Hardly Depressing and Far from Painful: Commentary on an article by Daniel A. London, BA, et al.: “The Impact of Depression and Pain Catastrophization on Initial Presentation and Treatment Outcomes for Atraumatic Hand Conditions”

The influence of psychosocial factors on treatment outcomes for various musculoskeletal conditions has been considered anecdotally for some time. Our understanding of this association is further improving through formal, scientific study. Instinctively, we, as clinicians, cringe when a patient observes that he or she has “a higher tolerance to pain than most people,” and yet we recognize that pain, as a perception, is difficult to quantify and is challenging to qualify in relative terms. It is notable that the prevalence of depression increased 60% from 2005 to 2008; perhaps this increase was due to variations in local or global sociopolitical factors, or perhaps was secondary to improved screening, greater implementation of testing, or a lowered threshold by the medical community for assigning some form of causation to a symptom or an outcome.

The considerable impact of both depression and pain catastrophization on various upper-extremity conditions, on a patient’s selection of treatment, and on patient satisfaction has been documented previously. Interestingly, many studies have concentrated on cross-sectional data without considering the change in outcomes as a consequence of treatment (or the absence of treatment), and they have not considered the relative variations in outcomes over time specific to the presence or absence of mental health conditions.

Validated screening instruments such as the Center for Epidemiologic Studies Depression (CES-D) scale and the Pain Catastrophizing Scale (PCS) have been utilized to provide a greater understanding of the links between secondary diagnoses, such as depression and pain catastrophization, and ultimate outcomes of treatment for conditions affecting the upper extremity. As demonstrated in the current study, a patient’s subjective history of depression does not always coincide with CES-D score. Often the existence of conflicting subjective and objective testing results points to the complexity of psychosocial factors influencing patient outcomes and patient satisfaction with medical treatment in general.