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R E S E A R C H A R T I C L E Open Access
Ethnic differences in the association
between depression and chronic pain:
cross sectional results from UK Biobank
Barbara I. Nicholl
1*
, Daniel J. Smith
1
, Breda Cullen
1
, Daniel Mackay
1
, Jonathan Evans
1
, Jana Anderson
1
,
Donald M. Lyall
1
, Chloe Fawns-Ritchie
2
, Andrew M. McIntosh
3
, Ian J. Deary
2
, Jill P. Pell
1
and Frances S. Mair
1
Abstract
Background: Comorbid chronic pain and depression is a challenging dyad of conditions to manage in primary
care and reporting has shown to vary by ethnic group. Whether the relationship between depression and chronic
pain varies by ethnicity is unclear. This study aims to explore chronic pain and depression reporting across ethnic
groups and examine whether this association differs, independently of potential confounding factors.
Methods: Cross-sectional study of UK Biobank participants with complete data on chronic pain and probable
lifetime history of depression, who reported their ethnic group as White, Asian/Asian British or Black/Black British.
Chronic pain classification: present if participants had ≥1 site of body pain (up to seven sites or “pain all over the
body”could be selected) that lasted ≥3 months; extent of chronic pain categories: 0, 1, 2–3, 4–7 sites or pain all
over the body. Probable depression classification: an algorithm of low mood, anhedonia and help-seeking
behaviour. Relationship between depression and presence/extent of chronic pain assessed using logistic/
multinomial regression models (odds ratio (OR); relative risk ratio (RRR), 95 % confidence intervals), adjusted for
sociodemographic, lifestyle, and morbidity factors; and a final adjustment for current depressive symptoms.
Results: The number of participants eligible for inclusion was 144,139: 35,703 (94 %) White, 4539 (3 %) Asian, and
3897 (3 %) Black. Chronic pain was less (40.5 %, 45.8 %, 45.0 %, respectively) and depression more (22.1 %, 12.9 %,
13.8 %, respectively) commonly reported in White participants than Asian and Black participants. Statistically
significant associations between depression and presence/extent of chronic pain persisted following adjustment for
potential confounding variables; this relationship was strongest for Black participants (presence of chronic pain: OR
1.86 (1.52, 2.27); RRR 1 site 1.49 (1.16, 1.91), 2–3 sites 1.98 (1.53, 2.56), 4–7 sites 3.23 (2.09, 4.99), pain all over the
body 3.31 (2.05, 5.33). When current depressive symptoms were considered these relationships were attenuated.
Conclusions: Chronic pain and depression reporting varies across ethnic groups. Differences in health seeking
behaviour between ethnic groups may impact on the results reported. Clinicians, particularly in primary care, need
to be aware of the cultural barriers within certain ethic groups to expressing concern over mood and to consider
their approach accordingly.
Keywords: Chronic pain, Depression, Ethnicity, Comorbidity
* Correspondence: Barbara.Nicholl@glasgow.ac.uk
1
Institute of Health & Wellbeing, University of Glasgow, Glasgow, UK
Full list of author information is available at the end of the article
© 2015 Nicholl et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Nicholl et al. BMC Family Practice (2015) 16:128
DOI 10.1186/s12875-015-0343-5
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Background
Chronic musculoskeletal pain and depression are com-
mon, complex disorders that are challenging to treat and
manage in primary care. They often co-occur and long-
standing debate has surrounded the temporal nature of
the relationship between chronic pain and depression
and on the causes and consequences of this relationship
[1]. Factors affecting the presentation and management
of symptoms are wide-ranging and will involve a com-
bination of demographic, personal, lifestyle, environmen-
tal and social elements.
Population-based studies have shown that self-reported
musculoskeletal pain is more prevalent among ethnic mi-
nority groups in the UK, particularly widespread pain at
multiple sites of the body [2–4]. In the US, the prevalence
of self-reported pain is higher in Hispanic and Black eth-
nic groups than non-Hispanic White individuals [5]; how-
ever, this difference was not apparent after adjusting for
potential confounders such as sociodemographic status,
comorbidity, and psychological distress. Minority ethnic
groups in US pain clinic populations have also reported
more severe or disabling pain than the non-Hispanic
White population in the US [6, 7]. Recent studies in the
US have focused on trying to better explain the racial and
ethnic disparities in pain treatment and management, and
suggest that access to healthcare, and patient attitudes and
behaviours may play a role in explaining some of the dis-
parities observed [8–10]. Similarly, ethnic minority groups
have also been reported to be less likely to seek profes-
sional help for mood problems [11] yet the prevalence of
depression is reported to be higher in these groups in the
UK than in the majority White ethnic group [12, 13].
Few studies have specifically considered the comorbid-
ity of chronic pain and depression across ethnic groups,
rather ethnicity has been considered as a covariate in the
relationship between pain and depression or as a pre-
dictor of pain and depression [14]. In a study of 866 par-
ticipants, Miller and Cano (2009) found that African
Americans were almost twice as likely to have comorbid
depression and pain as Caucasian Americans, relative to
those with no pain or depression [15]. However, it is
unclear whether similar patterns would be observed
amongst other ethnic groups and whether the relation-
ship between depression and pain is similar in US and
UK ethnic groups.
Chronic pain and depression have also been shown to
be some of the most common comorbidities in individuals
with other physical and mental long-term conditions
[16–18]. Given the ethnic [19, 20] and sociodemographic
[16] gradient evident in the pattern of long-term condition
reporting it is important to study the relationship between
socioeconomic status, ethnicity, pain, and depression in-
dependently of other physical long-term conditions, and
furthermore understand whether a history of depression
or current depressive symptoms are more important. De-
veloping an understanding of these relationships has the
potential to impact on how health professionals manage
chronic pain in primary care, particularly for ethnic mi-
nority groups that may be less likely to present with their
low mood problems.
The overall aim of this study is to determine: 1) the
prevalence of chronic pain and depression by ethnic
group; and two) whether the relationship between depres-
sion and chronic pain varies by ethnicity, using data from
UK Biobank. Here we report on differences in the preva-
lence of chronic pain and depression, and in the associ-
ation between depression and pain across ethnic groups,
independently of potential confounding factors, including
sociodemographic, lifestyle, and morbidity factors.
Methods
This study utilises baseline cross-sectional data from UK
Biobank (http://www.ukbiobank.ac.uk/). UK Biobank is a
large cohort study of over 500,000 persons aged 40–70
years across England, Scotland, and Wales. Individuals
registered with the National Health Service and living
within a 25 mile radius of one of 22 UK Biobank assess-
ment centres were invited to participate [21]. Participa-
tion involved completion of touch-screen questionnaires
and nurse-led interviews to collect epidemiological data
on demographic, health, environmental and lifestyle fac-
tors. Questions on mood disorder were added part-way
during recruitment and the 172,745 participants who
completed the detailed questions on lifetime features of
mood disorders were eligible for inclusion in this study.
Ethnic groups
Participants were asked in the touch screen questionnaire
“What is your ethnic group?”Response options were:
White, Mixed, Asian or Asian British, Black or Black
British, Chinese, and other ethnic group. Due to insuffi-
cient numbers in the other ethnic groups, only those
whoconsideredthemselvesasWhite,AsianorAsian
British (including Indian, Pakistani, Bangladeshi and “any
other Asian background”), and Black or Black British
(including Caribbean, African and “any other Black back-
ground”) were included in this study; these groups will be
referred to in this manuscript as White, Asian, and Black
ethnic groups.
Classification of chronic pain
Within UK Biobank, participants were asked whether
they had experienced pain in the past month that inter-
fered with their usual activities, in any of the following
sites: headache, facial, neck or shoulder, back, stomach
or abdominal, hip, and knee; and an eighth option of
“pain all over the body”. Multiple sites could be selected,
unless participants reported “pain all over the body”. For
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all sites selected a subsequent question asked whether
the pain had been present for more than three months.
Chronic pain was defined as pain that had persisted for
more than three months. The presence of chronic pain
was classified if participants reported any site of chronic
pain; those reporting no sites of chronic pain were clas-
sified as being free of chronic pain. The extent of
chronic pain was calculated by summing the number of
sites of chronic pain reported and the following categor-
ies were defined: free of chronic pain; chronic pain at
one site; chronic pain at 2–3 sites; chronic pain at 4–7
sites; and “pain all over the body”. This classification of
number of pain sites has previously been reported [22].
Classification of depression
The definition of probable lifetime depression history
among UK Biobank participants has been described in
detail previously [23]. Using the touch screen question-
naire, participants answered questions regarding their past
history of mood disorder symptoms and related medical
help-seeking, which were similar to questions within the
Structured Clinical Interview for DSM-IV Axis I Disorders
[24]. Probable major depressive disorder included partici-
pants that we classified as having a lifetime history of
recurrent severe, recurrent moderate or single episode
depression; the criteria for these definitions are outlined
in Fig. 1. Current depressive symptom score was calcu-
lated from four individual questions that assessed the fre-
quency of the following depression symptoms “over the
past 2 weeks”: depressed mood, unenthusiasm/disinterest,
tenseness/restlessness, and tiredness/lethargy. Questions
were answered on a four point scale: not at all; several
days; more than half the days; and nearly every day. Indi-
vidual answers were summed to give a score of 0–12 for
each participant; with higher scores reflecting greater
levels of current depressive symptoms. This score was in-
dependent of the classification of lifetime depression sta-
tus described above and in Fig. 1.
Potential confounding variables
Sociodemographic, lifestyle and morbidity factors are
associated with both depression and chronic pain.
Alongside age and sex, Townsend Score, an area level
measure of deprivation based on the participant’s
postcode of residence [25], was used to describe the
sociodemographic profile of the study population.
Quintiles of the Townsend score were generated for
the study population; quintile 1 represents the least
deprived and quintile 5 the most deprived areas.
Current smoking status (never, current, or former
smokers) and frequency of alcohol consumption
(daily/almost daily, 3–4 times per week, 1–2times
per week, 1–3 times per month, special occasions
only and never) were self-reported. Body mass index
(BMI) was calculated from height and weight mea-
surements taken at the assessment centre and cate-
gorised as underweight (<18.5 kg/m
2
), normal weight
(18.5–24.9 kg/m
2
), overweight (25.0–29.9 kg/m
2
), and
obese (≥30.0 kg/m
2
) to describe the population but
was treated as a continuous variable in the regression
analysis. A count of self-reported, non-cancer long-
term conditions was generated from the information
provided during the nurse interview. Inclusion of
conditions was based on previous literature [16], au-
thor experience (FM) and a UK Biobank prevalence
of ≥0.1 %. Painful and psychiatric conditions were ex-
cluded from the count for this study, resulting in 36
conditions being included in the count.
Ethical approval
Electronic, informed consent was given in person at the
assessment centre before participation in the study. This
study forms part of UK Biobank project 7155 and UK
Biobank has full ethical approval from NHS National
Research Ethics Service (approval letter dated 17 June
2011, Ref 11/NW/0382).
Fig. 1 Detailed description of the classification of a probable lifetime history of depression using available data fields in UK Biobank; a positive
classification for probable lifetime depression included all three depression categories: single, recurrent (moderate), and recurrent (severe)
Nicholl et al. BMC Family Practice (2015) 16:128 Page 3 of 10
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Statistical analysis
Chronic pain, depression, and comorbid pain and de-
pression prevalence are reported for each ethnic group,
along with sociodemographic, lifestyle and morbidity
variables. Chi squared tests for categorical variables and
Kruskal Wallis tests for continuous variables are used to
assess differences between ethnic groups for each of the
pain, depression and potential confounding variables. To
quantify the association between depression and the
presence of chronic pain, logistic regression models were
used; results are presented as odds ratios (OR) and 95 %
confidence intervals. To quantify the association be-
tween depression and the extent of chronic pain re-
ported, multinomial logistic regression models were
used; results are presented as relative risk ratios (RRR)
and 95 % confidence intervals. The association between
depression (independent variable) and chronic pain
(dependent variable) was quantified using a separate re-
gression model for each ethnic group as we were specif-
ically interested in the relationship between depression
and chronic pain within ethnic groups. Interaction be-
tween depression and ethnicity with both chronic pain
outcomes was assessed and was indicated for some sub-
groups at approximately p= 0.10. For both chronic pain
outcomes (presence and extent of chronic pain), levels
of adjustment for the regression models were as follows:
1) univariate analysis (no adjustment); 2) adjusted for
sociodemographic variables –age, sex and quintiles of
Townsend score; 3) adjusted for sociodemographic and
lifestyle variables –as in 2) plus smoking status, fre-
quency of alcohol consumption and BMI; 4) adjusted for
sociodemographic, lifestyle and morbidity count –as in
3) –plus number of long-term conditions reported. In
order to investigate the impact of current depressive
symptom score as this may impact on an individual’s
current pain reports (and vice versa), a final adjustment
for current depressive symptom score is described in the
text. All analysis was conducted using Stata V13.0 [26].
The number of participants included in each model var-
ied according to the proportion of missing data for each
of the potential confounding variables; however, the
completion rate of confounding variables included in the
regression models was at least 99.3 %, with the exception
of current depressive symptom score, which was com-
pleted by 92.0 %.
Results
Of the 172,743 UK Biobank participants who were asked
questions on lifetime history of depression and manic
symptoms, 28,604 (16.6 %) were excluded: 22,901 (13.3 %)
provided incomplete data precluding classification of their
lifetime history of mood disorder features; 1615 (0.9 %)
had probable bipolar disorder; 3876 (2.2 %) were not in
the three main ethnic groups (or did not provide data on
their ethnicity); and 212 (0.1 %) did not provide complete
data on pain. Thus, 144,139 participants were included in
the study: 135,703 (94.1 %) were White, 4539 (3.1 %)
Asian, and 3897 (2.7 %) Black. Of the 144,139 participants,
40.8 % reported chronic pain in one or more body sites
and 21.6 % were classified as having probable lifetime his-
tory of depression; comorbid chronic pain and depression
was present in 10.9 % of included participants (Table 1).
Description of ethnic groups
Over half the participants in all three ethnic groups con-
sidered in this study reported no chronic pain (54–60 %)
and approximately 23 % in all groups reported only one
site of chronic pain. A greater proportion of Asian and
Black participants reported multisite pain (2–3 and 4–7
sites) and pain all over the body compared to White par-
ticipants (Table 1). A more apparent difference in preva-
lence of lifetime history of depression was observed
across the three ethnic groups. A significantly greater
proportion of the White ethnic group were classified as
having a lifetime history of probable depression com-
pared to the Asian and Black ethnic groups (22.1 %,
12.9 % and 13.8 %, respectively). Eleven percent of
White participants reported depression without pain
compared to only 5 % of the Asian and Black groups. In
contrast, 38.4 % and 36.6 % of Asian and Black partici-
pants respectively reported chronic pain without depres-
sion, compared with 29.4 % of White participants.
Although comorbid chronic pain and depression was
more common in the White ethnic group (11.1 %) it was
the same proportion as that reporting depression only in
this group. Whereas in the Asian and Black groups, a
greater proportion reported comorbid chronic pain and
depression than depression alone.
Table 1 also summarises ethnic groups by demo-
graphic, lifestyle and morbidity factors. The Asian and
White groups included a lower proportion of females
than the Black ethnic group. A greater proportion of
both the White and Black ethnic groups reported being
former or current smokers and drinking alcohol than
the Asian ethnic group. A greater proportion of the
Asian and Black groups were classified in the most de-
prived quintile compared to the White group; these
groups were also younger than the White group. BMI
was noticeably higher in the Black ethnic group com-
pared to Asian and White groups and current depressive
symptom score was noticeably higher in the Asian and
Black groups than the White group.
Association between depression and the presence of
chronic pain
In the univariate analysis for all three ethnic groups,
having depression was associated with at least a 65 % in-
creased odds of reporting chronic pain; although this
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Table 1 Prevalence of chronic pain and depression overall and by ethnic group
Ethnic group
a
Overall N= 144,139 White N= 135,703 Asian N= 4539 Black N= 3897
Presence of chronic pain
b
Yes N (%) 58,785 (40.8) 54,949 (40.5) 2081 (45.8) 1755 (45.0)
Extent of chronic pain
b
0N (%) 85,354 (59.2) 80,754 (59.5) 2458 (54.2) 2142 (55.0)
1 32,948 (22.9) 31,040 (22.9) 1023 (22.5) 885 (22.7)
2–3 20,975 (14.6) 19,554 (14.4) 791 (17.4) 630 (16.2)
4–7 3371 (2.3) 3096 (2.3) 145 (3.2) 130 (3.3)
Pain all over the body 1491 (1.0) 1259 (0.9) 122 (2.7) 110 (2.8)
Depression (lifetime history)
b
Yes N (%) 31,080 (21.6) 29,957 (22.1) 584 (12.9) 539 (13.8)
Depression and chronic pain status
b
Free of depression and chronic pain N (%) 69,942 (48.5) 65,795 (48.5) 2214 (48.8) 1933 (49.6)
Depression only 15,412 (10.7) 14,959 (11.0) 244 (5.4) 209 (5.4)
Chronic pain only 43,117 (29.9) 39,951 (29.4) 1741 (38.4) 1425 (36.6)
Chronic pain and depression 15,668 (10.9) 14,998 (11.1) 340 (7.5) 330 (8.5)
Sex
b
Female N (%) 79,596 (53.1) 72,166 (53.2) 2122 (46.8) 2308 (59.2)
Age (years)
b
Mean (SD) 56.8 (8.1) 57.1 (8.1) 53.6 (8.6) 52.3 (8.0)
Townsend Index quintiles
Missing data N230 210 10 10
1 (least deprived) N (%) 24,482 (17.0) 24,091 (17.8) 304 (6.7) 87 (2.24)
2 29,077 (20.2) 28,557 (21.1) 351 (7.8) 169 (4.4)
3 29,978 (20.8) 28,959 (21.4) 674 (14.9) 345 (8.9)
4 32,347 (22.5) 29,760 (22.0) 1575 (34.8) 1012 (26.0)
5 (most deprived) 28,025 (19.5) 24,126 (17.8) 1625 (35.9) 2274 (58.5)
Smoking status
Missing data N445 389 35 21
Never N (%) 80,000 (55.7) 73,679 (54.5) 3544 (78.7) 2777 (71.7)
Former 53,717 (37.4) 52,184 (38.6) 718 (15.9) 815 (21.0)
Current 9977 (6.9) 9451 (7.0) 242 (5.4) 284 (7.3)
Frequency of alcohol intake
Missing data N66 44 15 7
Daily/almost daily N (%) 30,118 (20.9) 29,530 (21.8) 335 (7.4) 253 (6.5)
3–4 times/week 33,362 (23.2) 32,552 (24.0) 412 (9.1) 397 (10.2)
1–2 times/week 36,663 (25.5) 35,204 (30.0) 664 (14.7) 795 (20.4)
1–3 times/month 16,190 (11.2) 15,239 (11.2) 378 (8.4) 573 (14.7)
Special occasions only 16,376 (11.4) 14,388 (10.6) 876 (19.4) 1112 (28.6)
Never 11,364 (7.9) 8745 (6.5) 1859 (41.1) 760 (19.5)
BMI
Missing data N980 765 126 89
Mean (SD) 27.5 (1.8) 27.4 (4.7) 27.0 (4.4) 29.6 (5.4)
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relationship was greater in Asian and Black ethnic
groups. Adjusting for demographic factors in model two
had little effect on these relationships (see Table 2). Fur-
ther adjustment to include lifestyle factors did decrease
the strength of the relationship between depression and
chronic pain reporting, however,therelationshipsremained
significant. Fully adjusting the models for demographic and
lifestyle factors, and number of morbidities, attenuated the
relationships further but a significant association between
depression and the presence of chronic pain remained for
all three ethnic groups, and was strongest in the Asian and
Black ethnic groups: White (OR = 1.46, 95 % CI 1.43, 1.51),
Asian (OR = 1.53, 95 % CI 1.27, 1.85), and Black ethnic
group (OR = 1.86, 95 % CI 1.52, 2.27).
Association between depression and the extent of
chronic pain
For all three ethnic groups, the RRR between depression
and chronic pain in model one (unadjusted) increased as
the number of pain sites reported increased. The strength
of the relationship between depression and chronic pain
reporting was more apparent in both Asian and Black eth-
nic groups than in the White ethnic group, when 2–3pain
sites, 4–7 pain sites, or pain all over the body was re-
ported. This pattern of association remained through all
levels of adjustment, although the RRRs were attenuated
(Table 3). In the fully adjusted model (model 4) a dose re-
sponse relationship between depression and extent of pain
reported was evident for Asian and Black ethnic groups.
In the White ethnic group this dose response was evident
up to 4–7 sites of pain and then leveled off for “pain all
over the body”. The RRR of reporting 4–7 sites of pain
was 2.35 (95 % CI 2.17, 2.54) in the White ethnic group,
2.63 (95 % CI 1.67, 4.13) in the Asian ethnic group, and
3.31 (95 % CI 2.05, 5.33) in the Black ethnic group.
Impact of current depressive symptoms
Including current depressive symptom score in a final
model greatly attenuated the relationship between prob-
able depression and both the presence and extent of
chronic pain for all three ethnic groups. There was no lon-
ger a statistically significant relationship between probable
depression and presence/extent of chronic pain in Asian
participants. However, a statistically significant relationship
remained between depression and presence of chronic
pain for both the White (OR = 1.22, 95 % CI 1.19, 1.27)
and Black (OR= 1.41, 95 % CI 1.13, 1.78) ethnic groups,
and a similar pattern to model 4 (Table 3) was observed
with the extent of chronic pain for these groups.
Discussion
Our study has demonstrated that chronic pain in at least
one body site is very common, affecting more than 40 %
of our UK Biobank study population. Furthermore over
one fifth of the population were classified as having a
probable lifetime history of depression, and comorbid
chronic pain and depression was present in 11 % of in-
cluded participants. Chronic multisite pain was reported
more commonly and lifetime history of probable depres-
sion less commonly in Black and Asian ethnic groups in
UK Biobank compared to the majority White study popu-
lation. Quantification of the association between
Table 1 Prevalence of chronic pain and depression overall and by ethnic group (Continued)
Morbidity count
b
Mean (SD) 0.9 (1.0) 0.8 (1.0) 0.9 (1.1) 0.9 (1.0)
Current depressive symptom score
Missing data N11,511 10,018 833 660
Mean (SD) 1.5 (2.0) 1.4 (1.9) 2.5 (2.8) 2.2 (2.7)
SD Standard deviation; BMI Body mass index
a
Differences between groups were statistically significant at p< 0.001 for all variables (tested by Chi
2
test for categorical variables and Kruskal Wallis test for
continuous variables)
b
No missing data
Table 2 Logistic regression analysis, stratified by ethnic group, of the relationship between depression and the presence of chronic
pain
Ethnic group
Level of adjustment
a
White OR (95 % CI)* Asian OR (95 % CI)* Black OR (95 % CI)*
Model 1 - no adjustment 1.65 (1.61, 1.69) 1.77 (1.48, 2.11) 2.14 (1.78, 2.58)
Model 2 - adjusted for demographic factors 1.61 (1.57, 1.66) 1.71 (1.43, 2.05) 2.12 (1.75, 2.56)
Model 3 - adjusted for demographic and lifestyle factors 1.53 (1.45, 1.57) 1.62 (1.35, 1.95) 1.99 (1.63, 2.42)
Model 4 - adjusted for demographic, lifestyle and morbidity count 1.46 (1.43, 1.51) 1.53 (1.27, 1.85) 1.86 (1.52, 2.27)
*All individual associations and the overall models were significant at p< 0.001
a
Referent group for all models is the free of chronic pain group
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depression and chronic pain suggests that the relation-
ship between depression and both the presence and ex-
tent of chronic pain is stronger in the minority ethnic
groups, particularly the group comprising those of
Black ethnicity. These findings suggest that although
depression is less common in minority ethnic groups it
is more strongly associated with chronic pain, particu-
larly in Black ethnicities. However, on a formal test of
the coefficients in model 4 (suest command in Stata),
the difference between ethnic groups was not statistically
significant for the presence or extent of chronic pain,
except for the difference between the presence of chronic
pain in Black compared to White ethnic groups.
This study resonates with previous reports from much
smaller study populations of an increased prevalence of
chronic pain, including multiple sites of joint pain and
widespread pain, in UK minority ethnic groups [2–4].
We have also shown that there is a dose-response rela-
tionship in the association between depression and the
number of sites of pain reported across all ethnic
groups, although this pattern appears to be more
marked for the minority ethnic groups studied. To our
knowledge this is the first study to have reported this re-
lationship. The pattern of the association between de-
pression and “pain all over the body”was not consistent
across ethnic groups. Participants in Asian and Black
ethnic groups were three times more likely to report
“pain all over the body”than White participants.
Replication in a larger sample of participants from mi-
nority ethnic groups with “pain all over the body”would
be valuable. Miller and Cano reported (based on 80 par-
ticipants) that African Americans in the United States
were more likely to report comorbid depression and
chronic pain than a non-Hispanic White group [15].
However, in the current study, comorbid chronic pain
and depression reporting was more common in the
White population, which was a similar proportion to
that which reported depression only in this group
(11 %). In contrast, in the Asian and Black groups, a
greater proportion reported comorbid chronic pain and
depression (8 and 9 %, respectively) than depression
alone (5 % for both groups), suggesting that ethnic mi-
nority groups in the UK are more likely to report de-
pression alongside their pain rather than depression
alone, showing some similarity with the American study.
We have also shown that although probable lifetime
depression was reported less commonly in minority eth-
nic groups in this study; these groups did report a higher
mean current depressive symptom score compared to
the White ethnic group. Including current depressive
symptom score in the fully adjusted regression models
attenuated the relationship between probable depression
and presence/extent of chronic pain in White and Black
ethnic groups, and completely diminished the relation-
ship in the Asian ethnic group. Our definition of prob-
able lifetime depression was based on a relatively strict
Table 3 Multinomial logistic regression analysis, stratified by ethnic group, of the relationship between depression and the extent of
chronic pain
Ethnic group
Level of adjustment^ Extent of chronic pain White RRR (95 % CI) Asian RRR (95 % CI) Black RRR (95 % CI)
Model 1 –no adjustment 1 pain site 1.36 (1.32, 1.40) 1.25 (0.99, 1.57)** 1.58 (1.25, 2.00)
2–3 pain sites 1.89 (1.82, 1.95) 1.97 (1.57, 2.47) 2.29 (1.80, 2.92)
4–7 pain sites 3.16 (2.94, 3.40) 3.46 (2.35, 5.09) 4.26 (2.87, 6.33)
Pain all over the body 2.96 (2.64, 3.31) 3.65 (2.41, 5.52) 4.32 (2.82, 6.61)
Model 2 - adjusted for demographic factors 1 pain site 1.35 (1.31, 1.39) 1.22 (0.97, 1.54)** 1.61 (1.27, 2.05)
2–3 pain sites 1.82 (1.76, 1.89) 1.92 (1.53, 2.41) 2.23 (1.74, 2.86)
4–7 pain sites 2.94 (2.73, 3.17) 3.30 (2.22, 4.90) 4.18 (2.78, 6.29)
Pain all over the body 2.80 (2.49, 3.14) 3.60 (2.37, 5.48) 4.05 (2.61, 6.29)
Model 3 - adjusted for demographic
and lifestyle factors
1 pain site 1.31 (1.27, 1.36) 1.16 (0.92, 1.47)** 1.52 (1.19, 1.95)*
2–3 pain sites 1.72 (1.66, 1.78) 1.82 (1.47, 2.34) 2.11 (1.64, 2.73)
4–7 pain sites 2.66 (2.47, 2.87) 3.02 (2.00, 4.58) 3.63 (2.36, 5.58)
Pain all over the body 2.48 (2.20, 2.79) 3.23 (2.08, 5.00) 4.10 (2.59, 6.50)
Model 4 –adjusted for demographic,
lifestyle and morbidity count
1 pain site 1.29 (1.24, 1.33) 1.14 (0.90, 1.45)** 1.49 (1.16, 1.91)*
2–3 pain sites 1.63 (1.57, 1.69) 1.77 (1.40, 2.24) 1.98 (1.53, 2.56)
4–7 pain sites 2.35 (2.17, 2.54) 2.52 (1.65, 3.87) 3.23 (2.09, 4.99)
Pain all over the body 2.19 (1.94, 2.47) 2.63 (1.67, 4.13) 3.31 (2.05, 5.33)
All individual associations were significant at p< 0.001 except for *p≤0.002 and **p> 0.05
Overall models were significant at p< 0.001
^ Referent group for all models is the free of chronic pain group
Nicholl et al. BMC Family Practice (2015) 16:128 Page 7 of 10
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
definition which included help-seeking behaviour as a
key criterion (Fig.1) [23]. It is therefore quite possible
that individuals from minority ethnic groups in the UK
are aware of symptoms of low mood but may not have
sought medical help for these and may be more likely to
seek help for physical symptoms. Furthermore there is
evidence to suggest that mental health problems in
Black and minority ethnic groups are less likely to be de-
tected by a GP [27, 28]. It could be hypothesised that
somatic symptoms included in the current depressive
score (tenseness/restlessness and tiredness/lethargy) may
be more highly endorsed than the psychological symp-
toms of low mood and anhedonia by individuals in the
minority ethnic groups, yet closer inspection revealed
that all items are endorsed as experienced on “more
than half the days”or “nearly every day”over the past
two weeks more frequently by participants from the
Asian and Black ethnic groups than the White ethnic
group. However, this tool to assess current depressive
symptoms has not been validated and the items could
potentially function differently across the three ethnic
groups in this study.
Strengths and Limitations
Major strengths of this study include the large scale of
the UK Biobank dataset of middle-aged to older adults
in England, Scotland, and Wales. We conducted this
analysis on a large subset of the UK Biobank population,
which included over 3000 participants from both Asian
and Black ethnic groups. Furthermore, participation in
UK Biobank involved detailed assessment of a large
number of demographic, lifestyle and morbidity factors,
which allowed the association between depression and
chronic pain (presence and extent) to be considered in-
dependently of potential confounders, including number
of comorbid physical long-term conditions. Multimor-
bidity has been shown to be more common in minority
ethnic groups [20]; our results suggest that the relation-
ship between depression and pain is independent of
other physical long-term conditions across all ethnic
groups although we were unable to consider the func-
tional or physical limitations caused by such conditions,
which has been shown to be important [13]. There are
further limitations to this study. The information in-
cluded in this study (except BMI) was self-reported. This
has potential implications for the reliability of the data;
however, the large sample size suggests it is unlikely that
over or under reporting of chronic pain or depressive
symptoms would impact on the results observed. The
validity of our classification of a lifetime history of prob-
able depression has previously been considered in detail
[23] and shown to be distributed as expected by socio-
economic status, gender, self-reported health, and smok-
ing. Our study was cross-sectional in nature and we are
therefore unable to determine the temporal relationship
between pain and depression reporting in this group.
Due to the smaller number of participants from “mixed”
(N= 1062), Chinese (N= 534) and “other ethnic group”
(N= 1719), participants from these groups were ex-
cluded from the current study as no meaningful conclu-
sions could have been drawn. It is known that
individuals from minority ethnic groups are less likely to
take part in medical research [29, 30]; however, it is un-
clear from UK Biobank how many individuals from mi-
nority ethnic groups were invited to take part and did
not respond. The 2011 England and Wales census re-
ported the population to be 86 % White; 7.5 % Asian or
Asian British and 3.3 % Black or Black British [31]. Our
study population comprised 94 % White, 3 % Asian or
Asian British, and 3 % Black or Black British. We have
applied exclusion criteria based on ethnicity to our study
population and therefore cannot make a direct com-
parison between our study population and the UK
population.
Our study is lacking information on the severity of the
pain reported by participants. Increasing pain severity
has been shown to correlate with an increased number
of sites of chronic pain [32] and in our study we have
shown that participants of Asian or Black ethnicity are
more likely to report multisite chronic pain, suggesting
that they may be experiencing more severe chronic pain.
Another limitation is our lack of information on; accul-
turation, the extent to which ethnic groups and individ-
uals change their culture as a result of migration
[33], which may affect beliefs and actions and influence
reporting of health issues. This has been demonstrated
previously by Choudhury et al [4] who reported that in a
study of 1223 individuals (50 % White) chronic pain and
chronic widespread pain were more prevalent in the
group who identified as being Bangladeshi (72 and 16 %,
respectively) compared to both White (56 and 10 %, re-
spectively) and British Bangladeshi (54 and 9 %, respect-
ively), living in a borough of London, England. Without
information on acculturation it may be that our esti-
mates of chronic pain prevalence are an under-
estimation of that in ethnic groups who do not identify
as being British.
Clinical implications
In the present study we were interested, not only in dif-
ferences in the prevalence and type of pain reporting
across ethnic groups, but also in the relationship be-
tween depression and chronic pain reporting; and al-
though we found only limited statistical differences
between ethnic groups for the relationship between de-
pression and chronic pain, differences in pain and de-
pression reporting across the groups were observed. Our
findings have implications for patient management,
Nicholl et al. BMC Family Practice (2015) 16:128 Page 8 of 10
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
especially in primary care. Differences in coping strat-
egies, language barriers and the cultural interpretation of
pain and low mood may influence a person’s likelihood
to self-report symptoms or seek medical help, and may
affect how they present in the clinical encounter, making
it more difficult for health professionals to recognise
these problems.
Ethnicity adds a further complexity to the already clin-
ically complex dyad of pain and depression. It is clear,
however, that early professional medical advice is helpful
and further consideration of a package of treatment for
the comorbid conditions is required [1] but our findings
suggest that attention should be paid to whether differ-
ent approaches may be more suitable for certain ethnic
groups. Ethnic disparities in the management of chronic
pain have received much attention in the US and studies
suggest that better strategies need to be implemented to
reduce these inequalities [8–10].
Conclusions
Cultural differences and language deficits can be bar-
riers to good care provision for minority ethnic groups
but so too can health professionals’poor understanding
of these barriers and of potential ethnic differences in
modes of presentation. A key question for clinicians is
how to best respond to these issues? An increased
awareness of cultural differences and their potential
implications for management is essential. Bhui and
Bhugra (2004) suggest culturally grounded explanations
of mental illness are needed [34]. This is especially im-
portant since healthcare providers are increasingly deal-
ing with ever more ethnically diverse populations and
this is likely to increase as time goes on as there are ap-
proximately 214 million migrants worldwide [35]; with
73 million currently residing in the WHO European re-
gion [36]. However, further research is needed to exam-
ine how these ethnic differences in chronic pain and
depression reporting affect long term health outcomes
and to explore whether there are differences in health
care utilisation and the type of care accessed.
Abbreviations
BMI: Body mass index; CI: Confidence interval; OR: Odds ratio; RRR: Relative
risk ratio; SD: Standard deviation.
Competing interests
The authors declare that they have no competing interests.
Authors’contributions
BN and FM conceived of the study. All authors contributed to design. BN
performed all statistical analyses. All authors agreed on analyses and
interpreted the results. BN and FM drafted the manuscript. All authors
revised the manuscript and approved the final version.
Availability of data and materials
Not applicable.
Authors’information
Not applicable.
Acknowledgements
This research has been conducted using the UK Biobank resource; we are
grateful to UK Biobank participants. UK Biobank was established by the
Wellcome Trust medical charity, Medical Research Council, Department of
Health, Scottish Government and the Northwest Regional Development
Agency. It has also had funding from the Welsh Assembly Government and
the British Heart Foundation.
Author details
1
Institute of Health & Wellbeing, University of Glasgow, Glasgow, UK.
2
Centre
for Cognitive Ageing and Cognitive Epidemiology, Department of
Psychology, University of Edinburgh, Edinburgh, UK.
3
Division of Psychiatry,
University of Edinburgh, Edinburgh, UK.
Received: 9 April 2015 Accepted: 18 September 2015
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