Alex Simotas, MD

Hospital for Special Surgery
Board Certified Physiatrist
Specializing In Spine & Sports Medicine

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Depression & Back Pain

Depression is four times more common in patients with chronic back pain than in the general population. Depression and chronic back pain share many of the same or similar symptoms so it is easy to understand how they often co-exist and can overlap each other.

A major depression is defined by the presence of at least five of the following symptoms for a minimum of two weeks:

  • A persistent prevailing mood that is sad, depressed, low, blue, or irritable.
  • Sleep dysfunction: too little or sometimes too much.
  • Sluggishness, low energy, restlessness, or agitation.
  • Loss of interest in pleasurable activities.
  • Decreased sex drive.
  • Low self esteem and / or feelings worthlessness or guilt.
  • Difficulty with concentration.
  • Appetite and weight disorders: either too much or too little.
  • Suicidal thoughts.

You can compare the presence of some of the symptoms of depression with some of the symptoms of chronic back pain:

  • Pain that makes for difficult sleep contributing to fatigue and irritability during the day.
  • Pain that makes movement difficult so that many individuals with back pain spend a good deal of their time at home, which in turn leads to social isolation and loss of enjoyable activities.
  • Loss of work which can lead to financial stress.
  • Use of pain medications which can cause mental side effects or even depression.
  • Distraction leading to problems with memory and concentration.
  • Depressed sexual activity.

Most individuals with low back pain suffer a great sense of loss of control once pain starts to make it difficult to engage in various activities including work, recreation and social interactions with family and friends. The physical and mental deconditioning creates a negative downward spiral that can lead to depression. Many individuals with back pain have some prior history of depression. Additionally, patients with depression who undergo back surgery seem to have poorer outcomes from the surgery.

The fact that the diagnosis of depression is often undetected presents a challenge. The individual with pain will often define their problem as being entirely caused by the pain. The depressive symptoms are downplayed and there is a belief that if you can get rid of the back pain, all the other symptoms would resolve themselves.

This leaves most patients with a loss of a sense of control and they experience a physical and mental deconditioning that can leave them in a state of virtual paralysis. The depression is often undiagnosed because many patients with chronic back pain don’t realize they are also suffering with major depression. Treatments directed strictly at the pain are more likely to fail. Some of the depression may be hastened by incorrect beliefs the patients have about the “real” cause of their back pain. Depressed individuals may adopt more negative perspectives and believe the condition is permanent.

The Depression Questionnaire*

You may use this questionnaire to assess whether you experience depression.
Circle the number that best indicates how much of this type of feeling you have experienced over the past one to two weeks. Make sure that all the questions are answered. If it is difficult to answer any of the questions, a best guess should suffice.

SYMPTOMS Not At All Somewhat Moderate A Lot
Do you feel sad, low, blue, or unhappy? 0 1 2 3
Do you feel hopeless or discouraged about the future? 0 1 2 3
Do you feel useless or believe yourself to be a failure? 0 1 2 3
Do you feel inadequate or inferior to others? 0 1 2 3
Do you feel guilty or blame yourself for everything? 0 1 2 3
Do you find it difficult to make decisions? 0 1 2 3
Do you feel frustrated and irritable? 0 1 2 3
Have you lost interest in other people or your usual activities? 0 1 2 3
Do you feel unmotivated and find it difficult to do things? 0 1 2 3
Do you think you’re looking old, unattractive or ugly? 0 1 2 3
Have you lost your appetite or had a change in weight not due to dieting? 0 1 2 3
Do you have trouble falling asleep, or do you wake up during the night, earlier than you would like? 0 1 2 3
Do you feel tired much of the time? 0 1 2 3
Have you had crying spells or felt like crying but couldn’t? 0 1 2 3
Have you lost your interest in sex? 0 1 2 3
Do you worry often about your general health even beyond your current back pain? 0 1 2 3
Do you have thoughts about killing yourself or do you think you might be better off dead? 0 1 2 3

Add up your total score for the 17 symptoms. The total score will be somewhere between 0 (answering “Not at all” to each item) and 51 (answering “A lot” for each item).
TOTAL SCORE: ________ Use the following key to interpret your score:

0-5 Minimal or no depression
6-11 Borderline depression
12-21 Mild depression
22-31 Moderate depression
32-51 Severe depression


Most important—seek help! Make your physician, caregivers, family and friends aware of how you feel. Depression can be effectively treated with multidisciplinary treatments. Specifically, treatment for the depression may include:

  1. Supportive therapy with a trained therapist
  2. Medication
  3. Cognitive therapy
  4. Relaxation training
  5. Biofeedback
  6. Exercise

Explore and further understand the meaning of the Mind-Body Connection. (See the article “The Mind-Body Connection: How Your Emotions Affect Your Health”.)

* The Depression Questionnaire: Beck (1996) Beck Depression Inventory, Harcourt