J Occup Rehabil (2015) 25:648–657
DOI 10.1007/s10926-015-9572-7
Rates and Correlates of Unemployment Across Four Common
Chronic Pain Diagnostic Categories
Hili Giladi • Whitney Scott • Yoram Shir •
Michael J. L. Sullivan
Published online: 19 February 2015
Ó Springer Science+Business Media New York 2015
Abstract Purpose To examine rates and correlates of
unemployment across distinct common chronic pain diag-
noses. Methods Data were analyzed from a sample of 2,382
patients with chronic pain in the Quebec Pain Registry
(QPR). Patients were grouped into the following diagnostic
categories based on their primary pain diagnosis recorded
in the QPR: musculoskeletal pain; myofascial pain; neu-
ropathic pain, and visceral pain. Analyses were performed
to examine the associations between pain diagnosis, patient
demographics, pain intensity, depressive symptoms, and
unemployment status. Results Pain diagnosis, age, marital
status, education, pain intensity, and depressive symptoms
were each significant unique predictors of unemployment
status in a hierarchical logistic regression analysis; the
addition of depressive symptoms in this model contributed
to the greatest increment of model fit. Conclusions
Depressive symptoms are associated with unemployment
across a number of common chronic pain conditions, even
when controlling for other factors that are associated with
unemployment in these patients. Depressive symptoms, as
H. Giladi
Y. Shir
The Alan Edwards Pain Management Unit, McGill University
Health Centre, Montreal, QC, Canada
H. Giladi (&)
PO Box 390, 8499000 Midreshet Ben Gurion, Israel
e-mail: giladih@post.bgu.ac.il
W. Scott
Institute of Psychiatry, Psychology and Neuroscience,
King’s College London, London, UK
M. J. L. Sullivan
Department of Psychology, McGill University, Montreal, QC,
Canada
123
a modifiable factor, may thus be an important target of
intervention for unemployed patients with chronic pain.
Keywords Depressive symptomatology
Chronic pain

Unemployment
Introduction
Chronic pain is a common condition, affecting at least one
in five Canadian adults [1]. It is characterized as pain in
any body part, usually persisting more than 3 months [2],
and often occurring during the most productive years of life
[3]. Previous studies suggest that chronic pain is associated
with reduced occupational activity and considerable eco-
nomic loss [1, 4]. Consequently, reducing occupational
disability has been highlighted as an important treatment
goal for patients with chronic pain [5].
A large body of research has examined factors associ-
ated with unemployment in patients with musculoskeletal
pain [6–9]. To date, several correlates of unemployment in
patients with musculoskeletal pain have been identified,
including older age, lower education level, physical
workplace demands, and greater pain intensity [10, 11].
Across a number of studies, depressive symptomatology
has also emerged as a consistent correlate of unemploy-
ment status in patients with chronic pain following mus-
culoskeletal injury [12, 13]. Additionally, research suggests
that the severity of depressive symptoms both prior to and
following occupationally-based rehabilitation prospective-
ly predict return to work [14, 15].
Although many studies have investigated unemployment-
related issues in patients with chronic musculoskeletal pain,
relatively fewer have investigated rates and correlates of
unemployment in patients with other common chronic pain
J Occup Rehabil (2015) 25:648–657 649

diagnoses. Similar to the findings from the musculoskeletal
pain literature, age, education, pain duration, pain intensity,
physical and mental workplace demands, and depressive
symptoms have been associated with employment status in
patients with neuropathic, visceral and myofascial pain con-
ditions [16–20]. Investigation of the association between
depressive symptoms and unemployment in patients with
chronic pain of varying etiology remains particularly impor-
tant given high rates of depression in this population [21, 22].
Depressive symptomatology is of further interest in this
context as it represents a potentially modifiable correlate of
unemployment in patients with chronic pain. Indeed, findings
suggest that reductions in depressive symptoms following
intervention are associated with an increased chance of work
return in patients with subacute and chronic pain [23, 24].
To date, a direct comparison of rates and correlates of
unemployment across common chronic pain diagnostic
categories, such as musculoskeletal, myofascial, neuropathic,
and visceral pain, has not been undertaken. These conditions
have different underlying mechanisms and each has distinct
clinical manifestations [2, 25–28]. Given these differences, it
is plausible that rates and correlates of unemployment would
differ among these diagnostic categories. Investigation of
factors associated with unemployment within and across
these diagnostic groups might facilitate better screening and
identification of patients in need of targeted intervention to
improve their occupational functioning.
The purpose of this study was to examine rates and
correlates of unemployment across a range of common
chronic pain diagnoses. Data was extracted from the Quebec
Pain Registry (QPR), a province-wide database of patients
with persistent pain, which includes data on pain diagnosis
and intensity, patient demographics, depressive symptoms,
and employment status. Analyses identified unemployment
rates across diagnostic categories and factors associated with
unemployment status within and across diagnoses. The
findings of this study may contribute to the identification of
patients with chronic pain in need of more targeted treatment
to improve their occupational functioning.
present study, patients were excluded if they had pain for
less than 3 months or if their pain duration was not recorded.
As work status was the primary outcome variable in this
study, only patients of working age were included. Thus,
patients aged 65 years or older were excluded. Patients with
pain diagnoses that could not be classified as one of the four
diagnostic groups (e.g., migraine, vascular pain, cancer pain,
and ambiguous diagnoses) were also excluded. The final
study sample consisted of 2,382 patients (Fig. 1).
Procedure
This study utilized data drawn from the Quebec Pain
Registry (QPR) [29]. The QPR is a province-wide initiative
aimed at establishing a database of the majority of patients
with persistent pain attending one of the three tertiary pain
management centers in the province. From 2008 until
2011, all patients attending one of three tertiary pain
management centers in Quebec, Canada were invited to
participate in the QPR. Patients with a wide range of pain
diagnoses are included in this database.
As part of the QPR, data were collected prior to patients’
first appointment at the pain center. Following the first ap-
pointment, patients’ treating physician indicated a primary
pain diagnosis in accordance with the diagnostic codes
established for the QPR. Information regarding patients’

Methods

This was a cross-sectional study of assessment data col-

lected from patients with chronic pain who were referred to
large university-affiliated tertiary care facilities offering
multidisciplinary pain treatment in the province of Quebec
(Canada).

Approach to Sample Selection

The initial sample extracted from the Quebec Pain Registry

(QPR) consisted of 3,478 patients. For the purpose of the Fig. 1 Approach to sample selection

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demographics, pain intensity, and psychological distress was
also collected in accordance with the recommendations of
the Initiative on Methods, Measurement and Pain assess-
ment in Clinical Trials (IMMPACT) [30]. For the purpose of
the present study, a subset of variables was extracted from
the QPR database. The variables that were extracted were
patient demographics, primary pain diagnosis, pain duration,
pain intensity, depressive symptoms, and employment sta-
tus. All patients enrolled in the QPR provided written in-
formed consent to have their data used for research purposes
[29]. The QPR project was approved by the Institutional
Ethics Boards of all the participating tertiary pain centers
and conducted in accordance with applicable Canadian
regulatory requirements. More information about the QPR is
available at www.quebecpainregistry.org.
Measures
Primary Pain Diagnosis
Patients’ treating physician provided a pain diagnosis fol-
lowing initial assessment at the pain clinic. A code for
primary diagnosis was given in accordance with diagnostic
codes established by the QPR group [29]. Diagnostic
categories represented in the study sample included mus-
culoskeletal pain, neuropathic pain, myofascial pain, and
visceral pain. These categories were chosen based on the
International Association of the Study of Pain (IASP)
clinical classification of chronic pain [2] and the clinical
criteria for myofascial pain [31]. The categories encompass
the vast majority of pain diagnoses encountered at the
tertiary pain management centers, and assist the clinicians
as an initial step towards formulating a treatment plan.
Musculoskeletal pain arises from damage or overuse in
structures such as bones, ligaments, muscles, intervertebral
discs and facet joints [25]. Myofascial pain is characterized
by the presence of trigger points that are located in the
fascia, tendons and/or muscle, which result in a symp-
tomatic pain response [26]. Neuropathic pain is defined as a
painful condition caused by a lesion or dysfunction of the
peripheral or central nervous system and is characterized
by constant, burning pain with spontaneous sharp exacer-
bations [2, 27]. Visceral pain is defined as pain originating
from an internal organ, such as irritable bowel syndrome or
dysmenorrhea [28]. Together, these four clinically distinct
and prevalent categories encompass the most common pain
diagnoses among patients treated in tertiary pain manage-
ment clinics in the province of Quebec, Canada.
Employment Status
Patients were asked to indicate their current employment
status: unemployed, part-time, or full-time. In addition to
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reporting their involvement in paid employment activities,
patients were asked to indicate whether they identified
themselves as students or homemakers.
Pain Intensity
Patients rated their average pain intensity using an 11-point
numerical rating scale ranging from 0 (no pain) to 10
(worst pain imaginable) [32].
Depressive Symptoms
Depressive symptoms were assessed using the Beck De-
pression Inventory, version 1 (BDI-1) [33]. This 21 item
questionnaire assesses the presence and severity of symp-
toms of depression. Each item has four response choices,
ranging in intensity from 0 to 3, that are summed to cal-
culate the final score. The highest score is 63. Higher
scores on this measure indicate more severe depressive
symptoms. The BDI has been reported to have high internal
reliability (coefficient alpha = 0.86) and is validated for
assessment of depressive symptoms among patients with
chronic pain [34].
Demographic Variables
Patients responded to questions regarding their age, dura-
tion of pain, gender, ethnicity, marital status, and education
level.
Approach to Data Analysis
Patients working part- or full-time hours at the time of
assessment were coded as ‘‘employed’’. Those not working
any hours were coded as ‘‘unemployed’’. Homemakers and
students were only coded as ‘employed’ if they had also
indicated that they were working part- or full-time upon
initial assessment. The education and marital status variables
originally consisted of multiple categories (e.g., elementary,
high school, college, university; married, single, divorced,
widowed). However, for the purpose of minimizing the
number of comparisons conducted, these variables were
each recoded as binary variables with the following cate-
gories: less than high school education or high school
education or higher; married or not married, with the latter
including single, divorced, and widowed individuals.
Frequencies were tabulated for nominal variables. Means
and standard deviations were calculated for continuous study
variables. Examination of normality assumptions indicated
that values of skewness and kurtosis were above the ac-
ceptable limits for the pain duration variable. A log trans-
formation of this variable corrected this issue and, therefore,
the log transformed pain duration variable was used in
J Occup Rehabil (2015) 25:648–657
subsequent analyses. All other continuous variables satisfied
the normality assumptions.
A Chi squared analysis was computed to examine dif-
ferences in employment status across diagnostic groups.
Chi squared analyses were likewise computed to compare
proportions for nominal variables (e.g., sex, education,
etc.) according to unemployment status and pain diagnosis.
Separate 4 9 2 analyses of variance (ANOVAs) were
computed to examine differences on continuous study
variables as a function of pain diagnosis and employment
status. Significant ANOVAs were followed up with post
hoc analyses using Tukey’s HSD to correct for multiple
comparisons. A hierarchical logistic regression analysis
was conducted to examine the shared and unique contri-
bution of study variables to unemployment status. For this
analysis, variables with a significant association with
unemployment status in the preceding Chi squared ana-
lyses or ANOVAs were entered into the regression.
Secondary analyses examined clinically meaningful
levels of depressive symptoms in relation to unemployment
status. A nonparametric Receiver Operating Characteristic
(ROC) curve analyses [35] was computed to identify a BDI-I
cutoff score that represents risk for occupational dis-
ability. ROC curve analyses generate a value for the Area
Under the Curve (AUC). The diagonal reference line
(AUC = 0.50) indicates that a measure performs no better
than chance in discriminating clinically ‘‘at risk’’ and ‘‘not
at risk’’ individuals. ROC curve analyses also compute
sensitivity and specificity pairs for the entire range of values
of a continuous test. The balance of sensitivity and speci-
ficity at a given test value indicates the diagnostic accuracy
of that value [35]. The Optimal BDI-I cutoff score was
chosen at the point which sensitivity and specificity were
closest to being equal. This approach has previously been
used to identify clinically meaningful scores on pain-related
variables [36]. SPSS 17.0 (SPSS Inc., Chicago, USA) and
MedCalc 11.6.1 (MedCalc software, Mariakerke, Belgium)
were used to conduct the analyses.
Results
Sample Characteristics
The final study sample consisted of 2,382 patients with
chronic pain (Fig. 1). The sample consisted of 987 men and
1,395 women. Patients had an average age of 47.46 years
(range 18–64 years), and an average pain duration of
6.40 years (range 3 months–52 years). The majority of the
sample (92 %) was Caucasian. Most patients (93 %) had at
least a high school education and the majority of patients
(55 %) were married or in a common law partnership. Two
hundred and four patients identified themselves as
651
homemakers; Seventy six identified themselves as students.
The mean pain intensity of the sample was 6.75
(SD = 1.99). Patients’ average score on the BDI-I was
19.90 (SD = 10.68). One thousand six hundred and forty-
six (69.1 %) patients were not working.
Characteristics of Diagnostic Groups
The following diagnostic groups were of interest for the
present study: musculoskeletal pain, myofascial pain,
neuropathic pain, and visceral pain. Table 1 displays
specific pain diagnoses made by physicians following pa-
tients’ first clinic visit, that were assigned to these four
broader diagnostic categories for the present study. To-
gether these four groups accounted for approximately 95 %
of all patients with diagnoses recorded in the QPR. Mus-
culoskeletal pain (58.8 %) was the most common diagno-
sis. Neuropathic, myofascial, and visceral pain comprised
23.1, 12.7, and 5.4 % of the sample, respectively.
Patients with myofascial pain had the highest rate of
unemployment (78 %), while patients with visceral pain
showed the lowest (64 %). Rates of unemployment in pa-
tients with musculoskeletal pain and neuropathic pain were
67 and 71 %, respectively. A Chi squared analysis indi-
cated that employment rates differed significantly across
diagnostic categories, v2 = 17.17, p = 0.001.
Comparison of Study Variables According
to Diagnostic Group and Employment Status
Separate 4 9 2 ANOVAs were computed to compare con-
tinuous study variables (age, pain duration, pain intensity, and
depressive symptoms) according to patients’ diagnostic group
and employment status. Significant main effects of pain di-
agnosis were observed for all continuous study variables
(Table 2). Likewise, significant main effects of employment
status were observed for patient age, pain intensity, and de-
pressive symptoms, with unemployed participants being
older, and reporting significantly more severe pain and de-
pressive symptoms (Table 3). No significant interactions were
observed between pain diagnosis and employment status for
any of the continuous variables. Therefore, only the results for
the main effects are reported in Tables 2 and 3, respectively.
Chi square analyses were computed to examine differ-
ences in categorical variables according to patients’ diag-
nostic group and employment status (Table 4). For patients
with myofascial pain, significantly more males were unem-
ployed than females. For patients with musculoskeletal and
neuropathic pain, significantly fewer married patients were
unemployed than unmarried patients. Across all diagnoses
except myofascial pain, patients with less than a high school
education were significantly more likely to be unemployed
than those with a high school education or greater.
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Table 1 Classification of chronic pain diagnoses

Musculoskeletal Myofascial Neuropathic Visceral

Lumbar pain (±radicular pain)a Plantar fasciitis Radicular pain only Refractory pain angina
Cervical pain (±radicular pain)a Fibromyalgia Post therapeutic neuralgia Post-cholecystectomy
syndrome
Thoracic pain (±radicular pain)a Diffuse trigger point Pudendal neuropathy Post-herniorrhaphy
syndromes
Sacral paina Brachial plexopathy Irritable bowel syndrome
Sacroiliitis Cubital tunnel syndrome Chronic pancreatitis
Coccygeal paina Carpal tunnel syndrome Crohn’s disease
Costochondritis Plexopathy Abdominal pain
Bicipital tendinitis Upper/lower limb peripheral Endometriosis
neuropathy
Subacromial bursitis Complex regional pain syndrome Vulvodynia
Rotator cuff tear or tendinitis Phantom pain
Adhesive capsulitis and frozen Sciatica neuralgia
shoulder
Lateral/medial epicondylitis Obturator neuralgia
Upper/lower stump pain Femoral neuralgia
Upper/lower limb paina Restless leg syndrome
Ischial bursitis Occipital neuralgia
Trochanteric bursitis Trigeminal neuralgia
Osteoarthritis (hip/knee/generalized) Polyneuropathies
Piriformis
Post phlebetic syndrome
Temporomandibular joint disorder
Head/face paina
Rheumatoid arthritis
Torticolis
Pelvic paina
a
Pain not otherwise identified as primarily myofascial, neuropathic, or visceral

Table 2 Values of continuous study variables according to diagnostic group

Musculoskeletal Myofascial Neuropathic Visceral (n = 129) F p g2p
(n = 1,400) (n = 302) (n = 551)

Age 47.26 (46.69–47.83)a 46.69 (45.30–48.08)a 47.52 (46.58–48.47)a 43.99 (42.15–45.83)b 4.14 \0.01 0.01
a b c
Pain duration* 6.59 (6.17–7.01) 9.51 (8.49–10.53) 4.34 (3.64–5.03) 6.20 (4.85–7.55)a 59.75 \0.001 0.07
Pain intensity 6.67 (6.57–6.78)a 7.04 (6.77–7.30)b 6.42 (6.24–6.60)ac 6.05 (5.70–6.40)c 8.45 \0.001 0.01
Depressive 18.40 (17.83–18.97)a 22.81 (21.42–24.20)b 17.65 (16.71–18.60)a 19.31 (17.47–21.14)a 13.27 \0.001 0.02
symptoms
Means and confidence intervals (in parentheses) presented for continuous variables. For each variable, means with different superscripts differ
significantly at p \ 0.05
* Non-transformed means reported for pain duration for descriptive purposes; ANOVA and post hoc comparisons computed using log-trans-
formation for pain duration

Logistic Regression Analysis Examining Unique
Predictors of Employment Status
A hierarchical logistic regression analysis was conducted
to examine the unique contribution of study variables to the
prediction of employment status (Table 3). Pain duration
was excluded from this analysis, as there was no main
effect of employment status on pain duration in the
ANOVA. All other study variables were entered into the
regression analysis.

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Table 3 Values of continuous Employed (n = 736) Unemployed (n = 1,646) F p g2p

study variables according to
employment status Age 45.43 (44.37–46.49) 47.30 (46.59–48.02) 8.30 \0.01 0.003
Pain duration 6.82 (6.04–7.60) 6.49 (5.97–7.02) 0.44 ns 0.000
Pain intensity 6.19 (5.98–6.39) 6.91 (6.77–7.04) 33.58 \0.001 0.01
Depressive symptoms 16.96 (15.90–18.02) 22.13 (21.42–22.84) 63.14 \0.001 0.03

Table 4 Comparison of categorical demographic variables according to diagnosis and employment status
Employed Unemployed v2 p Odds ratio

Sex (male/female)
Musculoskeletal 196/268 386/550 0.13 ns 1.04
Myofascial 16/51 97/138 6.74 \0.01 0.45
Neuropathic 61/97 174/219 1.48 ns 0.79
Visceral 22/25 35/47 0.21 ns 1.18
Marital status (married/not married)
Musculoskeletal 289/175 496/440 10.88 0.001 0.68
Myofascial 30/37 117/118 0.52 ns 1.22
Neuropathic 105/53 209/184 8.10 \0.01 0.57
Visceral 29/18 43/39 1.04 ns 0.68
Education (high school or more/less than high school)
Musculoskeletal 451/13 847/89 20.66 \0.001 0.27
Myofascial 64/3 211/24 2.11 ns 0.41
Neuropathic 154/4 363/30 5.07 \0.05 0.31
Visceral 47/0 74/8 4.89 \0.05
Odds ratio could not be computed for employment 9 education analysis for patients with visceral pain, as one cell had no participants

Demographic variables, including patients’ age, sex,
marital status and education level, were entered in the first
step of the analysis, and contributed significant unique
variance to the prediction of unemployment status. Pain
diagnosis was entered in the second step and contributed
significantly to the prediction of unemployment, above
and beyond that accounted for by demographic variables.
Pain intensity was entered in the third step of the analysis
and contributed significant unique variance to the pre-
diction of unemployment status, above and beyond that
accounted for by diagnosis and demographic variables.
Depressive symptoms were entered in the fourth step and
contributed significant unique variance to the prediction
of unemployment status, above and beyond that ac-
counted for in the preceding three steps. Inspection of the
values of Nagelkerke’s R2 indicated that, of all the steps
entered in the model, depressive symptoms contributed
the greatest increment in model fit. In the final regression
equation, contrasts of the pain diagnosis variable indi-
cated that patients with myofascial pain and neuropathic
pain had significantly greater odds of being unemployed,
as compared to patients with musculoskeletal pain. Patient
age, marital status, education level, pain intensity, and
depressive symptoms were each significant unique pre-
dictors of unemployment in the final regression equation
(Table 5).
Identification of BDI-I Cutoff Scores in Relation
to Unemployment Status
In light of the finding showing that the addition of de-
pressive symptoms to the logistic regression model pro-
duced the greatest increment in model fit, even after
controlling for all other variables, secondary analyses
examined clinically meaningful values on the Beck De-
pression Inventory (BDI-I) in relation to unemployment
status to facilitate clinical assessment of depressive
symptoms. Table 6 displays the results of a Receiver
Operating Characteristic (ROC) curve analysis computed
to identify clinical cutoff scores on the BDI-I. The value
of the Area Under the Curve (AUC) was significant and
indicated that, in 66 % of cases, patients who were not
working obtained higher scores on the BDI-I than those
who were working. Examination of specific BDI-I scores
revealed that a score of 18 or greater best identified pa-
tients that were unemployed.

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Table 5 Logistic regression analyses examining predictors of unemployment

Dv2 Nagelkerke R2 B Wald p OR 95 % CI

Step 1 75.17** 0.04

Age 0.02 21.32 \0.001 1.02 1.01–1.03
Sex (female = 1) -0.13 1.78 ns 0.88 0.73–1.06
Marital status (married = 1) -0.31 10.43 0.001 0.73 0.61–0.89
Education status ([high school = 1) -1.09 19.10 \0.001 0.34 0.21–0.55
Step 2 15.67** 0.05
Diagnosis (reference group: musculoskeletal) 10.30 \0.05
Myofascial 0.31 3.96 \0.05 1.37 1.01–1.87
Neuropathic 0.31 7.26 \0.01 1.37 1.09–1.72
Visceral -0.06 0.10 ns 0.94 0.63–1.40
Step 3 43.62** 0.08
Pain intensity 0.08 10.42 0.001 1.08 1.03–1.13
Step 4 121.96** 0.14
Depressive symptoms 0.06 108.62 \0.001 1.06 1.05–1.07
** p \ 0.01

Table 6 ROC curve analysis for BDI-I cut off scores in relation to
employment status
AUC 95 % CI p BDI Score Sensitivity Specificity
0.66 0.64–0.68 \0.0001 C18 60.80 63.20
BDI-I Beck depression inventory, version 1
Discussion
The purpose of this study was to examine rates and cor-
relates of unemployment across a range of common
chronic pain diagnoses. Consistent with previous findings
showing an association between chronic pain and em-
ployment status [37], the present results suggest that the
substantial majority of patients with chronic pain present-
ing at tertiary care pain clinics in Quebec, Canada, are
unemployed. Indeed, approximately 70 % of patients in the
present sample were unemployed, which is nearly 9 times
higher than the provincial unemployment rate [38]. This
study adds to previous work by showing that unemploy-
ment rates varied across diagnostic categories [16, 17, 20].
The present results indicated that patients with visceral and
myofascial pain showed the lowest and highest rates of
unemployment, respectively.
Patients with myofascial pain rated their pain as sig-
nificantly more intense and reported significantly more
severe depressive symptoms than patients in the other di-
agnostic categories. Greater severity of pain and depressive
symptoms were both significantly associated with in-
creased likelihood of unemployment in the present study.
Therefore, these factors might account for the higher rate
of unemployment in patients with myofascial pain.
Consistent with previous findings [10, 39], patient age
and education level were associated with employment
status. Examination of the odds ratios in the final equation
of the logistic regression analysis indicated that education
and marital status showed the strongest association with
employment status, with married patients and those with a
high school education or higher having significantly lower
odds of being unemployed. Therefore, irrespective of pain
diagnosis, unmarried patients and patients with lower
education may be particularly likely to be unemployed.
The results indicated that pain intensity was a significant
unique predictor of unemployment even when controlling
for demographic variables and pain diagnosis. This finding
is consistent with previous findings [40]. Research in pa-
tients with low back pain suggests that ongoing pain rep-
resents a significant obstacle to carrying out occupational
demands, particularly when physical in nature [41, 42].
However, the relatively weak magnitude of the association
between pain intensity and unemployment in this study is
consistent with previous research that indicates that pain
intensity is not the most important determinant of work-
related disability [43, 44]. Taken together, these findings
suggest that pain reduction alone may be insufficient to
influence work return in patients with chronic pain.
The association between depressive symptoms and
unemployment in the present study adds to a growing body
of research [14, 15, 45]. The addition of depressive
symptoms in the final step of the logistic regression ana-
lysis contributed the largest increment in model fit of all
the variables entered into the model. Thus, while the
magnitude of the odds ratio for depressive symptoms was
small, depressive symptoms added to the prediction of

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unemployment status even when controlling for a number
of other predictors.
Several explanations may account for the association
between depressive symptomatology and unemployment in
patients with chronic pain. Research suggests the risk for
pain-related disability increases as the number of presenting
problem domains increases [46, 47]. Thus, depressive
symptoms in addition to chronic pain may represent a cu-
mulative burden that augments employment-related dis-
ability. Symptoms of depression including sleep difficulties,
fatigue, and concentration problems may directly interfere
with patients’ work productivity and ability to carry out
occupational demands [48, 49]. Finally, research suggests
that depressed individuals have more difficulties coping
with job-related pressures, and face workplace accommo-
dation barriers and discrimination [41].
The present results suggest that interventions targeting
depressive symptoms may be important for reducing the
burden of living with chronic pain, irrespective of the specific
pain condition. Despite increasing awareness of the impor-
tance of depressive symptomatology, research has only begun
to investigate screening benchmarks for identifying clinically
important levels of depressive symptoms in patients with pain
[50]. To this end, secondary analyses in the present study
identified a score of 18 on the Beck Depression Inventory
(BDI) as clinically significant in relation to unemployment.
Thus, this score may serve as a cutoff for implementing in-
terventions specifically addressing depressive symptoms as-
sociated with chronic pain and unemployment.
To date, several interventions have been identified as
useful for reducing comorbid depressive symptoms in pa-
tients suffering from musculoskeletal pain. Physical ther-
apy, cognitive behavioral therapy, and multidisciplinary
rehabilitation programs have been shown to yield statisti-
cally significant reductions in depressive symptoms asso-
ciated with musculoskeletal pain [51–53]. Among available
treatment options, multidisciplinary approaches have gar-
nered particular support for the treatment of comorbid pain
and depression [54–56].
This study has several limitations. First and foremost, the
cross-sectional nature of the present study precludes causal
statements about the relationship between depressive
symptoms and unemployment. Indeed, several studies have
shown that the relation between depression and unemploy-
ment is bidirectional [49, 57, 58]. For example, Rost et al.
[59] showed that patients resuming work after a cardiac
event were less emotionally distressed at follow-up com-
pared to patients who did not return to work. Likewise,
Watson et al. [60] showed that ongoing unemployment
contributes to depressive symptoms. Alternately, epi-
demiological research has shown that employed individuals
with depressive symptoms are significantly more likely to
experience a new onset of unemployment over the course of
655
an extended follow-up period, as compared to those without
depressive symptoms [59]. In the present study, data de-
scribing patients’ duration of disability, last work episode,
and employment status upon pain onset were not collected.
Therefore, the direction of the association between chronic
pain, depressive symptoms, and unemployment cannot be
determined from the current data and is an important issue for
investigation. Future research using longitudinal designs is
needed to determine the nature of the relationship between
pain, depressive symptoms, and employment status across
the pain diagnostic categories studied here.
It is important to note that the magnitude of effects
observed in this study were small. It is likely that factors
that were not measured in the current study, including
patients’ employment history, also make important con-
tributions to employment status. More comprehensive
models of unemployment in patients with a range of
chronic pain diagnoses are needed in the future. Finally,
patients in the current study were recruited from tertiary
care pain management clinics. These patients may have
more prolonged pain and experience higher levels of psy-
chological distress than patients presenting in primary care.
Therefore, caution is warranted in the generalization of the
results to the general population.
Despite these limitations, this large-scale study provides
support for an association between depressive symptoms
and unemployment across a range of common chronic pain
diagnoses. Depressive symptomatology added to the pre-
diction of unemployment status, even when controlling for
patient demographics, pain diagnosis, and pain intensity.
Future research is needed to determine the efficacy of in-
terventions for reducing depressive symptoms associated
with chronic pain and unemployment.
Acknowledgments This study was supported by unrestricted
education and research grants from the Louise and Alan Edwards
Foundation, Montreal, Canada. The authors thank Annie Trépanier
for her assistance in accessing the Quebec Pain Registry and in ex-
tracting data. Hili Giladi was supported by a grant from the Louise
and Alan Edwards Foundation, Montreal, Canada. The Quebec Pain
Registry is supported by funds from the Fonds de la Recherche en
Santé du Québec and Pfizer.
Conflict of interest The authors declare no conflict of interest.
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