surgical intervention.”

We have now reached the point that many people have. The point of what is causing what and how do I treat it? For many people, they may have reached the point where they are not surgical candidates for their back pain, have already had spinal surgery that failed, may have spinal cord stimulator devices, been given multiple Epidural Steroid Injections or may be on prolonged pain medication. Now what?

Preoperative anxiety and postoperative delirium

October 2022 study in the journal Aging clinical and experimental research (12) examined the relationship between between preoperative anxiety and postoperative delirium among older patients undergoing elective surgery for lumbar disc herniation. Their study results found that “anxiety is an independent risk factor of postoperative delirium among older patients undergoing elective surgery for lumbar disc herniation. Preoperative anxiety assessment can help to identify older patients at high risk of postoperative delirium and facilitate perioperative management of older patients undergoing elective surgery for lumbar disc herniation.”

Should psychotherapy be involved?

Many people will need psychotherapy. Many may not. Others become angry when psychotherapy is suggested to them because their belief is that if they can get their back pain fixed they would not have anxiety anymore. Let’s look at a November 2022 study published in the journal Frontiers in physiology. (13) In this study, the researchers could not find a strong connection of anxiety and back pain working on each other, however they did write: “Although the relationship between symptoms of low back pain and anxiety is very weak in addition to the quality of life and quality of sleep, the problem still commonly exists in patients with low back pain . . .”

What the researchers did was to take two groups of low back pain patients, one group had symptomatic anxiety and one group did not. They found that both groups had similar back pain problems. They could not show that the anxiety made it worse. However the patients nonetheless had anxiety and this was impacting their sleep and quality of life and that the anxiety should not be ignored. The researchers suggest that “psychotherapy should be an integral part of a multidisciplinary rehabilitation training strategies, psychological consultant for patients with anxiety, and other negative emotions control strategy of education to improve their psychological state.”  The choice to psychotherapy needs to be made on an individual basis.

Did my back pain cause anxiety and depression or did depression and anxiety cause back pain?  

Catastrophizing thoughts and low back pain. Can exercise be effective for back pain and emotional health?

A December 2022 paper in the journal Pain practice (14) examined why exercise, often effective in mental health, does not work for some lower back pain patients. The authors write: “Exercise is the most recommended treatment for chronic low back pain and is effective in reducing pain, but the mechanisms underlying its effects remain poorly understood. Exercise-induced hypoalgesia (pain reducing capacities) may play a role and is thought to be driven by central pain modulation mechanisms (pain sensation changes in the brain). However, Exercise-induced hypoalgesia appears to be disrupted in many chronic pain conditions and its presence in people with chronic low back pain remains unclear.”

What the researchers are saying is that exercise-induced hypoalgesia does not work for everyone and it is not clear why it may not be effective in chronic low back pain patients.

The researchers are suggesting that exercise-induced hypoalgesia does not work for everyone and it is not clear why it may not be effective in chronic low back pain patients. To test this thinking the researchers asked patients with and without lower back pain to perform wrist exercise to see if these exercises had any impact on there mental well being. The patients with no back pain were used as a control group. What they found was in some patients the wrist exercises did not “wake up” the exercise-induced hypoalgesia regions of the brain. The lack of exercise working as a pain mediator was seen as a possible alteration in pain modulation control in chronic low back pain. However, psychological factors and central sensitization symptoms may not explain the differences observed.” Then what is it? Perhaps it is a structural problem and treating the back pain successfully may be the answer.

Can exercise be effective for back pain and emotional health?

Fear of pain reduces daily walking steps more than the pain itself does

An October 2022 study in the journal Physiotherapy theory and practice (15) examined the “psychological factors associated with physical activity in people with lumbar spinal stenosis.” The authors of the study noted that typical characteristics of  lumbar stenosis patients who have limited physical activity are patients who are considered overweight or obese, have a lot of pain, are older, and are female more so than men.  However, the researchers noted, few studies have assed their psychological factors. In this paper, daily step count was used as a factor to determine psychological factors.

Here is the summary research:

  • Daily step count (lower walking measures) was significantly predicted by the patient’s age, the number of stenoses they were diagnosed with and the severity of stenosis at L3-L4.
  • Further: Higher scale scoring for cognitive anxiety, escape/avoidance, fear, and depression predicted a lower daily step count.

This is what the author’s concluded: “lower walking capacity, higher anxiety, and fear-avoidance beliefs about pain and depression are more closely associated with lower daily step count than are back and leg pain. Assessment and treatment of psychological factors might help to increase physical activity in patients with lumbar spinal stenosis.”

In essence, it was not the pain itself, but rather, it was the fear and desire to avoid pain that prevented these people from walking.

The structural, mechanical pain aspect of anxiety and depression

Many people that read articles on back pain are clearly still searching for answers for their chronic pain issues. These people are typically someone who have had many years of treatments, and, a list of general and more specific recommendations to consider for the various forms of spinal surgery that may be available to them, and most impactful, they suffer from a reduced quality of life because of back pain and loss of function.

From the chronic pain persisting, emotional factors start to enter such as depression, anxiety, hopelessness (of never getting better) and various fears. This is why cognitive behavior techniques, biofeedback, counseling, faith, anti-depressant and other central nervous system altering drugs are helpful to relieve symptoms but do little to cure the chronic pain. Structural, mechanical pain needs a structural solution. Both traditional and non-traditional therapies are temporarily helpful but not curative.

If you have questions about your back pain, get help and information from our Caring Medical staff

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