The tie between physical pain and mental illness can feel like a never-ending and inseparable cycle, with pain causing or worsening mental health symptoms, and mental health issues provoking or exacerbating pain.

Unfortunately, some factors can make that cycle even worse, like being a person of color, qualifying as low-income, having low health literacy, or identifying as LGBTQ+, particularly those who are transgender or nonbinary.

Mental Health of America (MHA | mhanational.org), a nonprofit that promotes mental health and offers resources to those living with mental illness, recently explored this tie in a report titled “Early, Equitable and Trauma Responsive Care for Chronic Pain and Mental Health.”

The report examines thousands of results from individuals who took one of 10 anonymous online screenings for mental health—including depression, bipolar disorder, anxiety, substance and alcohol abuse, psychosis, and post-traumatic stress disorder (PTSD)—and also reported experiencing chronic pain.

MHA found repeated evidence that the challenges inherent in the combination of mental and physical health issues were more stark for members of populations that traditionally have faced disparities, says Maddy Reinert, MHA’s senior director of population health.

“We see a lot of individuals with mental health concerns, and chronic pain, and who are from some of these populations like BIPOC [Black, Indigenous, and people of color] communities, feel especially written off when they try to engage in care, or like they’re not believed because of how invisible both conditions are and how intertwined they are,” Reinert says.

Stark inequity in screening results

MHA’s screenings found that 31% of LGBTQ+ individuals taking a mental health screening reported chronic pain, while 57% of respondents reporting both mental health issues and chronic pain identified as low-income.

“For people who identify as LGBTQ+, for BIPOC individuals, with increasingly visible discrimination and violence and the trauma that carries—all of these experiences are really intertwined and are likely to exacerbate both pain and mental health,” Reinert says.

The MHA report notes that the majority of respondents with chronic pain were white, which reflects research that has found racial disparities in diagnosing chronic pain, particularly among Black individuals. “Other communities of color are even less likely to report experiencing chronic pain in screening, indicating a possible need for more research in the pain experience among diverse communities, to ensure equitable diagnosis and treatment,” the report states.

Of the BIPOC individuals who did fill out a screening, some said they were labeled as “pill shoppers” when they tried to be honest with health care providers about their pain. Others said their experiences with health care providers were so negative that they’ll continue to live with pain and mental health challenges rather than seeking out help again.

Disparity-related trauma worsens health outcomes

Trauma plays a major role in both physical and mental health, notes the MHA report, including trauma that disproportionately affects vulnerable populations, such as the COVID-19 pandemic, police brutality, or racial violence.

“Intentional interpersonal trauma”—in which a perpetrator harms someone knowingly and on purpose—is even more related to pain than non-intentional trauma such as accidents or illness. According to the report, “Widespread exposure to intentional interpersonal trauma that Black, Indigenous, and people of color (BIPOC) experience both in-person and through media may contribute to higher rates of chronic pain and mental health conditions, including PTSD.”

More than half of all adults with a mental illness in America don’t receive treatment, Reinert says. The percentage of Black individuals able to access mental health treatment is 15% lower than that of white patients, while statistics show that access by Asian American individuals with mental illness is 31% lower. Individuals of color are also less likely to have health insurance.

“Those percentages are wild,” Reinert says. “Those are very stark disparities in who’s able to access care.”

For underserved populations seeking mental health care, finding culturally appropriate care and representative providers is one more challenge to add to the list.

“A lot of people of color and people who identify as LGBTQ+ have had negative or even actively traumatizing experiences when they’ve either had a mental health crisis or sought help for their mental health,” Reinert shares. “That creates another barrier to staying in care.”

Closing the gap

On a provider and policy level, there are steps that can be taken, the MHA report states.

Health care providers should proactively initiate conversations about mental health and chronic pain, and should include behavioral health as a central feature of care for chronic pain.

Medical school curriculum needs continual updating to address discrimination and bias—a National Academy of Sciences report found that about half of medical school students falsely believe there are biological differences in pain between Black and white patients, “which leads to racial bias in pain recognition and treatment,” the report states.

On a state and federal level, the MHA recommends that there be a greater investment in better treatments both for chronic pain and mental health conditions.

“This includes investing in better, more representative research to find treatments and develop better pain measurement tools that work for a diverse population,” the report states, “so BIPOC, LGBTQ+, gender diverse, and other communities traditionally underrepresented in this research can be identified, diagnosed, and treated more effectively and appropriately.”

Rebecca McKinsey