Abstract Depressive symptoms are commonly experienced by people with persistent musculoskeletal (MSK) pain. There is evidence for some individuals that this may be best characterised as pain-related distress; a reaction to living with the impact of pain, rather than a depressive illness. No explorations exist of how to differentiate between these in primary care. This study aimed to explore key factors that may differentiate between pain-related distress and depression, and the effectiveness of existing symptom screening tools (Patient Health Questionnaire-9 PHQ-9 and 4-Dimensional Symptom Questionnaire 4DSQ) in identifying distress through a mixed methods approach. First, 21 general practitioners and 21 people with pain were interviewed about their experiences of pain-related distress. Second, 597 primary care patients with MSK pain completed a cross-sectional questionnaire study reporting on their pain, mental health symptoms, and other life events. Qualitative data suggested key factors distinguishing between pain-related distress and depression included general positive outlook, physical function, and acceptance. Quantitative findings showed that the PHQ-9 may overcategorise participants as depressed; of the 207 participants classified as distressed (but not depressed) on the 4DSQ, 118 (57%) were categorised as moderately or severely depressed on the PHQ-9. Lower positive outlook and sleep interference scores, and higher PHQ-9 and perceived stress scores significantly predicted participants experiencing distress only compared with distress and depression, matching the qualitative findings. These findings indicate that differentiation between pain-related distress and depression may be possible in primary care consultations for persistent musculoskeletal pain. This is essential to ensure that patients are offered appropriate, acceptable, and effective management.
Birkinshaw et al. (2026) studied this question.