She has had back pain for three years. The MRI report lists disc degeneration at two levels, which the previous doctor circled in pen. She has tried physiotherapy twice, stopped both times, and now sleeps about four hours a night. Nobody has asked her about the sleep.

This is one of the most common presentations in any musculoskeletal clinic, and one of the most commonly half-treated, which is why platforms like Marham see psychiatric consultations booked years after the pain started. The structural side of the problem gets imaged, injected and sometimes operated on. The other side, the part that decides whether the patient improves, rarely gets written down.

How often do pain and mood travel together?

About four times out of ten, which is higher than most clinicians estimate. A 2025 systematic review and meta-analysis in JAMA Network Open pooled 376 studies from 50 countries, covering 347,468 adults living with chronic pain.

Clinically significant depressive symptoms were present in 39.3% of them, and anxiety symptoms in 40.2%. Diagnosed major depressive disorder was present in 36.7%. The rates were not uniform. Among people with fibromyalgia, depression reached 54.0% and anxiety 55.5%, while among people with osteoarthritis the figures were 29.1% and 17.5%.

Women, younger patients, and people with nociplastic pain, meaning pain that arises from altered pain processing rather than tissue damage, carried the highest rates. That last group is precisely the group whose scans come back looking unremarkable.

Why the scan answers a different question

Imaging tells you what a spine looks like. It does not tell you what hurts. Those two things separate more often than patients are ever told.

A systematic review in the American Journal of Neuroradiology pooled imaging findings from 3,110 people with no symptoms at all. Disc degeneration was present in 37% of asymptomatic 20 year olds and 96% of asymptomatic 80 year olds. Disc bulges ran from 30% to 84% across the same age span. The authors concluded that many degenerative features are part of normal ageing and are not associated with pain.

Set that beside the scale of the problem. GBD 2021 data published in The Lancet Rheumatology put low back pain at 619 million people globally in 2020, the leading cause of years lived with disability, with a projected 843 million cases by 2050.

So the most common musculoskeletal complaint in the world is one where the scan frequently shows changes that healthy people also have. Handing that report to a patient without explanation does not reassure them. It gives them a diagnosis they cannot unsee.

The headache that arrives with the neck

The overlap extends past mood. Patients who come in for neck pain often mention headache as an afterthought, and the two get managed as separate complaints by separate people.

Migraine is not a rare comorbidity to work around. A GBD 2021 analysis in The Journal of Headache and Pain estimated 593.8 million prevalent cases among people aged 15 to 39 in 2021, a rise of 39.5% since 1990. Prevalence peaked in the 35 to 39 age group and was consistently higher among women. That is the same demographic band that fills most chronic neck pain clinics.

The practical consequence shows up in treatment plans. A patient whose headaches are migrainous will get limited benefit from months of cervical traction and postural correction, however reasonable those look on paper. A patient whose headache is driven by the upper cervical spine will not improve on preventive medication alone. Both of them will be told the treatment failed.

Distinguishing cervicogenic headache from migraine with neck symptoms is genuinely difficult, and getting it wrong sends patients through months of the wrong treatment. Where the pattern is unclear, assessment by a neurologist for persistent migraine is more productive than another round of cervical imaging.

Why patients in Pakistan rarely get both problems treated

The overlap is not controversial in the literature. It is just difficult to act on in a system built around single complaints. A few reasons come up repeatedly.

• 
  There are almost no specialists to refer to: WHO Global Health Observatory data records about 0.4 psychiatrists per 100,000 people in Pakistan. A 2025 paper in Frontiers in Health Services put the figure at 0.19 per 100,000 and estimated that around 24 million Pakistanis need mental health services.
• 
  Mental health is funded as an afterthought: That same paper notes mental health receives roughly 0.4% of the national health budget. Pain clinics with an integrated psychological service barely exist outside a handful of tertiary centres.
• 
  Raising mood feels like dismissal: When a doctor asks about stress, many patients hear that their pain is being called imaginary. Unless that is addressed directly, the question closes the conversation instead of opening it.
• 
  Stigma is heavier than the symptom: Families worry about what a psychiatric referral means for marriage prospects and employment. Patients often accept a stronger painkiller instead.
• 
  Sleep never gets measured: Sleep loss amplifies pain and worsens mood, and it is the single most treatable thread in the knot. It also takes thirty seconds to ask about, which is why its absence from the notes is so striking.

What changes when both problems are treated

Treating mood and sleep alongside the musculoskeletal problem does not replace the physical side of care. It makes the physical side more likely to work.

Patients who sleep badly and feel hopeless do not complete exercise programmes. They attend fewer physiotherapy sessions, return sooner for repeat imaging, and ask for stronger drugs. None of that is a character flaw. It is what untreated depression does to any treatment plan that requires effort over months.

The language patients use is a clue worth listening for. “I can’t do anything anymore” is a different statement from “my back hurts when I lift”. The first describes a life narrowing around the pain, and it predicts a slower recovery than anything visible on a scan. It usually arrives late in a consultation, after the clinical questions are finished, which is exactly when most appointments have run out of time.

Access has improved faster than most clinicians realise. Video consultation now makes a first psychiatric assessment possible without a waiting room, a queue, or a relative asking where the patient has gone. Verified platforms let patients consult a psychiatrist through a scheduled video call, usually the same day, with fees listed before booking. For patients who have spent years being told their scan is fine, that privacy is often what makes the first appointment happen.

Five things worth adding to a musculoskeletal consultation

None of these need extra equipment or a longer clinic slot. Most take under two minutes.

• 
  Screen, briefly and routinely: Two questions about mood and two about anxiety identify most patients who need a fuller assessment. Validated short tools exist for exactly this purpose, and the score belongs in the notes.
• 
  Ask about sleep before asking about pain scores: Hours slept, times woken, and how the morning feels. It gives you a treatable target and often explains a stalled recovery.
• 
  Explain the scan out loud: Telling a patient that disc changes appear in most people their age, and showing them the numbers, undoes a good deal of damage done by an unexplained report.
• 
  Name nociplastic pain when it fits: Patients cope better with a mechanism they can understand than with the implication that nothing is wrong.
• 
  Refer without apology: Framing a psychological referral as standard practice for long-standing pain, rather than as a last resort, changes how it is received.

Signs that need attention sooner rather than later

Some findings in a patient with long-standing musculoskeletal pain should not wait for the next routine review:

• 
  New weakness, numbness in the saddle area, or loss of bladder or bowel control
• 
  Unexplained weight loss, fever, or night sweats with back pain
• 
  Pain that is worse at night and not relieved by position changes
• 
  A first episode of severe back pain after the age of 50, or after significant trauma
• 
  Escalating use of painkillers, alcohol, or sedatives to get through the day
• 
  Thoughts of self-harm or of ending one’s life

Important: If a patient expresses thoughts of self-harm, treat it as urgent. Pakistan’s Umang helpline (0311-7786264) offers crisis support, and emergency care can be reached through Rescue 1122.

A realistic way forward

Musculoskeletal medicine has spent two decades getting better at imaging and worse at listening. The data now sits squarely against that trade. Roughly four in ten people with chronic pain carry clinically significant depression or anxiety, and the imaging findings used to explain their pain show up in healthy people at similar rates.

That is not an argument for imaging less. It is an argument for interpreting it out loud, with the patient, and then asking the questions the scan cannot answer.

The patient with three years of back pain and four hours of sleep does not need a third MRI. She needs someone to ask about the sleep, explain the second one, and treat both halves of what is actually wrong.

This article is for educational purposes and is not a substitute for medical advice. Assessment and treatment decisions should be made with a qualified healthcare provider.

Sources

1. Aaron RV, Ravyts SG, Carnahan ND, et al. (2025). Prevalence of Depression and Anxiety Among Adults With Chronic Pain: A Systematic Review and Meta-Analysis. JAMA Network Open. https://pubmed.ncbi.nlm.nih.gov/40053352/

2. Brinjikji W, Luetmer PH, Comstock B, et al. (2015). Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR American Journal of Neuroradiology. https://pubmed.ncbi.nlm.nih.gov/25430861/

3. GBD 2021 Low Back Pain Collaborators. (2023). Global, regional, and national burden of low back pain, 1990-2020, and projections to 2050. The Lancet Rheumatology. https://pubmed.ncbi.nlm.nih.gov/37273833/

4. Chen ZF, Kong XM, Yang CH, et al. (2024). Global, regional, and national burden and trends of migraine among youths and young adults aged 15-39 years from 1990 to 2021. The Journal of Headache and Pain. https://link.springer.com/article/10.1186/s10194-024-01832-0

5. World Health Organization. Global Health Observatory: psychiatrists working in the mental health sector (per 100,000 population). https://www.who.int/data/gho/data/indicators/indicator-details/GHO/psychiatrists-working-in-mental-health-sector-(per-100-000)

6. Thompson AM, Saleem SM. (2025). Closing the mental health gap: transforming Pakistan’s mental health services. Frontiers in Health Services. https://www.frontiersin.org/journals/health-services/articles/10.3389/frhs.2024.1471528/full

Author Bio

Farwa Hassan is the Web Acquisition Lead at Marham.pk. A homeopath pursuing further studies in psychology, she creates health content that helps patients across Pakistan find reliable information and the right doctors. Reach her at farwa.hassan@marham.pk

or on LinkedIn.

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