The relationships between prolonged or chronic musculoskeletal pain and psychological factors are complex and multifactorial. The relationships can be characterized as neurobiopsychological in etiology and manifestation. Mental health influences the experience and perception of pain, treatment adherence, and functional outcomes. Thus, patients with chronic pain should be screened for comorbid mental health conditions. Accurate diagnosis helps determine which integrative modalities are most likely to be effective for treatment of musculoskeletal pain and dysfunction. Pharmacologic treatment can reduce or alleviate mental health symptoms that negatively interact with pain and dysfunction. Integrative modalities include psychological therapies such as cognitive behavior therapy, mindfulness-based stress reduction, acceptance and commitment therapy, and cognitive functional therapy. Physicians should engage their patients in open and nonjudgmental discussion about beliefs regarding pain and dysfunction and the use of integrative therapies. They can educate patients on how to identify accurate information about these modalities, allowing patients to make informed decisions regarding their use. Health insurance will typically pay for short courses of psychotherapies and some somatic therapies, but access to licensed clinicians is limited in many areas. Insurance rarely covers supplements and other integrative, nonmainstream therapies.

Case 4. JJ is a 45-year-old man with chronic low back pain who is experiencing significant stress and anxiety related to the pain, which in turn exacerbate his symptoms. He had cognitive behavior therapy (CBT) for depression as a young adult, and he asks whether CBT will help with his current problem.