Urgent need for more research and focus on treating pain in people with severe mental illness, new evidence review shows

A review in PAIN, the official journal of the International Association for the Study of Pain (IASP), highlights significant ongoing challenges in the assessment, reporting, and treatment of pain in people with severe mental illness (SMI).

People with severe mental illness have poorer physical health, shorter life spans, and experience increased likelihood of health problems that carry a high burden of pain compared to the general population. Yet “pain is not routinely assessed and managed in this population and pain communication and assessment might be obscured by the nature of the severe mental illness,” according to Whitney Scott, Ph.D., Kings College London, in a topical review of the literature published in PAIN. The review focuses specifically on major depression, bipolar disorder, and psychosis, and highlights potential methods to improve pain management in these populations.

Involving people with lived experience of both severe mental illness and pain is essential to improving treatment.

According to many studies, pain prevalence is higher in people with severe mental illness compared to those in healthy populations. In people with depression, the mean pain prevalence is 65%; in bipolar disorder, 29%, double that of healthy people. In people with schizophrenia, pain prevalence is similar to healthy control groups. Given the high burden of ordinarily painful health conditions in people with schizophrenia, this might suggest under-reporting or under-recognition of pain in this group. Yet current understanding of the effects of existing pain management treatments in people with severe mental illness are incomplete, as they are often excluded from clinical trials.

Although pharmacological therapies are often an important part of treatment for people with severe mental illness, medications to treat severe mental illness can adversely interact with pain medication. Both pain and severe mental illness are associated with low physical activity, and though studies do indicate the promise of exercise in improving overall physical and mental health, the data remains unclear as to its specific effects on pain in people with severe mental illness. Psychological treatments like cognitive-behavioral therapy (CBT) are also commonly used to manage the impact of pain on a person’s quality of life. However, 60% of clinical trials of such treatments for pain reviewed in one study excluded people with severe mental illness. Such exclusions also happen in clinical practice, often due to the perceived “complex mental health needs” of this population.

Yet there are opportunities to more fully integrate pain care and severe mental illness care, including innovations in treatment. As family and caregiver support are associated with reduced hospitalization and identification of poor health in people with severe mental illness, their involvement is integral to advancing research on pain and severe mental illness. Pain assessment in people with severe mental illness is often lacking and mental health stigma may contribute to clinicians underestimating the pain experience of people with severe mental illness.

To mitigate this stigma, Scott and her co-authors suggest service planning and funding to increase access to more integrated and inclusive treatments. They also suggest the potential benefits of clinical role-plays developed with people with lived experience “to improve clinicians’ communication with people with pain and severe mental illness so interactions are empathic and respectful.” Psychological treatments may also support people to manage the impact of mental health and pain stigma, although this needs to occur alongside wider changes in health systems and society to reduce stigma toward people with pain and severe mental illness.

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