Loneliness Exacerbates the Association Between Bodily Pain and Depressive Symptoms Among Middle-Aged and Older Latinx Adults

Abstract

Objectives: To investigate the associations between three bodily pain dimensions (intensity, frequency, severity) and depressive symptoms among middle-aged and older Latinxs ages 40–94 and to determine whether loneliness conditioned the pain-depressive symptoms associations. Methods: Data are from a community-based study of community-dwelling residents in Florida (N = 527). Multivariable linear regression models assessed the impact of each pain dimension on depressive symptoms, controlling for sociodemographic factors. Interactions determined whether loneliness moderated the pain-depressive symptoms relationships. Results: Each pain dimension was positively associated with depressive symptoms (p < .01). Loneliness modified the impact of pain frequency and pain severity on depressive symptoms. Those with moderate and high loneliness levels experienced an amplified pain-depressive symptoms association. Discussion: Findings underscore the synergistic effects of pain and loneliness in exacerbating depressive symptomatology among middle-aged and older Latinx adults. Loneliness is an important point of intervention to improve mental health among aging Latinxs.

Keywords

pain loneliness depressive symptoms Latinx

The prevalence of depressive symptoms is disproportionately high among Latinxs, relative to non-Hispanic Whites (Vrany et al., 2021). National estimates show that over one-quarter of all Latinx adults experience high depressive symptomatology, making it an urgent public health concern (Wassertheil-Smoller et al., 2014). Latinxs are the largest ethnic minoritized population in the U.S., comprising 17.8% of the total U.S. population in 2016 (U.S. Census Bureau, 2018a). Latinxs are an aging population, as Latinxs 65 years and older are projected to increase from 8% of the U.S. population in 2016% to 21% by 2060 (U.S. Census Bureau, 2018b). Depression is especially problematic among Latinx adults 65 years and older as they experience a higher prevalence of depression than their non-Hispanic White counterparts (Hooker et al., 2019). Depression is associated with a wide-range of adverse health outcomes, such as higher risk of stroke, heart disease, and all-cause mortality (Castañeda et al., 2016; Clarke & Currie, 2009; Lerman et al., 2018; Wei et al., 2022). Moreover, Latinxs experience several barriers in accessing mental health care services, which further contributes to an underutilization of mental health service use and an exacerbation of mental health disparities among this population (Barrio et al., 2008; Padilla-Frausto et al., 2021). Given that the adverse consequences associated with depression are significant, it is imperative to ameliorate this high mental health burden among this aging population. Furthermore, because the prevalence of depression is under-diagnosed and undertreated among racial and ethnic minoritized groups (Wassertheil-Smoller et al., 2014), assessing depressive symptoms (e.g., restless sleep, poor appetite, feelings of guilt and worthlessness) rather than depression is better suited to investigate mental health burden among middle-aged and older Latinx adults.

Pain and Depressive Symptoms

Bodily pain is a well-established risk factor for depressive symptoms (Bauer et al., 2016; Bierman & Lee, 2018). Given that older Latinx adults experience a high burden of bodily pain (Jimenez et al., 2013; Reyes-Gibby et al., 2007; Sodhi et al., 2020), it is especially important to investigate the pain-depressive symptoms relationship among this population. Although the relationship between pain and depressive symptoms is well-established in general, research on the mental health implications of bodily pain among Latinxs is less clear.

An emerging body of research has documented the negative impact of bodily pain for depressive symptoms among Latinx adults (Bierman & Lee, 2018; Paulus et al., 2016; Zvolensky et al., 2017, 2021). For instance, bodily pain can contribute to emotional suffering and pain-related life alterations that reduce mobility and physical activity, thereby increasing the risk for depressive symptoms (Rutledge et al., 2013). Cross-sectional studies indicate that bodily pain significantly increases the risk of depressive symptoms among Latinx adults (Paulus et al., 2016; Zvolensky et al., 2017). Likewise, longitudinal studies show that chronic pain is associated with higher depressive symptomatology among Latinx adults over time (Bierman & Lee, 2018). Collectively, this research underscores the adverse role of bodily pain for depressive symptoms among Latinx adults. Although bodily pain has been causally linked with elevated levels of depressive symptoms among Latinx adults (Bierman & Lee, 2018), not all Latinxs who experience bodily pain experience elevated depressive symptomatology. This raises questions concerning under what conditions and for whom is bodily pain linked with depressive symptoms, ultimately providing strong grounds to identify the factors that may modify the pain-depressive symptoms relationship. Given its significance among aging populations, the present study investigates the role of loneliness in shaping the impact of bodily pain on depressive symptoms among Latinx adults.

Loneliness Among Latinx Adults

Prior research has extensively documented the centrality of family relationships and familismo (loyalty to the family) among Latinxs (Alvirez & Bean, 2014; Gallo et al., 2009; Sarmiento & Cardemil, 2009; Villatoro et al., 2014). Perhaps because of the centrality of family among Latinxs and because Latinx adults 65 and older are also more likely to live with family members and less likely to live alone than their non-Hispanic White counterparts (Landale et al., 2006; Lee & Edmonston, 2019), prior research among this population has focused on assessing the role of social resources (e.g., social support, positive and negative family interactions for health (Campos et al., 2008, 2014; Gutierrez & Thomas Tobin, 2021). For instance, familismo values have been linked with both advantageous health outcomes, such as high levels of well-being (Campos et al., 2014) and adverse health outcomes, such as lower cognitive function (Estrella et al., 2021) and high psychological distress (Schwartz et al., 2010). Yet, far less research has investigated loneliness among this population. Although rates of living alone are generally low and familismo is generally high among older Latinxs, these do not necessarily protect individuals from feeling lonely. Regular interactions with others, social isolation, and the psychological state of feeling lonely are fundamentally distinct (Gutierrez & Thomas Tobin, 2021).

Loneliness refers to the subjective feeling of being isolated (National Academies of Sciences, Engineering, and Medicine, 2020) and the subjective feeling of having insufficient social relationships (Hawkley & Cacioppo, 2010). Loneliness is a risk factor for a broad range of adverse health outcomes, such as functional decline, premature mortality, and high rates of clinically significant anxiety and depression (Hawkley & Cacioppo, 2010; Heinrich & Gullone, 2006; National Academies of Sciences, Engineering, and Medicine, 2020). Older Latinx adults are at particularly high risk of experiencing loneliness (Gerst-Emerson et al., 2014). Because loneliness is also associated with increased pain (Jaremka et al., 2013; Wolf & Davis, 2014), there are strong grounds to assess whether loneliness exacerbates the relationship between bodily pain and depressive symptoms. It may be that those who experience high levels of loneliness experience an amplification of the well-documented pain-depressive symptoms relationship, relative to those who experience low levels of loneliness. Yet, no studies have assessed whether bodily pain and high levels of loneliness interact to intensify depressive symptoms among middle-aged and older Latinx adults. This gap in the literature ultimately obscures a potentially high-risk segment of the population and undermines efforts to mitigate the high mental health burden among this population.

Prior research has begun investigating the psychosocial factors that explain, amplify, or diminish the adverse impact of pain on depressive symptoms. For instance, research has documented a range of psychosocial mechanisms (e.g., anxiety sensitivity, emotion dysregulation) through which bodily pain shapes depressive symptoms among Latinxs (Paulus et al., 2016; Zvolensky et al., 2017). Other studies have investigated whether race and ethnicity and subjective social status moderate the relationship between chronic pain and depressive symptoms (Bierman & Lee, 2018). Yet, no studies have assessed whether loneliness modifies the pain and depressive symptoms relationship among Latinx adults. Although prominent sociological perspectives point to the protective role of some psychosocial factors (e.g., social support) for mental health (Pearlin, 1999), far less research has focused on assessing whether loneliness amplifies the adverse impact of distinct risk factors on health. Just as it is critical to identify the factors that buffer against the adverse impact of pain on depressive symptoms, it is also critical to identify the factors that may exacerbate this relationship among Latinx adults. Identifying subgroups of Latinx adults who may be at high risk of experiencing elevated depressive symptoms can inform health promotion efforts among this fast-growing segment of the U.S. population.

The Present Study

Although a large body of literature has investigated the relationship between bodily pain and depressive symptoms among non-Hispanic Whites, far less research has focused on the pain-depressive symptoms relationship among Latinxs. Among the few studies focused on the Latinx population, several gaps remain. First, research among Latinxs has primarily assessed a single domain of bodily pain, such as pain intensity or pain severity (Paulus et al., 2016; Zvolensky et al., 2017, 2021). Assessing a single domain of bodily pain may obscure the unique role of distinct pain dimensions for depressive symptoms among this population. Assessing the distinct relationships between multiple domains of body pain (e.g., frequency, intensity, severity) and depressive symptoms can identify the most effective points of intervention. Pain frequency refers to how often individuals experience pain; pain intensity refers to the magnitude of the pain; and pain severity refers to the combination of pain frequency and intensity (Gayman et al., 2011). Second, although a large body of research has documented the protective role of psychosocial factors for mental health outcomes, no studies, to our knowledge, have investigated whether loneliness exacerbates the relationship between pain and depressive symptoms among Latinx adults. Given that older adults experience a high burden of both bodily pain and loneliness, it is critical to assess whether bodily pain and loneliness interact to exacerbate depressive symptomatology among this population. Third, prior research assessing the pain-depressive symptoms relationship among Latinxs has focused on young (Zvolensky et al., 2021) or middle-aged adults (Paulus et al., 2016; Zvolensky et al., 2017), with few studies focusing on older adults (Bierman & Lee, 2018). Given that the risk of experiencing pain increases with age (Johannes et al., 2010) and the prevalence of loneliness is high among older adults (Gerst-Emerson et al., 2014), it is critical to identify whether subgroups of the middle-aged and older Latinx population are at high-risk for depressive symptoms. As midlife is the time in the life course when health disparities become apparent (House et al., 2005; Upchurch et al., 2015), we focus on Latinx adults ages 40 and older. To mobilize resources and promote healthy aging among this fast-growing segment of the population, it is critical to identify under-resourced and high-risk segments of this population. Collectively, these gaps suggest we have a limited understanding of the association between bodily pain, loneliness, and depressive symptoms among middle-aged and older Latinx adults.

Therefore, the aims of the present study were to evaluate the direct relationship between three dimensions of bodily pain (frequency, intensity, and severity) and depressive symptoms and to determine whether the pain-depressive symptoms association is conditional on loneliness among middle-aged and older Latinx adults. We hypothesized that each pain dimension would be positively associated with depressive symptoms. We also hypothesized that high levels of loneliness would exacerbate the pain -depressive symptoms association among middle-aged and older Latinx adults.

Methods

Study Design and Sample

Data are from a community-based study of community-dwelling residents of Miami-Dade County, Florida. The primary objectives of the larger study were to develop epidemiological estimates of lifetime and current prevalence of psychiatric and substance disorders among community-residing individuals with and without a physical disability and to identify factors that increase and decrease risk for psychiatric and substance disorders (Turner et al., 2006). Data were collected between 2003 and 2004 (n = 1600). To obtain an equal distribution of those with and without disability, data collection oversampled those with a disability. All interviews were administered in English or Spanish (Turner et al., 2006). Interviewers obtained informed consent prior to commencing each interview.

Participants were sampled so as to achieve equal representation (25% each) of Cuban, Non-Cuban Latinx, Black, and non-Hispanic White racial and ethnic groups (Turner et al., 2006). Given the oversampling of individuals with a disability and the older age of participants, relative to the general population, the authors do not claim that this sample is representative of the broader Latinx population in the U.S. (Gayman et al., 2008; Turner et al., 2006). To assess relationships between bodily pain, loneliness, and depressive symptoms among middle-aged and older Latinx adults, data for this study were restricted to Latinx adults ages 40 and older (n = 527). Over half of participants were born in Cuba (57%), 39% were born in a different Latin-American country (e.g., Colombia, Nicaragua, Mexico), and 5% were born in the U.S. Additional details on these data have been described in detail elsewhere (Turner et al., 2006).

Measures

Depressive Symptoms

Depressive symptoms were measured using the 20-item Center for Epidemiologic Studies Depression (CES-D) scale (α = .879). The CES-D measures how often a person has experienced depressed mood, sleep disturbance, appetite loss, and feelings of guilt and worthlessness in the past 30 days (Radloff, 1977). Response options were (0) Not at all, (1) Occasionally, (2) Frequently, and (3) Almost all the time. Positive items were reverse coded. Given the lack of consensus determining a cutoff score for constituting a case for depressive symptomatology among Latinxs (Radloff, 1977; Vilagut et al., 2016), CES-D was treated as a continuous variable for all analyses. The possible range of scores is 0–60, with higher scores indicating more depressive symptoms.

Bodily Pain

Participants were asked whether they experienced any bodily pain during the past 4 weeks. Those who noted that they experienced pain were asked about the frequency and intensity of the pain. Those who indicated they did not have bodily pain were not asked questions about pain intensity or pain frequency and received “No pain” and “Never,” respectively, as responses. Pain frequency was assessed by asking, “How often during the past four weeks have you had pain or discomfort?” Responses were (0) Never, (1) A few times, (2) Often, and (3) Everyday or almost everyday. Pain intensity was assessed using one item: “On average, how bad has your bodily pain been during the past four weeks?” Responses were (0) No pain, (1) Mild pain, (2) Moderate pain, and (3) Severe pain. Pain severity, which considers both pain frequency and intensity, was obtained by multiplying pain frequency and pain intensity with each other (Gayman et al., 2008, 2011).

Loneliness

Loneliness was assessed using a three-item scale (α = .663): “During the past few months, about how often have you felt lonely?,” “During the past few months, when you felt lonely, how lonely did you feel?,” and “Compared to other people your age, how lonely do you think you’ve been during the past few months?” (Gutierrez & Thomas Tobin, 2021). Responses were (0) Occasionally, (1) About half the time, (2) Often, and (3) Most of the time. Items were summed so that higher scores indicate higher levels of loneliness. The possible range of scores is 0–9. Although the Cronbach Alpha value was within an acceptable range for internal stability and consistency (Daud et al., 2018; Pallant, 2001), we also conducted a factor analysis to further examine the three items of the loneliness scale. Factor loadings confirmed that all three items load onto one factor: loneliness. Loneliness was continuous in all regression models. Loneliness was dichotomized (0–4 = low loneliness; 5–9 = moderate to high loneliness) to assess whether each of the three bodily pain dimensions varied between those with low levels of loneliness compared to those with moderate to high levels of loneliness (see Supplemental Table 1) and to estimate predicted depressive symptom scores associated with bodily pain.

Covariates

Gender was dichotomized as (0) Male and (1) Female. Marital status was categorized as (0) Married, (1) Never Married, and (2) Formerly Married (divorced, separated, and widowed). Socioeconomic status (SES) was calculated based on the composite scores of three equally-weighted items: occupational prestige, household income of each participant, and education (Hollingshead, 1957). Education was measured using years of education. Self-reported annual household income was measured using five categories ranging from less than $35,000 to $95,000+. Occupational prestige was determined using the Nam-Powers-Boyd occupational scores for 2000, such that higher scores correspond with higher occupational levels (Nam and Boyd, 2004). Consistent with prior research and to circumvent problems with missing data, SES scores were then calculated for each respondent by first standardizing and summing the three SES dimensions; scores were then divided by the number of dimensions on which data were available (Brown, 2014; Gayman et al., 2011). SES scores were then categorized to approximate tertiles. Equally weighting education, income, and occupational prestige to form a single SES measure yields a comprehensive assessment of SES while reducing data loss on individual indicators (Brown, 2014). Moreover, by considering simultaneous positions in multiple social locations, this comprehensive approach may better capture individuals’ placement within a social hierarchy (Erving & Thomas, 2018). Language preference was assessed using one item: “What language do you prefer to speak?” Responses were (0) English most or all the time, (1) Spanish and English equally, (2) Spanish most or all of the time. Country of birth was assessed by asking participants, “Where were you born?” Responses were (1) U.S., (2) Cuba, (3) Columbia, (4) Mexico, (5) Dominican Republic, (6) Nicaragua, (7) Puerto Rico, (8) Guatemala, (9) El Salvador, and (10) Other. Response categories were collapsed into three categories: (0) U.S., (1) Cuba, and (3) Other Latin American Country. Age was measured continuously by asking, “How old are you?” Age ranged from 40 to 94 years.

Analysis

Data analysis was conducted in three steps using Stata 16 (StataCorp, 2013). First, descriptive statistics were used to describe the sample (see Table 1). Second, t-tests were used to assess whether each of the three bodily pain dimensions varied between those with low levels of loneliness compared to those with moderate to high levels of loneliness (see Supplemental Table 1). Third, seven multivariable linear regression models were conducted to predict depressive symptoms. To assess the individual role of each pain dimension in predicting depressive symptoms, pain dimensions were entered in separate regression models. Model one considered the role of pain frequency on depressive symptoms; Model 2 considered pain intensity, and Model 3 considered pain severity. Model 4 considered the role of loneliness in predicting depressive symptoms. Models 5-7 assessed the interactions between each pain dimension and loneliness. For ease of interpretation, both the unstandardized (B) and standardized (β) regression coefficients were presented (see Table 2). All regression models controlled for age, gender, marital status, SES, and country of birth. Although a score of 16 is the recommended CES-D cutoff score for constituting a case for depressive symptomatology among non-Hispanic Whites, prior research suggests the cutoff should be higher (between 16 and 20) among some racial and ethnic minoritized groups (Radloff, 1977; Vilagut et al., 2016). Given the lack of consensus determining a cutoff score among Latinxs (Radloff, 1977; Vilagut et al., 2016), CES-D was treated as a continuous variable for all analyses and, therefore, multivariable linear regressions were conducted. Fourth, for all interactions, we estimated predicted depressive symptom scores associated with bodily pain across two levels of loneliness (low loneliness and moderate to high loneliness). All interactions are depicted graphically in Figure 1.

Table 1.

Participant Characteristics, 2003–2004 (N = 527).

	Percent	Mean (SD.)
Depressive symptoms [0, 48]		15.6 (9.13)
Pain frequency [0, 3]		.7 (1.04)
Pain intensity [0, 3]		.8 (1.16)
Pain severity [0, 9]		1.7 (2.69)
Loneliness [0, 9]		4.2 (1.72)
Gender
Male	46.5
Female	53.5
Marital status
Married	50.7
Formerly married	42.5
Never married	6.8
SES
Low	42.9
Moderate	27.1
High	30.0
Language preference
English most or all of the time	72.5
Spanish and english equally	16.9
Spanish most or all of the time	10.6
Country of birth
U.S.	4.6
Cuba	56.7
Other Latin American Country	38.7
Age [40, 94]		62.0 (13.00)

Note: Variable ranges included in brackets. Percents may not add up to one-hundred due to rounding.

Table 2.

Depressive Symptoms Regressed on Pain and Loneliness (N = 527).

	b	SE b	95% CI	β
Model 1
Pain frequency	1.73***	.38	(.98, 2.49)	.20***
Model 2
Pain intensity	1.15**	.35	(.47, 1.83)	.15**
Model 3
Pain severity	.54***	.15	(.25, .83)	.16***
Model 4
Loneliness	.85***	.23	(.39, 1.30)	.16***
Model 5
Pain frequency	−.43	1.03	(−2.46, 1.60)	−.05
Loneliness	.41	.28	(−.13, .96)	.08
Pain frequency x loneliness	.46*	.21	(.03, .88)	.26*
Model 6
Pain intensity	−.57	0.9	(−2.34, 1.21)	−.07
Loneliness	.46	.29	(−.11, 1.03)	.08
Pain intensity x loneliness	.38	.19	(−.00, .76)	.24
Model 7
Pain severity	−.28	.39	(−1.05, .49)	−.08
Loneliness	.47	.08	(−.06, 1.01)	.09
Pain severity × loneliness	.18*	.08	(.01, .34)	.26*

Note: All models control for age, gender, marital status, SES, and country of birth. b = unstandardized beta; SE b = standard error of unstandardized beta; CI = 95% confidence interval; β = standardized beta. *p < .05; **p < .01; ***p < .001 (two-tailed tests).

Figure 1.

Bodily pain and depressive symptoms across loneliness levels. (a) presents the significant interaction between pain frequency and loneliness on depressive symptoms, p = .035. (b) presents the statistically non-significant relationship between pain intensity and depressive symptoms across loneliness levels, p = .052. (c) presents the significant interaction between pain severity and loneliness on depressive symptoms, p = .032. Collectively, findings indicate there were significant interactions between pain frequency and pain severity, but not pain intensity, on depressive symptoms across loneliness levels. Results demonstrate that the adverse risk of pain frequency and pain severity on depressive symptoms was amplified among those with moderate and high loneliness levels. *p < .05; **p < .01; ***p < .001 (two-tailed tests).

Results

Participant Characteristics

Descriptive statistics of depressive symptoms, bodily pain, loneliness, and participant sociodemographic characteristics are presented in Table 1. Most participants were born outside of the United States (95%); over half of participants were born in Cuba (57%). Most participants preferred to speak English most or all of the time (73%). The sample is comprised of a similar distribution of men (47%) and women (54%). The average age among participants was 62 years. On average, participants had high depressive symptoms scores (M = 15.6, SD = 9.13) and moderate levels of loneliness (M = 4.2, SD = 1.72).

Pain and Loneliness

T-tests were used to assess whether each of the three bodily pain dimensions varied between those with low levels of loneliness compared to those with moderate to high levels of loneliness. Results indicate that there were no mean differences in bodily pain across loneliness levels (see Supplemental Table 1). In other words, results show that loneliness was not associated with pain frequency, intensity, or severity.

Pain and Loneliness Positively Associated with Depressive Symptoms

Multivariable linear regression models are presented in Table 2. Models 1–3 present the relationship between each bodily pain dimension and depressive symptoms, controlling for age, gender, marital status, SES, and country of birth. Each bodily pain dimension was significantly associated with higher depressive symptoms. For instance, controlling for age, gender, marital status, SES, and country of birth, each one unit increase in pain frequency was associated with a 1.73 unit increase in depressive symptom scores (p < .001). Likewise, pain intensity (p = .001) and pain severity (p < .001) were positively associated with depressive symptom scores. Although each pain dimension was significantly associated with depressive symptoms, pain frequency had the strongest association with depressive symptoms (β = .20), relative to pain severity (β = .16) and pain intensity (β = .15). Model 4 results indicate that loneliness is positively associated with depressive symptoms, (p < .001).

Pain and Depressive Symptoms Across Loneliness Levels

The interactive effects of pain and loneliness on depressive symptoms are presented in Table 2, Models 5-7 and graphically presented in Figure 1. Model 5 shows there is a significant interaction between pain frequency and loneliness on depressive symptoms, p = .035. Figure 1(a) presents the interaction between pain frequency and loneliness on depressive symptoms. Among those with low levels of loneliness, increases in pain frequency were associated with a slight increase in depressive symptoms scores. Among those with moderate to high levels of loneliness, an increase in pain frequency was associated with a steep rise in depressive symptom scores. Overall, results demonstrate that the relationship between pain frequency and depressive symptoms is amplified among those with moderate to high levels of loneliness.

Table 2, Model 6 tests the interaction between pain intensity and loneliness on depressive symptoms. Results indicate that the impact of pain intensity on depressive symptoms was consistent across loneliness levels, p = .052. Figure 1(b) graphically depicts the relationship between pain intensity and depressive symptoms across loneliness levels. Although not statistically significant, the trends presented in Figure 1(b) are similar to those in Figures 1a and 1(c), such that the relationship between pain intensity and depressive symptoms is amplified among those with high levels of loneliness.

Results from Table 2, Model 7 indicate there is a significant interaction between pain severity and loneliness on depressive symptoms, p = .032. Figure 1(c) presents the interaction between pain severity and loneliness on depressive symptoms. Among those with low loneliness levels, increases in pain severity were associated with a slight increase in depressive symptoms. However, among those with moderate and high loneliness levels, increases in pain severity were associated with steeper increases in depressive symptoms. To determine whether results remained consistent if using the binary CES-D variable (cutoff of 16), we also conducted a sensitivity analysis using multivariable logistic regression. The associations between each pain dimension and depressive symptoms remained the same. However, the association between loneliness and depressive symptoms and some interactions between pain and loneliness on depressive symptoms differed. Specifically, the interactions between loneliness and pain frequency and pain severity dropped below conventional statistically significant thresholds. Given that logistic regression is inherently different from linear regression and only 42% of the sample (n = 225) fell within the “depressed” category, it is possible that the small sample size resulted in limited statistical power for detecting differences.

Collectively, findings from the multivariable linear regressions indicate there were significant interactions between pain frequency and pain severity, but not pain intensity, on depressive symptoms across loneliness levels. Results show that those with moderate and high levels of loneliness experienced the highest depressive symptom scores across all levels of bodily pain. Findings demonstrate that the adverse risk of pain frequency and pain severity on depressive symptoms was amplified among those with moderate and high loneliness levels.

Discussion

Latinx adults experience a disproportionately high burden of depressive symptomatology. To inform culturally-tailored mental health promotion programs, it is critical to identify factors that amplify or diminish depressive symptomatology among this population. Given the dearth of research investigating the direct and indirect roles of loneliness in shaping depressive symptoms among middle-aged and older Latinx adults, the purpose of this study was to two-fold. First, we assessed the direct relationships between three dimensions of bodily pain (frequency, intensity, and severity) and depressive symptoms. We hypothesized that each pain dimension would be positively associated with depressive symptoms. We found evidence to support this hypothesis. Each bodily pain dimension was independently associated with more depressive symptoms. Second, we examined whether loneliness conditioned the pain-depressive symptoms association among middle-aged and older Latinx adults. We hypothesized that high levels of loneliness would exacerbate the pain-depressive symptoms relationship. We found evidence to partially support this hypothesis. Specifically, loneliness modified the impact of pain frequency and pain severity—but not pain intensity—on depressive symptoms. Collectively, findings demonstrate the direct and indirect mechanisms by which bodily pain and loneliness shape mental health among middle-aged and older Latinx adults.

Our finding that each bodily pain dimension was positively associated with depressive symptoms bolsters prior research documenting the adverse consequence of bodily pain for depressive symptoms among Latinx adults (Paulus et al., 2016; Zvolensky et al., 2017). Prior research has focused on young (Zvolensky et al., 2021) or primarily middle-aged adults (Zvolensky et al., 2017). To our knowledge, only one study has assessed the role of chronic pain on depressive symptoms among Latinxs ages 51 and older (Bierman & Lee, 2018). Moreover, prior research has typically assessed the association between a single pain dimension (e.g., pain intensity, pain severity) on depressive symptomatology. Consequently, the present study extends prior research by demonstrating that pain frequency, pain intensity, and pain severity are each risk factors for elevated depressive symptoms among middle-aged and older Latinx adults. Results from supplemental analyses (see Supplemental Table 2) further illustrate the clinical significance of these findings. For instance, even a one-point increase in pain frequency or intensity corresponded with a significant increase in depressive symptoms, such that individuals who reported experiencing pain only a few times in the past month or had mild pain relative to no pain at all had depressive symptoms scores that reached the threshold for clinical significance (i.e., scores of 16 or higher; Radloff, 1977). Slight increases in pain severity scores (e.g., increase of three points) were also linked to clinically meaningful depressive symptoms scores. Thus, our findings underscore the impact of bodily pain on depressive symptoms for Latinx adults. Moreover, by assessing distinct pain dimensions, findings suggest that although each pain dimension was significantly associated with depressive symptoms, pain frequency has the strongest association with depressive symptoms, relative to pain severity and pain intensity.

Our finding that loneliness is a significant predictor of higher depressive symptomatology extends the dearth of loneliness research among Latinxs. Although prior research among the general population has investigated the adverse mental health consequences of loneliness (Beutel et al., 2017; National Academies of Sciences, Engineering, and Medicine, 2020), only a handful of studies have assessed the loneliness-depressive symptoms relationship among Latinxs. Among Latinxs, research has focused on the role of social isolation (Ramos et al., 2015; Ward et al., 2018), social support (Bostean et al., 2019), and social ties (Viruell-Fuentes et al., 2013) on mental health among Latinxs, but loneliness itself remains largely understudied among Latinxs. Only one study has investigated the adverse role of loneliness on depressive symptoms among Latinx college students (Chang et al., 2011). As such, the present study advances this area of research by highlighting loneliness as a risk factor for depressive symptoms among our sample of middle-aged and older Latinxs in Miami-Dade County.

Our finding that loneliness conditions the pain-depressive symptoms association extends the knowledge base on risk factors for depressive symptoms. Those with moderate and high levels of loneliness experienced the highest depressive symptom scores across all levels of bodily pain. Interestingly, we only observed significant patterns for pain frequency and pain severity, not pain intensity. Given that severity is the multiplicative combination of frequency and intensity, we can think about severity as the impact of frequent pain that is amplified by how intense one’s pain is, or the intensity of an individual’s pain amplified by how frequently it occurs. Thus, loneliness seems to be particularly influential for pain that is both frequent and intense. To our knowledge, no prior study has assessed the modifying role of loneliness in the pain-depressive symptoms association. Our findings contribute to a growing body of research documenting the health risks of loneliness. Findings identify the synergistic effects of loneliness and bodily pain in shaping mental health among this population. Findings underscore the need to address the burden of bodily pain, loneliness, and mental health among aging Latinx adults, given the triple threat that that Latinxs are experiencing in today’s context: (1) Latinxs experience a high prevalence of bodily pain, (2) Latinxs experience barriers to and underutilization of mental health services, and (3) older adults have experienced an increase in loneliness during the COVID-19 pandemic (Barrio et al., 2008; Fuller & Huseth-Zosel, 2022; Padilla-Frausto et al., 2021; Wassertheil-Smoller et al., 2014).

Strengths and Limitations

Results should be considered in light of several limitations. First, by using cross-sectional data, findings cannot be used to determine causality or temporal ordering. Although this study found that loneliness is positively associated with higher depressive symptomology, prior research has also documented depressive symptoms as a predictor of loneliness among Latinxs ages 80 and older (Gerst-emerson et al., 2014). Furthermore, research has also documented the reciprocal relationship between pain and depressive symptoms (Gayman et al., 2011). Similarly, prior research has documented the bidirectional relationship between pain and loneliness (Emerson et al., 2018; Jaremka et al., 2013; Wolf & Davis, 2014). As a result of using cross-sectional data and because of the bidirectional relationships between pain, loneliness, and depressive symptoms, determining directionality is a limitation of this study. To address this limitation, future research using longitudinal data should assess directional and bidirectional relationships linking bodily pain, loneliness, and mental health over time. Second, the regional sample of Latinxs in our study limits our ability to generalize results to the broader Latinx population living in the U.S. For instance, given the oversampling of individuals with disability and the older age of participants, relative to the general population, the authors do not claim that this sample is representative of the broader Latinx population in the U.S. (Gayman et al., 2008; Turner et al., 2006). For instance, over half of our sample was born in Cuba, yet only 1.1 million of the U.S. 50.7 million Latinxs were foreign-born Cubans in 2010 (Noe-Bustamante et al., 2019; Noe-Bustamante & Flores, 2019). While Miami-Dade is an important area for Latinx history and culture, a sample from this county may not be representative of the broader Latinx experience in the U.S. For instance, prior research has documented subgroup differences in depressive symptomatology among older Latinxs, with Puerto Ricans having the highest prevalence of depressive symptoms, followed by Cuban Americans, Mexican Americans, and other Latinxs (Yang et al., 2008). Although some scholars have investigated depressive symptomatology among Cuban-Americans (Martinez et al., 2019), there is a dearth of research that has conducted within-group analyses using large datasets to investigate factors that amplify and diminish depressive symptomology among Latinxs. Given the heterogeneity of Latinxs living in the U.S., future research drawing on nationally representative disaggregated data with large sample sizes should consider sub-group analyses that consider the role of distinct factors (e.g., gender, generational status, geographic location, and country of birth) in shaping these focal relationships. Third, data for this study were collected in 2003–2004. Despite the data being collecting nearly two decades ago, bodily pain, loneliness, and depressive symptoms continue to be persistent public health concerns. Investigating the linkages between bodily pain, loneliness, and depressive symptoms can elucidate points of intervention to promote mental health among an under-researched yet growing segment of the U.S. population. Fourth, individuals who were disabled as a result of social, cognitive or psychological causes (e.g., mental retardation, developmental disability, dementia) were excluded from this study. Individuals in these groups were excluded as they represent very small subcategories of the community-based population with activity limitations; their inclusion would yield far fewer cases than necessary for separate analyses (Turner et al., 2006). Although social, cognitive, or psychosocial disabilities are potentially important factors in bodily pain, loneliness, depressive symptoms, it would be more appropriate to conduct separate studies tailored for these subgroups (Turner et al., 2006). Nevertheless, the sampling approach was uniquely positioned to investigate physical and mental health impairments among community-dwelling Latinx adults. Given the prevalence of co-occurring psychiatric disorders in adults with intellectual disabilities (Mazza et al., 2020), the sampling approach allowed us to effectively capture the pain, loneliness, and depressive symptoms experiences of community-dwelling Latinx adults in Miami-Dade county. Ultimately, these data were a strong fit given the fact that the dataset could be used to test the research questions and hypotheses raised in this study, the unique sampling approach, and the sample size of 527 middle-aged and older Latinx adults. Finally, as age was not statistically significant in any of the seven regression models, we did not stratify the analysis by age. Findings suggest that middle-aged and older Latinx adults would both benefit from mental health programs targeting pain and loneliness. To develop tailored interventions, future research with larger sample sizes should investigate the relationships between bodily pain, loneliness, and depressive symptoms across the life course.

Nevertheless, this study makes several important contributions. First, we identify three distinct pain dimensions as risk factors for elevated depressive symptomatology. Prior research has generally assessed a single pain dimension at a time, which obscures which pain dimension(s) should be a focus of health promotion programs. Our findings suggest that pain frequency, pain intensity, and pain severity are each risk factors for elevated depressive symptomatology among our sample of middle-aged and older Latinxs. Although each pain dimension was significantly associated with depressive symptoms, pain frequency has the strongest association with depressive symptoms, relative to pain severity and pain intensity. Second, we extend the knowledgebase on the adverse health consequences of loneliness. There is a dearth of loneliness research among Latinxs (National Academies of Sciences, Engineering, and Medicine, 2020). Importantly, findings underscore the role of high loneliness levels in amplifying the pain-depressive symptoms association among middle-aged and older Latinxs. Finally, we used a within-group approach. Prior research shows that pain experiences differ across racial and ethnic groups, that loneliness varies by culturally determined norms and values, and that the pain-depressive symptoms relationship varies across racial and ethnic groups (Bierman & Lee, 2018; Edwards et al., 2005). Using a within-group approach identifies pain, loneliness, and mental health relationships among an underexplored segment of the population: middle-aged and older Latinxs.

Conclusions and Implications for Practice and Policy

Findings show that three dimensions of bodily pain (frequency, intensity, and severity) are each independently associated with more depressive symptoms and that pain frequency had the strongest association with depressive symptoms. These findings suggest that interventions addressing bodily pain—and especially pain frequency—may be effective points of intervention to address depressive symptoms among middle-aged and older Latinxs. Findings also demonstrate the health risks linked with loneliness. Loneliness was associated with higher depressive symptomatology. Moreover, the adverse role of pain frequency and pain severity on depressive symptoms was amplified among those with moderate and high loneliness levels. Thus, combating loneliness and bodily pain are important points of public health intervention to address mental health disparities. Prior research shows the centrality of familismo among Latinxs and the value of social programs (e.g., dance programs, support groups) for promoting physical and mental health. Therefore, mobilizing resources to develop culturally-proficient in-person and virtual (Gutierrez et al., 2022) group programs can be an effective strategy to address bodily pain and loneliness among Latinx adults. For instance, in-person and virtual community-based group activities (e.g., Zumba and walking groups) involving family, friends, and community members can tap into familismo and hermandad (solidarity and brotherhood among group) values among Latinxs and can function to reduce loneliness while enhancing social networks, social support, and health. Collectively, our findings demonstrate the need to mobilize resources that address bodily pain, loneliness, and depressive symptoms among middle-age and older Latinxs to promote healthy aging.

Supplemental Material

Supplemental Material - Loneliness Exacerbates the Association Between Bodily Pain and Depressive Symptoms Among Middle-Aged and Older Latinx Adults

Supplemental Material for Loneliness Exacerbates the Association Between Bodily Pain and Depressive Symptoms Among Middle-Aged and Older Latinx Adults by Ángela Gutiérrez, Rosana L. Bravo and Courtney Thomas Tobin in Journal of Aging and Health

Footnotes

Acknowledgements

The authors would like to express deep gratitude and appreciation for Dr. Steven P. Wallace. He was a giant in health disparities scholarship and advocacy. He dedicated his career to advancing health equity. He was a great mentor who so generously gave his time and wisdom to mentor and train countless health disparities scholars. Thank you, Steve. Your legacy will live on through the people and policies you impacted.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Angela Gutierrez

Courtney Thomas Tobin

Supplemental Material

Supplemental material for this article is available online.

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A. G.

Peraza

Nizio

(2021). Pain intensity, pain-related anxiety, and somatic and mental health symptoms: A test among latinx young adults. Psychology, Health & Medicine, 26(3), 289–297. https://doi.org/10.1080/13548506.2020.1764598

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