A patient comes in with depression. She describes low mood, restless nights, and a gradual withdrawal from the activities that once gave her a sense of purpose. Her voice is steady, almost rehearsed. Then, almost as an afterthought, she mentions a persistent, dull ache in her lower back. It has been there for months, perhaps longer, but she has learned to live with it.
The consultation moves on. Antidepressants are adjusted, sleep is discussed, follow-up is scheduled. The pain is acknowledged with a brief nod, but it is not explored in depth. It lingers at the margins of the conversation, quietly receding into the background.
This separation between “mental” and “physical” symptoms is deeply embedded in clinical practice. We are trained to categorise, to prioritise, to treat what appears most central. Yet, what if this distinction is less clear-cut than we assume?
Chronic pain and mental disorders frequently co-occur, often reinforcing each other in ways that complicate both diagnosis and treatment (Lawson K., 2016; Munafo M., 2016; Williamson G. et al, 2024). Despite this, their intersection remains insufficiently integrated into routine care.
A recent umbrella review by Stubbs et al. (2025) brings together evidence to address a deceptively simple question: how common, and how consequential, is chronic pain across mental disorders?
Low mood may be the focus of the consultation, but physical pain is often present and easily overlooked.
Methods
The authors carried out a hierarchical umbrella review, bringing together evidence from systematic reviews, meta-analyses, and some large primary studies on chronic pain in mental disorders. They searched several major databases, including MEDLINE, PsycINFO, Embase, and Web of Science, which suggests that most relevant studies were likely captured. Study quality was assessed using established tools such as AMSTAR and the Newcastle–Ottawa Scale, which adds some confidence to the findings. At the same time, the included studies differed in design and in how chronic pain was defined, so the overall picture is not entirely consistent.
Results
Although the overall findings are striking, the quality of the underlying evidence is mixed. Much of the data comes from observational studies, and there is considerable variation in how chronic pain is defined and measured across studies. This means that while general patterns are clear, the precision and comparability of estimates are more limited.
This umbrella review brought together evidence from 20 studies, covering a very large, combined sample of over 950,000 individuals with mental disorders and more than 16 million controls. The scale alone gives weight to the findings, but what stands out most is just how common chronic pain appears to be across different psychiatric conditions.
Prevalence varied widely depending on the disorder, reflecting both real differences and variation in how pain was measured across studies. In bipolar disorder, estimates were around 23.7 percent, while in post-traumatic stress disorder (PTSD), rates reached as high as 88 to 96 percent. In depression, more than half of individuals reported chronic pain, with figures typically ranging between 53 and 65 percent. This means that for many patients, pain is not an exception, but part of the usual clinical picture.
Importantly, the relationship was not one-directional. In depression, the review found evidence of a bidirectional link, where chronic pain increased the risk of depression and depression, in turn, increased the likelihood of experiencing pain. This suggests that the two conditions may reinforce each other over time rather than exist independently. While this suggests an important interaction, the evidence is largely observational, so causal conclusions remain tentative.
Across disorders, several risk factors appeared repeatedly. These included female gender, greater symptom severity, and socioeconomic disadvantage. However, the evidence was uneven, with stronger data available for depression and PTSD compared to other conditions such as schizophrenia or ADHD. This unevenness makes it difficult to draw equally strong conclusions across all diagnoses.
When it came to treatment, the picture was less encouraging. Psychosocial interventions such as cognitive behavioural therapy showed only small effects on pain outcomes. Some approaches, such as acupuncture combined with medication, showed more promising reductions in pain, and certain body-based interventions appeared helpful in smaller studies. However, overall, the evidence base for treating chronic pain in people with mental disorders remains limited and inconsistent.
Some interventions, such as acupuncture combined with medication and body-based approaches, show promise in pain reduction, but the overall treatment evidence remains limited.
Conclusions
The authors conclude that chronic pain is a highly prevalent and clinically significant comorbidity across a wide range of mental disordersconsistently exceeding rates seen in the general population. They emphasise that this overlap is not incidental, but reflects a complex, often bidirectional relationship between pain and psychological distress.
Despite this, treatment evidence remains limited, and current approaches do not adequately address both conditions together.
Overall, the review highlights the need for more integrated models of care, where chronic pain is routinely assessed and managed alongside mental health, rather than being treated as a secondary or peripheral concern.
Chronic pain is highly prevalent across mental disorders, but remains insufficiently addressed in current treatment approaches.
Strengths and limitations
One of the main strengths of this review is its scope. By bringing together evidence from systematic reviews, meta-analyses, and large primary studies, the authors provide a broad overview of how chronic pain presents across a range of mental disorders. The inclusion of a very large, combined sample also adds weight to the findings. In addition, the use of established quality appraisal tools such as AMSTAR and the Newcastle Ottawa Scale strengthens confidence that the included evidence was assessed systematically rather than selectively.
At the same time, this breadth comes with trade-offs. Combining evidence from different study designs, populations, and outcome measures inevitably introduces heterogeneity. Chronic pain itself was defined and measured in different ways across studies, which makes direct comparisons difficult and limits the precision of any overall estimate. In this sense, the review is more useful for identifying patterns than for providing exact prevalence figures.
There is also an imbalance in the underlying evidence base. Conditions such as depression and PTSD are relatively well represented, while others, including schizophrenia and ADHD, rely on far fewer studies. This raises the possibility of selection bias at the level of the literature, where conclusions are more robust for some disorders than others.
Another issue relates to the nature of the included studies. Much of the evidence comes from observational designs, which means that confounding factors such as physical health conditions, medication use, or socioeconomic status may not be fully accounted for. This is particularly relevant when interpreting the reported bidirectional relationship between pain and mental disorders.
Finally, although the review touches on treatment, the evidence in this area remains limited and somewhat fragmented. This makes it difficult to draw firm conclusions about what actually works in practice, highlighting an important gap between epidemiological insight and clinical application.
The review provides a broad overview, but differences in study design and measurement make the overall picture less precise.
Implications for practice
If we return to the patient in the opening vignette, it becomes clear that her back pain is not just an additional symptom. It is part of the same clinical picture, even if it is not immediately recognised as such. This review suggests that such cases are not unusual, but rather the norm across many mental disorders. That alone has important implications for everyday practice.
At a basic level, it points to the need for more routine and deliberate assessment of pain in psychiatric settings. Asking about pain is not enough. It requires follow-up, clarification, and at times, a willingness to treat it as a central concern rather than a secondary one. Without this shift, there is a risk that pain remains documented but unaddressed.
The findings also challenge the way care is often organised. Mental health services and pain management are typically delivered in parallel, with limited integration. Yet the evidence here suggests that these conditions frequently interact and may even reinforce each other. This makes a strong case for more collaborative models of carewhere psychological and physical symptoms are addressed together rather than in isolation.
At the same time, the review highlights how limited the treatment evidence still is. While some interventions show modest benefits, there is no clear, consistently effective approach for managing chronic pain within mental health populations. This points to an important gap in research. Future studies need to move beyond documenting prevalence and focus more on developing and testing integrated interventions that can address both domains simultaneously.
From a clinical perspective, perhaps the most important takeaway is a shift in mindset. It is easy to prioritise symptoms that fit neatly within diagnostic frameworks. Pain does not always do that, but if it is as common and as consequential as this review suggests, then it deserves a more central place in both assessment and treatment. Recognising this may not solve the problem immediately, but it is a necessary starting point.
Addressing chronic pain alongside mental health requires active assessment and a more integrated approach to care.
Statement of interests
Meenakshi Shukla declares no conflicts of interest. AI-assisted tools were used to support language refinement. All interpretations and final content are the author’s own.
Editor
Edited by Laura Hemming.
Links
Primary paper
Brendon Stubbs, Ruimin Ma, Marco Solmi, Nicola Veronese, Tine Van Damme, Eugenia Romano, Robert Stewart, Nilufar Mossaheb, José Francisco López-Gil, Joseph Firth, Davy Vancampfort (2025) Chronic pain in mental disorders: An umbrella review of the prevalence, risk factors, and treatments across 957,168 people with mental disorders and 16,606,910 controls. European Psychiatry68(1), e113.
https://doi.org/10.1192/j.eurpsy.2025.10074
Other references
Lawson K. Will it hurt? Chronic pain and psychological functioning. The Mental Elf, 24 Mar 2016.
Munafo M. Chronic pain and depression: genetic and environmental risks. The Mental Elf, 09 Nov 2016.
Williamson G, Leightley D. Cannabis use and its legalisation: analysing chronic pain in US veterans using electronic health records. The Mental Elf, 09 Feb 2024.
