In a cohort of individuals with HIV-associated distal neuropathic pain we hypothesized that pain intensity, rather than depressed mood, would be more strongly associated with worse life quality and worse sense of overall well-being. Contrary to this hypothesis our results suggest that greater severity of depression symptoms is more highly correlated with worse well-being than is pain intensity. The result supports the psychiatric consultants position that efforts to improve well-being in this population should consider mood disturbance, as well as pain intensity, as part of a comprehensive approach to treatment.
Painful HIV-associated neuropathy is recognized as a prevalent and growing world health problem 38
. As described in the results, the burden of current pain was high, with nearly three in four individuals reporting their intensity in the “moderate” to “very severe” range. This burden of pain intensity is in the range reported in one recent epidemiologic survey for acute and chronic pain of diverse etiology in ambulatory HIV-infected individuals 27
. HIV neuropathy pain is often resistant to standard therapy with antidepressants, anticonvulsants, opioids, and topical agents 4
. This implies that a comprehensive approach addressing factors beyond pain intensity may be important to improving life quality outcomes. HIV disease status is one clear target, since disease symptom complaints are linked to worse life quality 21
, and disease status is customarily the primary treatment focus. But, mood disturbance is known to have significant impact upon HIV HRQOL 3,15,16,17,18,19,20,21,22
One of the difficulties in better understanding relationships between life quality, HIV disease, mood, and HIV-associated pain is that each of these variables is often studied in relative isolation. Studies of HIV and life quality may omit assessment of either mood or pain or both 39
, making it impossible to assess their relative contributions. In turn, studies relating pain intensity to mood and HIV-disease variables may omit assessment of life quality 21
. Furthermore, pain syndromes in HIV have diverse etiologies 24
, but research relating pain, mood, and life quality does not routinely report diagnosis of specific pain syndromes nor differentiate acute pain from chronic pain. Pain symptoms may affect over 25% of HIV-infected men and women 27,21
, and presence of pain may be related to worse HIV outcomes, including life quality 3
as well as disability in everyday function and unemployment 3
despite the advances of modern treatment. Pain may be linked to worse immune function (CD4+ lymphocyte count) and worse mood 25,17,21
while depressed mood itself is associated with lower overall and painrelated life quality 17
. The relation of pain intensity to mood is uncertain: some work finds no correlation 3
, but other evidence suggests a relation between intensity of pain and severity of mood disturbance 17,21
, particularly in socioeconomically disadvantaged patients with high rates of substance abuse 27
. Other carefully conducted research, on the other hand, suggests overall life satisfaction is similar in those with and without pain, at least for mild pain intensity 25
. Part of this variability of results among studies with regard to pain intensity may as well be related to the study entry criteria in terms of chronicity and diagnostic heterogeneity. In this regard there is evidence that patients with neuropathic pain differ from those with nociceptive pain in responses to and beliefs about pain, major problems experienced and factors increasing pain 40
. It may be important to evaluate carefully diagnosed, more homogeneous pain samples in future work.
Limitations of the present study include its cross-sectional design, which leaves us unable to explore possible cause and effect relationships among life quality, pain intensity and mood. Another limitation is that this multi-site cohort was drawn from individuals enrolled in HIV care, rather than from a random sample, and therefore may not be generalizable to all HIV-infected individuals. Because participants in this cohort underwent extensive assessments, and were modestly reimbursed for time and travel, it is probable that unemployed persons were more likely to enroll. One set of limitations includes the fact that our study group was defined as HIV patients with clinician-rated neuropathic pain severity rated as of at least “mild” severity. Participant self-reported pain intensity was derived from the MOS-HIV question regarding intensity of “body pain”. Given the definition of the cohort, it is likely that participants reported “body pain” in reference to “neuropathic pain,” but we cannot be certain of this in all cases. Also the correlations between pain intensity and Well-Being may be artificially restricted since we limited the range of pain to include only individuals with at least mild symptoms. Finally, Well-Being may be more highly correlated with the BDI-II than with pain intensity since well-being components such as mental health, fatigue, and health distress are likely to reflect depression symptoms, at least in part. Compensating for some of these limitations may be the fact that this was a large cohort drawn from diverse geographic sites, which included a wide range of HIV disease status, and which underwent rigorous standardized assessment of pain diagnosis, pain intensity, mood, and life quality.
Given the prevalence and impact of HIV neuropathic pain, and the need to improve everyday outcomes in those living with HIV disease, these results suggest that additional research may be warranted to assess effects of depression treatment on life quality in painful HIV neuropathy.