Research paperDepression increases subjective stigma of chronic pain
Introduction
Stigma has been defined as “the situation of the individual who is disqualified from full social acceptance” (Goffman, 1963). A stigmatized trait “is deeply discrediting” to the bearer and degrades them “from a whole and usual person to a tainted, discounted one” (Goffman, 1963). Link and Phelan (2001) conceptualize stigma as the convergence of a number of components:
- 1)
the distinguishing and labeling of human differences
- 2)
the association of human difference with negative attributes
- 3)
the separation of “us” from “them”
- 4)
status loss and discrimination
As they note, though many human differences, such as the color of one’s hair, are generally overlooked and inconsequential, some differences can identify individuals as ‘other’ and lead to social consequences. This occurs when social, economic, and political power allows for the identification and labeling of the ‘other’ and the implementation of disapproval, rejection, exclusion, and discrimination.
Both mental health diagnoses such as major depression (Barney et al., 2006, Bharadwaj et al., 2015, Gaudiano and Miller, 2012, Kanter et al., 2008, Latalova et al., 2014, Oakley et al., 2011, Rusch et al., 2008), and physical health conditions, like chronic pain (Holloway et al., 2007, Marbach et al., 1990, Slade et al., 2009), are often associated with stigma. Experiencing stigma for having a particular health condition may increase the burden of that condition (Leventhal et al., 2004), dissuade patients from accessing healthcare, and decrease overall quality of life (Earnshaw and Quinn, 2012).
Stigma associated with mental illnesses, including depression, can further exacerbate the mental health condition, and further harm an individual’s health. Depression stigma can discourage depressed individuals from seeking medical help (Barney et al., 2006, Clement et al., 2015), lead to social isolation (Crisp et al., 2000), decrease social opportunities (Corrigan, 2004), and decrease satisfaction with life (Markowitz, 1998).
Individuals suffering from chronic pain likewise experience stigma due to their condition. Stigma has been reported as coming from the general public, family and friends, and even from their treating healthcare professionals (Holloway et al., 2007, Marbach et al., 1990, Slade et al., 2009). In one representative study, individuals with chronic pain reported feeling disrespected and distrusted; they also reported being suspected of drug-seeking, and believing that their healthcare providers were dismissive of their symptoms (Upshur et al., 2010). Stigmatization may have a negative effect on the attitudes and behaviors of individuals with chronic pain towards healthcare providers (Holloway et al., 2007). As De Ruddere and Craig (2016) note in their review of stigma and chronic pain, though there is ample evidence that patients with chronic pain experience stigma in all aspects of their lives, this stigma is still not well understood, particularly with regards to its determinants, underlying mechanisms, and impact on the patient.
Chronic pain and major depression are frequently comorbid (Arnow et al., 2006, Bair et al., 2003, Dworkin and Gitlin, 1991, Miller and Cano, 2009, Romano and Turner, 1985, Ruoff, 1996). We aim to better understand the subjective experience of these diseases and their social consequences given the high prevalence of depression and chronic pain, their economic burden, and the suffering these diseases cause. In the US, over 15 million adults are estimated to have depression (Center for Behavioral Health Statistics and Quality, 2015) and 100 million adults are estimated to have chronic pain (Institute of Medicine, 2011). Both depression and chronic pain are also costly; depression is estimated account for $210.5 billion in health costs and lost productivity (Greenberg et al., 2015), and chronic pain is estimated to account for $560 billion to $635 billion (Institute of Medicine, 2011). Both conditions are experienced most days for much of the day, and both interfere with one’s functioning. Both conditions may be chronic but non-progressive, that is, they may last a considerable amount of time, even decades, but their intensity does not inevitably worsen over time. The combination of these two disorders can exacerbate the experience of one’s health state. For example, in one study of patients who visited a primary care clinic, those with comorbid depression and disabling chronic pain reported poorer health-related quality of life and greater somatic symptom severity compared to other patients (Arnow et al., 2006). The combination of chronic pain and major depression may also affect the perception of stigma; however, the specific effect of the comorbidity on the experience of stigma is not yet known.
Given the high prevalence of depression and chronic pain, their economic burden, and the suffering these diseases cause, we aim to better understand the subjective experience of these diseases and their social consequences. Major decisions about the healthcare of individuals suffering from depression and pain are often made by policymakers, healthcare professionals, or even family members who have not themselves experienced these health conditions. It is therefore important to understand whether health conditions and their social sequelae such as stigma perceived by healthy individuals differs from the perceptions of the sufferers. Thus, the purpose of this investigation is to characterize the perception of stigma associated with depression and chronic pain among individuals diagnosed with depression, with chronic pain, with comorbid depression and pain, as well as among healthy individuals never affected by either condition. Because of the numerous studies that demonstrate the existence of stigma associated with depression and chronic pain and its impact, we hypothesized that healthy controls will underestimate the stigma associated with depression and chronic pain. However, less was known about the experience of stigma among patients with co-morbid depression and chronic pain – the information obtained from our study could help fill some of the gaps in our knowledge about chronic pain stigma (De Ruddere and Craig, 2016). A better understanding of stigma experiences and the differences of such experiences between the groups, as well as an understanding of the differences in stigma perceptions between those experiencing a disorder and those who are not would be helpful in educating providers and other stakeholders about the unique challenges of individuals struggling with these health conditions.
Section snippets
Participants
Participants were recruited to a parent study that evaluated individuals’ decision-making regarding joining clinical trials (Leykin et al., 2017). Participants (N = 236) were recruited to four groups: 61 participants were in the Depression group, 59 in the Chronic Pain group, 56 in the Comorbid (depression and pain) group, and 60 were healthy controls. For the Depression and Comorbid groups, the current diagnosis of primary major depression disorder (MDD) was determined by the SCID-IV-TR (First
Participant characteristics
Chi-square tests and one-way ANOVAs were used to identify differences in demographic characteristics (age, gender, race, marital status, and education level) between the groups. The percentages and means (SDs) of these variables, by group, can be found in Table 1.
There were significant differences between groups based on race (Χ2(3,N = 236) = 10.7, p = 0.01), education level (Χ2(6,N = 236) = 13.5, p = 0.04), and age (F(3,234) = 8.60, p < 0.001). The Depression and Healthy Control groups were
Discussion
Depression and chronic pain are prevalent disorders that cause considerable personal and social challenges, with stigma being a particularly burdensome social challenge. In this investigation, we aimed to understand the differences in the perceptions of stigma of depression and chronic pain between those who suffer these conditions, as well as to contrast them with healthy individuals.
Compared to healthy participants, individuals with depression endorsed higher levels of perceived stigma.
Acknowledgements
Funding for this work was provided by the National Institute of Mental Health grant 5K08MH091501 (Leykin, P.I.). We are grateful to the Center for Health and Community (Nancy Adler, Director) for providing office space and additional resources. We acknowledge and are grateful for the contributions of research assistants, clinical interviewers, and participants.
References (42)
- et al.
Symptoms of depression and stress mediate the effect of pain on disability
Pain
(2011) - et al.
Comorbid chronic pain and depression: who is at risk?
J. Pain
(2009) - et al.
The effect of catastrophizing and depression on chronic pain--a prospective cohort study of temporomandibular muscle and joint pain disorders
Pain
(2011) Diagnostic and Statistical Manual of Mental Disorders
(2000)- et al.
Comorbid depression, chronic pain, and disability in primary care
Psychosom. Med.
(2006) - et al.
Depression and pain comorbidity: a literature review
Arch. Intern. Med.
(2003) - et al.
Stigma about depression and its impact on help-seeking intentions
Aust. N.Z. J. Psychiatry
(2006) - Bharadwaj, P., Pai, M.M., Suziedelyte, A., 2015. Mental Health Stigma: NBER Working Paper No....
- et al.
The mini-cog: a cognitive'vital signs' measure for dementia screening in multi-lingual elderly
Int. J. Geriatr. Psychiatry
(2000) - Center for Behavioral Health Statistics and Quality, 2015. Behavioral health trends in the United States: Results from...