New research reveals that mental health struggles begin years before chronic pain emerges, highlighting the urgent need for early support to protect vulnerable older adults.

Study: Trajectories of loneliness, social isolation, and depressive symptoms before and after onset of pain in middle-aged and older adults. Image Credit: Jorm Sangsorn / Shutterstock

In a recent article published in the journal eClinicalMedicine, researchers studied how depressive symptoms, social isolation, and loneliness changed before and after middle-aged and older adults in England began experiencing pain. Their findings indicate that people often experienced worse depressive symptoms and loneliness before pain onset, which generally increased further afterwards, with depression worsening sharply at the time pain began and remaining elevated afterwards.

Background

Moderate or severe pain, which can become chronic, affects up to 40% of adults living in Europe and the United Kingdom and is a leading cause of disability. Because of its wide-ranging impacts on well-being, such pain is best understood through biopsychosocial models, which consider psychological and social factors along with biological ones.

Loneliness, defined as a subjective lack of social connection, social isolation, defined as an objective lack of contact, and depression, are all associated with pain. Studies have shown that loneliness and depression can both contribute to and result from pain that becomes chronic, while findings on social isolation appear less consistent. These psychosocial factors are also linked, creating complex, potentially bidirectional relationships that affect individuals’ well-being.

Despite this, prior studies, whether cross-sectional or longitudinal, have not examined how social isolation, loneliness, and depression change in the years before and after the onset of pain. Understanding these trajectories, particularly how they differ by age, sex, education, and wealth, is important for designing effective and timely prevention and management strategies. This is especially relevant for older adults, who are more likely to experience pain, depression, social isolation, and loneliness.

About the study

This study used data from the English Longitudinal Study of Ageing (ELSA), a nationally representative cohort study. Data collection started in 2002 and followed adults aged 50 and above living in England until 2021–2023. Participants without pain at baseline and with at least two data points were included.

Pain status was assessed biennially based on self-reports of being “often troubled with pain” and experiencing moderate or severe pain. Psychosocial outcomes, namely depressive symptoms, loneliness, and social isolation, were measured using validated scales.

Participants who reported pain during follow-up were categorized into the “pain group” and matched to a comparison group of pain-free individuals using coarsened exact matching. Matching criteria included age, sex, birth cohort, and education level. The analysis adjusted for other baseline variables (including health conditions and lifestyle behaviors). The authors note that due to exclusions during matching and for missing data, the final analyzed sample may not be fully nationally representative, potentially impacting generalisability.

The study used statistical models to examine changes in psychosocial outcomes before and after the onset of pain. Each participant’s timeline was centered around the age of first reported pain (or matched median age in controls), creating pre- and post-onset periods. Models included interaction terms to compare trajectories between pain and no-pain groups. They were adjusted for key covariates, including wealth, physical activity, smoking, alcohol use, and the coronavirus disease 2019 (COVID-19) pandemic. Subgroup analyses were conducted to explore differences by wealth, education, age, and sex.

Key findings

This study analyzed data from 7,336 matched participants aged 50 and older, comparing 3,668 individuals who reported pain with the remaining who did not.

At baseline, the pain and no-pain groups were demographically similar but differed in health and socioeconomic status: the pain group was less wealthy, less physically active, and had higher rates of chronic conditions and depression.

Over time, loneliness scores were consistently higher in the pain group. Eight years before the onset of pain, they already had higher loneliness scores (0.19 points higher). While the severity of loneliness increased in the pain group leading up to pain onset, the difference in trajectories between the groups only reached statistical significance after pain onset. The difference in scores increased to 0.33 points eight years after pain onset. The odds of high loneliness were 1.68 times higher at pain onset and 1.61 times higher eight years later.

In contrast, social isolation scores showed minimal differences between groups across the study period. Depressive symptoms were higher in the pain group, even before onset (0.14 points higher eight years prior), and the trajectory showed scores increased sharply before pain onset. At onset, depressive symptom scores were 0.58 points higher, and odds of depression were 2.33 times greater. These differences persisted eight years after pain onset, with odds 2.21 times greater.

Demographic analysis showed that disparities in symptoms of depression were more pronounced among those younger than 65 at pain onset, less educated, and lower-income individuals. Still, such patterns were less evident for loneliness and social isolation.

Conclusions

This study highlights strong longitudinal associations between pain and both depressive symptoms and loneliness, with effects beginning years before the onset of pain and persisting thereafter. Social isolation, however, remained relatively unaffected. The amplified depressive impact in socioeconomically disadvantaged groups suggests that pain may exacerbate existing mental health disparities. The findings underscore the need for early psychological intervention, as depressive symptoms increased years before pain onset, and suggest that interventions might prioritise enhancing perceived social support and connection for individuals with pain, rather than solely increasing social interaction.

Strengths include the large sample from a nationally-representative cohort, longitudinal design, and use of validated scales over an extended follow-up period, allowing for matched comparisons and adjustment for multiple covariates. Limitations involve reliance on self-reported measures, potential misclassification of pain onset (as the study could not definitively distinguish chronic pain from other types of pain based on ELSA’s assessment, though sensitivity analyses for longer-term pain were consistent), and the inability to assess causal direction or account for all aspects of pain severity beyond moderate/severe categorisation.

In conclusion, persistent pain is closely linked with elevated loneliness and depression in older adults, especially in socioeconomically disadvantaged groups. Interventions addressing pain should integrate mental health support, including proactive strategies and targeted support for vulnerable populations, to mitigate long-term psychosocial consequences. Future research should explore mechanisms linking pain and mental health so that targeted intervention strategies can be tested.