Prevalence, severity, and determinants of depressive disorder among patients with low back pain in Al-Qassim Region, Saudi Arabia

Prevalence, severity, and determinants of depressive disorder among patients with low back pain in Al-Qassim Region, Saudi Arabia | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Prevalence, severity, and determinants of depressive disorder among patients with low back pain in Al-Qassim Region, Saudi Arabia Abdullah Naif This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4702923/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Background: Low back pain (LBP) is a widespread health problem that poses a severe economic burden on both affected patients and their societies. A bidirectional relationship between depression and other chronic illnesses, including chronic LBP, has been suggested. However, the exact association between them remains unclear. Objectives: To investigate the association between depressive disorder and low back pain and its impact on disability of patients. Patients and methods: A cross-sectional study carried out in the orthopedic clinics of AlBadaya General Hospital, Qassim Region, Saudi Arabia, among a sample of patients with LBP throughout the period of the study (April-June 2024,). An interview questionnaire composed of four parts was utilized: personal information, medical history, and habits, the Arabic-validated version of the Roland-Morris Disability Questionnaire (RMDQ), and the Patient Health Questionnaire (PHQ)-9 to assess depression. Results: A total of 365 patients were included in this study. Their age ranged between 18 and 85 years, with an arithmetic mean of 47.9 and a standard deviation (SD) of 10.4 years. Females represented 55.6% of them. The overall prevalence of depressive disorder among the participants was 56.2%, being mild in 40.3% of patients and moderately severe or severe among 2.7% of them. The disability score ranged between 0 and 24 with an arithmetic mean of 10.7 and SD of 6.2, while its median 1 value was 11, and its interquartile range was 6-15.5. Patients with moderately severe/severe depression had the highest disability score (median value was 15 and the mean rank was 243.25), while those with no depression had the lowest disability score (median value was seven and mean rank was 130.62), p<0.001. Multivariate logistic regression analysis revealed that with each unit increase in disability score, there was a 20% increase in depression (Adjusted odds ratio "AOR" =1.20; 95% confidence interval "CI": 1.14-1.26), p<0.001. Conclusion: Depression is very commonly associated with chronic LBP, although it is mostly mild. Disability is a serious complication of chronic LBP, and its severity is associated with the degree of depression. Therefore, patients with chronic LBP should be screened for depression. Low back pain Disability Depression Prevalence determinants Figures Figure 1 Figure 2 Figure 3 Introduction Low back pain (LBP) is a widespread health problem as it affects approximately 80% of people throughout their lifetime. [ 1 ]Moreover, Stubbs et al. (2016) reported that the global point prevalence of lower back pain was 9.4%, which was the number one cause of disability among 291 conditions.[ 2 ] LBP has a severe economic burden on both affected patients and their societies.[ 3 – 6 ] Furthermore, according to the Global Burden of Disease Study (2013), LBP was one of the main reasons for years lived with disability (YLDs).[ 7 ] On a global level, the prevalence of LBP among the adult general population was greater in high-income than low-income countries (30% versus 18.2%) and in females compared to males.[ 8 ] In the Kingdom of Saudi Arabia (KSA), the prevalence/incidence of LBP has been investigated only within specific occupational groups rather than the general population. A recently published systematic review revealed a prevalence ranging from 64–89% among different occupational groups in KSA.[ 9 ] Studies have shown that chronic LBP, as a stress condition, often leads to depression [ 10 – 12 ] and, in the majority of cases, a severe form of depression.[ 13 , 14 ] Furthermore, it has been documented that patients suffering from chronic LBP associated with depression exhibit a worse prognosis than their counterparts.[ 15 ] A bidirectional relationship between depressive disorder and chronic illnesses, including chronic LBP, has been suggested by Katon et al. (2010).[ 16 ] However, the exact association between chronic LBP and depression remains unclear, which represents a great problem in managing the status. However, recent studies have suggested considerable overlap between chronic pain and depression-induced neurobiological as well as neuroplasticity changes, which are essential to enhancing the development of chronic LBP-induced depression.[ 17 ] The present study aims to explore the possible association between depression and low back pain and its impact on disability of patients. Patients and methods A cross-sectional study was carried out in the orthopedic clinics of AlBadaya General Hospital, which belongs to the Ministry of Health in the Qassim Region, Saudi Arabia. It is located at the heart of the country and has a population of 1,336,179, according to the 2022 estimated census.[ 18 ] All patients who attended orthopedic outpatient clinics in the hospital with LBP throughout the period of the study (April-June 2024) were eligible for inclusion in the study, provided that they fulfilled the inclusion criteria, which are an age range between 30 and 60 years and had acute or chronic low back pain. Patients with complex orthopedic complaints were excluded from the study. Using Roasoft online sample size calculator, the sample size calculated on the assumption that the estimated total population of patients with LBP who visit the orthopedic outpatient clinic of the hospital in three months is approximately 450, the prevalence of depression among patients with LBP as 16.5% (according to a study conducted in Japan),[ 19 ] 95% confidence interval and 5% acceptable errors, the minimum required sample was 145 patients. A systematic random sampling technique adopted to recruit patients with clinically confirmed diagnoses of LBP, according to the total number of eligible patients visiting the clinic daily till we have reached the required sample size. An interview questionnaire was utilized in this study. It consists of four parts: personal information (age, gender, educational level, marital status, working status), medical history and habits (smoking, history of other chronic illnesses, family history of mental illness, duration of low back pain, nature of the LBP, presence of associated somatic symptoms, cause of LBP and treatment of LBP), the Arabic validated version[ 20 ] of Roland-Morris Disability Questionnaire (RMDQ),[ 21 , 22 ] which is a tool consists of 24 items to assess disability caused by LBP while the greater levels of disability are indicated by higher numbers of statements marked by the patients on the scale with 0 means no disability while 24 means severe disability, [ 22 ] and Patient Health Questionnaire (PHQ)-9 which was used to assess depression among the patients. It can be completed in a few minutes and rapidly scored by the researcher.[ 23 ] Liu et al. [ 24 ] reported that the PHQ-9 had an excellent internal consistency (α = .80) and test-retest reliability (intra-class correlation coefficient = 0.87). The PHQ-9 has nine questions with scores ranging from 0 to 3 for each one. The validated Arabic version will be utilized in this study.[ 25 ] The provisional diagnoses for scoring classes were as follows: scores 0–4 indicate no depression, 5–9 indicate mild depression, 10–14 indicate moderate depression, 15–19 indicate moderately severe depression, and 20–27 indicate severe depression. [ 26 ] The researcher visited the involved hospital after getting approval from the Ministry of Health and the hospital director. Interviews with all patients were conducted by the researcher and trained medical assistants (male and female) to collect data. Permissions to use the Arabic versions of PHQ-9 and RMDQ questionnaires were requested from the corresponding authors through an e-mail communication. Individual informed consents were taken from all participants, and the local research and ethical committee in Qassim obtained approval of the study's proposal. The data were collected and verified by hand and coded before the computerized data entry. Statistical Package for Social Sciences (SPSS) program version 28.0 was used for data entry and analysis. The test of normality of disability score was done using the Shapiro-Wilk test. Descriptive statistics (e.g., number, mean, range, percentage, median, standard deviation (SD), and interquartile range) and analytic statistics using the Kruskal-Wallis non-parametric test were applied. Multiple regression analysis used to determine the significant predictors of depression after controlling for confounders among patients with LBP, and p-values ≤ 0.05 were considered statistically significant. Results A total number of 365 patients were included in the study. The socio-demographic data are summarized in Table 1. Their age ranged between 18 and 85 years, with an arithmetic mean of 47.9 and SD of 10.4 years. Females represented 55.6% of them. Almost two-thirds (64.4%) were Bachelor holders, and 41.7% were government employees. The prevalence of current smoking was 8.2%. History of other chronic diseases and family history of mental illness were observed among 31.5% and 6.6% of patients, respectively. The duration of LBP exceeded five years for more than a third of patients (35.6%). LBP was intermittent among the majority of patients (90.1%). It was associated with somatic symptoms in 37.5% of patients. The main cause of LBP was strains and sprains (62%). The main line of treatment was medications (775), followed by physical therapy (44.1%). Table 2 The overall prevalence of depressive disorder among the participants was 56.2%, mild in 40.3% of patients, and moderately severe or severe among 2.7% of them (Figure 1). The difficulty of depression-related problems that patients experienced at work, at home, and dealing with others was described as very/extremely difficult by 4.6% of patients. Figure 2 Disability caused by LBP was assessed using the RMDQ. It was abnormally distributed, as evidenced by a significant Shapiro-Wilk test. The score ranged between 0 and 24 with an arithmetic mean of 10.7 and standard deviation of 6.2, while its median 1 value was 11 and its interquartile range was 6-15.5. Figure 3 Patients with moderately severe/severe depression had the highest disability score (median value was 15 and the mean rank was 243.25), while those with no depression had the lowest disability score (median value was 7 and mean rank was 130.62), p<0.001. Table 3 With each year's increase in LBP patients` age, there was a 5% reduction in depression (Adjusted odds ratio "AOR" =0.95; 95% confidence interval "CI": 0.92-0.97), p<0.001. Compared to the lowest educated patients (secondary school/intermediate Diploma/ below), postgraduates were at a significantly lower risk for depression (AOR=0.29; 95% CI: 0.11-0.75), p=0.010. Patients with a history of other chronic illnesses were at almost double risk for depression compared to those with such a history (AOR=2.04; 95% CI: 1.15-3.63), p=0.015. Those with a family history of mental illness were at significantly higher risk for depression compared to their peers (AOR=3.79; 95% CI: 1.13-12.71), p=0.031. Considering LBP duration of less than one year as a reference category, patients with more than five years duration were at borderline significantly higher risk for depression (AOR=1.94; 95% CI: 1.00-3.79), p=0.051. Patients with associated somatic symptoms were at significantly higher risk for depressive disorder compared to their counterparts (AOR=1.72; 95% CI: 1.01-2.93), p=0.046. With each one unit increase in disability score, there was a 20% increase in depression (Adjusted odds ratio "AOR" =1.20; 95% confidence interval "CI": 1.14-1.26), p<0.001. Patients` gender, smoking history, working status, nature of LBP, LBP causes, and LBP treatment were not significantly associated with depression after controlling for confounding effects. Table 4 Discussion A significant part of the literature addressed and emphasized a connection and interlinkage between depression and pain symptoms.[ 27 ] This indicates that the cases often accompany each other and exaggerate one another as they share the same biological neurotransmitter pathways.[ 28 ] Furthermore, according to a review article, studies have shown that pain prevalence rates in depressed patients are considered high, with an average of 65%. Likewise, depression was present in 5–85% of patients suffering from pain conditions, and the prevalence of pain in the depressed sample and the prevalence of depressive disorder in the pain sample are higher than prevalence rates when the conditions are individually examined.[ 29 ] The present study revealed an overall prevalence of depression among the patients with LBP as 56.2%; however, the rate of mild depression was 40.3%, and that of moderately severe/severe depression was 2.7%. Almost the same has been reported in Japan among patients with chronic back pain.[ 19 ] Hartvigsen et al. (2018) mentioned that the existence of depressive symptoms in patients with LBP could worsen the disease and increase the rate of associated disability. [ 30 ]On the other hand, Demyttenaere et al. (2007) reported that LBP patients were more likely than their peers to meet the criteria for major depressive episodes.[ 31 ] Shaw et al. (2016) reported that depression is commonly associated with low back pain, even when symptoms are of short duration and not severe from a medical point of view.[ 32 ] In accordance with the aforementioned findings, the present study confirmed the association between disability induced by LBP and the severity of depression among those patients. Furthermore, after controlling for the confounders in multivariate logistic regression analysis, the increase in the rate of depression with an increase in the disability score was sustained. Moreover, studies indicated that the coexistence of depression with low back pain was associated with the deterioration of a patient's quality of life and increased risk of disease chronicity.[ 33 , 34 ] Therefore, it is recommended by the International Association for Study of Pain (2021) to associate psychological processes in the treatments of chronic back pain.[ 35 ] Also, studies showed that depression is associated with hormonal and neural processes; through them, depressive disorder usually worsens the pain over time and increases the disability caused by it. [ 36 – 38 ] Therefore, treating depression could help improvement of back pain. [ 39 ] Two important limitations of the present study should be addressed. First, a single-center study could impact the ability to generalize findings over other centers. Therefore, a multi-centric study is recommended to overcome this limitation in the future. Second, because of the study's cross-sectional nature, the temporal relationship between depression and LBP cannot be ascertained. Therefore, a longitudinal study is needed to explore better the nature of the relationship between depression and LBP. Despite those limitations, the study is unique in its nature in our region and, up to our knowledge, in the whole Kingdom of Saudi Arabia, and it is one of the few studies carried out on an international level to assess the association between depression and chronic low back pain. In addition, valid tools were utilized to assess both depression and disability caused by LBP. Conclusion Depression is very commonly associated with chronic LBP, although it is mostly mild. Disability is a serious complication of chronic LBP, and its severity is associated with the degree of depression. Therefore, patients with chronic LBP should be screened for depression. Furthermore, antidepressants should be considered in the treatment of LBP comorbid with depression, together with other treatment modalities. Further, a larger multi-centric study is warranted to explore this problem comprehensively in our community, where LBP is a common health problem. Abbreviations LBP Low Back Pain KSA Kingdom of Saudi Arabia RMDQ Roland-Morris Disability Questionnaire PHQ Patient Health Questionnaire SD Standard Deviation CI Confidence Interval AOR Adjusted Odds Ratio YLDs Years Lived with Disability SPSS Statistical Package for Social Sciences Declarations Ethical approval and consent to participate: The local research and ethical committee in Qassim approved the study protocol. Informed consents were taken from each participant to take part in the study. Consent for publication: Not required. Competing interests: The author declares that there are no conflicts of interest. Funding: The study did not receive grants or funding from government, private, or commercial sources. Acknowledgments: The author would like to thank all of patients who participated in this study. Author Contribution It is single author References Casiano VE, De NK. Back Pain. InStatPearls [Internet] 2019 Feb 24. StatPearls Publishing. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538173/. [Last accessed 21.1.2020] Stubbs B, Koyanagi A, Thompson T, Veronese N, Carvalho A, Solomi M et al. The epidemiology of low back pain and its relationship with depressive disorder, psychosis, anxiety, sleep disturbances, and stress sensitivity: Data from 43 low- and middleincome countries. General Hospital Psychiatry 2016; 43:63-70. Thelin A, Holmberg S, Thelin N. Functioning in neck and back pain from a 12-year perspective: a prospective population-based study. J Rehabil Med. 2008; 40(7):555-61. Dutmer AL, Henrica RP, Remko S, Sandra B, Ute B, Dijkstra PU, et al. 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Tables Table 1: Socio-demographic characteristics of patients (n=365) Frequency Percentage Gender Male Female 162 203 44.4 55.6 Age (years) Range Mean±SD 18-85 47.9±10.4 Educational level Secondary school/intermediate Diploma/ below Bachelor`s degree Postgraduate 91 235 39 24.9 64.4 10.7 Working status Unemployed/housewife Governmental employee Private sector employee Student Retired Others 91 152 30 5 87 24.9 41.7 8.2 1.4 23.8 Smoking status Never smoke Current smoker Ex-smoker 312 30 23 85.5 8.2 6.3 SD: Standard deviation Table 2: Low back pain-related and medical history of the patients (n=365) Frequency Percentage History of other chronic illnesses No Yes 250 115 68.5 31.5 Family history of mental illness No Yes 341 24 93.4 6.6 Duration of low back pain in years 3-5 >5 89 83 63 130 24.4 22.7 17.3 35.6 Nature of the LBP Intermittent Chronic 329 36 90.1 9.9 Is there associated somatic symptoms with LBP No Yes 228 137 62.5 37.5 Cause of LBP Strains and sprains Fractures/accidents Disk problems Structural problems Arthritis Spondylolisthesis Diseases such as Spine tumors, infections, kidney stones and abdominal aortic aneurysm 226 7 46 10 35 34 7 62.0 1.9 12.6 2.7 9.6 9.3 1.9 Treatment of LBP* Medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) muscle relaxants. Physical therapy Steroid injections Surgery 281 161 22 9 77.0 44.1 6.0 2.5 *Not mutually exclusive (sum exceeded 100%) Table 3: Association between depression`s severity and disability score among patients with low back pain Disability score (0-24) Depression No N=160 Mild N=147 Moderate N=48 Moderately severe/severe N=10 Median 7 13 14.5 15 IQR 3.25-11 8-17 10.25-19.75 6.75-21.50 Mean rank 130.62 215.82 244.53 243.25 p-value of Kruskal-Wallis test<0.001 Table 4: Predictors of depression among patients with low back pain: Multivariate logistic regression analysis Variables B SE AOR 95% CI p-value Age (years) -0.053 0.014 0.95 0.92-0.97 <0.001 Educational level Secondary school/intermediate Diploma/ below a Bachelor`s degree Postgraduate -0.458 -1.247 0.307 0.487 1.0 0.63 0.29 0.35-1.15 0.11-0.75 0.136 0.010 History of other chronic illnesses No a Yes 0.715 0.293 1.0 2.04 1.15-3.63 0.015 Family history of mental illness No a Yes 1.333 0.617 1.0 3.79 1.13-12.71 0.031 Duration of low back pain in years 3-5 >5 -0.115 0.336 0.665 0.336 0.399 0.341 1.0 0.89 1.44 1.94 0.46-1.72 0.66-3.15 1.00-3.79 0.752 0.358 0.051 Associated somatic symptoms with LBP No a Yes 0.542 0.272 1.0 1.72 1.01-2.93 0.046 Disability core 0.184 0.025 1.20 1.14-1.26 <0.001 B: Slop SE: Standard error AOR: Adjusted odds ratio CI: Confidence interval a : Reference category LBP: Low back pain Terms of gender, smoking, working status, nature of LBP, LBP causes, and LBP treatment were not included in the final logistic regression model (not significant) Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 11 Jul, 2024 Editor assigned by journal 09 Jul, 2024 Submission checks completed at journal 09 Jul, 2024 First submitted to journal 08 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4702923","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":325638763,"identity":"ad2be5de-5298-4c94-941a-fe1e9e4d1da6","order_by":0,"name":"Abdullah Naif","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA90lEQVRIiWNgGAWjYHACxgNAIoENyHgA5h8gQg9MC7MBaVqAmE2CKC3mDMwPDv5sq83jY+99VvG2jUGO70YC84cfeLRYNrAZHOZtO17MxnPc7ObcNgZjyRsJbJI9eLQYHGAwOMzYdiyxTSKN7TZvG0PiBqAWBh68Wtg/AB0G1CL/jK0YqKUeqIX54x+8WngMDvC21QBtYWNjBmpJMLiRwCCN15bDPAWHec4dSGzjSWOWnHNOwnDmmYdt0jL4tBxv3/jwR1ld4vz2Y4wf3pTZyPMdTz788Q0eLQzMYPIwhMPDAIoaxgZ8GmCgDqZlFIyCUTAKRgEmAACi30+GKn2M3AAAAABJRU5ErkJggg==","orcid":"","institution":"Qassim University","correspondingAuthor":true,"prefix":"","firstName":"Abdullah","middleName":"","lastName":"Naif","suffix":""}],"badges":[],"createdAt":"2024-07-08 06:00:34","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4702923/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4702923/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":62154109,"identity":"a3816fe7-4f29-462a-a73d-46ef4df1d261","added_by":"auto","created_at":"2024-08-09 20:56:26","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":20353,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePrevalence of depression and its severity among patients with low back pain\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4702923/v1/430d831f887cb6751ef71e25.png"},{"id":62154107,"identity":"078ae1f7-2c14-4804-9f84-9531293444a0","added_by":"auto","created_at":"2024-08-09 20:56:26","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":25026,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDegree of difficulty of depression-related problems that patients experienced at work, home and dealing with others\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4702923/v1/2c4758de6f3e22cf25bbd428.png"},{"id":62155232,"identity":"dec08ec0-ba5e-411e-b2cd-b4349bf6ca52","added_by":"auto","created_at":"2024-08-09 21:04:26","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":41523,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDistribution of total disability score, according to Roland-Morris Disability Questionnaire among patients with low back pain\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4702923/v1/754383b72c067ab4d74003af.png"},{"id":62156848,"identity":"114d4137-4d37-4472-a8b4-3e607ddfdc7d","added_by":"auto","created_at":"2024-08-09 21:12:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":801718,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4702923/v1/f08b1894-0080-4bd8-be51-623810c9c24e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Prevalence, severity, and determinants of depressive disorder among patients with low back pain in Al-Qassim Region, Saudi Arabia","fulltext":[{"header":"Introduction","content":"\u003cp\u003eLow back pain (LBP) is a widespread health problem as it affects approximately 80% of people throughout their lifetime. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]Moreover, Stubbs et al. (2016) reported that the global point prevalence of lower back pain was 9.4%, which was the number one cause of disability among 291 conditions.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eLBP has a severe economic burden on both affected patients and their societies.[\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] Furthermore, according to the Global Burden of Disease Study (2013), LBP was one of the main reasons for years lived with disability (YLDs).[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] On a global level, the prevalence of LBP among the adult general population was greater in high-income than low-income countries (30% versus 18.2%) and in females compared to males.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] In the Kingdom of Saudi Arabia (KSA), the prevalence/incidence of LBP has been investigated only within specific occupational groups rather than the general population. A recently published systematic review revealed a prevalence ranging from 64\u0026ndash;89% among different occupational groups in KSA.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] Studies have shown that chronic LBP, as a stress condition, often leads to depression [\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] and, in the majority of cases, a severe form of depression.[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] Furthermore, it has been documented that patients suffering from chronic LBP associated with depression exhibit a worse prognosis than their counterparts.[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] A bidirectional relationship between depressive disorder and chronic illnesses, including chronic LBP, has been suggested by Katon et al. (2010).[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] However, the exact association between chronic LBP and depression remains unclear, which represents a great problem in managing the status. However, recent studies have suggested considerable overlap between chronic pain and depression-induced neurobiological as well as neuroplasticity changes, which are essential to enhancing the development of chronic LBP-induced depression.[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] The present study aims to explore the possible association between depression and low back pain and its impact on disability of patients.\u003c/p\u003e"},{"header":"Patients and methods","content":"\u003cp\u003eA cross-sectional study was carried out in the orthopedic clinics of AlBadaya General Hospital, which belongs to the Ministry of Health in the Qassim Region, Saudi Arabia. It is located at the heart of the country and has a population of 1,336,179, according to the 2022 estimated census.[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] All patients who attended orthopedic outpatient clinics in the hospital with LBP throughout the period of the study (April-June 2024) were eligible for inclusion in the study, provided that they fulfilled the inclusion criteria, which are an age range between 30 and 60 years and had acute or chronic low back pain. Patients with complex orthopedic complaints were excluded from the study. Using Roasoft online sample size calculator, the sample size calculated on the assumption that the estimated total population of patients with LBP who visit the orthopedic outpatient clinic of the hospital in three months is approximately 450, the prevalence of depression among patients with LBP as 16.5% (according to a study conducted in Japan),[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] 95% confidence interval and 5% acceptable errors, the minimum required sample was 145 patients.\u003c/p\u003e \u003cp\u003e A systematic random sampling technique adopted to recruit patients with clinically confirmed diagnoses of LBP, according to the total number of eligible patients visiting the clinic daily till we have reached the required sample size.\u003c/p\u003e \u003cp\u003eAn interview questionnaire was utilized in this study. It consists of four parts: personal information (age, gender, educational level, marital status, working status), medical history and habits (smoking, history of other chronic illnesses, family history of mental illness, duration of low back pain, nature of the LBP, presence of associated somatic symptoms, cause of LBP and treatment of LBP), the Arabic validated version[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] of Roland-Morris Disability Questionnaire (RMDQ),[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] which is a tool consists of 24 items to assess disability caused by LBP while the greater levels of disability are indicated by higher numbers of statements marked by the patients on the scale with 0 means no disability while 24 means severe disability, [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] and Patient Health Questionnaire (PHQ)-9 which was used to assess depression among the patients. It can be completed in a few minutes and rapidly scored by the researcher.[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] Liu et al. [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] reported that the PHQ-9 had an excellent internal consistency (α\u0026thinsp;=\u0026thinsp;.80) and test-retest reliability (intra-class correlation coefficient\u0026thinsp;=\u0026thinsp;0.87).\u003c/p\u003e \u003cp\u003eThe PHQ-9 has nine questions with scores ranging from 0 to 3 for each one. The validated Arabic version will be utilized in this study.[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] The provisional diagnoses for scoring classes were as follows: scores 0\u0026ndash;4 indicate no depression, 5\u0026ndash;9 indicate mild depression, 10\u0026ndash;14 indicate moderate depression, 15\u0026ndash;19 indicate moderately severe depression, and 20\u0026ndash;27 indicate severe depression. [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThe researcher visited the involved hospital after getting approval from the Ministry of Health and the hospital director. Interviews with all patients were conducted by the researcher and trained medical assistants (male and female) to collect data.\u003c/p\u003e \u003cp\u003ePermissions to use the Arabic versions of PHQ-9 and RMDQ questionnaires were requested from the corresponding authors through an e-mail communication. Individual informed consents were taken from all participants, and the local research and ethical committee in Qassim obtained approval of the study's proposal.\u003c/p\u003e \u003cp\u003eThe data were collected and verified by hand and coded before the computerized data entry. Statistical Package for Social Sciences (SPSS) program version 28.0 was used for data entry and analysis. The test of normality of disability score was done using the Shapiro-Wilk test. Descriptive statistics (e.g., number, mean, range, percentage, median, standard deviation (SD), and interquartile range) and analytic statistics using the Kruskal-Wallis non-parametric test were applied. Multiple regression analysis used to determine the significant predictors of depression after controlling for confounders among patients with LBP, and p-values\u0026thinsp;\u0026le;\u0026thinsp;0.05 were considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total number of 365 patients were included in the study. The socio-demographic data are summarized in Table 1. Their age ranged between 18 and 85 years, with an arithmetic mean of 47.9 and SD of 10.4 years. Females represented 55.6% of them. Almost two-thirds (64.4%) were Bachelor holders, and 41.7% were government employees. The prevalence of current smoking was 8.2%.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHistory of other chronic diseases and family history of mental illness were observed among 31.5% and 6.6% of patients, respectively. The duration of LBP exceeded five years for more than a third of patients (35.6%). LBP was intermittent among the majority of patients (90.1%). It was associated with somatic symptoms in 37.5% of patients. The main cause of LBP was strains and sprains (62%). The main line of treatment was medications (775), followed by physical therapy (44.1%). Table 2\u003c/p\u003e\n\u003cp\u003eThe overall prevalence of depressive disorder among the participants was 56.2%, mild in 40.3% of patients, and moderately severe or severe among 2.7% of them (Figure 1). The difficulty of depression-related problems that patients experienced at work, at home, and dealing with others was described as very/extremely difficult by 4.6% of patients. Figure 2\u003c/p\u003e\n\u003cp\u003eDisability caused by LBP was assessed using the RMDQ. It was abnormally distributed, as evidenced by a significant Shapiro-Wilk test. The score ranged between 0 and 24 with an arithmetic mean of 10.7 and standard deviation of 6.2, while its median 1 value was 11 and its interquartile range was 6-15.5. Figure 3\u003c/p\u003e\n\u003cp\u003ePatients with moderately severe/severe depression had the highest disability score (median value was 15 and the mean rank was 243.25), while those with no depression had the lowest disability score (median value was 7 and mean rank was 130.62), p\u0026lt;0.001. Table 3\u003c/p\u003e\n\u003cp\u003eWith each year\u0026apos;s increase in LBP patients` age, there was a 5% reduction in depression (Adjusted odds ratio \u0026quot;AOR\u0026quot; =0.95; 95% confidence interval \u0026quot;CI\u0026quot;: 0.92-0.97), p\u0026lt;0.001. Compared to the lowest educated patients (secondary school/intermediate Diploma/ below), postgraduates were at a significantly lower risk for depression (AOR=0.29; 95% CI: 0.11-0.75), p=0.010. Patients with a history of other chronic illnesses were at almost double risk for depression compared to those with such a history (AOR=2.04; 95% CI: 1.15-3.63), p=0.015. Those with a family history of mental illness were at significantly higher risk for depression compared to their peers (AOR=3.79; 95% CI: 1.13-12.71), p=0.031. Considering LBP duration of less than one year as a reference category, patients with more than five years duration were at borderline significantly higher risk for depression (AOR=1.94; 95% CI: 1.00-3.79), p=0.051. Patients with associated somatic symptoms were at significantly higher risk for depressive disorder compared to their counterparts (AOR=1.72; 95% CI: 1.01-2.93), p=0.046. With each one unit increase in disability score, there was a 20% increase in depression (Adjusted odds ratio \u0026quot;AOR\u0026quot; =1.20; 95% confidence interval \u0026quot;CI\u0026quot;: 1.14-1.26), p\u0026lt;0.001. Patients` gender, smoking history, working status, nature of LBP, LBP causes, and LBP treatment were not significantly associated with depression after controlling for confounding effects. Table 4\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eA significant part of the literature addressed and emphasized a connection and interlinkage between depression and pain symptoms.[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] This indicates that the cases often accompany each other and exaggerate one another as they share the same biological neurotransmitter pathways.[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] Furthermore, according to a review article, studies have shown that pain prevalence rates in depressed patients are considered high, with an average of 65%. Likewise, depression was present in 5\u0026ndash;85% of patients suffering from pain conditions, and the prevalence of pain in the depressed sample and the prevalence of depressive disorder in the pain sample are higher than prevalence rates when the conditions are individually examined.[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThe present study revealed an overall prevalence of depression among the patients with LBP as 56.2%; however, the rate of mild depression was 40.3%, and that of moderately severe/severe depression was 2.7%. Almost the same has been reported in Japan among patients with chronic back pain.[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eHartvigsen et al. (2018) mentioned that the existence of depressive symptoms in patients with LBP could worsen the disease and increase the rate of associated disability. [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]On the other hand, Demyttenaere et al. (2007) reported that LBP patients were more likely than their peers to meet the criteria for major depressive episodes.[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] Shaw et al. (2016) reported that depression is commonly associated with low back pain, even when symptoms are of short duration and not severe from a medical point of view.[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eIn accordance with the aforementioned findings, the present study confirmed the association between disability induced by LBP and the severity of depression among those patients. Furthermore, after controlling for the confounders in multivariate logistic regression analysis, the increase in the rate of depression with an increase in the disability score was sustained.\u003c/p\u003e \u003cp\u003eMoreover, studies indicated that the coexistence of depression with low back pain was associated with the deterioration of a patient's quality of life and increased risk of disease chronicity.[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] Therefore, it is recommended by the International Association for Study of Pain (2021) to associate psychological processes in the treatments of chronic back pain.[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eAlso, studies showed that depression is associated with hormonal and neural processes; through them, depressive disorder usually worsens the pain over time and increases the disability caused by it. [\u003cspan additionalcitationids=\"CR37\" citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] Therefore, treating depression could help improvement of back pain. [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eTwo important limitations of the present study should be addressed. First, a single-center study could impact the ability to generalize findings over other centers. Therefore, a multi-centric study is recommended to overcome this limitation in the future. Second, because of the study's cross-sectional nature, the temporal relationship between depression and LBP cannot be ascertained. Therefore, a longitudinal study is needed to explore better the nature of the relationship between depression and LBP. Despite those limitations, the study is unique in its nature in our region and, up to our knowledge, in the whole Kingdom of Saudi Arabia, and it is one of the few studies carried out on an international level to assess the association between depression and chronic low back pain. In addition, valid tools were utilized to assess both depression and disability caused by LBP.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eDepression is very commonly associated with chronic LBP, although it is mostly mild. Disability is a serious complication of chronic LBP, and its severity is associated with the degree of depression. Therefore, patients with chronic LBP should be screened for depression. Furthermore, antidepressants should be considered in the treatment of LBP comorbid with depression, together with other treatment modalities. Further, a larger multi-centric study is warranted to explore this problem comprehensively in our community, where LBP is a common health problem.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLBP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLow Back Pain\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eKSA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eKingdom of Saudi Arabia\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRMDQ\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRoland-Morris Disability Questionnaire\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePHQ\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePatient Health Questionnaire\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStandard Deviation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eConfidence Interval\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAOR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAdjusted Odds Ratio\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eYLDs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eYears Lived with Disability\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSPSS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStatistical Package for Social Sciences\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe local research and ethical committee in Qassim approved the study protocol. Informed consents were taken from each participant to take part in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot required.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author declares that there are no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study did not receive grants or funding from government, private, or commercial sources.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author would like to thank all of patients who participated in this study.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eIt is single author\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eCasiano VE, De NK. Back Pain. InStatPearls [Internet] 2019 Feb 24. StatPearls Publishing. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538173/. [Last accessed 21.1.2020] \u003c/li\u003e\n\u003cli\u003eStubbs B, Koyanagi A, Thompson T, Veronese N, Carvalho A, Solomi M et al. The epidemiology of low back pain and its relationship with depressive disorder, psychosis, anxiety, sleep disturbances, and stress sensitivity: Data from 43 low- and middleincome countries. General Hospital Psychiatry 2016; 43:63-70. \u003c/li\u003e\n\u003cli\u003eThelin A, Holmberg S, Thelin N. Functioning in neck and back pain from a 12-year perspective: a prospective population-based study. J Rehabil Med. 2008; 40(7):555-61.\u003c/li\u003e\n\u003cli\u003eDutmer AL, Henrica RP, Remko S, Sandra B, Ute B, Dijkstra PU, et al. Personal and ssocietal impact of low back pain: The Groningen Spine Cohort SPINE 2019 Dec;44(24): E1443-E1451. DOI: 10.1097/BRS.0000000000003174\u003c/li\u003e\n\u003cli\u003eSteenstra IA, Verbeek JH, Heymans MW, Bongers PM. Prognostic factors for durations of sick leave in patients sick listed with low back pain: a systematic review of the literature. Occup Environ Med. 2005; 62(12):851-60.\u003c/li\u003e\n\u003cli\u003eFatoye F, Gebrye T, Mbada CE, Useh U. Clinical and economic burden of back pain in low and middle income countries: a systematic review. BMJ Open. 2023; 13(4): e064119. doi: 10.1136/bmjopen-2022-064119\u003c/li\u003e\n\u003cli\u003eVos T, Barber RM, Bell B, Bertozzi-Villa A, Biryukov S, Bolliger I, et al. Global, and national prevalence, and years lived with disability for 301 diseases and injuries in 188 countries, 1990-2013: a systematic analysis for Global Burden of Disease Study 2013. Lancet. 2015; 386(9995):743\u0026ndash;800.\u003c/li\u003e\n\u003cli\u003eMaher C, Underwood M, Buchbinder R. Non-specific back pain. Lancet. 2017;389:736-47. doi: 10.1016/S0140-6736(16)30970-9.\u003c/li\u003e\n\u003cli\u003eAldera MA, Alexander CM, McGregor AH. Prevalence and incidence of low back pain in Kingdom of Saudi Arabia: A systematic review. J Epidemiol Glob Healt. 2020 Dec;10(4):269-275. doi: 10.2991/jegh.k.200417.001.\u003c/li\u003e\n\u003cli\u003evon Knorring L, Perris C, Eisemann M, Eriksson U, Perris H. Pain as a symptom in depression. II. Relationship to the personality traits as assessed by means of KSP. Pain. 1983; 17(4):377\u0026ndash;384. doi:10.1016/0304-3959(83)90169-0\u003c/li\u003e\n\u003cli\u003eLee P, Zhang M, Hong JP, Chua H-C, Chen K-P, Tang SW, et al. Frequency of painful physical symptoms with depression in Asia: relationship with the disease severity and quality of life. J Clin Psychiatry. 2009; 70(1):83\u0026ndash;91. doi: 10.4088/JCP.08m04114.\u003c/li\u003e\n\u003cli\u003eAguera-Ortiz L, Failde I, Mico JA, Cervilla J, Lopez-Ibor JJ. Pain as a symptom of depressive disorder: prevalence and clinical correlations in patients attending psychiatric clinics. Journal of Affective Disorders. 2011;130(1-2):106\u0026ndash;112. doi: 10.1016/j.jad.2010.10.022.\u003c/li\u003e\n\u003cli\u003eBair MJ, Robinson RL, Katon W, Kroenke K. Depressive disorder and pain comorbidity: a literature review. Archives of Internal Medicine. 2003; 163(20):2433\u0026ndash;2445. doi: 10.1001/archinte.163.20.2433.\u003c/li\u003e\n\u003cli\u003eWilliams LS, Jones WJ, Shen J, Robinson RL, Weinberger M, Kroenke K. Prevalence and impact of depressive disorder and pain in neurology outpatients. Journal of Neurology, Neurosurgery, and Psychiatry. 2003;74(11):1587-1589. doi: 10.1136/jnnp.74.11.1587.\u003c/li\u003e\n\u003cli\u003eFishbain DA, Cutler R, Rosomoff HL, Rosomoff RS. Chronic pain-associated depressive disorder: antecedent or consequence of chronic pain. A review. The Clinical Journal of Pain. 1997; 13(2):116\u0026ndash;137. doi: 10.1097/00002508-199706000-00006.\u003c/li\u003e\n\u003cli\u003eKaton W, Lin E, Von Korff M, Ciechanowski P, Ludman E, Young B et al. Collaborative Care for Patients with depressive disorder and Chronic Illnesses. New England Journal of Medicine. 2010; 363(27):2611-2620\u003c/li\u003e\n\u003cli\u003eSheng J, Liu S, Wang Y, Cui R, Zhang X. The Link between depressive disorder and chronic pain: Neural mechanisms in brain. Neural Plast. 2017; 2017: 9724371. 10.1155/2017/9724371\u003c/li\u003e\n\u003cli\u003eWikipedia. Qassim Province, Saudi Arabia. Available at: https://en.wikipedia.org/wiki/Al-Qassim_Province. [last cited on 17 April 2024]\u003c/li\u003e\n\u003cli\u003eTsuji T, Matsudaira K, Sato H, Vietri J. The impact of depressive disorder among low back pain patients in Japan. BMC Musculoskeletal Disorders 2016; 17:447. DOI 10.1186/s12891-016-1304-4\u003c/li\u003e\n\u003cli\u003eAl-Abbad H, Al-Howimel A. Translation, adaptation, and reliability of Modern Standard Arabic Version of the Roland Morris Disability Questionnaire. J Nov Physiother 2015, 5(2): 1000254 http://dx.doi.org/10.4172/2165-7025.1000254\u003c/li\u003e\n\u003cli\u003eRoland MO, Morris RW. A study of natural history of back pain. Part 1: Development of reliable and sensitive measures of disability in low back pain. Spine 1983; 8: 141-144.\u003c/li\u003e\n\u003cli\u003eThe Roland-Morris Disability Questionnaire and the Oswestry Disability Questionnaire. Spine 2000; 25: 3115-3124.\u003c/li\u003e\n\u003cli\u003eBartlett JE, Kotrlik JW, Higgins CC. Organizational Research: Determining Appropriate Sample Size in Survey Researches. Information Technology, Learning, and Performance Journal 2001; 19(1):43-50.\u003c/li\u003e\n\u003cli\u003eLiu SI, Yeh ZT, Huang HC, Sun FJ, Tjung JJ, Hwang LC, Shih YH, Yeh AW. Validation of Patient Health Questionnaire for depressive disorder screening among primary care patients in Taiwan. Compr Psychiatry. 2011;52(1):96-101.\u003c/li\u003e\n\u003cli\u003eAlHadi AN, AlAteeq DA, Al-Sharif E, Bawazeer HM, Alanazi H, AlShomrani AT, et al. Arabic translation,validation and reliability of Patient Health Questionnaire in Saudi sample. Ann Gen Psychiatry. 2017; 16: 32. doi: 10.1186/s12991-017-0155-1\u003c/li\u003e\n\u003cli\u003eArroll B, Goodyear-Smith F, Crengle S, et al. Validation of PHQ-2 and PHQ-9 to screen for major depression in the primary care population. Ann Fam Med. 2010;8(4):348-53.\u003c/li\u003e\n\u003cli\u003eMeda RT, Nuguru SP, Rachakonda S, Sripathi S, Khan MI, Patel N. Chronic pain-induced depression: A review of prevalence and management. Cureus. 2022 Aug; 14(8): e28416. doi: 10.7759/cureus.28416\u003c/li\u003e\n\u003cli\u003eRobertson D, Kumbhare D, Nolet P, Srbely J, Newton G. Associations between low back pain and depressive disorder and somatization in a Canadian emerging adult population. J Can Chiropr Assoc. 2017 Aug; 61(2): 96-105.\u003c/li\u003e\n\u003cli\u003ePinheiro MB, Ferreira ML, Refshauge K, Maher CG, Ordonana JR, Andrade TB, Ferreira PH. Symptoms of depressive disorder as a prognostic factor for low back pain: a systematic review. Spine J. 2016; 16:105-116.\u003c/li\u003e\n\u003cli\u003eHartvigsen J, Hancock MJ, Kongsted A, Louw Q, et al. What low back pain is and why we need to pay attention. Lancet 2018; 391(10137):2356-2367.\u003c/li\u003e\n\u003cli\u003eDemyttenaere K, Bruffaerts R, Lee S, Posada-Villa J, et al. Mental disorders among persons with back or neck pain: results from World Mental Health Surveys. Pain 2007; 129(3):332-342.\u003c/li\u003e\n\u003cli\u003eBaumeister H, Hutter N, Bengel J, Harter M. Quality of life in medically ill patients with comorbid mental disorders: a systematic review and meta-analysis. Psychother Psychosom 2011; 80(5):275-286.\u003c/li\u003e\n\u003cli\u003ePincus T, Burton AK, Vogel S, Field AP. Systematic review of psychological factors as predictors of chronicity and disability in prospective cohorts of low back pain. Spine (Phila Pa 1976) 2002; 27(5):E109-120.\u003c/li\u003e\n\u003cli\u003eScott KM, Von Korff M, Alonso J, Angermeyer MC, Bromet E, Fayyad J, et al. Mental and physical comorbidity and their relationship with disability: results from the World Mental Health Surveys. Psychol Med 2009; 39(1):33-43. \u003c/li\u003e\n\u003cli\u003eInternational Association for the Study of pain. Psychology of back pain, fact sheest. Available at: https://www.iasp-pain.org/resources/fact-sheets/psychology-of-back-pain/. [Cited on 9 July, 2021]\u003c/li\u003e\n\u003cli\u003eHartvigsen J, Hancock MJ, Kongsted A, Louw Q, Ferreira ML, et al. Lancet Low Back Pain Series Working G. What low back pain is and why we need to pay attention. Lancet 2018;391(10137):2356-2367.\u003c/li\u003e\n\u003cli\u003eLee HI, H\u0026uuml;bscher M, Moseley GL, Kamper SJ, Traeger AC, et al. How does pain lead to disability? Systematic review and meta-analysis of mediation studies in patients with back and neck pain. Pain 2015;156(6):988-997. \u003c/li\u003e\n\u003cli\u003eRamond A, Bouton C, Richard I, Roquelaure Y, Baufreton C, et al. Psychosocial risk factors for low back pain in primary care\u0026ndash;a systematic review. Fam Pract 2011;28(1):12-21. \u003c/li\u003e\n\u003cli\u003eValjakka AL, Salantera S, Laitila A, Julkunen J, Hagelberg NM. The association between physicians\u0026rsquo; attitudes to psychosocial aspects of back pain and clinical behaviour: A complex issue. Scand J Pain 2013;4(1):25-30. \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1: Socio-demographic characteristics of patients (n=365)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"65.04702194357367%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.987460815047022%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.96551724137931%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"65.04702194357367%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.987460815047022%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e162\u003c/p\u003e\n \u003cp\u003e203\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.96551724137931%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e44.4\u003c/p\u003e\n \u003cp\u003e55.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"65.04702194357367%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e (years)\u003c/p\u003e\n \u003cp\u003eRange\u003c/p\u003e\n \u003cp\u003eMean\u0026plusmn;SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.95297805642633%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e18-85\u003c/p\u003e\n \u003cp\u003e47.9\u0026plusmn;10.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"65.04702194357367%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducational level\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eSecondary school/intermediate Diploma/ below\u003c/p\u003e\n \u003cp\u003eBachelor`s degree\u003c/p\u003e\n \u003cp\u003ePostgraduate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.987460815047022%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e91\u003c/p\u003e\n \u003cp\u003e235\u003c/p\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.96551724137931%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e24.9\u003c/p\u003e\n \u003cp\u003e64.4\u003c/p\u003e\n \u003cp\u003e10.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"65.04702194357367%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eWorking status\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eUnemployed/housewife\u003c/p\u003e\n \u003cp\u003eGovernmental employee\u003c/p\u003e\n \u003cp\u003ePrivate sector employee\u003c/p\u003e\n \u003cp\u003eStudent\u003c/p\u003e\n \u003cp\u003eRetired\u003c/p\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.987460815047022%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e91\u003c/p\u003e\n \u003cp\u003e152\u003c/p\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003cp\u003e87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.96551724137931%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e24.9\u003c/p\u003e\n \u003cp\u003e41.7\u003c/p\u003e\n \u003cp\u003e8.2\u003c/p\u003e\n \u003cp\u003e1.4\u003c/p\u003e\n \u003cp\u003e23.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"65.04702194357367%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSmoking status\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eNever smoke\u003c/p\u003e\n \u003cp\u003eCurrent smoker\u003c/p\u003e\n \u003cp\u003eEx-smoker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.987460815047022%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e312\u003c/p\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.96551724137931%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e85.5\u003c/p\u003e\n \u003cp\u003e8.2\u003c/p\u003e\n \u003cp\u003e6.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eSD: Standard deviation\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Low back pain-related and medical history of the patients (n=365)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"65.04702194357367%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.987460815047022%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.96551724137931%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"65.04702194357367%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHistory of other chronic illnesses\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.987460815047022%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e250\u003c/p\u003e\n \u003cp\u003e115\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.96551724137931%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e68.5\u003c/p\u003e\n \u003cp\u003e31.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"65.04702194357367%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFamily history of mental illness\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.987460815047022%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e341\u003c/p\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.96551724137931%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e93.4\u003c/p\u003e\n \u003cp\u003e6.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"65.04702194357367%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuration of low back pain in years\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026lt;1\u003c/p\u003e\n \u003cp\u003e1-3\u003c/p\u003e\n \u003cp\u003e\u0026gt;3-5\u003c/p\u003e\n \u003cp\u003e\u0026gt;5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.987460815047022%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e89\u003c/p\u003e\n \u003cp\u003e83\u003c/p\u003e\n \u003cp\u003e63\u003c/p\u003e\n \u003cp\u003e130\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.96551724137931%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e24.4\u003c/p\u003e\n \u003cp\u003e22.7\u003c/p\u003e\n \u003cp\u003e17.3\u003c/p\u003e\n \u003cp\u003e35.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"65.04702194357367%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNature of the LBP\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eIntermittent\u003c/p\u003e\n \u003cp\u003eChronic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.987460815047022%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e329\u003c/p\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.96551724137931%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e90.1\u003c/p\u003e\n \u003cp\u003e9.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"65.04702194357367%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eIs there associated somatic symptoms with LBP\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.987460815047022%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e228\u003c/p\u003e\n \u003cp\u003e137\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.96551724137931%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e62.5\u003c/p\u003e\n \u003cp\u003e37.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"65.04702194357367%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCause of LBP\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eStrains and sprains\u003c/p\u003e\n \u003cp\u003eFractures/accidents\u003c/p\u003e\n \u003cp\u003eDisk problems\u003c/p\u003e\n \u003cp\u003eStructural problems\u003c/p\u003e\n \u003cp\u003eArthritis\u003c/p\u003e\n \u003cp\u003eSpondylolisthesis\u003c/p\u003e\n \u003cp\u003eDiseases such as Spine tumors, infections, kidney stones and abdominal aortic aneurysm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.987460815047022%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e226\u003c/p\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.96551724137931%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e62.0\u003c/p\u003e\n \u003cp\u003e1.9\u003c/p\u003e\n \u003cp\u003e12.6\u003c/p\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003cp\u003e9.6\u003c/p\u003e\n \u003cp\u003e9.3\u003c/p\u003e\n \u003cp\u003e1.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"65.04702194357367%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTreatment of LBP*\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMedications such as nonsteroidal anti-inflammatory drugs (NSAIDs) muscle relaxants.\u003c/p\u003e\n \u003cp\u003ePhysical therapy\u003c/p\u003e\n \u003cp\u003eSteroid injections\u003c/p\u003e\n \u003cp\u003eSurgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.987460815047022%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e281\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e161\u003c/p\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.96551724137931%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e77.0\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e44.1\u003c/p\u003e\n \u003cp\u003e6.0\u003c/p\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*Not mutually exclusive (sum exceeded 100%)\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3: Association between depression`s severity and disability score among patients with low back pain\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.031298904538342%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDisability score\u003c/strong\u003e (0-24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"79.96870109546165%\" colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDepression\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eN=160\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eMild\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eN=147\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eN=48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eModerately severe/severe\u003c/p\u003e\n \u003cp\u003eN=10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003eMedian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003e14.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003eIQR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003e3.25-11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003e8-17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003e10.25-19.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003e6.75-21.50\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003eMean rank\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003e130.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003e215.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003e244.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20%\" valign=\"top\"\u003e\n \u003cp\u003e243.25\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003ep-value of Kruskal-Wallis test\u0026lt;0.001\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4: Predictors of depression among patients with low back pain: Multivariate logistic regression analysis\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.29780564263323%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.344827586206897%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.344827586206897%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.404388714733543%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAOR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.106583072100314%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.501567398119123%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.29780564263323%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.344827586206897%\" valign=\"top\"\u003e\n \u003cp\u003e-0.053\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.344827586206897%\" valign=\"top\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.404388714733543%\" valign=\"top\"\u003e\n \u003cp\u003e0.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.106583072100314%\" valign=\"top\"\u003e\n \u003cp\u003e0.92-0.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.501567398119123%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.29780564263323%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducational level\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eSecondary school/intermediate Diploma/ below\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003eBachelor`s degree\u003c/p\u003e\n \u003cp\u003ePostgraduate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.344827586206897%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-0.458\u003c/p\u003e\n \u003cp\u003e-1.247\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.344827586206897%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.307\u003c/p\u003e\n \u003cp\u003e0.487\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.404388714733543%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003cp\u003e0.63\u003c/p\u003e\n \u003cp\u003e0.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.106583072100314%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.35-1.15\u003c/p\u003e\n \u003cp\u003e0.11-0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.501567398119123%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.136\u003c/p\u003e\n \u003cp\u003e0.010\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.29780564263323%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHistory of other chronic illnesses\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNo\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.344827586206897%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.715\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.344827586206897%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.293\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.404388714733543%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003cp\u003e2.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.106583072100314%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.15-3.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.501567398119123%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.015\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.29780564263323%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFamily history of mental illness\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNo\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.344827586206897%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.333\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.344827586206897%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.617\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.404388714733543%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003cp\u003e3.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.106583072100314%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.13-12.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.501567398119123%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.031\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.29780564263323%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuration of low back pain in years\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026lt;1\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e1-3\u003c/p\u003e\n \u003cp\u003e\u0026gt;3-5\u003c/p\u003e\n \u003cp\u003e\u0026gt;5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.344827586206897%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-0.115\u003c/p\u003e\n \u003cp\u003e0.336\u003c/p\u003e\n \u003cp\u003e0.665\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.344827586206897%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.336\u003c/p\u003e\n \u003cp\u003e0.399\u003c/p\u003e\n \u003cp\u003e0.341\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.404388714733543%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003cp\u003e0.89\u003c/p\u003e\n \u003cp\u003e1.44\u003c/p\u003e\n \u003cp\u003e1.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.106583072100314%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.46-1.72\u003c/p\u003e\n \u003cp\u003e0.66-3.15\u003c/p\u003e\n \u003cp\u003e1.00-3.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.501567398119123%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.752\u003c/p\u003e\n \u003cp\u003e0.358\u003c/p\u003e\n \u003cp\u003e0.051\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.29780564263323%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAssociated somatic symptoms with LBP\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eNo\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.344827586206897%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.542\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.344827586206897%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.272\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.404388714733543%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003cp\u003e1.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.106583072100314%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.01-2.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.501567398119123%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.046\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.29780564263323%\" valign=\"top\"\u003e\n \u003cp\u003eDisability core\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.344827586206897%\" valign=\"top\"\u003e\n \u003cp\u003e0.184\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.344827586206897%\" valign=\"top\"\u003e\n \u003cp\u003e0.025\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.404388714733543%\" valign=\"top\"\u003e\n \u003cp\u003e1.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.106583072100314%\" valign=\"top\"\u003e\n \u003cp\u003e1.14-1.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.501567398119123%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eB: Slop\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;SE: Standard error\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;AOR: Adjusted odds ratio\u003c/p\u003e\n\u003cp\u003eCI: Confidence interval\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003csup\u003ea\u003c/sup\u003e: Reference category\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;LBP: Low back pain\u003c/p\u003e\n\u003cp\u003eTerms of gender, smoking, working status, nature of LBP, LBP causes, and LBP treatment were not included in the final logistic regression model (not significant)\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"middle-east-current-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"mecp","sideBox":"Learn more about [Middle East Current Psychiatry](http://mecp.springeropen.com)","snPcode":"43045","submissionUrl":"https://submission.nature.com/new-submission/43045/3","title":"Middle East Current Psychiatry","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Low back pain, Disability, Depression, Prevalence, determinants","lastPublishedDoi":"10.21203/rs.3.rs-4702923/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4702923/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: Low back pain (LBP) is a widespread health problem that poses a severe economic burden on both affected patients and their societies. A bidirectional relationship between depression and other chronic illnesses, including chronic LBP, has been suggested. However, the exact association between them remains unclear.\u003c/p\u003e\n\u003cp\u003eObjectives: To investigate the association between depressive disorder and low back pain and its impact on disability of patients.\u003c/p\u003e\n\u003cp\u003ePatients and methods: A cross-sectional study carried out in the orthopedic clinics of AlBadaya General Hospital, Qassim Region, Saudi Arabia, among a sample of patients with LBP throughout the period of the study (April-June 2024,). An interview questionnaire composed of four parts was utilized: personal information, medical history, and habits, the Arabic-validated version of the Roland-Morris Disability Questionnaire (RMDQ), and the Patient Health Questionnaire (PHQ)-9 to assess depression.\u003c/p\u003e\n\u003cp\u003eResults: A total of 365 patients were included in this study. Their age ranged between 18 and 85 years, with an arithmetic mean of 47.9 and a standard deviation (SD) of 10.4 years. Females represented 55.6% of them. The overall prevalence of depressive disorder among the participants was 56.2%, being mild in 40.3% of patients and moderately severe or severe among 2.7% of them. The disability score ranged between 0 and 24 with an arithmetic mean of 10.7 and SD of 6.2, while its median 1 value was 11, and its interquartile range was 6-15.5. Patients with moderately severe/severe depression had the highest disability score (median value was 15 and the mean rank was 243.25), while those with no depression had the lowest disability score (median value was seven and mean rank was 130.62), p\u0026lt;0.001. Multivariate logistic regression analysis revealed that with each unit increase in disability score, there was a 20% increase in depression (Adjusted odds ratio \"AOR\" =1.20; 95% confidence interval \"CI\": 1.14-1.26), p\u0026lt;0.001.\u003c/p\u003e\n\u003cp\u003eConclusion: Depression is very commonly associated with chronic LBP, although it is mostly mild. Disability is a serious complication of chronic LBP, and its severity is associated with the degree of depression. Therefore, patients with chronic LBP should be screened for depression.\u003c/p\u003e","manuscriptTitle":"Prevalence, severity, and determinants of depressive disorder among patients with low back pain in Al-Qassim Region, Saudi Arabia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-09 20:56:21","doi":"10.21203/rs.3.rs-4702923/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-07-11T11:22:43+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-09T13:48:29+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-09T13:45:50+00:00","index":"","fulltext":""},{"type":"submitted","content":"Middle East Current Psychiatry","date":"2024-07-08T05:59:12+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"middle-east-current-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"mecp","sideBox":"Learn more about [Middle East Current Psychiatry](http://mecp.springeropen.com)","snPcode":"43045","submissionUrl":"https://submission.nature.com/new-submission/43045/3","title":"Middle East Current Psychiatry","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"78619229-fc36-4c0d-baf7-464a823cbde0","owner":[],"postedDate":"August 9th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-09-04T11:26:25+00:00","versionOfRecord":[],"versionCreatedAt":"2024-08-09 20:56:21","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4702923","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4702923","identity":"rs-4702923","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}