Andrew Stewart¹, John Furler¹ Prasuna Reddy² and Michael Kyrios³
¹ Department of General Practice, The University of Melbourne,
² Department of Psychology, The University of Melbourne
³ Faculty of Life and Social Sciences, Swinburne University of Technology
beyondblue Victorian Centre of Excellence
Project completion year
Between 50% to 80% of people with depression initially come to their general practitioner (GP) with a physical symptom. These people are less likely to have their psychological condition detected and receive an accurate diagnosis of depression than those who report symptoms of depression. This is often seen in people with musculoskeletal pain.
In the primary care setting, up to 38% of patients with musculoskeletal pain (e.g. neck and back pain) report experiencing depression. The prevalence of depression in patients with chronic low back pain is 3-4 times greater than in the general population. However, approximately 50% of patients experiencing depression are not diagnosed by their GPs, and the reasons for this are not clear.
Pain may cause depression and depression may also cause physical pain. This complex relationship makes pain and depression more difficult to treat than depression alone. If a GP treats physical pain only and excludes treatment of depression, it is unlikely either condition will improve to remission. The failure to identify and treat depression in such patients may have negative consequences for both mental and physical health.
This study examined the factors associated with detection and management of depression in patients with musculoskeletal pain in Australian General Practice.
Twenty nine GPs recruited up to 20 consecutive patients who they had treated for musculoskeletal pain for at least 12 months, and who they have seen at least three times in the last 12 months. During the consultation, each patient completed questionnaires regarding their current depressive and pain symptoms. Patients then completed a waiting-room questionnaire regarding socio-economic circumstances, anxiety, insecurity and depressive symptoms in the last 12 months. GPs completed an audit of their management of the patient in the last 12 months, with particular attention to the screening, diagnosis and management of depression.
Nearly half of all patients with chronic pain were not screened for depression, a third of patients with current depression had not been screened and a quarter of patients with depression in the past year had not been screened. Approximately 25% of patients with depression did not have a diagnosis of depression. This indicates the GPs in the study correctly diagnosed depression at a higher rate than that reported in previous studies.
The study identified several factors associated with an increased likelihood of screening, diagnosis and management of depression. These are detailed below.
Patient anxiety was one of the most powerful factors influencing whether GPs screened for depression, prescribed stronger analgesics, prescribed antidepressant medication, and referred patients for specialist psychological services.
The severity of the patient’s pain had a strong influence on GP behaviour, reducing the likelihood of the prescription of depression medication. It also reduced the likelihood that GPs implemented non-pharmacological interventions for patients who were currently depressed or who had been depressed in the past 12 months.
There was no association between socio-economic disadvantage and screening for depression and diagnosis of depression. However, in the management of patients with both pain and depression, there was possible evidence that depressed people living in more-advantaged areas had greater odds of receiving antidepressant medication than those living in less-advantaged areas. Patients with health care cards were less likely to be prescribed stronger pain medication, and less likely to access non-pharmacological pain management options. It is possible that health care card holders may be receiving both sub-optimal pharmacological and non-pharmacological treatment for their pain. However, the study could not identify whether these results reflected patient request for particular treatments, patient uptake of treatments offered, or practitioner behaviour.
Implications for Policy and Practice
All patients with chronic pain should receive routine screening for depression, particularly patients with more severe pain.
In terms of practice training, the results support GP education and practice-based interventions that offer GPs an opportunity to reflect on the impact that pain can have on the emotional and mental well-being of the patient, and the way that severity of patient pain influences GP detection and management of depression.
The research team has a strong interest in the detection, diagnosis and management of depression in patients with chronic disease, in particular, chronic musculoskeletal pain, coronary heart disease and diabetes. For example, depression has an effect on coronary heart disease (CHD) at every stage of the course of the disease. Depression performs similarly to every other established risk factor for CHD, having a negative effect at every stage of disease progression.
Similar evidence is emerging for the role of depression in patients with diabetes. Unfortunately, many patients with these conditions have depression that goes undetected and untreated.
In patients with any chronic disease, depression should be screened as routinely as blood pressure.
About the Researchers
Andrew Stewart is a PhD candidate at the University of Melbourne, Department of Psychology. He is interested in the study of depression and chronic disease, with a focus on the role of close relationships.
John Furler is a GP researching chronic disease care in general practice with a particular interest in social inequalities in the experience of health care.
Professor Prasuna Reddy is located at Flinders University School of Medicine. Her main areas of research are high prevalence psychological disorders in chronic illness.
Professor Michael Kyrios is an academic clinical psychologist with a track record in the study of depression and anxiety disorders in psychiatric, primary care, and other health settings.