The relationship between pain and depression and anxiety in people with inflammatory arthritis: A systematic review
- PMID: 40902211
- DOI: 10.1016/j.semarthrit.2025.152808
The relationship between pain and depression and anxiety in people with inflammatory arthritis: A systematic review
Abstract
Objective: This PROSPERO-registered (CRD42023411823) systematic review synthesised literature on the associations between pain and depression/anxiety in inflammatory arthritis, including the direction of effect, relationship mediators, and treatment impacts.
Methods: Protocolised-database searches were conducted to May-2023 and studies assessing the associations between pain and depression/anxiety and/or impacts of depression/anxiety treatment on pain in people with rheumatoid arthritis/spondyloarthritis identified. Studies with mixed-populations, non-translatable non-English studies, case-reports/series/reviews/editorials, and abstracts/letters with insufficient-data were excluded. Vote-counting/meta-analysis synthesised single-time-point associations. Narrative synthesis summarised longitudinal associations/mediators/treatment effects. JBI critical-appraisal tools and the Grading of Recommendations, Assessment, Development and Evaluations approach evaluated risk-of-bias and strength-of-evidence.
Results: Seventy-nine studies were included. A bidirectional relationship between pain and depression was observed. At single-time-points, pain was higher in those with depression (standardised mean difference [SMD]=0.69 [95%CI 0.54,0.84]; representing a moderate effect as per Cohen's criteria); linear regressions demonstrated moderate associations between pain (outcome) and depression (explanatory-variable) (SMD=0.65 [0.31,0.99]) and small associations between depression (outcome) and pain (explanatory-variable) (SMD=0.24 [0.03,0.45]). Longitudinal studies indicated greater pain with worse depression. Findings were mixed for anxiety. Linear regressions showed minimal associations between pain (outcome) and anxiety (explanatory-variable) (SMD=0.03 [0.001,0.05]) and moderate between anxiety (outcome) and pain (explanatory-variable) (SMD=0.55 [0.20,0.91]). Two longitudinal studies considered mediators (one suggesting "passive coping" in depression). Trials indicated anti-depressants reduced pain in people with comorbid-depression. Thirty-five percent of studies were at high, 34% moderate, and 30% low risk-of-bias; evidence was very low/low-quality.
Conclusion: A modest bidirectional association exists between pain and depression in inflammatory arthritis (based on very low-quality evidence), supporting biopsychosocial pain management.
Keywords: Anxiety; Depression; Pain; Rheumatoid arthritis; Spondyloarthritis; Systematic review.
Copyright © 2025. Published by Elsevier Inc.
Conflict of interest statement
Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Natasha Cox reports financial support was provided by Haywood Foundation. Natasha Cox reports financial support was provided by Keele Haywood Academic Research Group. Ian Scott reports financial support was provided by National Institute for Health and Care Research. Sara Muller reports was provided by National Institute for Health and Care Research Applied Research Collaboration West Midlands. Ram Bajpai reports financial support was provided by National Institute for Health and Care Research Applied Research Collaboration West Midlands. Helen Twohig reports financial support was provided by National Institute for Health and Care Research. Saeed Farooq reports financial support was provided by National Institute for Health and Care Research. Chelsea Kettle reports financial support was provided by Haywood Foundation. Ashley Hawarden reports financial support was provided by Versus Arthritis. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.