Unemployment, Depression Tied to Pain Frequency in Sickle Cell Disease

Employment status, depression, sex, and age were all associated with pain frequency among patients with sickle cell disease (SCD), according to researchers.

In a cross-sectional study of more than 2,000 SCD patients, they found that almost half reported frequent pain (four or more pain crises in 12 months).

But while "SCD-related pain does not discriminate" in terms of education and income, it did in terms of depression, employment status, and age and sex, reported Kelly M. Harris, PhD, of the Washington University School of Medicine in St. Louis, and colleagues in JAMA Network Open.

Study participants reported mean pain frequency and pain severity scores of 48.6 and 50.3, respectively, on a 100-point scale where lower scores represent worse health impact. Most participants (79.8%) rated their pain as a 7 or higher on a scale of 1 to 10. Nearly half (47.8%) reported more than four pain episodes in the prior 12 months, and 49.7% reported pain episodes lasting 4 or more days.

Harris and colleagues observed that educational attainment and income were not significantly associated with increased pain episode frequency or severity. However, factors that were statistically significantly associated (β indicating the degree of change in the outcome variable) with those measures included the following:

• Unemployed status: β 2.13 for pain episode frequency and β 1.07 for severity
• Female sex: β 1.78 for frequency and β 2.13 for severity
• Daily use of pain medication: β 6.29 for frequency and β 2.87 for severity
• Age younger than 18 years: An inverse association of β -5.72 for frequency and β -5.10 for severity

Depression was not associated with pain severity, but was significantly associated with increased pain frequency (β 2.18, P<0.001)

"This finding is particularly important considering the disproportionate impact SCD has on individuals of African descent, the stigma Black youth with SCD encounter when they seek care for [vaso-occlusive crises] and the current climate and limitations to treatment for pain," the authors wrote.

In addition, Harris and colleagues suggested that pain interventions "cannot ignore screening for depression and other mental health challenges among patients with SCD," adding that SCD-related pain should not be treated with medications only, but that providers "must begin to consider and incorporate holistic or comprehensive approaches to reducing pain."

The study included 2,264 individuals between the ages of 15 and 45 (mean 27.9 years) with SCD who were treated at eight sites of the Sickle Cell Disease Implementation Consortium. More than half of participants were female (56.2%) and the vast majority (95.5%) identified as Black persons. Most individuals (78%) reported their highest level of education as high school diploma or lower, 63.9% were unemployed (23.3% by choice), and 54% reported annual household incomes less than $25,000.

About half of participants reported taking daily pain medication (47.0%) and taking hydroxyurea (49.2%), while 28.0% underwent regular blood transfusion.

One of every three (33.0%) self-reported or had medical record reports indicating depression, while 13.7% had a diagnosis of anxiety in their medical record. Harris and colleagues noted that that the association between depression and pain remained regardless of whether depression was patient reported or documented in the medical record.

"Although patient reports of depression are not the best measure, the medical record alone is insufficient," they observed. "The inconsistencies revealed in these measures suggest that the medical record under reports depression among individuals with SCD."

"Taken together," they added, "this indicates that our overall understanding, diagnosis, and documentation of depression and treatment for depression are suboptimal."

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