Mild Depression in Low Back Pain: the Interaction of Thought Suppression and Stress Plays a Role, Especially in Female Patients
Mild depression has been shown as a precursor and as a consequence of low back pain, even in early phases of acute or subacute pain. Chronic daily life stress as well as dysfunctional pain-related cognitions such as thought suppression (TS) seem to play a role in the pain-depression cycle; however, the mechanisms of these associations are less understood. Experimentally induced TS, conceived as the attempt to directly suppress sensations such as pain, has been shown to paradoxically cause a delayed and non-volitional return of the suppressed thoughts and sensations and to increase affective distress. These dysfunctional processes are supposed to increase under high cognitive load, such as high stress.
In the present cross-sectional study, we for the first time sought to examine a possible interaction between habitual TS and stress on depression in N = 177 patients with subacute low back pain (SLBP), using the following questionnaires: Subscale Thought Suppression from Avoidance-Endurance Questionnaire, Beck Depression Inventory, and Kiel Interview of Subjective Situation. A three-way ANOVA was conducted with two groups of TS (high/low), stress (high/low) and sex as independent factors and depression as dependent.
Results indicated a significant three-way interaction with highest depression scores in female patients showing high TS and high stress. Overall main effects for sex and stress indicated higher depression in women and in highly stressed patients.
Our findings support the hypothesis that TS heightens depressive mood under conditions of high cognitive load especially in female patients with SLBP indicating a special vulnerability for depressive mood in women with SLBP.
KeywordsDepression Coping behavior Low back pain Life stress Sex differences Suppression
This study was supported by a research grant from the German Research Foundation (Deutsche Forschungsgemeinschaft: HA 1684) awarded to MIH. We further thank Nina Kreddig for providing helpful comments.
Compliance with Ethical Standards
This study was supported by a research grant from the German Research Foundation (Deutsche Forschungsgemeinschaft: HA 1684) awarded to MIH.
Conflict of Interest
The authors have no conflict of interest to declare.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.
Informed consent was obtained from all individual participants included in the study.
- 3.Dilling H, Mombour W, Schmidt MH, Schulte-Markwort E, Remschmidt H, editors. Internationale Klassifikation psychischer Störungen: ICD-10 Kapitel V (F) klinisch-diagnostische Leitlinien. 10th ed. Bern: Hogrefe; 2015.Google Scholar
- 12.Hasenbring M, Rusu AC, Turk DC, editors. From acute to chronic back pain: risk factors, mechanisms, and clinical implications. Oxford, New York: Oxford University Press; 2012.Google Scholar
- 20.Hülsebusch J, Hasenbring MI, Rusu AC. Understanding pain and depression in back pain: the role of catastrophizing, help−/hopelessness, and thought suppression as potential mediators. IntJ Behav Med. 2015; doi: 10.1007/s12529-015-9522-y.
- 34.von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet. 2007:1453–7.Google Scholar
- 35.National Institute for Health and Care Excellence. Low back pain and sciatica in over 16s: assessment and management. 2016:NICE guideline (NG59).Google Scholar
- 38.Kammer D. Eine Untersuchung der psychometrischen Eigenschaften des deutschen Beck-Depressionsinventars (BDI). Diagnostica. 1983;29:48–60.Google Scholar
- 43.Hasenbring M, Hallner D, Rusu AC. Endurance-related pain responses in the development of chronic back pain. In: Hasenbring M, Rusu AC, Turk DC, editors. From acute to chronic back pain: risk factors, mechanisms, and clinical implications. Oxford, New York: Oxford University Press; 2012. p. 295–314.CrossRefGoogle Scholar
- 44.Hasenbring M, Kurtz B, Marienfeld G. Erfahrungen mit dem Kieler Interview zur subjektiven Situation (KISS). In: Brähler E, Dahme B, Klapp BF, Davies-Osterkamp S, Jacobi P, Koch-Gromus U, et al., editors. Psychosoziale Onkologie. Berlin: Springer Berlin Heidelberg; 1989. p. 68–85. doi: 10.1007/978-3-642-74986-5_6.CrossRefGoogle Scholar
- 45.Hasenbring M, Klasen B, Schaub C, Hallner D. KISS-BR. Kieler Interview zur subjektiven Situation – Belastungen/Ressourcen. In: Schumacher J, Klaiberg A, Brähler E, editors. Diagnostische Verfahren zu Lebensqualität und Wohlbefinden. Göttingen: Hogrefe; 2003. p. 189–91.Google Scholar
- 46.Sudhaus S, Fricke B, Schneider S, Stachon A, Klein H, von Düring M, Hasenbring M. The cortisol awakening response in patients with acute and chronic low back pain. Relations with psychological risk factors of pain chronicity. Schmerz. 2007;21:202–204, 206-11. doi: 10.1007/s00482-006-0521-4.CrossRefPubMedGoogle Scholar
- 47.Schulz-Kindermann F, Hennings U, Ramm G, Zander AR, Hasenbring M. The role of biomedical and psychosocial factors for the prediction of pain and distress in patients undergoing high-dose therapy and BMT/PBSCT. Bone Marrow Transplant. 2002;29:341–51. doi: 10.1038/sj.bmt.1703385.CrossRefPubMedGoogle Scholar
- 52.Scholich SL, Hallner D, Wittenberg RH, Rusu AC, Hasenbring MI. Pilot study on pain response patterns in chronic low back pain. The influence of pain response patterns on quality of life, pain intensity and disability. Schmerz. 2011;25:184–90. doi: 10.1007/s00482-011-1023-6.CrossRefPubMedGoogle Scholar
- 53.Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed. Hillsdale: Erlbaum; 1988.Google Scholar
- 54.Tabachnick BG, Fidell LS. Using multivariate statistics. 4th ed. Boston, Mass. [u.a.]: Allyn and Bacon; 2001.Google Scholar
- 55.Field A. Discovering statistics using IBM SPSS statistics. 4th ed. SAGE: Los Angeles; 2015.Google Scholar
- 57.IBM Corporation. IBM SPSS Statistics for Windows: version 23.0. Armonk: IBM Corporation; 2015.Google Scholar
- 58.Szasz PL. Thought suppression, depressive rumination and depression: a mediation analysis. Journal of Evidence-Based Psychotherapies. 2009;9:199–209.Google Scholar
- 68.Lebe M, Hasenbring MI, Schmieder K, Jetschke K, Harders A, Epplen JT, et al. Association of serotonin-1A and -2A receptor promoter polymorphisms with depressive symptoms, functional recovery, and pain in patients 6 months after lumbar disc surgery. Pain. 2013;154:377–84. doi: 10.1016/j.pain.2012.11.017.CrossRefPubMedGoogle Scholar
- 69.Beevers CG, Wenzlaff RM, Hayes AM, Scott WD. Depression and the ironic effects of thought suppression: therapeutic strategies for improving mental control. Clinical Psycholgy: Science and Practice. 1999;6:133–48.Google Scholar