The epidemiology of back pain and its relationship with depression, psychosis, anxiety, sleep disturbances, and stress sensitivity: Data from 43 low- and middle-income countries

Abstract

Background

Back pain (BP) is a leading cause of global disability. However, population-based studies investigating its impact on mental health outcomes are lacking, particularly among low- and middle-income countries (LMICs). Thus, the primary aims of this study were to: (1) determine the epidemiology of BP in 43 LMICs; (2) explore the relationship between BP and mental health (depression spectrum, psychosis spectrum, anxiety, sleep disturbances and stress).

Methods

Data on 190,593 community-dwelling adults aged ≥18 years from the World Health Survey (WHS) 2002–2004 were analyzed. The presence of past-12 month psychotic symptoms and depression was established using questions from the Composite International Diagnostic Interview. Anxiety, sleep problems, stress sensitivity, and any BP or chronic BP (CBP) during the previous 30 days were also self-reported. Multivariable logistic regression analyses were undertaken.

Results

The overall prevalence of any BP and CBP were 35.1% and 6.9% respectively. Significant associations with any BP were observed for subsyndromal depression [OR (odds ratio) = 2.21], brief depressive episode (OR = 2.64), depressive episode (OR = 2.88), psychosis diagnosis with symptoms (OR = 2.05), anxiety (OR = 2.12), sleep disturbance (OR = 2.37) and the continuous variable of stress sensitivity. Associations were generally more pronounced for chronic BP.

Conclusion

Our data establish that BP is associated with elevated mental health comorbidity in LMICs. Integrated interventions that address back pain and metal health comorbidities might be an important next step to tackle this considerable burden.

Introduction

Lower back pain (LBP) is a leading cause of global disability, with a global point prevalence of 9.4% (95% CI = 9.0 to 9.8%) [1]. LBP ranked as the number one cause of disability among 291 conditions, and sixth in terms of overall burden in the Global Burden of Disease 2010 study [1], [2]. Among Western populations, a plethora of evidence has demonstrated that back pain is associated with a range of deleterious consequences such as reduced quality of life, heightened risk of other physical health comorbidities and greatly increased health care costs [3], [4], [5], [6]. Given the rising prominence of the biopsychosocial model, a number of studies, largely focused on Western populations, have highlighted the important role of poor mental health as a risk factor for LBP [7] and as a consequence of a LBP episode [8].

To date, only a few large representative multinational studies have considered the mental health status of people with back pain, with a notable paucity in low- and middle-income countries (LMICs). However, there are indications that back pain is also highly prevalent in LMICs [9], where it is a source of substantial economic and health burden [10]. Previously, one large-scale multinational study [11] using data from the World Mental Health Survey including 5 LMICs (Ukraine, Mexico, Colombia, Nigeria, South Africa) found that the presence of chronic back/neck pain is associated with 2.3, 2.2, and 1.6 times greater odds for mood disorders, anxiety disorders and alcohol abuse respectively.

While progress has been made in attempting to understand the mental health impact of back pain, a number of pertinent questions remain unanswered. First, while the relationship between back pain and mental health disorders (including depression, psychosis spectrum, anxiety and stress sensitivity) is equivocal, there are no studies exploring these associations thoroughly in LMICs. This is an important research gap given that the association between back pain and mental health symptoms or disorders in LMICs may differ from high-income settings, owing to factors such as suboptimal management of physical and mental health conditions with limited availability of non-pharmacologic or pharmacologic treatments [12], [13]. Second, as people in LMICs mostly rely on labor-demanding jobs in the informal sector with no job security or compensation for lost income, maintaining good mental and physical health is crucial for their livelihoods. Therefore, there is a need to elucidate the potential mental health burden among people with back pain in LMICs.

Thus, the aims of the current study were to: (1) Determine the epidemiology of back pain (any back pain and chronic back pain) in 43 LMICs; and (2) explore the relationship between back pain and mental health (depression type, psychosis, anxiety, sleep problems, and stress sensitivity). Our hypothesis was that people with back pain would have worse mental health and this would be more pronounced among those with chronic back pain.