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I read with great interest the recently published article by Poleshuck et al on psychosocial stress, anxiety and its association with depression severity among patients with chronic musculoskeletal pain(1). Among patients with chronic conditions such as musculoskeletal pain, mental health remains an important overall component of general health (2) and I agree with the authors that anxiety and psychosocial distress should be carefully screened and assessed in this patient population. Previous studies have shown that the prevalence of serious psychological distress, frequent anxiety, and depression has been reported to be higher in adults with musculoskeletal pain than in those without musculoskeletal pain (3). In the study by Poleshuck et al, depressed patients reported significantly more psychosocial stressors and more severe anxiety and pain disability than the nondepressed counterparts. Nonetheless, items included in the depression scale utilized in the study may have overestimated the difference in the prevalence of depression among those patients with chronic musculoskeletal pain.
Large population-based and community surveys often employ abbreviated diagnostic interviews administered by lay interviewers. The Patient Health Questionnaire (PHQ) is a Diagnostic and Statistical Manual (DSM)-IV criteria-based scale that assesses 8 diagnoses, categorized into threshold disorders namely, disorders that correspond to specific DSM-IV diagnoses: major depressive disorder, panic disorder, other anxiety disorder, and bulimia nervosa (4). To qualify candidates to participate in the abovementioned study, the PHQ-9, a 9-item depression module from the full PHQ was utilized. However, some of the PHQ scale items of this questionnaire may be influenced by physical health and may not operate as a “pure” measure of mental health. For example, the PHQ-9, a measure of a major depressive episode in the preceding 2 weeks, inquires “Over the last 2 weeks, how often have you been feeling tired or having little energy?” and “Over the last 2 weeks, how often have you been moving or speaking so slowly that other people could have noticed?” It is possible that individuals with chronic musculoskeletal pain may misinterpret these scale item questions as part of their physical ailments rather than as part of their mental health. Similar misattribution of physical symptoms to mental health has been noted in clinical studies of the Centers for Epidemiological Studies-Depression scale in patients with rheumatoid arthritis (5). Psychiatric researchers should consider the possibility of misattribution when such scales are administered for inclusionary criteria in large-population studies, and consider whether the items in the scale may lead to an overestimate of the true burden of depression and mental health disorders in persons with musculoskeletal pain or other chronic physical conditions. Additional research into the validity of the scale items as they pertain to individuals with chronic conditions such as musculoskeletal pain is warranted.
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