Importance: Depression and anxiety are common among adults with chronic pain, but their prevalence is unclear.Objectives: To evaluate the prevalence of depression and anxiety among adults with chronic pain and identify factors that moderate prevalence.Data Sources: A literature search was conducted of MEDLINE, Embase, PsycINFO, and Cochrane Library from January 2013 to October 2023.Study Selection: Studies reporting the prevalence of depression or anxiety using a validated assessment tool among adults with chronic pain (excluding chronic headache disorders).Data Extraction and Synthesis: A total of 31 159 initial records were identified, and 5177 full texts were screened. Data were extracted per the Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline using Covidence. Two independent reviewers completed abstract screening, full-text review, and data extraction and rated risk of bias. Random-effects meta-analyses were applied to pool prevalence, assess moderation, and compare prevalence of depression or anxiety among samples with chronic pain vs control samples.Main Outcomes and Measures: Prevalence of depression and anxiety based on clinically significant symptoms or diagnosis. The moderators of prevalence identified were pain condition, recruitment setting, continent, age, percentage female, and pain duration.Results: The search identified 376 studies from 50 countries comprising 347 468 individuals (mean [SD] age, 51.3 [9.5] years; 70.0% female) with chronic pain. Among adults with chronic pain, clinical symptoms of depression were present in 39.3% (95% CI, 37.3%-41.1%; I² = 98.9%), and clinical symptoms of anxiety were present in 40.2% (95% CI, 38.0%-42.4%; I² = 99.0%). Prevalence differed by pain condition (highest among samples of people with fibromyalgia [depression, 54.0% (95% CI, 48.5%-59.4%); anxiety, 55.5% (95% CI, 50.4%-60.4%)]; lowest among samples of people with arthritis conditions [eg, osteoarthritis: depression, 29.1% (95% CI, 20.3%-39.7%); anxiety, 17.5% (95% CI, 6.6%-38.8%)]) and was highest among younger people (depression, β = −0.02 [95% CI, −0.03 to −0.01]; anxiety, β = −0.02 [95% CI, –0.03 to –0.01]) and women (depression, β = 0.69 [95% CI, 0.31-1.08]; anxiety, β = 0.90 [95% CI, 0.48-1.33]). With regard to diagnoses, 36.7% (95% CI, 29.0%-45.1%) had a major depressive disorder, and 16.7% (95% CI, 11.8%-23.2%) had generalized anxiety disorder. Women, younger people, and people with nociplastic pain (ie, pain arising from altered nociception without tissue damage) were most likely to have depression and anxiety.Conclusions and Relevance: In this systematic review and meta-analysis of depression and anxiety among individuals with chronic pain, approximately 40% of adults had clinically significant depression and anxiety. Women, younger people, and people with nociplastic pain were most likely to have depression and anxiety. The co-occurrence of chronic pain with depression and anxiety is a significant public health concern necessitating routine screening in clinical settings, equitable access to specialty care, and innovative treatment development.

Background This is an update of the original Cochrane review first published in Issue 1, 2003, and previously updated in 2009, 2012 and 2014. Chronic pain, defined as pain that recurs or persists for more than three months, is common in childhood. Chronic pain can affect nearly every aspect of daily life and is associated with disability, anxiety, and depressive symptoms. Objectives The aim of this review was to update the published evidence on the efficacy of psychological treatments for chronic and recurrent pain in children and adolescents. The primary objective of this updated review was to determine any effect of psychological therapy on the clinical outcomes of pain intensity and disability for chronic and recurrent pain in children and adolescents compared with active treatment, waiting‐list, or treatment‐as‐usual care. The secondary objective was to examine the impact of psychological therapies on children's depressive symptoms and anxiety symptoms, and determine adverse events. Search methods Searches were undertaken of CENTRAL, MEDLINE, MEDLINE in Process, Embase, and PsycINFO databases. We searched for further RCTs in the references of all identified studies, meta‐analyses, and reviews, and trial registry databases. The most recent search was conducted in May 2018. Selection criteria RCTs with at least 10 participants in each arm post‐treatment comparing psychological therapies with active treatment, treatment‐as‐usual, or waiting‐list control for children or adolescents with recurrent or chronic pain were eligible for inclusion. We excluded trials conducted remotely via the Internet. Data collection and analysis We analysed included studies and we assessed quality of outcomes. We combined all treatments into one class named 'psychological treatments'. We separated the trials by the number of participants that were included in each arm; trials with > 20 participants per arm versus trials with < 20 participants per arm. We split pain conditions into headache and mixed chronic pain conditions. We assessed the impact of both conditions on four outcomes: pain, disability, depression, and anxiety. We extracted data at two time points; post‐treatment (immediately or the earliest data available following end of treatment) and at follow‐up (between three and 12 months post‐treatment). Main results We identified 10 new studies (an additional 869 participants) in the updated search. The review thus included a total of 47 studies, with 2884 children and adolescents completing treatment (mean age 12.65 years, SD 2.21 years). Twenty‐three studies addressed treatments for headache (including migraine); 10 for abdominal pain; two studies treated participants with either a primary diagnosis of abdominal pain or irritable bowel syndrome, two studies treated adolescents with fibromyalgia, two studies included adolescents with temporomandibular disorders, three were for the treatment of pain associated with sickle cell disease, and two studies treated adolescents with inflammatory bowel disease. Finally, three studies included adolescents with mixed pain conditions. Overall, we judged the included studies to be at unclear or high risk of bias. Children with headache pain We found that psychological therapies reduced pain frequency post‐treatment for children and adolescents with headaches (risk ratio (RR) 2.35, 95% confidence interval (CI) 1.67 to 3.30, P < 0.01, number needed to treat for an additional beneficial outcome (NNTB) = 2.86), but these effects were not maintained at follow‐up. We did not find a beneficial effect of psychological therapies on reducing disability in young people post‐treatment (SMD ‐0.26, 95% CI ‐0.56 to 0.03), but we did find a beneficial effect in a small number of studies at follow‐up (SMD ‐0.34, 95% CI ‐0.54 to ‐0.15). We found no beneficial effect of psychological interventions on depression or anxiety symptoms. Children with mixed pain conditions We found that psychological therapies reduced pain intensity post‐treatment for children and adolescents with mixed pain conditions (SMD ‐0.43, 95% CI ‐0.67 to ‐0.19, P < 0.01), but these effects were not maintained at follow‐up. We did find beneficial effects of psychological therapies on reducing disability for young people with mixed pain conditions post‐treatment (SMD ‐0.34, 95% CI ‐0.54 to ‐0.15) and at follow‐up (SMD ‐0.27, 95% CI ‐0.49 to ‐0.06). We found no beneficial effect of psychological interventions on depression symptoms. In contrast, we found a beneficial effect on anxiety at post‐treatment in children with mixed pain conditions (SMD ‐0.16, 95% CI ‐0.29 to ‐0.03), but this was not maintained at follow‐up. Across all pain conditions, we found that adverse events were reported in seven trials, of which two studies reported adverse events that were study‐related. Quality of evidence We found the quality of evidence for all outcomes to be low or very low, mostly downgraded for unexplained heterogeneity, limitations in study design, imprecise and sparse data, or suspicion of publication bias. This means our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect, or we have very little confidence in the effect estimate; or the true effect is likely to be substantially different from the estimate of effect. Authors' conclusions Psychological treatments delivered predominantly face‐to‐face might be effective for reducing pain outcomes for children and adolescents with headache or other chronic pain conditions post‐treatment. However, there were no effects at follow‐up. Psychological therapies were also beneficial for reducing disability in children with mixed chronic...