The Relationship between Pain and Mood
Chronic pain and emotional wellbeing often affect each other. Persistent pain can disrupt sleep, movement, work, relationships, recreation and a person’s sense of identity or independence. Depression, anxiety and pain-related fear can, in turn, influence attention, sleep, activity, coping and how threatening or overwhelming pain feels.
This does not mean that pain is imagined, exaggerated or “all in the mind”. Pain is a real personal experience arising through the nervous system and influenced, to varying degrees, by biological, psychological and social factors. Recognising the relationship between pain and mood should complement—not replace—appropriate medical assessment of the pain itself.[2–4,11]
A 2025 systematic review and meta-analysis included 376 studies involving more than 347,000 adults with chronic pain across 50 countries. Approximately 39% had clinically significant depressive symptoms and 40% had clinically significant anxiety symptoms. However, rates varied considerably between pain conditions and study populations. Most studies used validated screening questionnaires, so these figures should not be interpreted as meaning that four in ten people necessarily had a formally diagnosed depressive or anxiety disorder. Chronic headache disorders were also excluded from that review.[1]
THE RELATIONSHIP CAN WORK IN BOTH DIRECTIONS
Persistent pain may contribute to low mood or anxiety through:
disrupted or unrefreshing sleep;
reduced physical, social or recreational activity;
uncertainty about the cause, treatment or future course of pain;
loss of employment, independence or valued roles;
financial, insurance or legal pressures; and
repeated experiences of treatment disappointment or feeling misunderstood.
Depression can make energy, concentration, decision-making and initiation of activity more difficult. Anxiety can increase vigilance to bodily sensations, worry about damage or reinjury, and fear of movement. These responses may increase pain-related distress and interference, even when they do not alter the underlying state of the tissues.
Prospective studies support a modest bidirectional association: depressive symptoms can be associated with later chronic pain, while chronic pain can be associated with later depressive symptoms. This does not establish that either condition simply causes the other. For some people, pain comes first; for others, depression or anxiety predates the pain; and in many cases, both are influenced by shared health, social and personal factors.[2–4]
LOW MOOD, DISTRESS AND DEPRESSION ARE NOT THE SAME
Periods of frustration, sadness, grief, anger or worry are understandable responses to persistent pain and do not automatically indicate a psychiatric disorder.
Depression should be considered when low mood, loss of interest or reduced enjoyment persists— for at least two weeks—and is accompanied by other changes such as hopelessness, guilt, altered sleep or appetite, reduced energy, poor concentration, slowed or agitated behaviour, or thoughts of death, suicide or self-harm. Symptoms such as fatigue, poor sleep and concentration problems can arise from pain, depression, medication effects or several factors together, so diagnosis requires an individual clinical assessment.[13]
Anxiety may involve persistent worry, panic symptoms, health-related fears or a heightened sense of threat. Pain-related fear can be more specific, such as fear that movement will cause damage or a severe flare. It can occur with or without a formal anxiety disorder. Avoidance should be explored sensitively rather than assumed to be irrational: some activities may genuinely require modification, while others may be safely reintroduced through an appropriately paced rehabilitation plan.
SHARED BIOLOGY AND BODY PROCESSES
There is no single “pain centre” in the brain and no single “chemical imbalance” that explains the relationship between pain and mood.
Pain involves distributed functional networks concerned with sensation, attention, salience, memory, emotion, motivation, threat assessment and the brain’s capacity to amplify or dampen incoming pain signals. Many of these systems also contribute to depression and anxiety. Serotonin, noradrenaline, endogenous opioid and other signalling systems have roles in both pain modulation and emotional regulation, but their involvement is considerably more complex than simply having too much or too little of one neurotransmitter.[4]
Neuroimaging research has identified some group-level overlap between chronic pain, depression and anxiety, including within regions such as the insula and anterior cingulate cortex. These findings may help researchers understand shared mechanisms, but they do not provide a diagnostic brain scan for an individual patient and do not prove that one condition caused the other.[5]
Sleep disruption, prolonged stress responses and inflammatory signalling are also being investigated. Their importance is likely to differ among people and pain conditions. At present, an inflammatory marker, cortisol, another routine blood test or imaging cannot explain the pain–mood relationship for an individual patient.
WHY THE OVERLAP MATTERS
When chronic pain and significant depression or anxiety symptoms occur together, people may experience greater limitations in mobility, work, self-care and social participation than people experiencing either problem alone. This does not mean that poorer function reflects a lack of motivation. Depression, disrupted sleep, fear, medication effects and physical limitations can all reduce the capacity to participate in treatment or everyday activity.[3]
Mood symptoms can also affect how treatment options are considered. Hopelessness may make improvement seem impossible, anxiety may make procedures or movement feel unsafe, and cognitive symptoms may make complex treatment plans difficult to follow. These factors should lead to additional support and clearer treatment planning—not dismissal of the person’s pain.
Chronic pain is also associated with an increased prevalence of suicidal thoughts and behaviours, particularly when accompanied by severe distress or other mental health difficulties. Most people with chronic pain are not suicidal, but thoughts of self-harm or suicide should always be taken seriously and assessed promptly.[10]
WHAT SHOULD A THOROUGH ASSESSMENT INCLUDE?
A good assessment looks beyond a pain score or questionnaire. Depending on the circumstances, it may consider:
the likely pain condition or mechanisms, including any new or concerning symptoms;
how pain affects sleep, mobility, work, relationships and daily responsibilities;
symptoms of depression, anxiety, trauma-related distress or pain-related fear;
current medicines, and their effectiveness weighed against side effects;
alcohol and other substance use;
previous treatments and what was or was not helpful;
personal strengths and supports;
values, preferences and meaningful goals; and
immediate safety, including thoughts of self-harm or suicide.
Brief questionnaires can help identify people who may need further assessment, but a screening score is not the same as a diagnosis. The results should be interpreted in the context of the person’s pain, physical health, medications, circumstances and cultural background.[1,11,12]
IMPACT ON DAILY LIFE AND TREATMENT
Low mood reduces motivation for self-management, exercise, or therapy adherence, while pain limits social connection and pleasure, deepening isolation. Comorbid pain and depression lead to higher healthcare use, slower recovery, and differential responses to antidepressants. For example, SNRIs like duloxetine often work better for both than SSRIs alone.[3][1]
BREAKING THE CYCLE: WHAT HELPS
There is no single treatment that reliably resolves both pain and mood symptoms for everyone. Management should be individualised according to the pain condition, psychiatric symptoms, physical health, treatment history, preferences, risks and goals.
PSYCHOLOGICAL THERAPIES
Psychological treatment does not imply that pain is imaginary. These therapies aim to reduce distress, improve coping and support engagement in meaningful activity.
Cognitive behavioural therapy, or CBT, may address sleep, activity patterns, problem-solving, unhelpful threat-focused thinking and responses to pain flares. In chronic pain studies, CBT produces small average improvements in pain, disability and distress, although benefits vary between individuals and conditions.[6]
Acceptance and commitment therapy, or ACT, focuses on psychological flexibility, present-moment awareness and taking workable steps towards personally important activities, even when some pain remains. Reviews suggest potential benefits for pain interference, functioning, depression, anxiety and pain acceptance, although the size and durability of effects vary.[7]
Other approaches may be appropriate when there is a specific condition such as major depression, panic disorder, post-traumatic stress disorder, insomnia or substance-use disorder.
PHYSICAL ACTIVITY AND REHABILITATION
Appropriately selected physical activity can support physical functioning, sleep, mood and confidence. The appropriate starting point differs between people. Rehabilitation may involve physiotherapy, exercise physiology, occupational therapy, pacing, activity modification or gradual reintroduction of feared but safe movements.
The aim is not to ignore pain or force activity regardless of symptoms. It is to identify a manageable level of activity and build capacity in a way that is consistent with the person’s condition, goals and response.[11,12,14]
SLEEP AND DAILY ROUTINE
Sleep disturbance can worsen fatigue, emotional regulation, negative thoughts and pain sensitivity. Assessment should carefully consider insomnia, sleep apnoea, restless legs, medication effects and irregular sleep schedules. A consistent daily routine, planned activity, rest periods and continued social contact may also reduce the disruption caused by pain and depression.
MEDICATION
Antidepressants should not be treated as one interchangeable group, and they should not be prescribed solely on the assumption that pain and depression share the same pathways.
Some antidepressants have evidence for pain relief in particular conditions. Among the antidepressants studied for chronic pain, duloxetine has the most consistent evidence for modest short-term improvements in pain and physical function across several selected conditions. However, benefit is not guaranteed, evidence of effectiveness varies across different pain diagnoses, and adverse effects or discontinuation due to adverse effects can occur.[8,9]
Selective serotonin reuptake inhibitors, or SSRIs, may be appropriate for depression or anxiety but do not have equally consistent evidence as analgesic treatments for most chronic pain conditions. Tricyclic antidepressants are sometimes used for selected neuropathic pain conditions, but their potential adverse effects and individual medical risks require consideration.
Medication choice should take account of the psychiatric diagnosis, type of pain, other medical conditions, interactions, previous response, pregnancy considerations where relevant, and risk of adverse effects. Medicines should not be started, stopped or changed without discussion with the prescribing clinician.
COORDINATED AND MULTIDISCIPLINARY CARE
People with complex pain and psychiatric conditions may benefit from coordinated input from several professionals, including a general practitioner, pain medicine specialist, psychologist, psychiatrist, physiotherapist, exercise physiologist, occupational therapist, pharmacist, or other health professionals.
Multidisciplinary care is not simply several disconnected appointments. Ideally, clinicians work from a shared understanding of the problem and agree on practical goals with the patient. These goals may include better sleep, reduced distress, increased activity, improved self-management, return to work or family roles, and less disruption from pain.[11,12] However, unfortunately, there are a number of barriers to ensuring that all your treating doctors act as a team, and the current funding models do not reflect the costs of providing complex care nor do they incentivise complex, chronic healthcare models.
WHAT CAN IMPROVEMENT LOOK LIKE?
Improvement does not always mean that pain disappears completely. Depending on the condition, meaningful progress may include:
fewer or less severe pain flares;
improved sleep;
improved mood stability;
improved confidence with and tolerance of movement;
reduced pain-related fear or distress;
increased participation in family, social or recreational life;
improved capacity for work or daily responsibilities; or
needing less time to recover after a difficult day.
Progress is often uneven. Function, sleep or mood may improve before pain intensity changes, and setbacks do not necessarily mean that treatment has failed.
WHEN TO SEEK HELP
Consider speaking with a general practitioner or treating clinician when:
low mood, loss of interest or marked anxiety persists for two weeks or longer;
pain or mood symptoms are increasingly affecting self-care, daily functioning, relationships or work;
fear of pain or further injury is causing withdrawal from otherwise safe activity;
alcohol, sedatives, opioids or other substances are being used increasingly to cope;
there is persistent hopelessness or a sense of being a burden; or
there are thoughts of self-harm, suicide or not wanting to live.
URGENT SUPPORT IN AUSTRALIA
If you or someone else is in immediate danger, cannot remain safe, or may act on suicidal thoughts, call 000 or attend the nearest emergency department.
For crisis support at any time:
Lifeline: call 13 11 14, text 0477 13 11 14, or use its online crisis chat.
Suicide Call Back Service: call 1300 659 467 for free 24-hour telephone counselling.
Readers outside Australia should contact their local emergency service or crisis-support service.
KEY MESSAGE
Pain and mood can reinforce one another, but neither is a personal failing. Addressing depression, anxiety, sleep or pain-related fear does not make the pain less real. Equally, treating the physical aspects of pain may not address every effect that persistent pain has had on a person’s life.
A coordinated and individualised plan can target pain, emotional wellbeing, sleep, function and participation together. The appropriate combination of treatments—and the degree of benefit—will differ from person to person.
General information only: This article provides general educational information and is not a substitute for an individual medical or mental health assessment. New, severe or changing symptoms should be assessed by an appropriately qualified health practitioner. Treatment benefits and risks vary between individuals.
Last medically reviewed: 26 August 2026
REFERENCES
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De La Rosa JS, Brady BR, Ibrahim MM, et al. Co-occurrence of chronic pain and anxiety/depression symptoms in US adults: prevalence, functional impacts, and opportunities. Pain. 2024;165(3):666–673. doi:10.1097/j.pain.0000000000003056.
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Yu W, Tao B, Zhu F, et al. Shared cortical characteristics in major depressive disorder, anxiety disorder, and chronic pain: a structural MRI meta-analysis study. Translational Psychiatry. 2025;15. doi:10.1038/s41398-025-03424-1.
Williams AC de C, Fisher E, Hearn L, Eccleston C. Psychological therapies for the management of chronic pain, excluding headache, in adults. Cochrane Database of Systematic Reviews. 2020;8:CD007407. doi:10.1002/14651858.CD007407.pub4.
Martinez-Calderon J, García-Muñoz C, Rufo-Barbero C, Matias-Soto J, Cano-García FJ. Acceptance and commitment therapy for chronic pain: an overview of systematic reviews with meta-analysis of randomised clinical trials. Journal of Pain. 2024;25(3):595–617. doi:10.1016/j.jpain.2023.09.013.
Birkinshaw H, Friedrich CM, Cole P, et al. Antidepressants for pain management in adults with chronic pain: a network meta-analysis. Cochrane Database of Systematic Reviews. 2023;5:CD014682. doi:10.1002/14651858.CD014682.pub2.
Ferreira GE, Abdel-Shaheed C, Underwood M, et al. Efficacy, safety, and tolerability of antidepressants for pain in adults: overview of systematic reviews. BMJ. 2023;380:e072415. doi:10.1136/bmj-2022-072415.
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International Association for the Study of Pain. What Do We Mean by Integrative Pain Care? 2023. Accessed 26 August 2026.
International Association for the Study of Pain. Developing an Integrative Pain Care Plan. 2023. Accessed 26 August 2026.
Healthdirect Australia. Depression: Symptoms, Types and Treatment. Accessed 26 August 2026.
Healthdirect Australia. Options for Managing Chronic Pain. Accessed 26 August 2026.
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