Depression and pain as interrelated somatic symptoms: Reflections on the Spanish consensus and areas for improvement

To the Editor,

I read with great interest the recently published consensus by Pérez-Solá et al. on the detection and treatment of major depressive disorder (MDD) in patients presenting with pain as a physical symptom. This document represents a valuable contribution toward reducing clinical variability and promoting a structured, interdisciplinary, and evidence-based approach through the rigorous application of the RAND/UCLA methodology and the GRADE system.¹

The authors offer relevant and practical recommendations for both specialized and primary care. I particularly value the emphasis on brief screening tools, the role of dual-action antidepressants such as duloxetine, and the therapeutic benefits of psychoeducational and cognitive-behavioral interventions.

Nonetheless, I identified several aspects that may enrich future iterations or guide further research. Firstly, by focusing solely on MDD, the consensus excludes other affective disorders in which pain is well documented, especially bipolar depression, where pain correlates with greater functional impairment and subjective distress.^2,3 Although the need for a focused scope is acknowledged, expanding the discussion to encompass the broader depressive spectrum would be advantageous.

Secondly, while the document acknowledges factors such as sex, advanced age and rural settings, it does not provide specific strategies to adapt recommendations to these realities in real-world settings. In primary care, structural constraints such as limited consultation time, long waiting lists for psychological support and resource scarcity hinder the practical implementation of several proposals, including access to cognitive behavioral therapy, or the routine use of certain antidepressants recommended in the consensus.^4,5

In addition, there is minimal reference to community-based interventions, social prescribing or group programs. These approaches, increasingly supported by evidence, may offer cost-effective solutions, particularly in settings with low adherence or unequal service access.^6–8 For example, the ‘Salut als Barris’ program in Barcelona (Catalonia, Spain) has successfully implemented more than 180 community-based activities in underserved areas, including psychoeducational groups and social prescribing schemes, with promising results in terms of patient engagement and overall well-being. These outcomes highlight the potential of such strategies to enhance treatment adherence, strengthen patient involvement, and support sustained clinical recovery.⁹

With regard to treatment recommendations, I concur on the importance of considering pain as a moderator of antidepressant response and of prioritizing dual-action agents such as duloxetine. However, I recommend that pharmacologic decisions be tailored to drug availability, individual tolerance, and comorbidity, particularly in older adults.¹⁰

Finally, I commend the consensus for emphasizing the importance of care coordination. Strengthening interdisciplinary organizational models and enhancing professional training will be essential to achieving this goal. In Spain, the feasibility of these models is increasing, as demonstrated by pilot experiences in collaborative care and social prescribing promoted through national mental health strategies and regional initiatives.¹¹ Models such as collaborative care in primary settings, which integrate follow-up, psychological support and patient participation, may facilitate feasible and scalable implementation.¹²

In conclusion, this consensus is an important step toward a more comprehensive approach to a frequent yet often underestimated clinical reality. I hope these reflections contribute to ongoing dialog and continued progress in this area.

Conflicts of interest

None declared.