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May 2015, Volume 65, Issue 5

Original Article

Determinants of depression and somatisation symptoms in low back pain patients and its treatment: global burden of diseases

Abdulbari Bener  ( Department of Medical Statistics & Epidemiology, Hamad Medical Corporation & Dept. of Public Health, Weill Cornell Medical College, Doha, Qatar, Department of Evidence for Population Health Unit, School of Epidemiology and Health Sciences, The University of Manchester, Manchester, England, United Kingdom. )
Elnour Elnaem Dafeeah  ( Department of Psychiatry, Rumeilah Hospital, Hamad Medical Corporation, Doha, Qatar. )
Mohamad Omar Salem  ( Department of Psychiatry, Al-Ahli Hospital, Doha, Qatar. )

Abstract

Objective: To determine the prevalence of Low Back Pain in primary care setting population and to examine its association with symptoms of depression and somatisation.
Methods: The cross-sectional study was conducted at 13 Primary Healthcare Centres (throughout Qatar from March to December, 2012. A General Health Questionnaire was used to identify the probable cases. A specially designed questionnaire with three parts was used for data collection: socio-demographic information of the studied subjects, modified version of the Roland-Morris scale for evaluating back-related functional disability, and Symptom Cheklist-90-Revised for depression and somatisation subscales.
Results: A representative sample of 2,600 patients was approached and 1,829(70.0%) of them participated in the study.  The prevalence of low back pain in the study sample was 56.5%.  There were statistically significant differences between subjects with and without low back pain in terms of body mass index (p<0.025), gender (p<0.003) and housing condition (p<0.001). There was a significant difference between subjects with and without the pain in terms of all aspects of functional disability. Somatisation disorder in low back pain was 203 (19.6%) and depression disorder was 265 (25.4%). Most of the patients with LBP reported pain in the arms and legs (p<0.001); shortness of breath (p<0.028) palpitations (p=0.004); gastrointestinal complaints such as abdominal pain (p<0.001), diarrhoea (p<0.001) and vomiting (p<0.001); feeling tired (p<0.001); trouble with sleeping (p<0.001); headache (p<0.001) and fainting (p=0.043). The mode of treatment taken by the patients for relief were bed rest 695 (67.2%) followed by warm compression 480 (47.6%), physiotherapy 491 (47.5%), regular exercise 414 (40%), and back plasters 346 (33.5%).
Conclusion: The present study showed that the symptoms of depression and somatisation were prevalent among low back pain patients.  Functional disability was higher in the patients. Recognising this problem may lead to better patient-treatment matching and improved clinical outcomes.
Keywords: Somatisation, Symptoms, Psychiatric disturbance, Treatment, Low back pain, Primary health care. (JPMA 65: 473; 2015).


Introduction

Low back pain (LBP) is prevalent worldwide1 and LBP disability has reached epidemic proportions2 in many industrialised1,3,4 and newly developing societies.2,5-8 LBP is ranked first as a cause of disability and inability to work and is expected to affect most adults at some point during their lifetime2,3 and it is a symptom commonly presented to general practitioners. It is an important clinical and public health problem, being the most ubiquitous illness among humans after the common cold. In general populations, LBP is the most prevalent form of chronic musculoskeletal pain, often leading to disability.3 It has been established that LBP is the second most frequent cause of disability in adult population in Europe. Eight in every ten adults experience LBP at some point in their life.4
LBP is a complex condition produced by multiple factors and it was reported5,9 that LBP can have a substantial negative impact on quality of life and that psychological distress is common in patients with LBP. It was reported that the risk of LBP increases rapidly with greater amounts of physical work and psychological distress. Primary prevention studies are important to identify the risk factors predictive of LBP before additional interventions can be developed. A previous study4 reported that LBP has high impact in the general population, as psychological disorders are very common. Also, a recent study6 observed a high rate of co-morbidity of somatisation, depression, anxiety and stress was found in the studied population and indicated a strong association between these psychological disorders in patients.3-10 The aim of this study was to determine the prevalence of LBP in primary care setting population and to examine its association with the symptoms of depression and somatisation.


Subjects and Methods

The prospective cross-sectional study was conducted from March to December 2012 at 13 Primary Healthcare Centres (PHCs) across Qatar which are frequented by all levels of the general population as a gateway to specialist care. The study comprised subjects aged 15 to 65 years who came to any of the 13 PHCs; 10 in urban areas and 3 in semi-urban. Approval was obtained from the Hamad Medical Corporation Institutional Review Board for conducting the study.
Qualified nurses were trained to interview the patients and complete the questionnaires.  The sample size was computed based on 50% prevalence of LBP in the UAE,7,8 assuming 2% bound on error estimation, and taking 99% confidence level, the required minimum sample size for this study was 2600. The survey instrument was tested on 100 patients who visited the health centres and thus validated the questionnaire. General Health Questionnaire (GHQ-12)9,10 was used to identify the probable cases. The study excluded patients aged below 15 years and above 65 years,  patients with any cognitive or physical impairment and those who refused to give consent to take part in the study.
A specially-designed questionnaire with three parts was used for data collection: socio-demographic information of the studied subjects, modified version of the Roland-Morris scale for evaluating back-related functional disability, and Symptom Cheklist-90-Revised (SCL-90-R) for depression and somatisation subscales.
The Roland-Morris disability questionnaire (RDQ)11,12 is constructed by choosing statements from the sickness impact profile (SIP), which is a 136-item health status measure covering a range of aspects of daily living about physical and mental function.5,11,12 We used a modified 24-item version of the Roland-Morris Scale for evaluating back disability. The scale consists of 21 yes/no items related specifically to physical functions to specifically assess the disability from LBP. The physical functions considered included walking, bending over, sitting, lying down, dressing, sleeping, self-care and daily activities. Patients were asked whether the statements apply to them that day (i.e. the preceding 24h). In the scale, one point is given for each item. The RDQ score can be obtained by adding up the number of items checked. The final score ranges from 0 (no disability) to 21 (severe disability). The questionnaire is self-administered by the patient. It can be completed in a maximum of 5min, and an un-weighted score can be calculated in less than 1min.
A variety of outcome measures are used for LBP.  Among the most common instruments developed to assess the functional status of patients with LBP is the Roland-Morris Disability Questionnaire (RMDQ).2,5,11 This questionnaire as well as the criteria for back-related disability-specific quality of life defined in litereature11-14 were used. This is a modified 24-item version of the Roland-Morris Scale15 for evaluating back disability. For the purposes of this study, three items were removed for the sake of simplicity and to avoid overlap of meanings on translation into Arabic.  For each question, there were two options; 1 for "Yes" and 2 for "No".
In the depression and somatisation part of the questionnaire, there were 10 items for depression and 7 items for somatisation.14 Respondents were asked to indicate how often they had depression and somatisation symptoms. For all these items, there were response options scored from 0 to 4 for "not at all", "a little bit", "moderately", "quite a bit", "extremely". Mean scores for depression and somatisation was calculated by taking the average over the relevant items. When less than four answers in the first section or three answers in the second section were missing, the raw scores for each of the questions of a section were totalled and this sum was divided by the number of non-missing answers.
The procedure of translation and back translation used for the RMDQ scale was followed. An Arabic version of the questionnaire was revised by a bilingual co-investigator and translated by a bilingual general practitioner unacquainted with the original English version. Both translators met and made necessary corrections, modifications and rewordings after considering the minor differences and discrepancies.
Use of descriptors of LBP functional disability and depression, somatisation symptoms was identified, selecting the responses with frequency of more than 50% among LBP patients when applying instruments 2 and 3, matching corresponding descriptors with WHO,15 International Classification of Functioning, Disability and Health  (ICF) Core-Set for the component of activity limitation and for body functioning.
Data was analysed using SPSS 20. Student-t test was used to ascertain the significance of differences between mean values of two continuous variables and confirmed by non-parametric Mann-Whitney test. Chi-square and the Fisher\'s exact test (two-tailed) were performed to test for differences in proportions of categorical variables between two or more groups. Kruskal Wallis one-way analysis of variance (ANOVA) was employed for comparison of several group means and to determine the presence of significant differences between group means. The factor structure of the somatisation and depression symptoms which were examined using a principal components analysis with a varimax rotation. The factor analysis divided the items into three factors for the somatic and depression symptoms. Internal consistencies of each factor with percentage variance were calculated using Cronbach\'s alpha coefficients. The level p<0.05 was considered significant.


Results

A representative sample of 2,600 patients was approached but 1,829(70%) agreed to participate in the study.
There were statistically significant differences between subjects with and without LBP in term of body mass index (BMI) (p=0.025), gender (p=0.003) and housing condition (p=0.001) (Table-1).


There was a significant difference between subjects with and without LBP in terms of all the aspects of functional disability. Significant higher proportion of subjects with LBP compared to those without LBP reported, "staying at home most of the time" [238(23%) vs. 111(14%); p<0.001], "changing position frequently to make back and legs comfortable" [743(71%) vs. 310(39%); p <0.001], "walking slowly than usual because of back pain" [480(46%) vs. 211(27%); p <0.001], "dressing more slowly than usual" [318(31%) vs. 141(18%); p <0.001], "more irritable and bad tempered with people" [373(36%) vs. 189(24%); p <0.001], and "staying in bed most of the time" [414(40%) vs. 183(23%); p <0.001] (Table-2).


Somatisation disorder in LBP was 203 (19.6%) and depression disorder was 265 (25.4%). Occupation was significantly associated with both depression and somatisation symptoms. LBP patients with sedentary professions represented highest mean score for depression 4.79±1.24 (95% CI 4.31-5.27). Similarly, subjects with army/police profession scored highest on somatisation scale (mean 3.27±1.26; 95% CI 2.75-3.79) while on the other hand housewives or unemployed men scored lowest on the somatisation scale (mean 2.56±1.12; 95% CI 2.33-2.79) (Table-3).


Most of patients with LBP reported pain in the arms and legs (p<0.001); shortness of breath (p<0.028) palpitations (p=0.004); gastrointestinal complaints such as abdominal pain (p<0.001), diarrhoea (p<0.001) and vomiting (p<0.001); feeling tired (p<0.001); trouble with sleeping (p<0.001); headache (p<0.001) and fainting (p=0.043) (Table-4).


Factor analysis divided the items into three factors for the somatic and depression symptoms. Factor one consisted of seven items related to psychosomatic problems, factor two had six items related to hopelessness and lack of interest, and in factor three only four items were present which were related to low energy and restlessness (Table-5).


Most of the subjects had taken bed rest 695(67.2%) followed by warm compression 480(47.6%), physiotherapy 491(47.5%), regular exercise 414(40%) and back plasters 346(33.5%) (Figure).




Discussion

LBP is a common problem affecting most adults at some point during their lifetime.2-5 At any one time, around 1 in 5 adults will report symptoms of LBP.16-18 High levels of functional impairment and the presence of back pain radiating to the leg have been cited as factors associated with a poor prognosis among primary care patients with LBP.17,18 The characteristics associated with both the development and the persistence of LBP include psychological factors such as depression and anxiety.5,18-21 Functional disability was higher in our studied patients with LBP as earlier reported among men and women.5
Multiple studies have documented a strong association between chronic LBP and psychopathology, including personality disorders, depressive disorders, anxiety, and somatoform disorders along with non-specific issues such as emotion, anger and drug dependency.22,23 This is consistent with the current study. However, still, depression, anxiety and somatisation appear to be crucial.
There is growing evidence that pain problems increase the risk of depression.5,6,9,24,25 Patients with depression present somatic symptoms including general aches and pains.  The presence of physical symptoms or painful complaints of unknown aetiology is a fairly common occurrence in populations. The somatoform disorders are a group of psychological disorders in which a patient experiences physical symptoms despite the absence of an underlying medical condition that can fully explain their presences.26
A study27 evaluating the relationship of psychopathology and chronic LBP in 200 patients showed that depressive disorders accounted for 49% of current prevalence and 68% of lifetime prevalence in chronic LBP patients, whereas anxiety disorders were present in 15% of the patients. Also, a study28 found high rates of psychopathology in chronic LBP group with higher rates of major depressive disorder, and personality disorders than the patients with acute LBP. However, acute patients were also diagnosed with more anxiety disorders.5-22,23
Apart from clinical disorders such as depression, generalised anxiety disorder and somatoform disorder, the influence of personality on pain experience has long interested clinicians working with individuals having chronic pain.22,23 Many of the early theories of chronic pain also maintain that personality played an important role in the development and maintenance of chronic pain conditions.22,23,29,30
It is a common clinical observation that patients with LBP also manifest concurrent psychiatric illnesses, most commonly depression and somatisation. The association between LBP and depression and somatisation remain a complex subject.5,27 Previous studies reported that chronic LBP duration was related to development of depression symptoms.5,16,26,31 Furthermore, a study16 on patients from primary care practices found that the pain was associated with severity of depression. This is consistent with the present study that there are clear relationship between the LBP and depression.
The present study identified that psychological distress was associated with increased risk of LBP. Positive correlation was seen with elevated scores and positive diagnosis of depression and somatisation. Hence, it may be prudent to evaluate most, if not all patients with chronic LBP presenting to interventional pain management for psychopathology. It is worth noting that significant association was observed in studied subjects with LBP with elevated scores of depression and somatisation. In a Qatari study the prevalence of somatisation (19.6%), depression (25.4%) was higher in LBP patients compared to their healthy counterparts.24 Our results are in line with a study23 that showed a significant proportion of patients in chronic LBO group presented with depression (30%), generalised anxiety disorder (20%), and somatisation (20%). The analysis of other studies indicated that those with LBP scored significantly higher on depression than those without.2-5,22 In another study,17 anxiety presented with the highest correlations, followed by somatisation, then by depression. This pattern of findings suggests that psychological factors play an influential part in the development of LBP. In an Australian study,23 depression was associated with LBP. The psychological factors associated with LBP shows that the distress may aggravate the pain. Iranian LBP patients32 have an increased occurrence of co-existent psychological distress, as has been shown in the current study.


Conclusion

Patients with LBP frequently have serious psychiatric disturbances and most often depression and somatisation. The study revealed that the symptoms of depression and somatisation were more prevalent among LBP patients. Also, functional disability was higher in LBP patients. Clinicians should take care of depression and somatisation symptoms with LBP treatment. These symptoms cannot be neglected or ignored because of its relationship with LBP. Further research is needed to identify practical interventions to reduce this burden from LBP.


Acknowledgements

We are grateful for financial support by the Qatar Foundation. We also thank Hamad Medical Corporation for support and granting ethical approval.

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