← Research 2023 National Health Interview Survey
Analysis in Preparation

Using the 2023 NHIS to Track Subtle Changes in Psychological Risk Profiles for Those Managing Chronic Pain in a Post-COVID World

[PLACEHOLDER — Alec to draft] This study examines psychological outcomes associated with chronic pain using data from the 2023 National Health Interview Survey. Despite relying on the more limited PHQ-4 mental health screening captured by the 2023 NHIS, this analysis expands on the 2019 NHIS manuscript by documenting potential cohort effects changing risk profiles in the youngest participants.

[PLACEHOLDER] The analysis also aims to demonstrate that the elevated risk associated with less intense but more frequent pain is not an artifact of a greater trend of higher treatment utilization for psychological symptoms in America at large. Using the same frequency × intensity × age cohort framework, the study produces nationally generalizable estimates from the NHIS Sample Adult interview.

[PLACEHOLDER] The study uses a population-representative sample from the NHIS Sample Adult interview, applying NCHS-provided survey weights and design variables to produce nationally generalizable estimates.

Initial Findings

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Visual Summary of Initial Findings

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Documentation

Initial Results

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Table 1 — Population Descriptives
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Characteristic n (unweighted) % (weighted) 95% CI
Total sample21,161——
Pain Frequency
Never / rarely14,28068.2%[67.1, 69.3]
Some days4,10319.1%[18.2, 20.0]
Most days / every day2,77812.7%[12.0, 13.5]
Table 2 — Adjusted Risk Ratios (Supplementary Analysis)
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Controlled for demographics, BMI, health behaviors, and health context. Shown below are clinical-threshold outcomes (PHQ-8 ≥ 10, GAD-7 ≥ 10); full results across all six outcomes available in CSV.

Age GroupPain ProfileOutcomeaRR95% CISig
Emerging Adults (18–29)
Intermittent mildPHQ-81.97(1.20–3.22)**
Intermittent mod-severePHQ-83.90(2.63–5.76)***
Frequent mildPHQ-87.15(3.73–13.72)***
Frequent mod-severePHQ-88.95(6.05–13.25)***
Intermittent mildGAD-71.70(1.12–2.59)*
Intermittent mod-severeGAD-72.92(2.04–4.18)***
Frequent mildGAD-76.58(3.67–11.81)***
Frequent mod-severeGAD-75.71(3.99–8.17)***
Young Adults (30–44)
Intermittent mildPHQ-81.72(1.17–2.51)**
Intermittent mod-severePHQ-83.18(2.24–4.52)***
Frequent mildPHQ-85.29(3.19–8.78)***
Frequent mod-severePHQ-88.34(6.06–11.48)***
Intermittent mildGAD-71.93(1.34–2.79)***
Intermittent mod-severeGAD-73.13(2.22–4.42)***
Frequent mildGAD-74.20(2.43–7.25)***
Frequent mod-severeGAD-77.57(5.59–10.26)***
Middle Adults (45–64)
Intermittent mildPHQ-81.57(0.99–2.49)
Intermittent mod-severePHQ-82.70(1.84–3.96)***
Frequent mildPHQ-83.16(1.95–5.13)***
Frequent mod-severePHQ-89.11(6.39–12.99)***
Intermittent mildGAD-71.45(0.90–2.32)
Intermittent mod-severeGAD-72.38(1.56–3.63)***
Frequent mildGAD-72.67(1.56–4.59)***
Frequent mod-severeGAD-77.97(5.43–11.69)***
Older Adults (65+)
Intermittent mildPHQ-81.30(0.85–1.99)
Intermittent mod-severePHQ-82.52(1.57–4.03)***
Frequent mildPHQ-82.65(1.61–4.36)***
Frequent mod-severePHQ-85.50(3.77–8.03)***
Intermittent mildGAD-70.71(0.41–1.23)
Intermittent mod-severeGAD-72.05(1.16–3.62)*
Frequent mildGAD-73.02(1.46–6.27)**
Frequent mod-severeGAD-75.76(3.67–9.05)***

Reference group: No pain within each age group. * p < .05, ** p < .01, *** p < .001

Table 3 — Bonferroni-Corrected Significance
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Bonferroni correction applied across 80 simultaneous tests (αadjusted = .000625), showing 71 tests still met the highest standards. Shown below are clinical-threshold outcomes; full correction results across all outcomes available in CSV.

Age GroupPain ProfileOutcomeaRR95% CIRaw pBonf.
Emerging Adults (18–29)
Intermittent mildPHQ-82.03(1.25–3.31).005
Intermittent mod-severePHQ-84.25(2.89–6.26)< .001✓
Frequent mildPHQ-87.10(3.72–13.56)< .001✓
Frequent mod-severePHQ-89.61(6.61–13.98)< .001✓
Intermittent mildGAD-71.73(1.13–2.62).011
Intermittent mod-severeGAD-73.13(2.20–4.46)< .001✓
Frequent mildGAD-76.56(3.69–11.66)< .001✓
Frequent mod-severeGAD-76.37(4.50–9.02)< .001✓
Young Adults (30–44)
Intermittent mildPHQ-81.77(1.21–2.57).003
Intermittent mod-severePHQ-83.34(2.38–4.70)< .001✓
Frequent mildPHQ-85.92(3.60–9.73)< .001✓
Frequent mod-severePHQ-89.51(7.09–12.76)< .001✓
Intermittent mildGAD-71.96(1.35–2.82)< .001✓
Intermittent mod-severeGAD-73.26(2.34–4.54)< .001✓
Frequent mildGAD-74.80(2.79–8.25)< .001✓
Frequent mod-severeGAD-78.78(6.62–11.66)< .001✓
Middle Adults (45–64)
Intermittent mildPHQ-81.64(1.04–2.58).032
Intermittent mod-severePHQ-82.96(2.04–4.29)< .001✓
Frequent mildPHQ-83.43(2.13–5.53)< .001✓
Frequent mod-severePHQ-810.75(7.66–15.09)< .001✓
Intermittent mildGAD-71.52(0.95–2.43).079
Intermittent mod-severeGAD-72.54(1.68–3.84)< .001✓
Frequent mildGAD-72.79(1.63–4.77)< .001✓
Frequent mod-severeGAD-79.02(6.27–12.98)< .001✓
Older Adults (65+)
Intermittent mildPHQ-81.42(0.93–2.16).106
Intermittent mod-severePHQ-82.80(1.76–4.45)< .001✓
Frequent mildPHQ-83.00(1.84–4.89)< .001✓
Frequent mod-severePHQ-86.65(4.56–9.71)< .001✓
Intermittent mildGAD-70.77(0.45–1.32).336
Intermittent mod-severeGAD-72.27(1.32–3.92).003
Frequent mildGAD-73.24(1.58–6.67).001
Frequent mod-severeGAD-76.67(4.34–10.23)< .001✓

✓ = Survives Bonferroni correction (padjusted < .05). Reference group: No pain within each age group.

Table 4 — E-Values for Unmeasured Confounding
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E-values quantify the minimum strength an unmeasured confounder would need — in its associations with both the exposure and the outcome — to explain away each observed association. Shown below are clinical-threshold outcomes; full results across all outcomes available in CSV.

Age GroupOutcomePain ProfileaRR95% CIE-value (point)E-value (CI)
Emerging Adults (18–29)
PHQ-8Frequent mod-severe9.61(6.61–13.98)18.7112.70
PHQ-8Frequent mild7.10(3.72–13.56)13.686.90
PHQ-8Intermittent mod-severe4.25(2.89–6.26)7.975.23
PHQ-8Intermittent mild2.03(1.25–3.31)3.481.81
GAD-7Frequent mild6.56(3.69–11.66)12.606.84
GAD-7Frequent mod-severe6.37(4.50–9.02)12.228.47
GAD-7Intermittent mod-severe3.13(2.20–4.46)5.713.82
GAD-7Intermittent mild1.73(1.13–2.62)2.851.51
Young Adults (30–44)
PHQ-8Frequent mod-severe9.51(7.09–12.76)18.5113.66
PHQ-8Frequent mild5.92(3.60–9.73)11.326.66
PHQ-8Intermittent mod-severe3.34(2.38–4.70)6.144.19
PHQ-8Intermittent mild1.77(1.21–2.57)2.941.71
GAD-7Frequent mod-severe8.78(6.62–11.66)17.0412.72
GAD-7Frequent mild4.80(2.79–8.25)9.075.02
GAD-7Intermittent mod-severe3.26(2.34–4.54)5.974.11
GAD-7Intermittent mild1.96(1.35–2.82)3.332.04
Middle Adults (45–64)
PHQ-8Frequent mod-severe10.75(7.66–15.09)20.9914.80
PHQ-8Frequent mild3.43(2.13–5.53)6.323.68
PHQ-8Intermittent mod-severe2.96(2.04–4.29)5.373.50
PHQ-8Intermittent mild1.64(1.04–2.58)2.661.24
GAD-7Frequent mod-severe9.02(6.27–12.98)17.5312.02
GAD-7Frequent mild2.79(1.63–4.77)5.022.64
GAD-7Intermittent mod-severe2.54(1.68–3.84)4.522.75
GAD-7Intermittent mild1.52(0.95–2.43)2.401.00
Older Adults (65+)
PHQ-8Frequent mod-severe6.65(4.56–9.71)12.788.59
PHQ-8Frequent mild3.00(1.84–4.89)5.453.08
PHQ-8Intermittent mod-severe2.80(1.76–4.45)5.042.92
PHQ-8Intermittent mild1.42(0.93–2.16)2.201.00
GAD-7Frequent mod-severe6.67(4.34–10.23)12.828.15
GAD-7Frequent mild3.24(1.58–6.67)5.932.54
GAD-7Intermittent mod-severe2.27(1.32–3.92)3.971.97
GAD-7Intermittent mild0.77(0.45–1.32)1.001.00

Higher E-values indicate greater robustness to unmeasured confounding. E-value (CI) represents the lower confidence bound — the more conservative estimate.

Literature Review

The literature review for this 2023 analysis is currently in preparation. It will build on the foundational review from the 2019 NHIS study while incorporating post-pandemic developments in chronic pain research and mental health screening methodology.

This section will be updated once the review is complete.

Working Abstract

Background: Chronic pain and psychological distress frequently co-occur, yet screening approaches typically emphasize pain intensity over frequency. Prior analysis of 2019 National Health Interview Survey (NHIS) data demonstrated that pain frequency independently predicts psychological outcomes and that pain-psychology relationships vary across the lifespan. This study sought to replicate these findings using 2023 NHIS data and to examine whether pain-psychology relationships changed between survey years.

Methods: Cross-sectional analysis of 29,522 adults from the 2023 NHIS, compared to 31,997 adults from the 2019 NHIS. Pain profiles were constructed from frequency and intensity yielding five categories: no pain, intermittent mild, intermittent moderate-severe, frequent mild, and frequent moderate-severe. Psychological outcomes in 2023 included dysphoria, anhedonia, PHQ-2 positive screen, and GAD-2 positive screen derived from the PHQ-4. Survey-weighted quasipoisson regression estimated prevalence ratios across four age groups, adjusting for demographics. Sensitivity analyses controlled for BMI and chronic conditions. Robustness was assessed via Bonferroni correction and E-values.

Results: Frequent mild pain conferred psychological risk equal to or exceeding intermittent moderate-severe pain, particularly in younger adults. Among emerging adults, frequent mild pain showed higher risk than intermittent moderate-severe pain for all five outcomes, including dysphoria (RR=6.64 vs. 2.62), clinical depression (RR=7.10 vs. 4.25), and clinical anxiety (RR=6.56 vs. 3.13). This pattern attenuated with age. When analyses were restricted to untreated individuals, the frequent mild pain association strengthened rather than diminished, ruling out treatment-seeking as an alternative explanation. Despite elevated psychological risk, only 15.0% of emerging adults with frequent mild pain received psychiatric treatment — the only pain profile where distress exceeded treatment utilization.

Conclusions: Core findings replicated: frequent mild pain carried higher psychological risk than intermittent moderate-severe pain in 81% of comparisons, and older adults demonstrated consistent resilience with relative risks 40–50% lower than younger groups. Comparison across survey years revealed population-level improvement, with 78% of age-outcome combinations showing decreased relative risks in 2023. However, 6 of 7 combinations showing increased relative risks occurred in the two youngest age groups, concentrated in frequent moderate-severe pain. Young adults (30–44) showed peak vulnerability in 2023, with relative risks of 7–8 for dysphoria and anhedonia — effects that peaked in middle adults (45–64) in 2019. All frequent moderate-severe findings survived Bonferroni correction (16/16, 100%), with E-values exceeding 5 for most high-risk profiles.

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