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Sci Rep
Sci Rep
Scientific Reports
2045-2322
Nature Publishing Group UK London

39237574
71543
10.1038/s41598-024-71543-8
Article
Effects of pain, hospitalization, and medication on depressive symptom in Syrian patients with chronic diseases
http://orcid.org/0000-0003-4848-6719
Ataya Jamal dr.jamalataya@gmail.com

1
http://orcid.org/0009-0008-2946-6820
Hamdi Mohammad 1
Daboul Rawan 2
http://orcid.org/0009-0006-0031-7229
Aboulkher MHD Ghazi 34
http://orcid.org/0000-0002-9265-5076
Ghanem Lubana 5
http://orcid.org/0009-0000-7260-1233
Shekhani Salah Eddin 3
http://orcid.org/0000-0002-4887-2321
Zarzar Mouayad 6
http://orcid.org/0009-0002-1764-0867
Alwaa Heba 6
Saduon Someia 6
Albardan Hussam 7
1 https://ror.org/03mzvxz96 grid.42269.3b 0000 0001 1203 7853 Faculty of Medicine, University of Aleppo, Aleppo, Syria
2 grid.36402.33 0000 0004 0417 3507 Faculty of Medicine, Al_Baath University, Homs, Syria
3 https://ror.org/03m098d13 grid.8192.2 0000 0001 2353 3326 Faculty of Medicine, Damascus University, Damascus, Syria
4 Stemosis for Scientific Research, Damascus, Syria
5 https://ror.org/03m098d13 grid.8192.2 0000 0001 2353 3326 Department of Laboratory Medicine, Faculty of Medicine, Damascus University, Damascus, Syria
6 https://ror.org/03m098d13 grid.8192.2 0000 0001 2353 3326 Department of Internal Medicine, Faculty of Medicine, Damascus University, Damascus, Syria
7 https://ror.org/03m098d13 grid.8192.2 0000 0001 2353 3326 Internal Medicine Department, Critial Care, Damascus University, Damascus, Syria
5 9 2024
5 9 2024
2024
14 2075114 12 2023
28 8 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
Chronic diseases and pain exacerbate depressive symptom in Syria. Limited research on hospital-induced depressive symptom among Syrian patients with chronic diseases warrants further study. A cross-sectional study in four Damascus hospitals revealed high rates of pain and depressive symptom. This study aims to investigate the prevalence and severity of chronic pain and hospital-induced depressive symptom in Syrian patients, as well as the relationship between pain, depressive symptom, and medication behavior. This study analyzes the impact of pain, hospitalization, and medication on patients with chronic diseases. The four Damascus hospitals included 453 patients from various departments. Data were collected through structured interviews and internationally recognized scales such as the PSEQ, HADS, and MMAS. These findings offer insights into pain management and psychological well-being, with implications for patient care and support strategies. The study involved 453 patients with chronic diseases, with gender distribution showing 46.6% females and 53.4% males. The age range was from 7 to 87 years, with an average of 46.87 years. Chi-square tests revealed a significant connection between gender and HADS-A scores, where 48.3% of females had abnormalities (χ2 (1, N = 453) = 7.125, p = 0.028). Marital status was significantly associated with anxiety and depressive symptom levels, particularly among widowed and divorced patients. Employment status, education, and comorbidity were linked to abnormal HADS-A scores, while education level showed a positive correlation with HADS-D scores. ANOVA tests showed significant differences in MMAS scores across income groups (F (3, 449) = 3.167, p = 0.024), with a notable difference between low-income and lower-middle-income groups (mean difference = 0.389, p = 0.031. Chronic pain and HID are prevalent among Syrian patients with chronic diseases and influenced by socio-demographic factors. Personalized interventions are needed to address psychological symptoms and medication behavior.

Keywords

Chronic diseases
Hospital-induced depressive symptom (HID)
Medication adherence
Pain management
Syria
Subject terms

Psychology
Public health
issue-copyright-statement© Springer Nature Limited 2024
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pmcIntroduction

Chronic diseases pose a substantial public health obstacle in Syria, significantly affecting both the health care system and society. Among the myriad challenges these diseases present, chronic pain is a prevalent and incapacitating symptom that profoundly impacts patients’ overall quality of life, physical and emotional wellness, and ability to engage in daily activities1. This enduring pain persists or recurs for more than three months, necessitating specialized treatment and care2. Notably, chronic pain, as a stressor, plays a pivotal role in precipitating depressive symptom and exacerbating the severity of both conditions3. Depressive symptom, distinct from transient sadness, endures for extended periods and significantly disrupts daily functioning4. Moreover, chronic diseases often give rise to hospital-induced depressive symptom (HID), which is a particularly severe issue among hospitalized patients. HID manifests as depressive symptoms that emerge or worsen during hospitalization and may persist post-discharge, leading to heightened pain levels, prolonged hospital stays, and poor recovery5. This study aime to offer valuable insights into the prevalence and severity of chronic pain and hospital-induced depressive symptom among Syrian patients and to explore the correlations between these factors. By shedding light on the burden of chronic pain and depressive symptom among Syrian patients, this study seeks to aid the development of more effective interventions and comprehensive management strategies for these challenging conditions.

Methods

Study design

A comprehensive cross-sectional investigation was undertaken to evaluate the implications of pain and the psychological impacts of hospitalization on patients diagnosed with chronic diseases, and to scrutinize their medication intake behavior. This study was executed from the 10th of September to the 10th of October, 2023. This cross-sectional study included patients with chronic diseases admitted to four public hospitals in Damascus, Syria (Al-Mouassat Hospital, Al-Assad Hospital, Cardiac Surgery Hospital, and Damascus Hospital). While these hospitals provide a comprehensive view, it should be noted that they may not fully represent the entirety of Syria’s population. Variability across regions and healthcare facilities could influence generalizability beyond Damascus. The sample comprised 453 patients drawn from diverse hospital departments, including internal medicine, surgery, ophthalmology, and otolaryngology.

Data collection & participants

Data were collected by a team of trained doctors using a structured questionnaire through personal interviews with the patients. All interviewers were extensively trained and ensured consistent data collection practices. Prior to the interviews, written informed consent was obtained from the participants who were assured that their participation was voluntary and that the study results would be published. Each interview lasted approximately 15 min, ensuring adequate time to collect the requisite information while respecting the participants’ time and energy. The sampling method employed was non-random convenience sampling, where patients meeting the inclusion criteria were selected from the available population in four major hospitals in Damascus. This approach was chosen due to logistical constraints and the need to access a diverse patient group across different hospital departments. Confidentiality of participant information was rigorously maintained through anonymization and secure data storage protocols. The study was approved by the Ethical Committee of the Faculty of Medicine at Damascus University, adhering to the principles of the Helsinki Declaration and was assigned a serial number (4424).

Inclusion and exclusion criteria

The inclusion criteria specified patients with chronic illnesses lasting more than three months, hospitalized for at least 2 weeks. In this study, a 3 month period was chosen as it is consistent with clinical research guidelines and previous studies on chronic pain and depression. This timeframe is adequate for observing significant changes in patient symptoms and responses to hospitalization and medication, making it a suitable period for analysis6,7. Exclusion criteria included patients with shorter hospital stays or those unable to communicate effectively.

Questionnaire

The questionnaire was adapted from a previous study. Expert translators translated the original questionnaire into Arabic with proficiency, ensuring a precise semantic and conceptual match. To preserve the meaning, the questionnaire was translated back into English. It consists of two sections:

Section 1 included sociodemographic characteristics, such as age, marital status, gender, weight, height, financial status, education level, occupation, housing situation, province of origin, chronic diseases, and the department to which the patient was admitted.

Section 2 includes multiple internationally recognized scales. The first scale is the PSEQ, which assesses patients’ confidence in their ability to perform specific tasks despite experiencing pain. It also measures the ability to cope with pain. This scale is an established 10-item measure of pain self-efficacy that has been adopted in clinical and research settings, in which patients rate their confidence from 0 points (not at all confident) to 6 points (completely confident). The total scores range from 0 to 60, with higher scores indicating greater self-efficacy for functioning despite pain. All other language versions of the PSEQ were found to have high internal consistency (Cronbach’s α = 0.92)8. The second scale is the HADS, which assesses anxiety and depressive symptom in patients during the last week of hospitalization. This scale consists of 14 questions, with seven questions assessing anxiety (A) and seven questions assessing depressive symptom (D). There are five choices for each question: “most of the time,” “a lot of the time,” “from time to time, occasionally,” and “not at all.” Each option was associated with a score ranging from 0 to 3. Finally, when the scores were summed, there were three possibilities: (0_7 = normal) (8_10 = borderline abnormal) (11_21 = abnormal). The Cronbach’s alpha for the entire scale was good (α = 0.81)9. The third scale is the MMAS, which assesses patient behavior regarding medication adherence. This scale consists of four items with a scoring scheme of “yes = 0”, and “no = 1”. The scores were then summed up to obtain a final score ranging from 0 to 4. The validity of this scale has been evaluated in previous studies as having good internal consistency, with a Cronbach’s alpha of 0.85710–12.

These scales were chosen for their established validity and reliability in clinical and research settings. While they were internationally validated, a pilot study involving 70 patients ensured their cultural appropriateness and further validated the Arabic version (Cronbach’s α = 0.79).

Statistical analysis

To minimize bias, data were collected electronically via Google Forms, reducing the risk of manual data entry errors. Statistical analyses were performed using SPSS Inc., version 23 software, incorporating descriptive statistics, independent t-test, chi-square test, ANOVA, and Pearson correlation. The significance threshold for all analyses was set at p < 0.05. Although adjustments for multiple comparisons were not explicitly stated, which could introduce potential type I errors.

Sample size

To determine the necessary sample size ((n)) for our study, we used Cochran’s sample size formula. This formula considers the following parameters:Confidence level (Z): represented by (Z = 1.96) for a 95% confidence level.

Margin of error (e): set at 5% (0.05).

Estimated proportion (p): we assumed an attribute of interest within the population with an estimated proportion of 50% (0.5). Therefore, (q = 1 − p).

The formula is as follows:n=Z2pqe2

By using the aforementioned formula, the necessary sample size (n) for this study was determined to be 38513.

Results

Demographic variables

The study comprised 453 participants, demonstrating a nearly equitable distribution between genders, with 46.6% females (n = 211) and 53.4% males (n = 242). The average age of the participants was 46.87 years, with a minimum of 7 years and a maximum of 87. Most participants belonged to the internal medicine Sect. (76.2%). A significant proportion of patients (52.5%) were unemployed. Additionally, a substantial proportion of the patients (48.1%) presented with concurrent medical conditions. The body mass index (BMI) of the participants range from 12.49 to 58.96, with a mean value of 24.42 and a standard deviation of 4.82. Further details are presented in Table 1. Table 1 Shows sample characteristics.

Variable	Number	Percentage	
Participants	453		
Gender split	
 Females	211	46.6%	
 Males	242	53.4%	
Education	
 Illiterate	114	25.2%	
 Primary	161	35.5%	
 High school	77	17.0%	
 University	101	22.3%	
Employment	
 Unemployed	238	52.5%	
 Employed	215	47.5	
Common medical sections	
 Internal medicine	345	76.2%	
 Surgery	67	14.8%	
 Clinics	33	7.3%	
 Obstetrics/gyn	8	1.8%	
 Orthopedics	4	0.8%	
Marital status	
 Married	328	72.4%	
 Single	100	22.1%	
 Widowed	15	3.3%	
 Divorced	10	2.2%	
Accompanying conditions	218	48.1%	
Financial status	
 Poor	159	35.1%	
 Moderate	203	44.8%	
 Good	80	17.7%	
 Excellent	11	17.7%	
BMI	
 Range	12.49–58.96		
 Mean	24.42		
 SD	4.82		
Age	
 Range	7–87		
 Mean	46.87		
 SD	18.54		

Association between categorical variables and HADS-A and HADS-D scores in the study sample

Chi-square tests were used to investigate the relationships between categorical variables and the HADS-A and HADS-D scores. Regarding the HADS-A subscale, chi-square analysis revealed significant associations with gender (χ2 (1, N = 453) = 7.125, p = 0.028). The results showed that 48.3% of females were categorized as exhibiting abnormalities on the HADS-A subscale compared to 36.0% of males. Furthermore, 43.8% of males were classified as “normal” on the HADS-A scale, while only 35.1% of females achieved this classification. Regarding marital status, half of the single patients (52%) did not display significant anxiety symptoms, whereas a lower percentage of widowed and divorced patients (26.7% and 10%, respectively) had lower levels of anxiety. Furthermore, 28% of the never-married patients had moderate-to-severe HADS-A scores. Widowed (53.3%) and divorced (70%) patients had a higher proportion of moderate-to-severe anxiety, as confirmed by chi-square analysis (χ2 (1, N = 453) = 14.792, p = 0.022).

Statistically significant associations were observed for occupation, marital status, education, and comorbidities. A higher prevalence of abnormal HADS-A scores (52.9%) was found among the employed patients, while 34.3% displayed normal scores, as confirmed by the chi-square analysis (χ2 (1, N = 453) = 15.268, p = 0.018). Among the patients, 54.5% displayed no signs of depressive symptom on the HADS-D subscale, while only 36.4% of outpatients exhibited depressive symptoms (χ2 (1, N = 453) = 16.084, p = 0.013). Among single patients, 49% had normal scores on the HADS-D subscale, whereas only 34% of married patients had abnormal scores. A significant positive correlation was observed in relation to HADS-D education, with the largest proportion of patients (49.1%) demonstrating depressive symptom on this subscale with no formal education. In contrast, among those with a university degree, 50.5% were free from depressive symptom, whereas only 29.7% displayed depressive symptoms, as indicated by the chi-square analysis (χ2 (1, N = 453) = 13.897, p = 0.031). A total of 45.5% of the patients with multiple chronic diseases demonstrated depressive symptom, while only 31.5% exhibited normal results. In contrast, among patients with a single chronic disease, 46.3% displayed normal scores on this subscale, while 29.8% had abnormal scores (χ2 (1, N = 453) = 13.841, p = 0.001).

Multifaceted associations between income, marital status, HADS-A, HADS-D, and pain tolerance, exploring medication-taking behavior, psychological symptoms, and PSEQ scores in a sample population

To investigate the relationship between income and MMAS, we performed an ANOVA. The results revealed a statistically significant difference in the mean MMAS scores among the income groups. The F-statistic was F (3, 449) = 3.167, p = 0.024, which was below the threshold of 0.05. To identify specific group disparities, we conducted a post-hoc analysis. The analysis revealed a statistically significant difference in the mean MMAS scores between the low- and lower-middle-income groups. The difference was 0.389 with a p-value of 0.031. This finding suggests that income level has a significant impact on medication-taking behavior among patients with specific conditions. This suggests that low-income patients have a higher degree of medication adherence than the other groups, indicating that income level is a substantial factor in medication adherence. To examine the association between marital status and PSEQ, we performed a one-way ANOVA. The F-statistic of F (3, 449) = 5.560 and a p-value of 0.001 indicated a statistically significant difference in the mean PSEQ scores among the different marital status groups. Post-hoc analysis revealed a statistically significant mean difference of 4.391 in PSEQ scores between the unmarried and married groups (p = 0.020) and a mean divergence of 13.253 in PSEQ scores between the married and widowed groups (p = 0.002), indicating a significant difference in PSEQ scores between these two groups. This outcome suggests that marital status plays a crucial role in shaping pain tolerance across different situations, with married individuals displaying a higher level of pain tolerance than widowed counterparts.

Chi-square analysis was performed to examine the relationship between the HADS-A and HADS-D. The results revealed a highly significant positive association (p = 0.000) with χ2 (1, N = 453) = 90.644. Furthermore, analysis of the relationship between the HADS-D and HADS-A also showed a strong positive association (p = 0.000) with the same χ2 (1, N = 453) = 90.644. It is worth noting that 66.9% of individuals who scored as “normal” on the HADS-D subscale did not display significant anxiety symptoms, while only 20% of those with “normal” HADS-D scores showed symptoms of anxiety. This indicates a robust positive correlation between HADS-A and HADS-D.

One-way ANOVA revealed a significant difference in the PSEQ scores across the HADS-A groups. The F-statistic of F (2, 450) = 10.299 and a p-value of 0.000 supported this distinction. Post-hoc analysis revealed a mean difference of 5.187 in PSEQ scores between the normal and abnormal categories (p = 0.000), indicating a significant variation in PSEQ scores between these two groups. Additionally, a mean difference of 6.487 in PSEQ scores was found between the borderline abnormal and abnormal groups (p = 0.001). This suggests that anxiety levels influence pain tolerance in various situations, with normal and borderline abnormal individuals exhibiting higher pain tolerance than the abnormal individuals with significant anxiety.

To investigate the PSEQ and HADS-D connections, we performed a one-way ANOVA and found a significant difference in the average PSEQ scores across HADS-D categories. The F-statistic (F (2, 450) = 10.299) and p-value (0.000) were both robust, indicating a noticeable difference. Post hoc analysis revealed a 5.524-point difference in PSEQ scores between the normal and borderline abnormal groups (p = 0.002) and a 5.405-point difference in PSEQ scores between the normal and abnormal groups (p = 0.000), underscoring the impact of depressive symptom on pain tolerance. These results suggest that healthy individuals have higher pain tolerance than individuals with depressive symptom.

Nonsignificant variables

No significant correlations were found between the HADS-A and MMAS, HADS-D and MMAS, or PSEQ and MMAS. Examination of the HADS-A revealed no significant connections with age, BMI, hospital of admission, section or department, country of birth or address, income status, education, or comorbidity. Similarly, the HADS-D showed no significant association with age, BMI, hospital of admission, country of birth or address, and income. MMAS only exhibited a significant association with income status. Finally, the PSEQ demonstrated a significant association with marital status alone, with no other variables revealing a substantial relationship. These findings suggest that these variables did not have a noteworthy impact on the measured outcomes, indicating an absence of meaningful connections in the context of this study.

Discussion

The relationship between depressive symptom and pain has long posed a clinical challenge, leading to diagnostic and therapeutic uncertainties14. The reciprocal nature of this association suggests that each could heighten the risk of the other, as supported by various empirical evidences15.

Given the increased burden of pain in illness, this study anticipated a clearer connection between pain and depressive symptom, particularly among chronic patients. Consequently, this research focused on assessing pain tolerance and the extent of depressive symptom in chronic patients, examining the impact of the disease on this relationship, and its correlation with medication adherence. The study involved 453 participants from different hospitals in Damascus, with a nearly equal distribution between genders (53.4% male, 46.6% female), lending greater credibility to the results.

Several opinions supporting the impact of population composition on mental health have been previously discussed16–18. A cross-sectional study in the American society revealed a higher prevalence of anxiety disorders among women in nearly all examined cases19. Similarly, in a systematic review of 44 studies, factors contributing to anxiety were discussed. It was evident that anxiety is more widespread among women, and they concluded that masculinity serves as a protective factor against anxiety20. Many studies have interpreted this prevalence in light of factors such as lower educational levels, rural settings, unemployment, pregnancy complications, and marital dissatisfaction. Brain composition, genetic factors, hormonal fluctuations, and reproductive urinary symptoms also play a role21,22. Our study yielded consistent results, which revealed a significant correlation with gender. Anxiety was more prevalent among women, with nearly half of female participants experiencing anxiety. This correlation was also linked, in some cases, to unfavorable social conditions, such as divorce. Regarding depressive symptom, no significant relationship with gender was found, suggesting that female anxiety may be attributed to increasing life pressures of balancing family and work responsibilities.

These results underscore the pivotal role of social status in shaping pain tolerance in various situations, given the significant impact of social status and familial relationships on anxiety and depressive symptom levels. The findings revealed that a high percentage of widowed patients (53.3%) and a large percentage of divorced patients (70%) exhibited moderate to severe levels of anxiety. Concerning depressive symptom, approximately two-thirds of widowed patients showed abnormal scores on the HADS-D subscale, unlike one-fifth who achieved normal scores. This could be explained by the fact that individuals experiencing feelings of loneliness are more prone to signal worse feelings in both components of depressive symptom and/or anxiety23. A study on social status and its association with depressive symptom found that emotional support and stability from marital partnerships could reduce the risk of depressive symptom. This evidence suggests a decrease in quality of life among divorced and widowed patients24. Perhaps intensifying this perspective is societal pressure on divorced and widowed individuals, coupled with the absence of financial support. The emotional shock resulting from the death or loss of a partner further increases the likelihood of depressive symptom and anxiety in this group compared with their married or single counterparts.

However, when referring to unmarried patients, our results indicated a generally lower rate of anxiety and depressive symptom among them compared to both married and divorced individuals. This is a noteworthy finding, in contrast to many previous studies, such as a Canadian study on partnership and depressive symptom, which revealed that the prevalence of depressive symptom among unmarried patients with Parkinson’s was approximately 25% higher than that among married individuals24. A German study also affirmed that social support from a partner could enhance emotional stability in patients25. The results of our study were anticipated to be contradictory because of the challenging nature of married individuals’ lives in securing basic life requirements. The need for long working hours may lead to fatigue and exhaustion, potentially resulting in decreased empathy and support among the partners. By contrast, unmarried individuals might be better equipped to face life challenges without added concerns about a partner.

Regarding the association between depressive symptom and age, our findings revealed that the HADS-A and HADS-D showed no significant correlation with age. This result was met by both support and opposition. Several studies, such as a German study, affirmed the positive impact of age on depressive symptom, with a similar prevalence between males and females26. However, anxiety levels differed between genders in this context26. A Korean study indicated that depressive symptom increases with age in women, but no clear symptoms of age-related depressive symptom have been observed in men16. On the other hand, other studies have suggested no age effect on depressive symptom. For instance, a British study found that age, weight, and social status could not determine depressive symptom symptoms27. We also could not identify any relationship between anxiety/depressive symptom and body mass index, hospital admission, country of birth or residence, or income. Our findings also reveal a significant positive relationship between depressive symptom and education. Statistically, half of the patients with depressive symptom in the HADS-D subscale had no formal education. Conversely, among those with university degrees, 50.5% were free from depressive symptom. This result aligns with a 1997 study, suggesting that educational disparities and poor educational status were prominent causes of depressive symptom28. This outcome is anticipated, given that education confers self-efficacy, raises self-esteem, and provides a greater opportunity to avoid depressive symptom. Additionally, education may contribute to better acceptance of medical advice and instructions. Some studies have suggested a close association between self-efficacy and depressive symptom. For example, a study from the University of Athens found that increased self-efficacy was linked to decreased depressive symptom in both genders. Higher self-efficacy has also been associated with stress regulation, higher self-esteem, better well-being, improved physical condition, and better adaptation to acute and chronic illnesses and recovery29. Their potential explanation is that high self-efficacy may lead to more adaptive coping strategies, task-oriented coping, and reduced emotion-focused and avoidance coping29. Another Chinese study confirmed that patients with greater confidence in managing daily activities and personal life, and better emotional management, had less severe symptoms and were less affected by their symptoms. In summary, educational level is linked to self-efficacy and, consequently, associated with depressive symptom, according to a study from the University of Athens29. Men with higher education tend to have higher levels of self-efficacy than those with a primary education29. Moreover, this seems to be attributable to the fact that men with lower education, even with equal access to healthcare, may face greater difficulty in understanding educational materials about the disease, its treatment, and post-treatment care. Regarding occupational status, according to our study, employed individuals, constituting about half of the sample, showed a noticeable increase in anxiety levels, with only about one-third having normal results. This might be attributed to burnout and immersion in work, which prevents employees from monitoring their health status and adhering to their health guidelines. Additionally, we could not confirm that occupation was a significant factor for other measures, such as HADS-D, PSEQ, and MMAS.

Previous studies have explored the specific elements of the relationship between depressive symptom and various chronic diseases. A British study investigating the link between comorbidities and depressive symptom found that an overall higher number of comorbidities was a significant indicator of depressive symptom27. Another study suggested that an increase in the number of comorbidities reduces physical activity, thus decreasing their quality of life, which may lead to higher levels of depressive symptom27. Confirming this, another meta-analysis of 49 studies showed that physical activity is a preventive factor against depressive symptom27. In our study, a positive relationship between comorbidities and depressive symptom was observed. Interestingly, the abnormal result for HADS-D was less than half for those suffering from a single chronic disease. This may be explained by the fact that as the number of diseases increases, medication adherence decreases30. This directly affects overall health and, consequently, depressive symptom levels in patients, as depressive symptom is associated with decreased self-reported health status31. Therefore, it seems that social and demographic factors are not the only influences on depressive symptom. Moreover, the reciprocal relationship between comorbidities and depressive symptom appears to be somewhat common.

Regarding the relationship between anxiety and depressive symptom, it was found that one may predict the presence of the other. A strong positive relationship between anxiety and depressive symptom was evident, with an increase in the HADS-A scale leading to an increase in the HADS-D scale, and vice versa. On the contrary, statistical analysis of the correlation between the two variables showed that two-thirds of individuals who scored “normal” on the HADS-D subscale did not exhibit significant anxiety symptoms. In contrast, only five of those with “normal” HADS-D scores did not show significant anxiety symptoms. Scores of D indicated anxiety symptoms, similar to a British study where core anxiety scores influenced depressive symptom outcomes27,32. Conversely, patients with a history of depressive symptom are also more likely to remain depressed when they have high levels of anxiety at baseline. This is attributed to the interconnected nature of anxiety and depressive symptom, creating a cycle where one feels anxious because they are depressed and becomes depressed because they are anxious, perpetuating until one of these issues is addressed27,33. The relationship between pain tolerance and depressive symptom appears to be influenced by anxiety levels. Our study indicates that individuals with normal and borderline abnormal anxiety levels exhibit higher pain tolerance compared to the abnormal group characterized by significant anxiety. Similarly, the impact of depressive conditions on pain tolerance is noteworthy, with normal individuals demonstrating higher pain tolerance than those in the borderline abnormal and abnormal groups with significant depressive symptom. A probable explanation lies in the role of self-efficacy, which is linked to both coping with pain and depressive symptom. High self-efficacy is associated with low depressive symptom and high pain tolerance17,29, suggesting that self-efficacy acts as a common factor controlling the relationship between them34. In terms of medication adherence, the results were somewhat distinctive. Detailed analysis revealed only one relationship between medication adherence and patient income groups. Surprisingly, the “low-income” category scored the highest on the medication adherence scale (MMAS). This indicates that income level plays a significant role in shaping medication-taking behavior among patients with a specific condition. The higher adherence among low-income individuals may be attributed to their desire for quick improvement and recovery, aiming to return to work, positively influencing their medication adherence35. However, Higher mortality risk was observed in patients with low income and poor medication adherence36,37. No other associations or relationships were identified regarding medication and drug intake. Despite encountering obstacles such as difficulty accessing patient files and low socioeconomic status affecting the results, the study recommends further research, including private hospitals, which often cater to individuals with a better socioeconomic status. Despite these challenges, efforts were made to ensure the accuracy and comprehensiveness of the information obtained by interviewing patients, studying their gestures, and balancing the sample in terms of gender, providing added value to the research.

Limitations

Cross-sectional design

The study’s cross-sectional design limits the ability to establish causal relationships between variables. It captures data at a single time point, making it impossible to determine the temporal sequence of events or changes over time in pain, hospital-induced depressive symptoms (HID), and medication behavior.

Sample size and generalizability

While the study included 453 patients from four major hospitals in Damascus, Syria, the sample may not fully represent the diversity of chronic disease patients across the country or in other regions. This limits the generalizability of the findings to broader Syrian populations or different healthcare settings.

Selection bias

The inclusion of patients with chronic illnesses lasting more than three months and hospitalized for at least two weeks may bias results towards those with more severe or advanced conditions. The exclusion of patients with shorter hospital stays or milder conditions could affect the study’s comprehensive representation of chronic disease populations.

Study duration

Conducted over one month, the study may not fully capture seasonal variations in hospital admissions or fluctuations in patient conditions. A longer study period could provide a more robust understanding of patient experiences over time.

Google forms limitations

While convenient, Google Forms may allow multiple responses from the same individual, which can skew data. Measures to prevent this, like tracking IP addresses or requiring sign-ins, could compromise participant anonymity. These limitations should be considered when interpreting the findings.

Abbreviations

PSEQ Pain self-efficacy questionnaire

MMAS Morisky medication adherence scale

HADS Hospital anxiety and depressive symptom scale

Acknowledgements

We would like to express our sincere gratitude to Dr. Philip Morisky for granting us permission to use the MMAS-4 as a gold standard in our study. His invaluable assistance has been instrumental in our research on chronic pain and hospital-induced depression among Syrian patients. ©MMAS www.adherence.cc.

Author contributions

JA, MH, RD, MGA, SES, SS have participated in writing the manuscript. JA, RD, MGA, SES reviewed the literature. JA, MH did the statistics and the relevant table. All Authors critically and linguistically revised the manuscript. JA, RD contributed to revision of the manuscript. JA prepared and revised the final manuscript. JA, HA supervised the conduct of the study. All authors read and approved the final manuscript. Written informed consent was obtained from all the patient for the publication of this study and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Data availability

All data generated or analysed during this study are included in this published article.

Competing interests

The authors declare no competing interests.

Ethical approval

Ethical approval for the study was obtained from the Ethical Committee of Damascus University, Faculty of Medicine, Syria.

Publisher's note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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