Anxiety and depression in fibromyalgia

In a recent study in Pakistan, 61% of patients with fibromyalgia had moderate-to-severe anxiety and 57% had moderate-to-severe depression

What is fibromyalgia?

Fibromyalgia is a musculoskeletal condition characterized by chronic widespread pain and a wide array of common, but not necessarily universal, secondary symptoms including sleep disturbances, morning stiffness, fatigue, irritable bowel syndrome, psychiatric conditions such as anxiety and depression, and cognitive impairment.2

The underlying aetiology of the disease is not completely understood.2 The disease typically manifests in the form of alterations in the pain processing areas of the central nervous system. It is hypothesized that these alterations are caused by an interplay between various mechanisms including genetic predisposition, stressful life events, inflammatory mechanisms in the body periphery, and mechanisms of the central nervous system such as cognitive and emotional, which create a dysperception of pain, also known as nociplastic pain.2

Epidemiology of fibromyalgia

Fibromyalgia is a prevalent disease, affecting about 2–3% of the population worldwide, with a prevalence range of 0.7% to 9.3% depending on the diagnostic criteria used.2 In Asian countries such as Hong Kong and Japan, the prevalence was reported to be 0.8% and 2.1%, respectively.

Fibromyalgia predominantly affects women; the estimated female to male ratio is about 3:1.3 The prevalence of the disease typically increases with age for both men and women, peaking around middle age. Among women aged 55–64 years, the prevalence of fibromyalgia was reported to be almost 8% whereas, in middle-aged males, it was about 2.5%.3

Real-world evidence on anxiety and depression in fibromyalgia

Lifetime psychiatric disorders have been commonly reported in patients with fibromyalgia, worldwide. The lifetime prevalence of depression in patients with fibromyalgia ranges between 40%−80% depending on the diagnostic criteria used.4 Anxiety disorders could be present in up to 32% of fibromyalgia cases.4 A Brazilian study reported a higher severity of depressive symptoms and a greater perception of stress in patients with fibromyalgia compared with those without the disease; the former group also reported a significantly higher incidence of depressive symptoms (75% versus 25%).4 In this study, positive correlations were observed between the severity of depressive symptoms and perceived stress, pain, impaired functionality, and reduced quality of life.

A recent cross-sectional survey of 502 patients in a rheumatology outpatient clinic of a tertiary care hospital in Pakistan, evaluated the levels of anxiety and depression and the overall quality of life in patients suffering from fibromyalgia and chronic pain.1 The study showed that among patients suffering from fibromyalgia, nearly 61% had moderate-to-severe anxiety versus 7% among healthy controls and 26% among patients with chronic pain, as measured by the Hospital Anxiety and Depression scale (HADS).

A significantly greater number of patients with fibromyalgia also presented with moderate-to-severe depression versus healthy controls and chronic pain (57% versus 10% and 30%), as measured by the HADS.1 Notably, patients who were suffering from chronic pain and high levels of anxiety and depression were reported to be at a higher risk of developing fibromyalgia.

Management approaches to consider

The link between depression and fibromyalgia has long been established.Fibromyalgia patients tend to have higher levels of stress, often overexaggerating otherwise mild stressful events. This heightened and constant state of stress may lead to dysfunction in the patients’ central stress response system (i.e. the hypothalamic pituitary adrenal axis), leaving them susceptible to depressive events and pain enhancement. Depression may interfere with the patients’ perception of their physical health.6 As such, fibromyalgia patients who suffer from depression and anxiety, usually have more physical symptoms, impaired functioning, and poorer quality of life than those who do not have these psychiatric disorders.7

Due to the varied presentation of symptoms mentioned so far, fibromyalgia is often considered a complex condition that is difficult to diagnose and treat.5 In addition to managing the pain symptoms, it is vital that clinicians address the psychiatric symptoms, amongst others, to achieve optimum long-term clinical outcomes. International guidelines underscore the importance of early diagnosis and a graduated treatment approach informed by shared decision-making activities between the patient and clinician.8-10 The initial management plan should include patient education and non-pharmacological strategies such as aerobic exercise, cognitive behavioral therapy and multicomponent therapy. In case of non-response, it is recommended that a multidisciplinary, step-wise, combination approach be employed, which is tailored to the case at hand based on the nature and intensity of symptoms.8-10 This approach may include psychological therapies for mood disturbances and ineffective coping strategies, pharmacotherapies for pain and sleep disturbances, and in the case of severe disabilities, a multimodal rehabilitation program.


  1. style='color:black;mso-ansi-language:EN-SG'> style='mso-spacerun:yes'> ADDIN EN.REFLIST field-separator'>1.    Muhammad JS, Ishaq M. Increased risk of anxiety and depression associated with chronic pain and fibromyalgia in Pakistani population. Biomed Res 2019; 4: 1-5.

    2.    Sarzi-Puttini P, Giorgi V, Marotto D, Atzeni F. Fibromyalgia: an update on clinical characteristics, aetiopathogenesis and treatment. Nature Reviews Rheumatology 2020; 16(11): 645-60.

    3.    White KP, Speechley M, Harth M, Ostbye T. The London Fibromyalgia Epidemiology Study: the prevalence of fibromyalgia syndrome in London, Ontario. J Rheumatol 1999; 26(7): 1570-6.

    4.    Homann D, Stefanello JM, Góes SM, Breda CA, Paiva Edos S, Leite N. Stress perception and depressive symptoms: functionality and impact on the quality of life of women with fibromyalgia. Rev Bras Reumatol 2012; 52(3): 319-30.

    5.    Arnold LM. Management of fibromyalgia and comorbid psychiatric disorders. J Clin Psychiatry 2008; 69 Suppl 2: 14-9.

    6.    Jensen KB, Petzke F, Carville S, et al. Anxiety and depressive symptoms in fibromyalgia are related to poor perception of health but not to pain sensitivity or cerebral processing of pain. Arthritis Rheum 2010; 62(11): 3488-95.

    7.    White KP, Nielson WR, Harth M, Ostbye T, Speechley M. Chronic widespread musculoskeletal pain with or without fibromyalgia: psychological distress in a representative community adult sample. The Journal of Rheumatology 2002; 29(3): 588-94.

    8.    Ablin J, Fitzcharles MA, Buskila D, Shir Y, Sommer C, Häuser W. Treatment of fibromyalgia syndrome: recommendations of recent evidence-based interdisciplinary guidelines with special emphasis on complementary and alternative therapies. Evid Based Complement Alternat Med 2013; 2013: 485272.

    9.    Goldenberg DL, Burckhardt C, Crofford L. Management of fibromyalgia syndrome. Jama 2004; 292(19): 2388-95.

    10.  Macfarlane GJ, Kronisch C, Dean LE, et al. EULAR revised recommendations for the management of fibromyalgia. Annals of the Rheumatic Diseases 2017; 76(2): 318-28.