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

“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).

[..] 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.

[..] 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.

[..] 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.

[..] The economic and social changes they [Anne Case and Angus Deaton] 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.”

Full editorial, Cutler D. JAMA Health Forum 2020.10.29