The Temporal and Bidirectional Relationship Between Low Back Pain and Mental Health Disorders: A Systematic Review and Synthesis of Longitudinal Evidence
Bibliographic record
Abstract
Introduction: Low back pain (LBP) is the leading global cause of disability. Its comorbidity with mental health disorders (MHDs) such as depression and anxiety is highly prevalent, complicating treatment and worsening prognosis. However, the temporal direction of this relationship remains ambiguous in cross-sectional literature. This systematic review synthesizes longitudinal evidence to clarify the bidirectional relationship between LBP and MHDs. Methods: A systematic review was conducted following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. PubMed, Google Scholar, Semantic Scholar, Springer, Wiley Online Library databases were searched for prospective cohort studies published between January 1990 and December 2024. Inclusion was restricted to longitudinal studies assessing the bidirectional link: (1) baseline MHDs predicting new-onset LBP, or (2) baseline LBP predicting new-onset MHDs. Risk of bias was assessed using the Newcastle-Ottawa Scale (NOS). Results: Fifteen longitudinal studies met the inclusion criteria. The evidence confirms a significant bidirectional relationship. (1) Meta-analysis data from included reviews demonstrate that baseline depressive symptoms significantly increase the risk of developing new-onset LBP (pooled OR = 1.59; 95% CI 1.26–2.01) (Pinheiro et al., 2015). (2) Conversely, baseline chronic LBP (CLBP) prospectively predicts the onset of depression (OR = 1.28; 95% CI 1.01-1.61) (Dickson et al., 2022) and dysthymia (HR = 1.53) (Schmaling and Nounou, 2018). Comorbid MHDs are significant prognostic indicators for worse LBP outcomes, including higher pain intensity (P=0.11), greater disability (P=0.16), and poorer recovery (RR=0.91) (Pinheiro et al., 2016). Discussion: The synthesis of longitudinal evidence confirms a reciprocal, prognostically significant relationship. This comorbidity is not incidental but is underpinned by shared neurobiological pathways, including monoaminergic system disruption (serotonin, norepinephrine), Hypothalamic-Pituitary-Adrenal (HPA) axis dysregulation, and neuroplastic changes in shared brain regions (e.g., anterior cingulate cortex, prefrontal cortex). The findings mandate a shift from a purely biomedical to an integrated biopsychosocial (BPS) model of care. Conclusion: The relationship between LBP and MHDs is bidirectional and significant. We recommend the implementation of routine, integrated screening protocols and multidisciplinary treatment pathways to address this comorbidity, as treating either condition in isolation is likely to be ineffective.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.039 | 0.123 |
| Meta-epidemiology (narrow) | 0.002 | 0.002 |
| Meta-epidemiology (broad) | 0.011 | 0.016 |
| Bibliometrics | 0.010 | 0.009 |
| Science and technology studies | 0.001 | 0.001 |
| Scholarly communication | 0.005 | 0.004 |
| Open science | 0.002 | 0.003 |
| Research integrity | 0.002 | 0.002 |
| Insufficient payload (model declined to judge) | 0.005 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".