Chronic Pain and Mental Health: The Connection | Trillium Counselling

Chronic pain and mental health feed each other in both directions — living with ongoing pain roughly doubles the odds of clinically significant depression or anxiety, and the reverse is also true. A March 2025 meta-analysis in JAMA Network Open, pooling 376 studies of over 347,000 adults, found clinically significant depression in 39.3% of people with chronic pain and clinically significant anxiety in 40.2% — with an estimated 7.6 million Canadians living with chronic pain. Depression and anxiety, in turn, amplify pain signals through a process called central sensitization.

Last updated: July 2026 · Written by Christopher Hein, Co-Founder, Trillium Counselling

How are chronic pain and mental health connected?

Chronic pain — usually defined as pain lasting longer than three months — and mental health conditions like depression and anxiety are connected at the level of the nervous system, not just at the level of "feeling discouraged." Ongoing pain signals keep stress-response circuits activated, disrupt sleep, and often force people to scale back activities and relationships they value. Each of those changes is independently linked to depression and anxiety. At the same time, depression and anxiety change how the brain and spinal cord process pain signals, which can make the same physical injury feel more intense. It's a two-way relationship, not a one-way consequence — and understanding that is the first step toward treating both effectively rather than just one.

What the research shows

The clearest recent evidence comes from a March 2025 systematic review and meta-analysis published in JAMA Network Open. Aaron and colleagues pooled data from 376 studies covering more than 347,000 adults with chronic pain across 50 countries and found that clinically significant depression was present in 39.3% of people with chronic pain, and clinically significant anxiety in 40.2%. Both figures were substantially higher than in comparison groups without chronic pain — moderate to large effect sizes for depression and anxiety, respectively — and roughly a third of people with chronic pain met full diagnostic criteria for major depressive disorder.

Chronic pain is also a major public health issue in its own right. According to the Canadian Pain Task Force's 2021 report to Health Canada, an estimated 7.6 million Canadians — about one in five people across the lifespan — live with chronic pain, and the report specifically notes that chronic pain often accompanies depression, anxiety, and post-traumatic stress. Put simply: if you have chronic pain and you're also struggling with your mood, you are not an outlier. You're describing one of the most well-documented overlaps in health research.

Why chronic pain increases depression and anxiety risk

The connection runs in both directions, and each direction has a distinct mechanism.

Pain → depression and anxiety. Three pathways do most of the work. First, chronic pain keeps low-grade inflammation active in the body, and inflammatory markers are independently associated with depressive symptoms. Second, pain restricts activity — people with chronic pain often withdraw from exercise, work, and social routines that normally protect mood, and that loss of activity and connection is itself a depression risk factor. Third, pain disrupts sleep, and poor sleep is one of the strongest known predictors of both depression and anxiety. These three pathways compound each other over time.

Depression and anxiety → pain. The reverse direction runs largely through a process called central sensitization — the nervous system becomes more reactive, amplifying pain signals that would otherwise register as mild. Depression and anxiety also reduce the brain's natural pain-dampening activity and increase muscle tension, both of which make existing pain feel worse. This is why treating mood and treating pain are rarely separate problems in practice — improvement in one domain can have the effect of easing the other.

How therapy can help chronic-pain clients

Several evidence-based approaches are specifically designed for the overlap between chronic pain and mental health, rather than treating either in isolation.

Cognitive Behavioural Therapy for Chronic Pain (CBT-CP)

CBT-CP is a structured, skills-based approach that helps you identify how thoughts, emotions, and behaviours around pain can amplify suffering — and change the patterns that make pain feel bigger than it needs to. A review in the American Psychologist describes CBT as the prevailing psychological treatment for chronic pain, with established benefits for pain intensity, mood, catastrophizing, and disability across a wide range of chronic pain conditions.

Acceptance and Commitment Therapy (ACT) for chronic pain

ACT takes a different angle: instead of trying to eliminate pain, it helps you build psychological flexibility — reducing the struggle against pain itself so you can stay engaged with a meaningful life alongside it. A 2018 narrative review in the Journal of Pain Research notes that ACT has reached "well-established treatment" status for chronic pain according to the American Psychological Association, with multiple systematic reviews supporting improved pain acceptance and day-to-day functioning.

Trauma-informed care for pain clients

For people whose pain coexists with a trauma history, trauma-informed pain care matters — a therapist who understands how the nervous system responds to both threat and pain can avoid approaches that feel invasive or dismissive, and can pace therapy in a way that builds safety first. At Trillium, our therapists bring trauma-informed training to pain-related mental health work — you can read more about that approach on our trauma therapy page.

When pain has a trauma dimension

For some people, chronic pain isn't only a physical or biochemical story — it also carries a trauma dimension. A 2023 review in BJA Open found a strong, dose-dependent association between adverse childhood experiences and chronic pain in adulthood, with poor mental health acting as one of the pathways connecting the two. This doesn't mean every chronic pain condition has a trauma root — many don't — but it does mean the body can carry the physiological signature of past trauma as ongoing physical symptoms, sometimes called somatic trauma expression. If your pain first appeared or worsened around a difficult period in your life, or if it comes with symptoms like hypervigilance, dissociation, or a body that never quite feels safe, that's worth naming to a therapist. This is the one place this guide connects with trauma therapy specifically: if that description fits your experience, our trauma therapy page explains how a trauma-informed approach works alongside pain-focused care.

When to seek support

You don't need to wait until pain or mood symptoms feel unbearable before reaching out. It's worth talking to a therapist if pain has been present for more than three months, if you've noticed your mood, sleep, or motivation declining alongside it, or if you've started avoiding activities, people, or places because of pain or worry about pain. Chronic pain and mental health respond best to treatment when both are addressed together rather than one at a time — and connecting with others who understand what long-term pain is like can also ease some of the isolation that often comes with it. At Trillium Counselling, we understand that chronic pain can be an invisible struggle. If you're finding it hard to cope, you can reach us directly at 226-752-8857 or book a free matching consult below.

Crisis Resources

If you or someone you know needs support right now, help is available:

• 988 Suicide Crisis Helpline (Canada-wide): call or text 9-8-8 — free, confidential, 24/7.
• Here 24/7 (Waterloo–Wellington crisis & mental health line): 1-844-437-3247.
• If someone is in immediate physical danger, call 911.