The Long-Term Mental Health Outcomes of Adolescent Chronic Pain
Adolescents who experience chronic pain have higher prevalence of anxiety and depressive symptoms in adulthood.
Several studies indicate a link between mental health disturbances, including anxiety, disruptive, and depressive symptoms, and headaches, fibromyalgia, abdominal pain, and chronic back and neck pain experienced during childhood and adolescence.1-5
Using the National Longitudinal Study of Adolescent to Adult Health (Add Health),6 researchers sought to investigate whether chronic pain experienced during adolescence led to increased prevalence of internalizing mental health disorders in adulthood. 7 Add Health included adolescents in the United States who were in grades 7 to 12 during the 1994-1995 school year and followed them with 4 at-home interviews or waves (I to IV), the most recent having taken place in 2008 (cohort age: 24 to 32 years).
Information collected included biological, behavioral, and environmental data, in an endeavor to determine the prevalence of chronic diseases in adult life. “Add Health combines longitudinal survey data on respondents' social, economic, psychological, and physical well-being with contextual data on the family, neighborhood, community, school, friendships, peer groups, and romantic relationships, providing unique opportunities to study how social environments and behaviors in adolescence are linked to health and achievement outcomes in young adulthood.”6
The initial study included 14,790 adolescents (representing a population of 21.95 million after survey weighting), including 7866 females, who completed all 4 waves of interviews, although data used in this study were gathered from waves I (mean age 16 years), II (grades 8 to 12), and IV.
Pain was assessed during waves I and II using self-report surveys in which adolescents were asked about frequency of painful episodes (from never to every day). Subjects were considered as having chronic pain when they reported experiencing pain almost every day or every day. Within the study cohort, 21.9% of subjects experienced chronic pain during adolescence (wave I and/or II), with females more affected than males (25.5% vs 18.4%, P <.0001).
Occurrence of adult depressive and anxiety disorders, including posttraumatic stress disorder (PTSD), was assessed at wave IV from self-reports of mental health diagnosis by a health care professional and medication usage. Anxiety symptoms during adolescence were assessed during wave I by asking subjects whether they had experienced heat all over, cold sweats, chest pains, fearfulness, or trouble relaxing. Responses to each question were assessed on a 5-point Likert scale, from never to every day. The Center for Epidemiologic Studies-Depression Scale (CES-D) was used to measure depressive symptoms during wave I and assessed the presence of depressive symptoms in the week preceding the interview using a 4-point Likert scale. Questions about sleep quality and general health were also included.
Adolescents who reported experiencing chronic pain had a higher prevalence of anxiety and depressive symptoms, insufficient sleep, and poorer general health compared with adolescents with no chronic pain (P <.0001 for all). Anxiety and depressive disorders were self-reported by 14.3% and 16.4% of all study participants, respectively, regardless of presence of chronic pain.
Within the adolescent chronic pain group, 21.1% experienced anxiety disorders as adults, which significantly higher than the 12.4% seen in the non-chronic pain group (P <.0001). Depressive disorders were also more prevalent in the adolescent chronic pain group than in the non-chronic pain group (24.5% vs 14.1%; P <.0001).
Using multivariate logistic regression, several factors were identified as being associated with higher likelihood of developing anxiety and depressive disorders in adulthood: adolescent chronic pain, female gender, white ethnicity, adolescent anxiety, and depressive symptoms (P <.0001 for all).
Study Limitations and Future Studies
Results from this large-scale study clearly indicate a link between adolescent chronic pain and development of psychopathology in adulthood. The authors argue that further research is warranted “to examine shared vulnerability and mutually maintaining factors that underlie these comorbidities.” Co-occurrence of chronic pain and depressive/anxiety disorders might be explained by mutual neurobiological mechanisms; indeed, the amygdala is involved in both chronic pain and fear processing.8 In addition, the opioid and endocannabinoid systems and immune factors are involved in both chronic pain and anxiety and depressive disorders.9 Commonalities between these structures and systems underlying both processes need to be further investigated.
As this study only assessed chronic pain in adolescence, the authors call for additional longitudinal research to better understand the link between childhood and adult chronic pain and mental health comorbidities. Also, self-reports of chronic pain did not include information regarding pain duration, impairment, or treatment. Other studies showed that psychological interventions for chronic pain during adolescence do not significantly affect the development of anxiety and depressive disorders.10 Therefore, research investigating the appropriate type of psychological intervention (eg, targeting both depressive/anxiety symptoms and chronic pain) is warranted.
1. Margari F, Lucarelli E, Craig F, Petruzzelli MG, Lecce PA, Margari L. Psychopathology in children and adolescents with primary headaches: categorical and dimensional approaches. Cephalalgia. 2013;33(16):1311-1318.
2. Kashikar-Zuck S, Zafar M, Barnett KA, et al. Quality of life and emotional functioning in youth with chronic migraine and juvenile fibromyalgia. Clin J Pain. 2013;29(12):1066-1072.
3. Simons LE, Sieberg CB, Claar RL. Anxiety and impairment in a large sample of children and adolescents with chronic pain. Pain Res Manag. 2012;17(2):93-97.
4. Tegethoff M, Belardi A, Stalujanis E, Meinlschmidt G. Comorbidity of mental disorders and chronic pain: chronology of onset in adolescents of a national representative cohort. J Pain. 2015;16(10):1054-1064.
5. Shelby GD, Shirkey KC, Sherman AL, et al. Functional abdominal pain in childhood and long-term vulnerability to anxiety disorders. Pediatrics. 2013;132(3):475-482.
6. The National Longitudinal Study of Adolescent to Adult Health (Add Health). Available at: http://www.cpc.unc.edu/projects/addhealth. Accessed July 7, 2016.
7. Noel M, Groenewald CB, Beals-Erickson SE, Gebert JT, Palermo TM. Chronic pain in adolescence and internalizing mental health disorders: a nationally representative study. Pain. 2016;157(6):1333-1338.
8. Simons LE, Pielech M, Erpelding N, et al. The responsive amygdala: treatment-induced alterations in functional connectivity in pediatric complex regional pain syndrome. Pain. 2014;155(9):1727-1742.
9. Mifflin K, Benson C, Kerr B, et al. Involvement of neuroactive steroids in pain, depression, and anxiety. Mod Trends Pharmacopsychiatri. 2015;30:94-102.
10. Fisher E, Heathcote L, Palermo TM, De C Williams AC, Lau J, Eccleston C. Systematic review and meta-analysis of psychological therapies for children with chronic pain. J Pediatr Psychol. 2014;39(8):763-782.