• Users Online: 130
  • Print this page
  • Email this page

 Table of Contents  
Year : 2021  |  Volume : 4  |  Issue : 3  |  Page : 116-121

Pain and depression among adult outpatients with osteoarthritis in Nigeria: A cross-sectional study

1 Mental Health Unit, Health Management Board, Jalingo, Taraba State, Nigeria
2 Department of Mental Health, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria
3 Department of Mental Health, Irrua Specialist Teaching Hospital, Irrua, Nigeria
4 Federal Neuro-Psychiatric Hospital Benin, Benin-City, Edo State, Nigeria

Date of Submission31-Mar-2021
Date of Decision25-May-2021
Date of Acceptance07-Jun-2021
Date of Web Publication26-Jul-2021

Correspondence Address:
Sunday O Oriji
Department of Mental Health, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/shb.shb_15_21

Rights and Permissions

Introduction: Arthritis is a degenerative joint disease with many forms, but osteoarthritis is most common resulting from trauma or infection to the joint or aging. Depressive disorders often go undiagnosed especially in chronic physical illnesses like osteoarthritis. Osteoarthritic pain is associated with a high risk of depressive illness. This study evaluated the prevalence of major depression and its relationship with physical pain among patients with osteoarthritis. Methods: This was a cross-sectional study involving 134 adult outpatients, with osteoarthritis at the University of Benin Teaching Hospital. The demographic profile, subjective pain intensity, and diagnosis of major depression were obtained with a sociodemographic questionnaire, Visual Analog Pain Scale, and depressive module of Composite International Diagnostic Interview, respectively. Results: Thirty-seven (27.61%) and 40 (29.85%) participants had current and 12-month depressive disorder, respectively. A unit (year) increase in the illness duration was associated with a 68% increase in the likelihood of having depression (adjusted odds ratio [aOR] 1.68, P = 0.044), while the presence of comorbidity was the only independent correlate of 12-month depression among the participants (aOR 0.11, P = 0.031). Subjective pain severity had no independent correlation with depressive disorder. Conclusion: Major depression is prevalent among patients with osteoarthritis. Clinicians should have a high index of suspicion of depressive disorder, especially in the presence of medical comorbidities and longer duration of illness.

Keywords: Depression, Nigeria, osteoarthritis, subjective pain

How to cite this article:
Chimbo C, Oriji SO, Erohubie PO, James BO, Lawani AO. Pain and depression among adult outpatients with osteoarthritis in Nigeria: A cross-sectional study. Asian J Soc Health Behav 2021;4:116-21

How to cite this URL:
Chimbo C, Oriji SO, Erohubie PO, James BO, Lawani AO. Pain and depression among adult outpatients with osteoarthritis in Nigeria: A cross-sectional study. Asian J Soc Health Behav [serial online] 2021 [cited 2021 Sep 21];4:116-21. Available from: http://www.healthandbehavior.com/text.asp?2021/4/3/116/322290

  Introduction Top

The impact of depression on osteoarthritis is great because depression has a substantial impact on two main symptoms of osteoarthritis: pain and disability. Regarding pain, previous studies have shown that individuals with depression are more likely to report chronic pain, and more than half of patients with chronic pain experience depression.[1],[2] Among patients with osteoarthritis, depression was found to be associated with increased pain sensitivity and less effective coping with the illness.[3] Osteoarthritic pain is associated with an increased risk of depressive symptoms as a result of fatigue and disability.[4]

Depression is the leading cause of disability and significantly contributes to the global burden of disease worldwide.[5],[6] Although effective treatments are available, depression often goes undiagnosed and undertreated,[7] especially in chronic physical illnesses.

Worthy to note that research evidences have shown inconsistent results with respect to the correlation between subjective pain and depressive disorder. While some studies reported that pain predicted depression among patients with osteoarthritis,[8],[9] a study on the other hand, reported perceived pain as an insignificant predictor of depression among patients with osteoarthritis.[10]

Approximately 350 million people worldwide have arthritis and cases in Nigeria account for about 9% of new patients with arthritis worldwide.[11] Arthritis is common in older people, especially osteoarthritis.[12] Osteoarthritis is a disease that commonly causes physical disability though the impact of its combination with other chronic diseases is yet to be assessed.[13] Psychological complications of osteoarthritis are hardly recognized by physicians outside the mental health domain[14] despite the knowledge that depression is a major risk factor for poor health outcomes among patients with arthritis.[15] Clinical factors to help nonmental health physicians to identify and initiate early consultation-liaison care for major depression in patients with osteoarthritis have not been well studied.

A recent systematic review reported that most studies that evaluated depression in persons with osteoarthritis used screening tools to diagnose depressive disorder.[16] Using a standardized diagnostic instrument such as the World Health Organization Composite International Diagnostic Interview (WHO CIDI), this study determined the prevalence of current and 12-month depressive disorder among adults with osteoarthritis and explored the association of depressive disorder with sociodemographic characteristics and subjective pain intensity.

  Methods Top

Study design and setting

This was a cross-sectional descriptive study. The study was conducted at the Outpatient Clinics of the University of Benin Teaching Hospital, Nigeria. The university is in Edo State, one of the six states of the South–South geopolitical zone of Nigeria.

Study population

One hundred and thirty-four participants diagnosed with and receiving care for osteoarthritis at the orthopedic outpatients' clinics of the University of Benin Teaching Hospital, who met the inclusion criteria, were recruited in the study. Participants aged between 18 years and 64 years diagnosed with osteoarthritis and who provided written informed consent were recruited, while those undergoing treatment for comorbid depression prior to the onset of arthritis were excluded from the study.

Minimum sample size estimation and sampling procedure

The minimum sample size was determined using WINPEPI 11.64 computer software, with the level of significance set at 5%, a sample proportion of 0.083,[17] and study power at 95%. A sample of 134 participants were recruited via a convenience sampling method.


Sociodemographic questionnaire

A sociodemographic questionnaire was designed to obtain information from the following variables: gender, age, religion, level of education, occupation, marital status, and living status. It also comprises information on clinical characteristics such as duration of illness, presence of comorbidity, type of arthritis, and the joints affected.

The World Health Organization composite international diagnostic interview

The CIDI is a fully structured diagnostic interview that can generate diagnosis according to both DSM IV and International Classification of Diseases (ICD-10). It was developed as a collaborative project between the WHO and the US National Institute of Health. As the most widely used structured interview in the world, the CIDI allows the investigator to measure the prevalence of mental disorders, including depressive disorder. It is scored as 1 for “endorsed,” 5 for “not endorsed,” “8 for refused,” and 9 for “don't know.” The computerized scoring algorithm gives a diagnosis according to ICD-10 or DSM-IV.[18] It is available in current, 12-month, and lifetime versions in both paper and computer-administered form and also available in many languages.[19] The CIDI has been used in Nigeria.[20],[21],[22]

Visual Analog Pain Scale

The Visual Analog Pain Scale (VAS) is an assessment tool consisting of a 10 cm line with zero at one end representing “no pain” and 10 on the other end representing “the worst pain ever experienced.”[23] It is a uni-dimensional measure of pain intensity which has been widely used in diverse adult populations, including those with rheumatic disease.[24]

The pain VAS is self-administered by the respondent. The respondent is asked to place a line perpendicular to the VAS line at the point that represents their pain intensity.[25] Using a ruler, the score is determined by measuring the distance (mm) on the 10 cm line between the “no pain” anchor and the patients' mark providing a range of scores from 0 to 100. A higher score indicates greater intensity.[23] No pain with a range of 0–4 mm, mild pain designated as 5–44 mm, moderate pain as 45–74 mm, and severe pain as scores ranging from 75 mm to 100 mm.[26] It has good test–retest reliability, but higher among literates (r = 0.71, P < 0.001) than illiterate patients.[27] The correlation between vertical and horizontal orientations of VAS was 0.99.[28] The VAS was used to measure the intensity of pain among respondents in this study. All data were obtained once in the clinic, immediately after patient's consultation with his/her doctor.

Ethical consideration

Ethical approval for this study was obtained from the Ethics Committee of the University of Benin Teaching Hospital, Benin City with Protocol Number: ADM/E 22/A/VOL VII/1074. The participants were duly informed of the nature and purpose of the study and assured of confidentiality; thereafter, written informed consent was obtained.

Statistical analysis

The data collected were analyzed using the Statistical Package for Social Sciences (SPSS) IBM version 23.0 (SPSS Chicago Inc., IL, USA). The results were displayed in tables and figures as appropriate. The categorical variables (gender, marital status, employment status, educational status, religion, living alone, previous treatment, and comorbidity) were compared to the presence or absence of major depression with Chi-square test. While Mann–Whitney U-test was used to assess the relationship between the continuous variables (age, duration of illness, Visual Analog Scale score) and major depression. The significant sociodemographic and clinical correlates of depressive disorder from bivariate analysis were entered into a binary logistic regression analysis to determine predictors of depressive disorder (present/absent).

Statistical significance was set at P < 0.05. All tests were two tailed.

  Results Top

Sociodemographic and clinical characteristics

The mean age of the participants was 58.37 years. Ninety-four (70.1%) were female. Fifty-eight (43.3%) were married and 68 (50.7%) were unemployed (retirees inclusive). Fifty-six had at least secondary level of education. Fourteen (10.4%) live alone [Table 1]. The mean duration of illness was 5.49 years. More than three-quarter of the participants had moderate–severe pain, while at least two-third had medical comorbidities [Table 2]. Hypertension (41.7%) was the most common comorbidity.
Table 1: The sociodemographic characteristics of participants

Click here to view
Table 2: The clinical characteristics of participants

Click here to view

Prevalence and correlates of current and 12-month depression

At least one in four (27.61%) and nearly one-third (29.85%) of the participants had current and 12-month depressive disorder, respectively. Participants who were single/widowed (P < 0.02), having at most a secondary level of education (P < 0.003), living alone (P < 0.003), and had a comorbidity (P < 0.001) were significantly more likely to report current depression. With respect to 12-month depression, participants who were single/widowed (P < 0.007), having at most a secondary level of education (P < 0.004), living alone (P < 0.001), and had a comorbidity (P < 0.001) were significantly more likely to report 12-month depression [Table 3]. Duration of illness and pain severity scores were significantly associated with depression on bivariate analysis [Table 4].
Table 3: Sociodemographic and clinical correlates of current and 12-month depression among the participants (categorical variables)

Click here to view
Table 4: Sociodemographic and clinical correlates of current and 12-month depression among the participants (continuous variables)

Click here to view

Independent correlates of current and 12-month depression among the participants

The significant sociodemographic and clinical correlates of depressive disorder from the bivariate analysis were entered into a binary logistic regression analysis to determine predictors of current and 12-month depression (present/absent). A unit increase in the illness duration (years) was associated with a 68% increase in the likelihood of having depression (adjusted odds ratio [aOR] 1.68, P = 0.044), while the presence of comorbidity was the only independent correlate of 12-month depression among the participants (aOR 0.11, P = 0.031) [Table 5].
Table 5: Independent correlates of current and 12-month depression among the participants

Click here to view

  Discussion Top

Age was not found to be significantly associated with current and 12-month major depression among the population studied. Contrarily, Rosemann et al.[8] reported that age has a statistically significant association with the diagnosis of depression among individuals with osteoarthritis. The different results could be attributed to the use of a screening tool – Patient Health Questionnaire-9 to diagnose depressive disorder among their participants, unlike the standard diagnostic instrument-CIDI employed in this study. More so, this study recruited participants within the age bracket of 18–64 years, while Rosemann et al. included participants who were more than 64 years of age.

With respect to gender, earlier studies[8],[10],[29] found no significant correlation with the diagnosis of major depression among patients with osteoarthritis, similar to what this study found. But generally, depressive disorder is twice more in females than males[30] outside the context of medical comorbidities.

This study found the duration of illness to be independently associated with major depression. This is in keeping with an earlier report by Yilmaz et al.[31] The presence of comorbidity was also found to be independently associated with depressive disorder. The role of environmental factors in the aetiological theories of major depression has been documented. The persistent or the chronicity of the overwhelming stressor (s) and addition of more burdens from any medical comorbidities increase individual's vulnerability to depressive disorder.[31],[32],[33]

This study found a prevalence of current and 12-month depression of 27.61% and 29.85%, respectively, among the participants. This contrasts sharply with the current depression prevalence of 10%, reported by Abdel-Nasser et al.[29] in Egypt. This difference might be accounted for by the inclusion of geriatric/elderly patients in the Egypt-based study and the restriction of the participants to strictly patients with knee osteoarthritis. Küçükşen et al.[9] in Portugal and Rosemann et al.[8] reported a much higher current prevalence of depressive disorder among patients with osteoarthritis of 49.3% and 38.92%, respectively. Conversely, some researchers[10],[34] reported lower prevalent rates of 19.9% and 20.9%. The methodological difference in the sense that Küçükşen et al., Rosemann et al., Marks,[10] and Pereira et al.[34] used screening instruments to assess the depression against the standard diagnostic instrument (CIDI) employed in this study could account for the divergent prevalence rates.

This study found subjective pain (VAS score) to be significantly associated with the diagnosis of depression in the studied population on bivariate analysis. However, after controlling for the possible confounders in the logistic regression analysis, the pain did not predict depressive disorder. Similarly, Abdel-Nasser et al.[29] found perceived pain as an insignificant predictor of major depression. Furthermore, individuals with osteoarthritis who were depressed engaged less in walking activities irrespective of their osteoarthritic pain.[35] This implies that depressive disorder among individuals with osteoarthritis may not be attributed to the presence of pain. However, the burden of pain might have been mitigated by medications and that could explain the nonpredictive effect of pain on depression among our study participants. This finding highlights the essence of clinicians to have a high index of suspicion of depressive disorder in patients with osteoarthritis irrespective of their pain score.


We acknowledged the limitations of our study. First, its cross-sectional design makes it difficult to determine a causal relationship between subjective pain and depression among individuals with osteoarthritis. Second, the study did not recruit those more than 64 years old; hence, our findings may have limited generalizability to all people with osteoarthritis.

Despite these limitations, the study has strength and clinical implication. The “golden standard” used to diagnose depression is a structured clinical interview and only a few studies have deployed this standard to diagnose major depression among persons with osteoarthritis.[16] This study utilized the WHO CIDI, a structured diagnostic instrument. Clinicians managing individuals with osteoarthritis should assess for major depression, especially in the presence of comorbidities and as the illness duration increases. These findings suggest the need for integration of rheumatologic and mental health services and generate hypotheses for future research toward a better understanding of both depression and osteoarthritis.

  Conclusion Top

The outcome of this study revealed that a great number of individuals living with osteoarthritis have a depressive disorder which is predicted by the presence of medical comorbidities and illness duration. The osteoarthritic pain had no independent depressive risk on patients with osteoarthritis.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Dworkin RH, Gitlin MJ. Clinical aspects of depression in chronic pain patients. Clin J Pain 1991;7:79-94.  Back to cited text no. 1
Arnow BA, Hunkeler EM, Blasey CM, Lee J, Constantino MJ, Fireman B, et al. Comorbid depression, chronic pain, and disability in primary care. Psychosom Med 2006;68:262-8.  Back to cited text no. 2
Zautra AJ, Smith BW. Depression and reactivity to stress in older women with rheumatoid arthritis and osteoarthritis. Psychosom Med 2001;63:687-96.  Back to cited text no. 3
Arthritis Research UK. Lending a Helpful Hand | Arthritis Research UK. Arthritis Today; 2011. Available from: http://www.arthritisresearchuk.org/arthritis-information/arthritis-today-magazine/158-autmn-2012/lending-a-helpful-hand.aspx. [Last accessed on 2017 Mar 10].  Back to cited text no. 4
Marcus M, Yasamy MT, van Ommeren M van, Chisholm D, Saxena S. Depression: A Global Public Health Concern: (517532013-004). American Psychological Association; 2012. doi: 10.1037/e517532013-004.  Back to cited text no. 5
Worid Health Organization. Depression is the Leading Cause of Disability Worldwide. Life and Health Style Express. Available from: http://www.express.co.uk/life-style/health/785830/depression-mental-health-leading-cause-ill-disability-worldwide-who. [Last accessed on 2017 May 09].  Back to cited text no. 6
Semple D, Smyth R, Burns J, Darjee R, Mcintosh A. Oxford Handbook of Psychiatry. Indian: Oxford University Press; 2005. p. 242.  Back to cited text no. 7
Rosemann T, Backenstrass M, Joest K, Rosemann A, Szecsenyi J, Laux G. Predictors of depression in a sample of 1,021 primary care patients with osteoarthritis. Arthritis Rheum 2007;57:415-22.  Back to cited text no. 8
Küçükşen S, Yılmaz H, Karahan AY, Bağçacı S. The prevalence of depression and its relevance to clinical and radiological characteristics among older adults with knee osteoarthritis. Clin Med Res 2014;3:25-30.  Back to cited text no. 9
Marks R. Depressive symptoms among community-dwelling older adults with mild to moderate knee osteoarthritis: Extent, interrelationships, and predictors. Am J Med Stud 2013;1:11-8.  Back to cited text no. 10
Mbanaefo TI. Arthritis; 2007. Available from: https://www.radionigeriaonline.com/blogs/tonia.html.arthritis. [Last accessed on 2017 Mar 19].  Back to cited text no. 11
NBF News. “Majority of Old People will Develop Arthritis”. The Nigerian Voice; 2012. Available from: https://www.thenigerianvoice.com/news/92192/majority-of-old-people-will-develop-arthritis.html. [Last accessed on 2017 Mar 10].  Back to cited text no. 12
Kadam UT, Croft PR. Clinical comorbidity in osteoarthritis: Associations with physical function in older patients in family practice. J Rheumatol 2007;34:1899-904.  Back to cited text no. 13
Ferreira LN, Ferreira PL, Baleiro RR. Health-related quality of life in patients with rheumatoid arthritis. Acta Reumatol Port 2008;33:331-42.  Back to cited text no. 14
Lin EH, Katon W, Von Korff M, Tang L, Williams JW Jr., Kroenke K, et al. Effect of improving depression care on pain and functional outcomes among older adults with arthritis: A randomized controlled trial. JAMA 2003;290:2428-9.  Back to cited text no. 15
Sambamoorthi U, Shah D, Zhao X. Healthcare burden of depression in adults with arthritis. Expert Rev Pharmacoecon Outcomes Res 2017;17:53-65.  Back to cited text no. 16
Memel DS, Kirwan JR, Sharp DJ, Hehir M. General practitioners miss disability and anxiety as well as depression in their patients with osteoarthritis. Br J Gen Pract 2000;50:645-8.  Back to cited text no. 17
Robins LN, Wing J, Wittchen HU, Helzer JE, Babor TF, Burke J, et al. The Composite International Diagnostic Interview. An epidemiologic Instrument suitable for use in conjunction with different diagnostic systems and in different cultures. Arch Gen Psychiatry 1988;45:1069-77.  Back to cited text no. 18
Andrews G, Peters L. The psychometric properties of the Composite International Diagnostic Interview. Soc Psychiatry Psychiatr Epidemiol 1998;33:80-8.  Back to cited text no. 19
Gureje O, Olowosegun O, Adebayo K, Stein DJ. The prevalence and profile of non-affective psychosis in the Nigerian Survey of Mental Health and Wellbeing. World Psychiatry 2010;9:50-5.  Back to cited text no. 20
Gureje O, Lasebikan VO, Kola L, Makanjuola VA. Lifetime and 12-month prevalence of mental disorders in the Nigerian Survey of Mental Health and Well-Being. Br J Psychiatry 2006;188:465-71.  Back to cited text no. 21
Uwakwe R, Okonkwo JE. Affective (depressive) morbidity in puerperal Nigerian women: Validation of the Edinburgh Postnatal Depression Scale. Acta Psychiatr Scand 2003;107:251-9.  Back to cited text no. 22
Jensen MP, Karoly P, Braver S. The measurement of clinical pain intensity: A comparison of six methods. Pain 1986;27:117-26.  Back to cited text no. 23
Huskisson EC, Wojtulewski JA, Berry H, Scott J, Hart FD, Balme HW. Treatment of rheumatoid arthritis with fenoprofen: Comparison with aspirin. Br Med J 1974;1:176-80.  Back to cited text no. 24
Hawker GA, Mian S, Kendzerska T, French M. Measures of adult pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 Bodily Pain Scale (SF-36 BPS), and Measure of Intermittent and Constant Osteoarthritis Pain (ICOAP). Arthritis Care Res (Hoboken) 2011;63 Suppl 11:S240-52.  Back to cited text no. 25
Jensen MP, Chen C, Brugger AM. Interpretation of visual analog scale ratings and change scores: A reanalysis of two clinical trials of postoperative pain. J Pain 2003;4:407-14.  Back to cited text no. 26
Ferraz MB, Quaresma MR, Aquino LR, Atra E, Tugwell P, Goldsmith CH. Reliability of pain scales in the assessment of literate and illiterate patients with rheumatoid arthritis. J Rheumatol 1990;17:1022-4.  Back to cited text no. 27
Scott J, Huskisson EC. Vertical or horizontal visual analogue scales. Ann Rheum Dis 1979;38:560.  Back to cited text no. 28
Abdel-Nasser AM, Abd El-Azim S, Taal E, El-Badawy SA, Raskerd JJ, Valkenburg HA. Depression and depressive symptoms in rheumatoid arthritis patients: An analysis of their occurrance and determinants. Br J Rheumatol 1998;37:391-7.  Back to cited text no. 29
Romans SE, Tyas J, Cohen MM, Silverstone T. Gender differences in the symptoms of major depressive disorder. J Nerv Ment Dis 2007;195:905-11.  Back to cited text no. 30
Yilmaz H, Karaca G, Polat HA, Akkurt HE. Comparison between depression levels of women with knee osteoarthritis, rheumatoid arthritis and fibromyalgia syndrome: A controlled study. Turk J Phys Med Rehab 2015;5:197-202.  Back to cited text no. 31
Sheehy C, Murphy E, Barry M. Depression in rheumatoid arthritis – Underscoring the problem. Rheumatology (Oxford) 2006;45:1325-7.  Back to cited text no. 32
Leite AA, Costa AJ, Lima Bde A, Padilha AV, Albuquerque EC, Marques CD. Comorbidities in patients with osteoarthritis: Frequency and impact on pain and physical function. Rev Bras Reumatol 2011;51:118-23.  Back to cited text no. 33
Pereira D, Severo M, Barros H, Branco J, Santos RA, Ramos E. The effect of depressive symptoms on the association between radiographic osteoarthritis and knee pain: A cross-sectional study. BMC Musculoskelet Disord 2013;14:214.  Back to cited text no. 34
White DK, Keysor JJ, Neogi T, Felson DT, LaValley M, Gross KD, et al. When it hurts, a positive attitude may help: The association of positive affect with daily walking in knee OA: The MOST Study. Arthritis Care Res (Hoboken) 2012;64:1312-9.  Back to cited text no. 35


  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Article Tables

 Article Access Statistics
    PDF Downloaded59    
    Comments [Add]    

Recommend this journal