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JAMA Forum
Social Determinants of Health
October 29, 2020

Where Health Improvement Lags in Recent Decades—Pain and Mental Health

Author Affiliations
  • 1Department of Economics and Kennedy School of Government, Harvard University, Cambridge, Massachusetts
JAMA Health Forum. 2020;1(10):e201351. doi:10.1001/jamahealthforum.2020.1351

The health of the US population has improved enormously in many areas but been stagnant in others. The biggest success may have been improvements for people with cardiovascular disease. Major cardiovascular events are declining in incidence, and cardiovascular disease risk factors are better controlled than they used to be. There are many elements behind this good news, the 2 most important being pharmaceuticals to treat cardiovascular disease and public health efforts to reduce smoking. Other areas of health in which there have been major improvements include lung cancer (associated with reduced smoking), breast cancer (stemming from improved treatment), and colorectal cancer (resulting from improvements in screening and treatment).

Other clinical areas have exhibited much more limited progress, including musculoskeletal pain and mental health impairment. My analysis of data from the National Health Interview Survey, representing thousands of people each year, illustrates a trend over 15 to 20 years of rising percentages of individuals experiencing musculoskeletal pain (measured as reports of joint pain in the past 30 days) or depressed mood (measured as whether a person reported feeling hopeless or worthless some of the time, a lot of the time, or all of the time in the past 30 days), as a reflection of mental health. The data included only individuals 45 years or older, in whom joint pain is particularly likely to occur. (The data were adjusted to a constant age and sex mix of the population to avoid trends resulting from population aging.)

Roughly 45% of individuals reported joint pain in the previous 30 days; about 10% of the population reported feeling hopeless or worthless at least some of the time. The share of individuals with each of these conditions had an upward trend. Joint pain was rising more rapidly than mental health impairment, but each was increasing.

The consequences of these trends are enormous. In addition to the loss in length and quality of life for individuals experiencing pain, people of working age with physical and mental pain are more likely to drop out of the labor force, apply for and enroll in disability insurance, and spend a lot of money on medical care.

What is particularly notable about health trends for these 2 conditions is that despite receiving so much attention, their prevalence has increased. Over the past 3 decades, there has been a great deal of focus on the chronic undertreatment of physical and mental pain. Thus, “pain is the fifth vital sign” has been a common slogan, and advertisements for antidepressants were (and still are) common in the US. In both cases, new treatments (for example, opioids and selective serotonin reuptake inhibitors) have been developed over time. And yet, there has been no progress in aggregate.

How is it that there has been so much progress in heart disease and some cancers but so little in other conditions? There are a few possibilities: lack of effective treatments, rising levels of obesity as a contributing factor, and adverse social changes.

Lack of Effective Treatments

For musculoskeletal pain in particular, part of the answer is that the effectiveness of newer treatments has fallen short of hopes for these medications. The experience of widespread opioid use in the 2000s has convinced many clinicians and policy makers that opioids were not the wonder drugs they were often touted to be. Given the limitations of these treatments, it is not a surprise that prevalence of pain has remained high.

That does not seem like a complete explanation, however. Joint replacement, which has been shown to reduce pain, has increased as well. More importantly, studies have repeatedly demonstrated effectiveness of many medications in addressing mental health conditions, and their use has greatly increased over time.

It is also possible, however, that for many individuals, the issue is limited access to medications that might be useful for a condition. People with low incomes have less access to medical care, less generous insurance, and more unstable arrangements with primary care clinicians. All of these factors make treating illness more difficult.

The Role of Obesity

The increase in obesity in the United States is an important contributing factor to the upward trend in musculoskeletal pain. Carrying excess weight has substantial negative consequences, particularly for people whose jobs are physically demanding, such as construction workers or home health aides. Obesity is also associated with depression. That said, the causality in this association is difficult to disentangle. It may be that people with mental health impairment have greater propensity to gain weight or some other factors, such as stress, influence both obesity and mental health.

It is unknown how much the increase in obesity can explain of the trend in rising prevalence of musculoskeletal pain. Musculoskeletal pain has increased more rapidly over time than obesity. However, musculoskeletal pain likely responds to lifetime obesity more than current obesity. No studies have adequately addressed the role of lifetime obesity in explaining this upward trend in musculoskeletal pain.

One argument against the idea that increasing obesity is the primary factor underlying the lack of health improvement is that it is also a major risk factor for heart disease, and heart disease health has improved greatly over the same period. So, it may sometimes be possible to counteract the association of rising obesity with health, but in some areas, we have not done so.

The Effect of Social Change

A third explanation for the continuing high rates of physical and mental pain is that adverse social changes have led to despair and this despair plays out as pain. In a number of articles and a book, Anne Case, MPA, PhD, and Angus Deaton, MA, PhD, of Princeton University, lay out the case that adverse economic and social trends have led to increased despair, and in turn, premature morbidity and mortality. The economic and social changes they highlight are longstanding: the decline of unions, the movement of manufacturing jobs out of the US, and the rise in pay concentrated at the upper end of the distribution.

These economic and social changes have been more severe for people with fewer years of education. That is true in the data from the mentioned National Health Interview Survey, which show that among people 45 years or older, joint pain increased 3 times more rapidly from 2002 to 2017 and mental health impairment increased twice as rapidly from 1997 to 2017 for individuals without a college degree compared with those who attained one.

Social problems often become manifest in the medical sector, and the high and rising prevalence of musculoskeletal pain and mental health impairment illustrate that point. For clinicians, a key issue going forward will be treating patients with fewer traditional risk factors (such as uncontrolled high blood pressure) but with more long-term physical and mental health issues. For clinical researchers and pharmaceutical companies, there is an urgent need to develop therapies that are safe and effective and address both physical and mental pain. Progress in these areas could be the key that unlocks the next generation of dramatic health improvement.

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Article Information

Open Access: This is an open access article distributed under the terms of the CC-BY License.

Corresponding Author: David Cutler, PhD, Harvard University, Department of Economics and Kennedy School of Government, 79 John F. Kennedy St, Cambridge, MA 02138 (dcutler@fas.harvard.edu).

Conflict of Interest Disclosures: Dr Cutler reported personal fees from MDL for opioid litigation and vaping litigation in which he was an expert witness outside the submitted work.

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