A Review of Chronic Pain with Depression and/or Anxiety Comorbidities in the Indian Population : Indian Journal of Pain

Secondary Logo

Journal Logo

Review Article

A Review of Chronic Pain with Depression and/or Anxiety Comorbidities in the Indian Population

Lokapur, M; Kumar, N1; Shah, H2; Shah, D3,

Author Information
Indian Journal of Pain 37(1):p 3-12, Jan–Apr 2023. | DOI: 10.4103/ijpn.ijpn_26_21
  • Open



Chronic pain disorders are the leading cause of disability globally and in India.[1] Both depression and anxiety are associated with increased pain intensity, poor pain outcomes, worse prognosis, increased medical visits, and higher medical costs during chronic pain management.[2–5] The complex interplay of chronic pain with comorbid depression and anxiety has not been well studied globally and even less so in India. This paper reviews the literature on comorbid depressive and/or anxiety disorders with chronic pain conditions in the Indian population, to understand the current landscape of the management for these comorbidities and identify need gaps for future research.


Search strategy

The scope of psychiatric comorbidities in this paper was limited to depressive and anxiety disorders as they are the leading contributors of disability due to psychiatric disorders accounting for 33.8% and 19.0% of disability-adjusted life-years, respectively in 2017.[6] A MEDLINE® database search through PubMed® was conducted on March 23, 2020, by an independent reviewer to identify relevant peer-reviewed scientific publications published from 2010 onward. The search string combined MeSH terms and keyword search terms related to chronic pain, depression and anxiety: ([“Pain”] OR [“Chronic Pain”] OR [“Neuralgia”] OR [“Diabetic Neuropathies”] OR Pain OR neuralgia OR neuropath*OR [Cancer Pain] OR [Cancer-Associated Pain] OR [Tumor-related Pain] OR [Oncology Pain] OR [Cancer-Related Pain] OR [Neoplasm-Associated Pain] OR [Neoplasm-Related Pain] OR [Cancer Pain]) AND ([“Depression”] OR [“Depressive Disorder”] OR [depression] OR “depressive disorder” OR depressive*OR [“Anxiety”] OR [“Anxiety Disorders”] OR anxiety) AND India*. The PubMed search results were limited to articles published in English language and with the availability of full texts. In addition, the archives of Indian Journal of Pain were searched using the terms “Pain,” “Depression,” “Anxiety,” and “Cancer Pain” for relevant articles published 2010 onward by the independent reviewer on March 25, 2020.

Eligibility criteria

The predefined eligibility criteria for articles included studies addressing chronic pain conditions (defined as persistent or recurrent pain lasting more than 3 months[7] or as specified in the study) as well as general pain (i.e., studies that did not specify pain location or duration); presence of comorbid depression and/or anxiety symptoms; and population sample comprised of Indian population. Articles reporting randomized controlled studies, systematic reviews, meta-analyses, literature reviews, observational studies, patient-reported outcomes, and treatment guidelines were included, whereas, case reports and conference proceedings were excluded. Acute pain was excluded as the scope of this study was limited to chronic pain conditions.

Data extraction and synthesis

The search output was exported into a Microsoft Excel document and deduplicated. In the first level screening, titles and abstracts of articles were independently screened by two reviewers for eligibility. In the second level screening, the full texts of articles were retrieved and screened for eligibility. Any disagreements regarding the eligibility of studies were resolved following discussion with the authors. Relevant, representative, and evidence-based data were extracted. Quality assessment of studies was not performed given the heterogeneity of study types. Given the broad scope of review, i.e., to analyze the landscape of chronic pain with comorbid depression and anxiety in the Indian population, the extracted data were summarized as a narrative review.


Overall, 866 articles were retrieved through structured search from PubMed, and 593 articles were retrieved through unstructured search; of these 84 articles met the inclusion criteria [Figure 1]. The population samples comprised of a wide variety of chronic pain etiologies, with cancer pain (25%) being the most commonly studied etiology. Both depression and anxiety were assessed with chronic pain in most of the articles (~60%). Between 2010 and 2019, there was an increasing trend observed in the number of articles published on chronic pain and comorbid depression/anxiety in the Indian population [Figure 2].

Figure 1:
Flow diagram for study article selection
Figure 2:
Trend in the number of articles published on chronic pain and comorbid depression or anxiety in the Indian population between 2010 and 2019

Epidemiology of comorbid depression and anxiety in chronic pain conditions

The prevalence and correlation of comorbid depression and anxiety in chronic pain conditions among the Indian population in different settings are provided in Supplementary Table S1.[8–45] The prevalence of comorbid depression with chronic pain ranged from 31% to 88% observed in prospective studies in Indian pain clinics.[8,9] The severity of depression and anxiety were positively correlated with the intensity of chronic pain.[10] In an online survey, most psychiatrists (85%) registered with the Indian Psychiatry Society agreed that pain and depression were interrelated and around 40% of the psychiatrists perceived that up to 50% of patients with chronic pain in India experienced depression.[11]

Supplementary Table S1:
Epidemiology of comorbid depression and anxiety in chronic pain conditions among the Indian population

Psychiatric comorbidities have been observed in numerous chronic pain conditions and patient subgroups in India. Pain is the most commonly presented symptom among patients with cancer admitted in hospitals, and its severity is strongly associated with increased anxiety and depression scores.[12] Pain is frequently identified and treated by oncologists, however, anxiety, depression, and tiredness that co-occur with pain remains underreported.[13] In a palliative care setting, chronic pain in two-thirds of patients was due to cancer etiology, and psychiatric illness was strongly associated with pain perception, impaired activity, and functional status in these patients.[14]

Several studies have further demonstrated evidence for the association of depression or anxiety with other chronic pain conditions including fibromyalgia, ankylosing spondylitis, temporomandibular disorders, chronic facial pain, myofascial pain syndrome, carpel tunnel syndrome, Guillain–Barre Syndrome, and epicrania fugax, a rare primary headache, in the Indian population.[15–20,27,28] People with amputations and phantom pain had a high prevalence of psychiatric disorders particularly major depressive disorder.[21,22] Chronic perinatal pain and pain symptoms occurring in menopausal and post-menopausal women was observed to be associated with depression.[23–26]

Notably, depression and anxiety were not observed as a comorbidity in all pain conditions. No difference in the prevalence of anxiety and depression was observed in patients with moderate-to-severe migraine compared with healthy people.[29] Conversely, severe anxiety and depression were significantly more prevalent in patients with new daily persistent headache than those with chronic low back pain (CLBP) or healthy people.[30] The contradictory results reported in the field of migraine may be due to variations in socioeconomic status and clinical conditions or study methodology.

Comorbid pain and psychological distress were also associated with certain occupations and industries in India. Cross-sectional studies of people employed in iron and textile industries found that 40%-68% of all workers experienced pain/discomfort and depression/anxiety, associated with long working hours (>48 h per week).[31,32] CLBP was highly prevalent among medical university students, who also had high levels of depression, anxiety, and monotonous work.[33]

Risk factor determinants of pain, depression, and anxiety

Although genetic factors have often been implicated as determinants of pain perception and response, depression and anxiety were similarly associated with pain due to Parkinson’s disease among Caucasian and Indian patients. Interestingly, patients of Caucasian ethnicity experienced more debilitating pain symptoms interfering with several dimensions of life than their Indian counterparts.[34] Given the bidirectional causality between pain and depression or anxiety, psychological factors also related to the onset of chronic pain.[46] Risk factors for depression in Indian chronic pain patients included female sex, pain intensity, and poor sleep quality.[8]

The evidence is conflicting on pain as a commonly observed symptom in psychiatric conditions among Indian patients. While a survey found that 44% of physicians agreed that chronic pain is present in most patients with masked depression, another study found that pain was a higher complaint among general patients than psychiatric inpatients with depression or anxiety.[35,36] Depression was highly prevalent among type 2 diabetes mellitus patients, with diabetic neuropathy and foot disease as risk factors for its development.[37,38]

Pain and psychiatric disorders are also risk factors of sedentary behavior, which in turn, may result in diabetes, stroke, and premature mortality. Analyses of the World Health Organization’s (WHO) Study on Global Ageing and Adult Health survey found that patients with depression and comorbid bodily pain were more likely to display sedentary behavior, and pain was a contributing factor to the association between anxiety and sedentary behavior.[39,40]

Effect of chronic pain and psychiatric disorders on quality of life

The association of depression and/or anxiety with pain impacts the quality of life (QOL) of patients [Supplementary Table S2].[47–53] Patients with higher pain, depression, and anxiety scores had lower QOL and meaning in life scores.[47–49] Besides depression and generalized anxiety disorder, pain conditions were also associated with panic disorder and poor QOL.[50,51] QOL also varied according to the population sub-group. Well-being of patients with advanced cancer was lower in India compared with the US patients.[52] Pain severity was a predictor of most QOL outcomes.[52]

Supplementary Table S2:
Impact of chronic pain and common comorbid psychiatric disorders on quality of life assessed in the Indian population

Screening and assessment tools

Evaluating patient history is an important step in diagnosing chronic pain and it aids clinicians in proper pain management. Numerous unidimensional instruments such as the Numerical Rating Scale (NRS) and Visual Analog Scale (VAS), and multidimensional instruments such as McGill Pain Questionnaire (MPQ) and Brief Pain Inventory (BPI) are used to assess pain intensity. Due to the high prevalence of comorbid psychiatric conditions in chronic pain conditions, patient history assessment must evaluate the mental status through questionnaires such as Patient Health Questionnaire-9 (PHQ-9), Beck Depression Inventory (BDI), Hamilton Depression Scale, Hospital Anxiety and Depression Scale, and Pain Catastrophizing Scale (PCS).[54] Several studies have validated chronic pain screening and assessment tools for the Indian population [Supplementary Table S3].[54–61]

Supplementary Table S3:
Chronic pain screening tools including depression and anxiety assessment evaluated in the Indian population

The American College of Rheumatology (ACR) 2016 criteria for fibromyalgia was validated as a diagnostic tool for use in tertiary settings in India.[55] Diagnosis by the ACR 2016 criteria had higher anxiety and depression scores than the ACR 1990 criteria suggesting that the two criteria identified different patient subsets with fibromyalgia; therefore, both criteria were recommended for diagnosis in referral settings.[55] Several international pain assessment instruments have been translated to local languages and validated for Indian populations, including the PCS, the University of Washington QOL Questionnaire, and the EuroQol five-dimensions (EQ-5D) questionnaire.[56–58]

In cancer, assessments of psychological well-being and QOL along with personalized symptom goals are important to manage symptoms properly.[59] Psychological assessments in a cancer pain clinic observed that physical aspects of distress were appropriately recorded; however, psychosocial aspects were severely underreported.[60] Of the 14 pain assessment tools assessed, the Distress Inventory for Cancer-2 and the American Pain Society Patient Outcome Questionnaire were recommended for the evaluation of both functional and nonfunctional pain symptoms.[60]

Treatment modalities

Supplementary Table S4 presents an overview of pain management treatment modalities studied in the Indian context and their effect on depression or anxiety scores.[62–88] Antidepressants such as selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors (SNRIs), and tricyclic antidepressants (TCAs) have demonstrated efficacy in the treatment of several painful conditions.[63] In an international randomized controlled study of juvenile fibromyalgia including Indian patients, although treatment with the SNRI duloxetine did not improve the mean 24-h pain severity scores, a 30%-50% reduction in pain severity was observed compared with placebo.[64] In patients with central poststroke pain, pregabalin or lamotrigine treatment was equally effective in improving pain, depression, and anxiety.[65] Lamotrigine, however, was associated with withdrawal in 10% of the patients due to adverse effects.[65] In patients with type 2 diabetes, minocycline treatment had greater improvement in peripheral and autonomic neuropathy accompanied with significant improvements in VAS and BDI scores compared with placebo.[66] The antipsychotic levosulpiride in combination with trigger point injections was associated with greater reductions in pain and depression for the treatment of myofascial pain syndrome compared with only trigger point injections.[67,79]

Supplementary Table S4:
Treatment strategies for chronic pain and comorbid depression and/or anxiety in the Indian population

Various nonpharmacological interventions for pain management demonstrated improvements in pain and associated depression or anxiety in Indian populations. Transcranial magnetic stimulation, spinal manipulation, use of lumbar belt, and surgical treatment improved pain, anxiety/depression scores, and QOL in several chronic pain conditions.[69–72] Music therapy, hypnotherapy, and cannabis powder were found to reduce cancer-associated pain, with cannabis also reducing anxiety and depression.[73–75] Cognitive behavioral therapy, largely used in managing psychological disorders, was effective in reducing headache severity and anxiety in adolescents with both these conditions and also in managing CLBP and fibromyalgia.[63,76]

Several studies extol the benefits of yoga therapy as an adjunct to the conventional pain therapies. Yoga reduced pain and psychological disorder symptoms in patients with CLBP and with knee osteoarthritis compared with physical therapy.[77–81] Yoga in combination with conventional therapy improved pain, anxiety, and stress in Guillain-Barré syndrome, myofascial pain syndrome, and cancer to varying degrees.[82–84] The use of other complementary and alternative treatments such as meditation and mindfulness also improved pain and psychological distress in numerous chronic pain conditions, including painful diabetic neuropathy pain, fibromyalgia, rheumatoid arthritis, migraine, and myofascial pain syndrome.[85,86]

In India, palliative care is mostly limited to patients with cancer as the field is still in the early stages of development.[87,88] Palliative care is not equipped to handle patients with special needs and often issues related to psychosocial and spiritual needs of patient subgroups such as adolescents remain unmet.[41]

Treatment guidelines

A consensus on pharmacological pain management in India recommended thorough evaluation of patient history, use of appropriate pain assessment tools (unidimensional: E.g., NRS and VAS; multidimensional: E.g., BPI and MPQ; disease-specific: Leeds Assessment of Neuropathic Symptoms and Signs and Neuropathic Pain Scale; elderly patients: Abbey’s Pain Scale) and systematic screening of underlying comorbidity including psychiatric comorbidities (depression, anxiety, psychological disorders) prior to starting treatment.[89] Treatment goals for chronic pain management included decreasing pain symptoms, reducing emotional distress, as well as increasing the coping ability and psychosocial well-being of patients. The multimodal treatment recommended for chronic pain included a combination of paracetamol, non-steroidal anti-inflammatory drugs, selective cyclooxygenase-2 inhibitors, analgesics, opioids, TCAs, corticosteroids, muscle relaxants, sedatives, and anxiolytics.[89] The recommended treatment for various neuropathic conditions included TCAs, antiseizure medications, and opioids.[89] In the case of suspected depression comorbidity, antidepressants may be included in the treatment plan.[89]

The Indian Society for Study of Pain recently issued Cancer Pain Special Interest Group guidelines for the assessment of cancer pain in adults. The guidelines recommended comprehensive pain assessment using scales such as the MPQ and the BPI Short Form and also screening for psychological distress using the PHQ-9.[61] Appropriately educating patients about the pharmacological and nonpharmacological methods of pain management was also recommended.[61] For patients with cancer experiencing comorbid pain and psychological distress, the guidelines recommended psychological intervention including psychoeducation and physical and complementary therapy as an adjunct treatment.[61,90] In ambulatory palliative care setting, the guidelines recommended following the WHO 3-step analgesic ladder for managing cancer pain.[91]


The prevalence of chronic pain among the general Indian population is estimated at 13%–30%.[92–94] Chronic pain adversely impacts the QOL such as the ability to sleep, exercise, walk, do household chores and attend social activities. The economic impact of chronic pain is a consequence of healthcare expenditure and lost employment and productivity.[93] Psychiatric illnesses such as depression and anxiety often coexist with chronic pain, with mean global prevalence rates of 13%–56% for comorbid major depression in patients with chronic pain.[95] From a neurobiological perspective, pain and depression are closely linked, whereby chronic pain may lead to depression.[96] The underlying mechanisms governing the interactions between pain and depression are not clearly defined, though some common factors such morphological changes in the brain, monoamine deficiency, brain-derived neurotrophic factor reduction in the hippocampus have been identified.[97] Similarly, anxiety disorders occur at rates similar to depression in individuals with chronic pain; the adjusted odds ratio for any anxiety disorder among people with chronic pain conditions was similar to that for any mood disorder (2.13 vs. 2.00).[3]

This review observed a high prevalence of comorbid depression and anxiety with chronic pain in the Indian population, which highlights a serious healthcare concern as the inadequate management of these interlinked conditions predict poor prognoses and outcomes. Depression and anxiety comorbidities are observed in numerous chronic pain conditions and population subgroups in the Indian setting. A recent study in primary care attendees in the Indian state of Kerala estimated chronic pain prevalence in those experiencing depression at 66% versus an overall prevalence of 27%.[98] Similar to global trends, Indian women are at a greater risk of developing chronic pain conditions than men.[99,100] Chromosomal or hormonal differences may contribute to this sex-based difference in pain prevalence.[100] Given the sex and gender differences in pain and analgesia, the International Association for the Study of Pain Sex, Gender, and Pain Special Interest Group outlined best practices for pain research with respect to sex and gender.[101]

Chronic pain conditions, specifically CLBP and musculoskeletal pain were more prevalent in industrial workers than the general population.[102–104] The working conditions of these populations predispose them to pain conditions as well as concurrent psychological distress. Therefore, it is important to educate patients about work-related conditions to improve the management of their symptoms.[31,32] Economic status is identified as a risk factor for both CLBP and depression.[105–108] Therefore, clinicians and policy makers must consider these unequal disparities while treating patients with chronic pain and formulate comprehensive chronic pain management policies.[106]

Several cultural, genetic, and biosocial factors contribute to variations in pain causation, manifestation, and reporting; hence, Western studies on the prevalence of chronic pain and comorbid psychiatric illnesses cannot be extrapolated to Asian populations.[34,52,109,110] India has a huge burden of chronic pain, with an estimated 180–200 million people living with chronic pain.[94] Compared with other Asian countries, chronic pain prevalence is higher among adult Indian population.[94] The shared mechanisms between pain, depression, and anxiety highlight the need to manage these conditions concurrently in comorbid populations to optimize diagnosis and treatment.[111]

Chronic pain had a higher prevalence in developing countries (41.1% vs. 37.3%) compared with developed countries, despite being similarly associated with depression-anxiety spectrum disorders in both developing and developed countries.[112] Reliable data on chronic pain is limited in developing countries such as India and is a contributing factor toward under-treatment of pain. In addition, barriers related to low levels of pain education among healthcare professionals and poor access to pain management facilities and medication, particularly strong opioids, prevent the delivery of adequate pain relief in developing countries.[113] Access to morphine is a crucial component to manage cancer and deliver quality palliative care. In the past two decades, six developed countries accounted for 79% of global morphine consumption while developing countries only accounted for 6%, highlighting the disparate status of pain treatment.[114] In 2007, the Indian government-produced < 10% of the morphine needed in the country for treating cancer patients in pain.[113] Undertreatment of chronic pain conditions has serious public health implications including high rates of disability, direct and indirect economic losses to health systems, families, and individuals, and an overall impact on the QOL of population. Building a current evidence base identifying risk factors and challenges in pain management allows the development of appropriate healthcare strategies to reduce the disease burden. Health systems in India need to consider developing stepped care and collaborative care models for pain management in primary care and specialized pain clinics in tertiary care.[98]

Pain management is a newly established specialty in India. The Medical Council of India has deemed pain clinic as an essential service in all teaching hospitals.[115] Currently, pain clinics are managed as independent outpatient facilities by pain physicians, as part of larger private/public institutes, or in anesthesiology departments of hospitals. Pain clinics are proficient in the assessment and management of pain, conducting interventional procedures, prescribing pain medications, and managing the psycho-socio-somatic aspect of pain.[116]

The barriers toward effective pain management in India can be categorized as related to patients, physicians, or healthcare systems. When seeking pain treatment, most Indians do not seek help from qualified physicians in the first instance, instead preferring the use of local topical treatments, followed by over-the-counter analgesics, then managing pain through relaxation techniques, and if still unresolved, take leave from work.[36] Cancer pain is accepted as an inevitable consequence of the condition and patients frequently avoid analgesics;[117] opioid use is perceived as a sign of imminent death for these patients.[118] Social stigma associated with opioid addiction discourages patients from seeking optimal pain management with opioids, instead preferring to bear the pain.[119] Many patients without access to pain medications remain untreated or undertreated and are likely to develop depression.

Psychiatrists diagnosing depression in patients with chronic pain are subjected to social stigma and nonacceptance of the psychiatric diagnosis by the patients. Other challenges include the lack of awareness among physicians, lack of diagnostic tools, comorbid conditions, and nonadherence to treatment.[11] In addition, primary care physicians’ lack of knowledge on the association between depression and chronic pain and appropriate use of opioids often leads to delayed referrals and improper pain management.[95,120] Effective communication between healthcare professionals and patients following a patient-centered care approach can help overcome these barriers.[121] Undergraduate medical curriculum is also in urgent need of updating pain and psychiatry education programs.[122,123] Affordability of pain treatment is a critical issue in India, with most pain relief drugs available only in private health facilities and not covered under health insurance.[124] Availability and access to drugs and carers are also obstacles in the rehabilitation of pain conditions, particularly cancer care.

Palliative care was introduced in India in the mid-80s; however, it still remains in infancy and is largely limited to cancer pain management.[125] Majority of Indian patients with cancer were not treated according to the WHO recommendations for pain management and inadequate pain management was correlated to hospital settings and patient groups.[126] Therefore, outpatient home-based palliative care may be utilized to treat patients with chronic conditions.[125] Palliative care must move toward a patient-oriented approach, with improved communication between medical personnel and patients to set personalized treatment goals and improve pain management.[59,125]

There are limited data available on the evidence-based treatment of chronic pain and comorbid depression or anxiety for Indian populations. Antidepressants are recommended to manage symptoms in case of comorbid depression with chronic pain.[89] Recent guidelines recommended antidepressants like TCAs including amitriptyline and SNRIs including venlafaxine and duloxetine along with anticonvulsants gabapentinoids including gabapentin and pregabalin as first-line treatments for neuropathic pain.[127,128] Antidepressants such as TCAs and SNRIs increase the levels of serotonin and norepinephrine neurotransmitters, which are involved in both pain and major depression pathways.[129] The effects of these antidepressants on alleviating pain in patients with comorbid depression are independent of their effect on depression.[129] SNRI antidepressants also demonstrated decreased functional connectivity in a thalamo-cortico-periaqueductal network associated with pain; this decrease was correlated with improvements in depressive symptom severity and pain symptoms.[130]

Psychological treatments such as cognitive behavior therapy, biofeedback therapy, mindfulness-based stress reduction, acceptance and commitment therapy, and Jacobson’s progressive muscle relaxation technique reduced pain and psychiatric distress in multiple pain conditions to varying degrees.[131,132] Compared with pharmacological treatments alone, a multidisciplinary approach adopting a biopsychosocial model of care provides a more comprehensive treatment for managing cancer pain conditions.[90] Yoga as an adjunct to conventional therapy demonstrated benefits in managing pain conditions; however, Indian yoga trials were significantly more likely to have positive outcomes compared with yoga trials elsewhere. Therefore, results of yoga trials performed in India must be cautiously evaluated before incorporating into pain practice.[133] Complexities of chronic pain require the collaboration of multidisciplinary experts, including pain specialists, psychiatrists, physical/occupational therapists, psychologists/social workers, and pharmacists, and registered nurses. The aim of this review is to impress upon the pain physicians that psychological comorbidities must be addressed alongside analgesics and/or nerve blocks to obtain satisfactory outcomes. Psychiatric comorbidities must be an important consideration in the evaluation and treatment planning for chronic pain.

Strengths and limitations

This review article provides an updated evidence base for chronic pain and comorbid depression and/or anxiety in the Indian population, as there are scarce recent reviews on this topic from an Indian perspective. A strength of the review is the systematic search to locate evidence on this topic supplemented with an unstructured search of local studies. This allowed coverage of maximum available data on comorbid pain and psychological disorders. Timeframe of the review was considered adequate as only one eligible article was retrieved from 2010, therefore, very minimal published data was expected prior to that period. A limitation of the review is the lack of quality appraisal step due to the heterogeneity of included study types. Another limitation was the inclusion of articles addressing chronic pain, defined as lasting more than 3 months,[7] as well as articles using any other specified definitions of chronic pain. This selection of articles was made to ensure a comprehensive review of the landscape of chronic pain with comorbid depression/anxiety in India.


The published literature on chronic pain with comorbid depression and/or anxiety emphasized the high burden of these interlinked comorbidities in India and highlighted challenges in the effective management of these conditions concurrently. Addressing barriers pertaining to patients, physicians, and the healthcare system is essential to improve both pain and depression/anxiety outcomes. Future initiatives are needed to support research to inform evidence-based treatment of chronic pain and comorbid psychiatric conditions and to promote a multidisciplinary approach for managing chronic pain in the Indian setting.

Financial support and sponsorship

Medical writing support for the development of this manuscript was funded by Pfizer Upjohn.

Conflicts of interest

There are no conflicts of interest.


The authors would like to thank Kaveri Sidhu and Aditi Karmarkar, from Pfizer Upjohn for providing medical writing support funded by Pfizer Upjohn.


1. GBD 2017 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017:A systematic analysis for the Global Burden of Disease Study 2017. Lancet 2018;392:1789–858.
2. Scott KM, Von Korff MR, Gureje O Contents, in Global Perspectives on Mental-Physical Comorbidity in the WHO World Mental Health Surveys Cambridge Cambridge University Press 2009 1–12.
3. Gureje O. Comorbidity of pain and anxiety disorders. Curr Psychiatry Rep 2008;10:318–22.
4. Li AL, Peng YB. Comorbidity of depression and pain:A review of shared contributing mechanisms. J Neurol Neuromed 2017;2:4–11.
5. Wang XQ, Peng MS, Weng LM, Zheng YL, Zhang ZJ, Chen PJ. Bibliometric study of the comorbidity of pain and depression research. Neural Plast 2019;2019:1657498.
6. India State-Level Disease Burden Initiative Mental Disorders Collaborators. The burden of mental disorders across the states of India:The Global Burden of Disease Study 1990-2017. Lancet Psychiatry 2020;7:148–61.
7. Treede RD, Rief W, Barke A, Aziz Q, Bennett MI, Benoliel R, et al. Aclassification of chronic pain for ICD-11. Pain 2015;156:1003–7.
8. Gupta M, Das PG, Kumar AG. Depression-sleep disturbance-chronic pain syndrome. Indian J Pain 2014;28:177–83.
9. Dutta D, Bharati S, Roy C, Das G. Measurement of prevalence of 'major depressive syndrome'among Indian patients attending pain clinic with chronic pain using PHQ-9 scale. J Anaesthesiol Clin Pharmacol 2013;29:76–82.
10. Patil V, Deshmukh A, Naik R, De Sousa A. A cross-sectional observational study on the levels of anxiety, depression, and somatic symptoms in patients with chronic pain undergoing physiotherapy treatment. Indian J Pain 2016;30:108–10.
11. Chaturvedi SK, Rao GP, Sarda KD, Suryawanshi SY. Chronic pain and depression:An online survey on Indian experiences. Indian J Pain 2014;28:166–72.
12. Arora A, Saini SK, Nautiyal V, Verma SK, Gupta M, Kalra BP, et al. Cancer pain, anxiety, and depression in admitted patients at a tertiary care hospital:A prospective observational study. Indian J Palliat Care 2019;25:562–6.
13. Ghoshal S, Miriyala R, Elangovan A, Rai B. Why newly diagnosed cancer patients require supportive care?An audit from a regional cancer center in India. Indian J Palliat Care 2016;22:326–30.
14. Rajmohan V, Kumar SK. Psychiatric morbidity, pain perception, and functional status of chronic pain patients in palliative care. Indian J Palliat Care 2013;19:146–51.
15. Jivnani HM, Tripathi S, Shanker R, Singh BP, Agrawal KK, Singhal R. A study to determine the prevalence of temporomandibular disorders in a young adult population and its association with psychological and functional occlusal parameters. J Prosthodont 2019;28:e445–9.
16. Patil D, Dheer D, Puri G, Konidena A, Dixit A, Gupta R. Psychological appraisal in temporomandibular disorders:A cross-sectional study. Indian J Pain 2016;30:13–8.
    17. Nadendla LK, Meduri V, Paramkusam G, Pachava KR. Evaluation of salivary cortisol and anxiety levels in myofascial pain dysfunction syndrome. Korean J Pain 2014;27:30–4.
      18. Alok R, Das SK, Agarwal GG, Salwahan L, Srivastava R. Relationship of severity of depression, anxiety and stress with severity of fibromyalgia. Clin Exp Rheumatol 2011;29:S70–2.
        19. Dhakad U, Singh BP, Das SK, Wakhlu A, Kumar P, Srivastava D, et al. Sexual dysfunctions and lower urinary tract symptoms in ankylosing spondylitis. Int J Rheum Dis 2015;18:866–72.
          20. Khan F, Shehna A, Ramesh S, Sandhya KS, Paul R. Subjective symptoms of carpal tunnel syndrome correlate more with psychological factors than electrophysiological severity. Ann Indian Acad Neurol 2017;20:69–72.
          21. Baby S, Chaudhury S, Walia TS. Evaluation of treatment of psychiatric morbidity among limb amputees. Ind Psychiatry J 2018;27:240–8.
          22. Bhutani S, Bhutani J, Chhabra A, Uppal R. Living with amputation:Anxiety and depression correlates. J Clin Diagn Res 2016;10:C09–12.
          23. Desai G, Sunil Kumar G, Manoj L, Gokul GR, Beena KV, Thennarasu K, et al. Prevalence and correlates of chronic perinatal pain-A study from India. J Psychosom Obstet Gynaecol 2019;40:91–6.
          24. Borker SA, Venugopalan PP, Bhat SN. Study of menopausal symptoms, and perceptions about menopause among women at a rural community in Kerala. J Midlife Health 2013;4:182–7.
            25. Kulkarni P, Savitha Rani BB, Kumar DS, Manjunath R. Burgeoning menopausal symptoms:An urgent public health concern. J Midlife Health 2016;7:83–7.
              26. Malik R, Goel S, Misra D, Panjwani S, Misra A. Assessment of anxiety and depression in patients with burning mouth syndrome:A clinical trial. J Midlife Health 2012;3:36–9.
              27. Karkare K, Sinha S, Taly AB, Rao S. Prevalence and profile of sleep disturbances in Guillain-Barre Syndrome:A prospective questionnaire-based study during 10 days of hospitalization. Acta Neurol Scand 2013;127:116–23.
              28. Rammohan K, Shyma MM, Das S, Shaji CV. Clinical features and psychiatric comorbidity of epicrania fugax. J Neurosci Rural Pract 2018;9:143–8.
              29. Sreedhar A, Kumar SM, Shobha AN. Executive function and its clinical correlates among migraineurs. Indian J Pain 2018;32:167–72.
              30. Uniyal R, Paliwal VK, Tripathi A. Psychiatric comorbidity in new daily persistent headache:A cross-sectional study. Eur J Pain 2017;21:1031–8.
              31. Chattopadhyay K, Chattopadhyay C, Kaltenthaler E. Health-related quality-of-life of coal-based sponge iron plant workers in Barjora, India:A cross-sectional study. BMJ Open 2014;4:e006047.
              32. Angeline GN, Bobby J. Work related musculoskeletal disorders among adolescent girls and young women employees of textile industries in Tamil Nadu, India-A comparative study. Int J Adolesc Med Health 2018;30:20160116.
              33. Aggarwal N, Anand T, Kishore J, Ingle GK. Low back pain and associated risk factors among undergraduate students of a medical college in Delhi. Educ Health (Abingdon) 2013;26:103–8.
              34. Rana AQ, Qureshi AR, Rizvi SF, Mohiuddin MM, Hussain Syed B, Sarfraz Z, et al. Parkinson's pain is more aching and interfering with social life in Caucasians compared to Indians. Int J Neurosci 2019;129:746–53.
              35. Shetty P, Mane A, Fulmali S, Uchit G. Understanding masked depression:A Clinical scenario. Indian J Psychiatry 2018;60:97–102.
              36. Sharma MK, Chaturvedi SK. Pain in mental health setting and community:An exploration. Indian J Psychol Med 2014;36:98–100.
              37. Raval A, Dhanaraj E, Bhansali A, Grover S, Tiwari P. Prevalence and determinants of depression in type 2 diabetes patients in a tertiary care centre. Indian J Med Res 2010;132:195–200.
              38. Singh H, Raju MS, Dubey V, Kurrey R, Bansal S, Malik M. A study of sociodemographic clinical and glycemic control factors associated with co-morbid depression in type 2 diabetes mellitus. Ind Psychiatry J 2014;23:134–42.
              39. Vancampfort D, Stubbs B, Mugisha J, Firth J, Schuch FB, Koyanagi A. Correlates of sedentary behavior in 2,375 people with depression from 6 low- and middle-income countries. J Affect Disord 2018;234:97–104.
              40. Vancampfort D, Stubbs B, Herring MP, Hallgren M, Koyanagi A. Sedentary behavior and anxiety:Association and influential factors among 42,469 community-dwelling adults in six low- and middle-income countries. Gen Hosp Psychiatry 2018;50:26–32.
              41. Salins NS, Vallath N, Varkey P, Ranganath K, Nayak MG. Clinical audit on “evaluation of special issues in adolescents with cancer treated in an adult cancer setting”:An Indian experience. Indian J Palliat Care 2012;18:196–201.
              42. Rai NK, Bitswa R, Singh R, Pakhre AP, Parauha DS. Factors associated with delayed diagnosis of migraine:A hospital-based cross-sectional study. J Family Med Prim Care 2019;8:1925–30.
                43. Ahmed A, Bhatnagar S, Rana SP, Ahmad SM, Joshi S, Mishra S. Prevalence of phantom breast pain and sensation among postmastectomy patients suffering from breast cancer:A prospective study. Pain Pract 2014;14:E17–28.
                  44. Sahu A, Gupta R, Sagar S, Kumar M, Sagar R. A study of psychiatric comorbidity after traumatic limb amputation:A neglected entity. Ind Psychiatry J 2017;26:228–32.
                    45. Bhagat V, Salgaonkar S, Devalkar P, Gite J. Risk factors analysis for development of chronic postsurgical pain after modified radical mastectomy:A single-centered, prospective, observational study. Indian J Pain 2019;33:131–5.
                    46. Linton SJ. A review of psychological risk factors in back and neck pain. Spine (Phila Pa 1976) 2000;25:1148–56.
                    47. Mathew AJ, Chopra A, Thekkemuriyil DV, George E, Goyal V, Nair JB, et al. Impact of musculoskeletal pain on physical function and health-related quality of life in a rural community in south India:A WHO-ILAR-COPCORD-BJD India study. Clin Rheumatol 2011;30:1491–7.
                    48. Prasad JD, Varghese AK, Jamkhandi D, Chakraborty A, Rakesh PS, Abraham VJ. Quality-of-life among elderly with untreated fracture of neck of femur:A community based study from southern India. J Family Med Prim Care 2013;2:270–3.
                      49. Gravier AL, Shamieh O, Paiva CE, Perez-Cruz PE, Muckaden MA, Park M, et al. Meaning in life in patients with advanced cancer:A multinational study. Support Care Cancer 2020;28:3927–34.
                      50. Ratnani IJ, Panchal BN, Tiwari DS, Vala AU. Association of panic disorder with quality of life among individuals with headache. East Asian Arch Psychiatry 2014;24:10–5.
                      51. Srivastava S, Shekhar S, Bhatia MS, Dwivedi S. Quality of life in patients with coronary artery disease and panic disorder:A comparative study. Oman Med J 2017;32:20–6.
                      52. Jacob J, Palat G, Verghese N, Kumari P, Rapelli V, Kumari S, et al. Health-related quality of life and its socio-economic and cultural predictors among advanced cancer patients:Evidence from the APPROACH cross-sectional survey in Hyderabad-India. BMC Palliat Care 2019;18:94.
                      53. Kandasamy A, Chaturvedi SK, Desai G. Spirituality, distress, depression, anxiety, and quality of life in patients with advanced cancer. Indian J Cancer 2011;48:55–9.
                      54. Gurumoorthi R, Manojkumar S, Mehta P, Patil V, Ray S, Das G, et al. The art of history taking in patient with pain:An ignored but very important component in making diagnosis. Indian J Pain 2013;27:59–66.
                      55. Ahmed S, Aggarwal A, Lawrence A. Performance of the American College of Rheumatology 2016 criteria for fibromyalgia in a referral care setting. Rheumatol Int 2019;39:1397–403.
                      56. Bansal D, Gudala K, Lavudiya S, Ghai B, Arora P. Translation, adaptation, and validation of Hindi version of the pain catastrophizing scale in patients with chronic low back pain for use in India. Pain Med 2016;17:1848–58.
                      57. Ganesan S, Thulasingam M, Gunaseelan K, Kalaiarasi R, Penumadu P, Ravichandran S, et al. Validity and reliability of Tamil translated University of Washington quality of life questionnaire for head and neck cancers. Asian Pac J Cancer Prev 2019;20:3649–54.
                        58. Tripathy S, Hansda U, Seth N, Rath S, Rao PB, Mishra TS, et al. Validation of the EuroQol Five-dimensions-Three-level quality of life instrument in a classical Indian language (Odia) and its use to assess quality of life and health status of cancer patients in eastern India. Indian J Palliat Care 2015;21:282–8.
                        59. Hui D, Park M, Shamieh O, Paiva CE, Perez-Cruz PE, Muckaden MA, et al. Personalized symptom goals and response in patients with advanced cancer. Cancer 2016;122:1774–81.
                        60. Bhatnagar S, Banerjee D, Joshi S, Gupta R. Assessing psychosocial distress:A pain audit at IRCH-AIIMS. Ann Palliat Med 2013;2:76–84.
                        61. Chatterjee A, Thota RS, Ramanjulu R, Ahmed A, Bhattacharya D, Salins N, et al. The Indian Society for Study of Pain, Cancer Pain Special Interest Group (SIG) guidelines, for the diagnosis and assessment of cancer pain. Indian J Pain 2019;33:1–10.
                        62. Singh S, Singh K, Gupta R, Kaur N, Bansal P, Singh S. Correlation of quality of life scores to clinical outcome of lumbar epidural steroids in chronic low back pain. Anesth Essays Res 2016;10:574–9.
                        63. Grover S, Kate N. Somatic symptoms in consultation-liaison psychiatry. Int Rev Psychiatry 2013;25:52–64.
                        64. Upadhyaya HP, Arnold LM, Alaka K, Qiao M, Williams D, Mehta R. Efficacy and safety of duloxetine versus placebo in adolescents with juvenile fibromyalgia:Results from a randomized controlled trial. Pediatr Rheumatol Online J 2019;17:27.
                        65. Kalita J, Chandra S, Misra UK. Pregabalin and lamotrigine in central poststroke pain:A pilot study. Neurol India 2017;65:506–11.
                        66. Syngle A, Verma I, Krishan P, Garg N, Syngle V. Minocycline improves peripheral and autonomic neuropathy in type 2 diabetes:MIND study. Neurol Sci 2014;35:1067–73.
                        67. Gupta P, Singh V, Sethi S, Kumar A. A comparative pilot study to evaluate the adjunctive role of levosulpride with trigger point injection therapy in the management of myofascial pain syndrome of orofacial region. J Maxillofac Oral Surg 2014;13:599–602.
                        68. Gupta P, Singh V, Sethi S, Kumar A. A comparative study of trigger point therapy with local anaesthetic (0.5 % bupivacaine) versus combined trigger point injection therapy and levosulpiride in the management of myofascial pain syndrome in the orofacial region. J Maxillofac Oral Surg 2016;15:376–83.
                          69. Mattoo B, Tanwar S, Bhatia R, Tripathi M, Bhatia R. Repetitive transcranial magnetic stimulation in chronic tension-type headache:A pilot study. Indian J Med Res 2019;150:73–80.
                          70. Agarwal SK, Munjal M, Koul R, Agarwal R. Prospective evaluation of the quality of life of oral tongue cancer patients before and after the treatment. Ann Palliat Med 2014;3:238–43.
                            71. Nambi G, Kamal W, Es S, Joshi S, Trivedi P. Spinal manipulation plus laser therapy versus laser therapy alone in the treatment of chronic non-specific low back pain:A randomized controlled study. Eur J Phys Rehabil Med 2018;54:880–9.
                              72. Tarfarosh SF, Lone BU, Beigh MI, Manzoor M. An innovative and portable multimodal pain relief device for the management of neuropathic low back pain-A study from Kashmir (Southeast Asia). Cureus 2016;8:e661.
                              73. Krishnaswamy P, Nair S. Effect of music therapy on pain and anxiety levels of cancer patients:A pilot study. Indian J Palliat Care 2016;22:307–11.
                              74. Sharma V, Pandya P, Kumar R, Gupta G. Evaluation of hypnotherapy in pain management of cancer patients:A clinical trial from India. Indian J Pain 2017;31:100–6.
                                75. Tavhare SD, Acharya R, Reddy RG, Dhiman KS. Management of chronic pain with Jalaprakshalana (water-wash) Shodhita (processed) Bhanga (Cannabis sativa L.) in cancer patients with deprived quality of life:An open-label single arm clinical trial. Ayu 2019;40:34–43.
                                76. Sharma P, Mehta M, Sagar R. Efficacy of transdiagnostic cognitive-behavioral group therapy for anxiety disorders and headache in adolescents. J Anxiety Disord 2017;46:78–84.
                                77. Ebnezar J, Nagarathna R, Yogitha B, Nagendra HR. Effect of integrated yoga therapy on pain, morning stiffness and anxiety in osteoarthritis of the knee joint:A randomized control study. Int J Yoga 2012;5:28–36.
                                78. Tekur P, Nagarathna R, Chametcha S, Hankey A, Nagendra HR. A comprehensive yoga programs improves pain, anxiety and depression in chronic low back pain patients more than exercise:An RCT. Complement Ther Med 2012;20:107–18.
                                  79. Telles S, Bhardwaj AK, Gupta RK, Sharma SK, Monro R, Balkrishna A. A randomized controlled trial to assess pain and magnetic resonance imaging-based (MRI-based) structural spine changes in low back pain patients after yoga practice. Med Sci Monit 2016;22:3228–47.
                                  80. Haldavnekar RV, Tekur P, Nagarathna R, Nagendra HR. Effect of yogic colon cleansing (Laghu Sankhaprakshalana Kriya) on pain, spinal flexibility, disability and state anxiety in chronic low back pain. Int J Yoga 2014;7:111–9.
                                    81. Wieland LS, Skoetz N, Pilkington K, Vempati R, D'Adamo CR, Berman BM. Yoga treatment for chronic non-specific low back pain. Cochrane Database Syst Rev 2017;1:CD010671.
                                    82. Sendhilkumar R, Gupta A, Nagarathna R, Taly AB. Effect of pranayama and meditation as an add-on therapy in rehabilitation of patients with Guillain-Barrésyndrome –A randomized control pilot study. Disabil Rehabil 2013;35:57–62.
                                    83. Khan AA, Srivastava A, Passi D, Devi M, Chandra L, Atri M. Management of myofascial pain dysfunction syndrome with meditation and yoga:Healing through natural therapy. Natl J Maxillofac Surg 2018;9:155–9.
                                      84. Kaur G, Prakash G, Malhotra P, Ghai S, Kaur S, Singh M, et al. Home-based yoga program for the patients suffering from malignant lymphoma during chemotherapy:A feasibility study. Int J Yoga 2018;11:249–54.
                                      85. Kalra S, Priya G, Grewal E, Aye TT, Waraich BK, SweLatt T, et al. Diabetes management and the buddhist philosophy:Toward holistic care. Indian J Endocrinol Metab 2018;22:806–11.
                                      86. Panta P. The possible role of meditation in myofascial pain syndrome:A new hypothesis. Indian J Palliat Care 2017;23:180–7.
                                      87. Deodhar JK, Noronha V, Muckaden MA, Atreya S, Joshi A, Tandon SP, et al. Astudy to assess the feasibility of introducing early palliative care in ambulatory patients with advanced lung cancer. Indian J Palliat Care 2017;23:261–7.
                                      88. Gupta N, Garg R, Kumar V, Bharati SJ, Mishra S, Bhatnagar S. Palliative care for patients with nonmalignant respiratory disease. Indian J Palliat Care 2017;23:341–6.
                                      89. Dureja GP, Iyer RN, Das G, Ahdal J, Narang P. Evidence and consensus recommendations for the pharmacological management of pain in India. J Pain Res 2017;10:709–36.
                                      90. Ahmed A, Thota RS, Bhatnagar S, Jain P, Ramanjulu R, Salins N, et al. The Indian Society for Study of Pain, Cancer Pain Special Interest Group Guidelines on Complementary Therapies for Cancer Pain. Indian J Pain 2019;33:S37–41.
                                      91. Salins N, Thota RS, Bhatnagar S, Ramanjulu R, Ahmed A, Jain P, et al. The Indian Society for Study of Pain, Cancer Pain Special Interest Group Guidelines on Palliative Care Aspects in Cancer Pain Management. Indian J Pain 2019;33:S49–53.
                                      92. Deshpande A. Prevalence of chronic pain based on primary health center data from a city in central India. Indian J Pain 2018;32:81–5.
                                      93. Dureja GP, Jain PN, Shetty N, Mandal SP, Prabhoo R, Joshi M, et al. Prevalence of chronic pain, impact on daily life, and treatment practices in India. Pain Pract 2014;14:E51–62.
                                      94. Saxena AK, Jain PN, Bhatnagar S. The prevalence of chronic pain among adults in India. Indian J Palliat Care 2018;24:472–7.
                                      95. Bair MJ, Robinson RL, Katon W, Kroenke K. Depression and pain comorbidity:A literature review. Arch Intern Med 2003;163:2433–45.
                                      96. Sheng J, Liu S, Wang Y, Cui R, Zhang X. The link between depression and chronic pain:Neural mechanisms in the Brain. Neural Plast 2017;2017:9724371.
                                      97. Li AL, Peng YB. Comorbidity of depression and pain:A review of shared contributing mechanisms. J Neurol Neuromed 2017;2:4–11.
                                      98. Desai G, Jaisoorya TS, Sunil Kumar G, Manoj L, Bajaj A, et al. Disentangling comorbidity in chronic pain:A study in primary health care settings from India. PLoS One 2020;15:e0242865.
                                      99. Ahangar AA, Hosseini SR, Kheirkhah F, Karimi M, Saadat P, Bijani A. Association between Chronic Pain and Depression among the Elderly of Amirkola City, Northern Iran. Elderly Health J 2017;3:74–9.
                                      100. Fillingim RB, King CD, Ribeiro-Dasilva MC, Rahim-Williams B, Riley JL 3rd. Sex, gender, and pain:A review of recent clinical and experimental findings. J Pain 2009;10:447–85.
                                      101. Greenspan JD, Craft RM, LeResche L, Arendt-Nielsen L, Berkley KJ, Fillingim RB, et al. Studying sex and gender differences in pain and analgesia:A consensus report. Pain 2007;132 Suppl 1 S26–45.
                                      102. Das B. An evaluation of low back pain among female brick field workers of West Bengal, India. Environ Health Prev Med 2015;20:360–8.
                                      103. Goswami S, Dasgupta S, Samanta A, Talukdar G, Chanda A, Ray Karmakar P, et al. Load handling and repetitive movements are associated with chronic low back pain among jute mill workers in India. Pain Res Treat 2016;2016:7843216.
                                        104. Inbaraj LR, Haebar OJ, Saj F, Dawson S, Paul P, Prabhakar AK, et al. Prevalence of musculoskeletal disorders among brick kiln workers in rural Southern India. Indian J Occup Environ Med 2013;17:71–5.
                                        105. Biglarian A, Seifi B, Bakhshi E, Mohammad K, Rahgozar M, Karimlou M, et al. Low back pain prevalence and associated factors in Iranian population:Findings from the national health survey. Pain Res Treat 2012;2012:653060.
                                        106. Ikeda T, Sugiyama K, Aida J, Tsuboya T, Watabiki N, Kondo K, et al. Socioeconomic inequalities in low back pain among older people:The JAGES cross-sectional study. Int J Equity Health 2019;18:15.
                                        107. Ahdhi GS, Subramanian R, Saya GK, Yamuna TV. Prevalence of low back pain and its relation to quality of life and disability among women in rural area of Puducherry, India. Indian J Pain 2016;30:111–5.
                                          108. Magni G, Caldieron C, Rigatti-Luchini S, Merskey H. Chronic musculoskeletal pain and depressive symptoms in the general population. An analysis of the 1st National Health and Nutrition Examination Survey Data. Pain 1990;43:299–307.
                                          109. Belfer I. Nature and nurture of human pain. Scientifica (Cairo) 2013;2013:415279.
                                          110. Nicholl BI, Smith DJ, Cullen B, Mackay D, Evans J, Anderson J, et al. Ethnic differences in the association between depression and chronic pain:Cross sectional results from UK Biobank. BMC Fam Pract 2015;16:128.
                                          111. Narasimhan M, Campbell N. A tale of two comorbidities:Understanding the neurobiology of depression and pain. Indian J Psychiatry 2010;52:127–30.
                                          112. Tsang A, Von Korff M, Lee S, Alonso J, Karam E, Angermeyer MC, et al. Common chronic pain conditions in developed and developing countries:Gender and age differences and comorbidity with depression-anxiety disorders. J Pain 2008;9:883–91.
                                          113. Bond M. Pain and its management in developing countries. Pain Manag 2011;1:3–5.
                                          114. Saini S, Bhatnagar S. Cancer pain management in developing countries. Indian J Palliat Care 2016;22:373–7.
                                          115. Indian Society for Study of Pain |Official Website 2020 Available from: http://www.issp-pain.org/ [Last accessed on 2020 Nov 10].
                                          116. Bhatnagar S, Patel A, Raja SN. Aspiring pain practitioners in India:Assessing challenges and building opportunities. Indian J Palliat Care 2018;24:93–7.
                                          117. Li Z, Aninditha T, Griene B, Francis J, Renato P, Serrie A, et al. Burden of cancer pain in developing countries:A narrative literature review. Clinicoecon Outcomes Res 2018;10:675–91.
                                          118. Reid CM, Gooberman-Hill R, Hanks GW. Opioid analgesics for cancer pain:Symptom control for the living or comfort for the dying?A qualitative study to investigate the factors influencing the decision to accept morphine for pain caused by cancer. Ann Oncol 2008;19:44–8.
                                          119. Dureja GP, Jain PN, Joshi M, Saxena A, Das G, Ahdal J, et al. Addressing the barriers related with opioid therapy for management of chronic pain in India. Pain Manag 2017;7:311–30.
                                          120. Bosnjak S, Maurer MA, Ryan KM, Leon MX, Madiye G. Improving the availability and accessibility of opioids for the treatment of pain:The International Pain Policy Fellowship. Support Care Cancer 2011;19:1239–47.
                                          121. Thapa D, Rastogi V, Ahuja V. Cancer pain management-current status. J Anaesthesiol Clin Pharmacol 2011;27:162–8.
                                          122. Wadhwa R, Chilkoti G, Saxena AK. Current clinical opinions, attitudes and awareness of interns regarding post-operative and cancer pain management in a tertiary care centre. Indian J Palliat Care 2015;21:49–55.
                                          123. Sagar R, Sarkar S. Psychiatry as a separate subject in the undergraduate medical curriculum:The need re-emphasized. J Ment Health Hum Behav 2016;21:88–90.
                                          124. Pant A The Hidden opioid Crisis:How the So-Called 'War on Drugs'Leaves Patients to die in Pain London, UK Health Poverty Action 2019.
                                          125. Khosla D, Patel FD, Sharma SC. Palliative care in India:Current progress and future needs. Indian J Palliat Care 2012;18:149–54.
                                          126. Doyle KE, El Nakib SK, Rajagopal MR, Babu S, Joshi G, Kumarasamy V, et al. Predictors and prevalence of pain and its management in four regional cancer hospitals in India. J Glob Oncol 2018;4:1–9.
                                          127. Attal N, Cruccu G, Baron R, Haanpää M, Hansson P, Jensen TS, et al. EFNS guidelines on the pharmacological treatment of neuropathic pain:2010 revision. Eur J Neurol 2010;17:1113–e88.
                                          128. Finnerup NB, Attal N, Haroutounian S, McNicol E, Baron R, Dworkin RH, et al. Pharmacotherapy for neuropathic pain in adults:A systematic review and meta-analysis. Lancet Neurol 2015;14:162–73.
                                          129. Verdu B, Decosterd I, Buclin T, Stiefel F, Berney A. Antidepressants for the treatment of chronic pain. Drugs 2008;68:2611–32.
                                          130. Wang Y, Bernanke J, Peterson BS, McGrath P, Stewart J, Chen Y, et al. The association between antidepressant treatment and brain connectivity in two double-blind, placebo-controlled clinical trials:A treatment mechanism study. Lancet Psychiatry 2019;6:667–74.
                                          131. Kothari K, Tilvawala K. Pain and psychology:Do we need to change the way we treat patient?Indian J Pain 2018;32:1–3.
                                          132. Suri K, Pandey M. Effect of Jacobson Progressive Muscle Relaxation (JPMR) on psychopathological problems in chronic non-malignant pain patients. Indian J Health Well Being 2018;9:630–3.
                                          133. Cramer H, Lauche R, Langhorst J, Dobos G. Are Indian yoga trials more likely to be positive than those from other countries?A systematic review of randomized controlled trials. Contemp Clin Trials 2015;41:269–72.

                                          Cancer pain; chronic pain; epidemiology; neuropathic pain; psychiatric comorbidities; treatment guidelines

                                          Copyright: © 2023 Indian Journal of Pain