Youth Mental Health in Crisis: Understanding the Relationship Between Mental Health and Physical Pain in Lebanon’s Youth – A Scoping Review

Abstract

Objectives:

The mental health crisis among young adults in Lebanon, worsened by events like the Beirut Blast and economic instability, requires urgent attention. Globally, 10%–20% of individuals aged 18–29 face mental health challenges, with many also experiencing physical pain. Despite growing evidence of the bidirectional relationship between mental health and pain, this intersection remains underexplored in Lebanon, especially compared to WEIRD countries. This scoping review examines the relationship between physical pain and mental health issues—anxiety, depression, and stress—among Lebanese youth.

Methods:

A systematic review of studies from January 2014 to February 2024 was conducted by screening PubMed, PsychInfo, and ScienceDirect. A total of 33 studies were included.

Results:

The findings indicate a bidirectional link between mental health and physical pain. University students (36.1% of studies) were particularly impacted, and 81% of studies reported higher pain prevalence among females. Additionally, mindfulness meditation was identified as a potential protective factor, although it remains underexplored in Lebanon.

Conclusion:

Addressing these gaps supports tailored interventions for Lebanese youth and enriches our understanding of mental health in non-WEIRD contexts.

Introduction

Mental health challenges among youth aged 18–29 have become a critical global concern, with 10%–20% of this demographic experiencing significant mental health issues [1]. This concern is particularly acute in Lebanon, where ongoing economic crises, political instability, and the aftermath of traumatic events such as the 2020 Beirut explosion and the COVID-19 pandemic have exacerbated mental health struggles among the youth [2]. Lebanese youth are increasingly affected by severe mental health problems, including stress, anxiety, depression, and post-traumatic stress disorder (PTSD) [3]. The International Labor Organization reports a staggering 23% unemployment rate among Lebanese youth [4], further adding to their financial and psychological burdens. Prior to the current crisis, approximately 25% of young adults in Lebanon experienced high rates of PTSD, with prevalent conditions such as depression (12.6%) and anxiety (16.7%) [5, 6]. Additionally, exposure to frequent violent conflict has left 70% of the population traumatized [7], with a significant proportion of young individuals reporting major depressive disorder, stress-related issues and other anxiety-related conditions [8].

In addition to mental health issues, physical pain has emerged as a major health problem among young populations globally, with around 54% of them reporting physical pain annually [9]. In WEIRD countries (Western, Educated, Industrialized, Rich, and Democratic), common symptoms of physical pain were found to be headaches (8%–83%) and abdominal pain (4%–53%), followed by musculoskeletal pain (4%–40%) and back pain (12%–24%) [10]. According to the Global Burden of Disease, physical pain was the second-highest contributor to global disability in 2018, with 1.9 billion people affected by recurring conditions such as headaches, low back pain, and neck pain—recognized as leading causes of disability [11, 12].

Physical pain was shown to be often associated with mental health issues, such as stress, anxiety and depression [13]. Individuals with depression, stress or anxiety report experiencing physical pain, and the presence of physical pain can also hinder the treatment of mental health conditions [13, 14]. Pereira et al. found that individuals with physical pain were four times more likely to suffer from stress, anxiety or depression than those without pain (Odds ratio [OR] = 4.1) [15]. Conditions such as back pain and stress, anxiety or depression significantly increase the risk of disability, and the co-occurrence of these issues exacerbates this risk [16, 17]. Most of the research on the relationship between mental health and physical pain has been well-documented in the WEIRD cultural contexts where healthcare access, cultural norms, and stressors differ significantly from those in non-WEIRD countries particularly in Middle Eastern regions like Lebanon that are affected by recurrent crises and ongoing wars.

Despite growing recognition of the link between mental health and physical pain, research within the Lebanese youth population remains scarce. Available studies suggest a high prevalence of physical pain conditions such as lower back pain (44.8% in Lebanese workers aged 20–64 [18]) and migraines (35.8% in young adults aged 18–29 [19]). However, these studies do not comprehensively explore the mental health correlates of physical pain in Lebanon’s youth. While evidence from India (non-WEIRD nation) and Switzerland (WEIRD nation) suggests strong links between stress, anxiety, depression, and pain [20], the extent to which these findings apply to Lebanon remains unclear. Given Lebanon’s unique sociopolitical stressors, including economic collapse and exposure to trauma [21], a scoping review is needed to consolidate existing data and identify key gaps. Most existing studies have been conducted in high-income, resource-rich settings, which do not accurately reflect Lebanon’s reality. Therefore, there is a pressing need for research to understand the interconnections between mental health and physical pain within the Lebanese context, particularly among the youth who are bearing the brunt of the country’s crises. This scoping review aims to systematically explore the relationship between physical pain and mental health issues among Lebanese youth. Specifically, it will examine the association between pain and conditions such as anxiety, depression, and stress—links that are well-documented in WEIRD countries but remain underexplored in Lebanon. By synthesizing existing research, this review seeks to provide a comprehensive understanding of how physical pain may be linked to mental health challenges in the Lebanese context. This will not only shed light on an understudied area but also provide valuable insights for future research, interventions, and support services tailored to improve both the physical and mental wellbeing of the youth in Lebanon.

Methods

Search Strategy and Inclusion Criteria

This scoping review was conducted in accordance with the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews) guidelines. A systematic literature search was performed across three major databases—PubMed, PsychInfo, and ScienceDirect—to identify studies investigating the relationship between physical pain and mental health issues in Lebanese youth (aged 18 years and above).

Search Strategy and Keywords

The search terms included “somatic symptoms,” “chronic pain,” “musculoskeletal pain,” “physical aches,” “somatization/somatization,” “somatic distress,” “mental health related somatic symptoms,” “unexplained medical symptoms,” “Lebanese youth,” “emergent youth/adult,” “adults in Lebanon,” “Lebanese adults,” “mental health disorders,” “anxiety,” “depression,” “stress,” “Lebanese youth,” and “non-WEIRD populations.” The search spanned January 2014 to February 2024 and included peer-reviewed studies written in English. Grey literature, conference abstracts, and case studies were excluded to maintain methodological rigor.

Inclusion and Exclusion Criteria

Studies were included if they i) studies that showed the relationship between physical pain and mental health ii) focused on Lebanese adults only (over 18 years of age), iii) were published in English, and iv) were published between January 2014 – February 2024. Studies were excluded if they: i) focused on Syrian refugees in Lebanon and ii) did not assess the interaction between mental health and physical pain. Rationale for Exclusion of Syrian Refugees: Syrian refugees in Lebanon face unique socio-economic conditions, mental health challenges, and barriers to higher education that differ significantly from the broader Lebanese young adult population. Their experiences of displacement, trauma, and limited healthcare access introduce distinct stressors that fall outside the scope of this review. To ensure a focused analysis on Lebanese young adults, studies on refugee populations were excluded.

Study Selection and Data Extraction

After screening 737 studies, 33 met inclusion criteria. The lead author (TT) conducted the initial screening, with a second reviewer (YR) verifying selected studies. Discrepancies were resolved through consensus. Data extracted included study design, sample size, pain type, mental health outcomes, and key findings.

Data Analysis

After screening and checking the articles for eligibility based on hand-searched, we found a total of 33 articles that were exported to excel. This was carried out by the lead author (TT), with decisions reviewed by second author (YR). Where discrepancies in classification existed, the article in question was discussed and agreement reached between authors. We present our results in the PRISMA flow chart (Figure 1).

FIGURE 1

Results

Search Results

A total of 33 studies were included in this review, summarizing the relationship between physical pain and mental health problems. The study selection process is depicted in Figure 1, and the characteristics of the studies are summarized in Table 1. Among these, 13 studies (36%) were conducted on university students between 18 and 26 years of age [22, 25, 28, 30, 32, 33, 38, 40–42, 44, 52, 54] while the remaining 23 studies (63.8%) examined individuals diagnosed with chronic pain and healthcare professionals, such as nurses [23, 24, 26, 27, 29, 31, 34–37, 39, 43, 44, 46, 48–51, 53, 55–57]. Of the included studies, 29 (81%) had majority of females participants [22, 23, 25–32, 34–37, 39–42, 44–47, 52–57] and in 30 studies (83.3%), quantitative self-report measures were the most common method of assessing physical pain and mental health [24, 26–30, 32, 34, 35, 37–49, 51, 53–57].

Only six studies adopted a qualitative approach using open-ended questionnaires to evaluate physical pain [23, 31, 33, 36, 50, 52].

Types of Physical Pain and the Tools Used to Assess

The review identified various types of physical pain frequently reported among participants, particularly university students and females. The most common types of pain included: musculoskeletal pain [24, 53], neck and lower back pain [35, 42, 48], migraine [25, 28, 52], and menstrual pain [41, 54]. These findings suggest that physical pain is highly prevalent among university students, with a particularly high burden among female participants [28, 30, 32, 38, 40, 52]. In these studies, the physical pain was measured using Premenstrual Symptoms Screening Tool (PSST) [54], Depression and Somatic Symptoms Scale (A-DSSS) [40], Pain Catastrophizing Scale-Arabic Version (PCS-A) [39], Patient Health Questionnaire (PHQ-9) [46], Neck Disability Index (NDI), Numeric rating scale (NRS) [42, 44, 48] Arabic version of Brief Pain Inventory (BPI-A) [39, 48], Beirut Distress Scale (BDS-10) [25], Multidimensional Assessment of Interoceptive Awareness Version 2 (MAIA-2) [22], Short Form Health Survey (SF-36) [27, 38], Neuropathic Pain Questionnaire (DN4) [39, 48], Migraine disability assessment test (MIDAS) [25, 28], standardized self-reported questionnaire to measure Irritable Bowel Syndrome [30], Widespread pain index (WPI) and Symptoms severity score (SSS) [32].

Mental Health Problems Associated With Physical Pain

A strong association between physical pain and mental health problems was observed across all included studies. The most frequently reported mental health concerns were stress, depression and anxiety that were strongly related to physical pain [25, 28, 30–34, 36, 42, 53]. In some of the studies, they acted as a predictor [25, 42, 53, 54], while in others they were the consequence of physical pain [31, 32, 34, 41]. This is in line with many studies conducted on pain [58–62]. Interestingly, only one study reported mindfulness meditation as a protective factor against the development of pain [44].

Gender Differences in Pain and Mental Health

Gender differences were evident in both the prevalence and intensity of physical pain and mental health symptoms. Female participants reported significantly higher levels of pain, particularly menstrual pain and migraines, which were associated with increased depressive symptoms [28, 32, 40].

Assessment Methods Used: Gaps and Limitations

Most studies reviewed relied heavily on quantitative measures [37, 38, 45, 46, 54], to assess pain and other mental health problems, with only 2 studies employing a mixed-methods approach [23, 50] that combined both qualitative and quantitative data. Additionally, only a few studies utilized the well-validated Arabic version of the scales like A-DSSS) [40], PCS-A [39], BDS-10 [25], and BPI-A [39, 48], emphasizing a significant gap in the cultural validation of assessment tools.

Discussion

This scoping review addresses a significant research gap by examining the relationship between physical pain and mental health issues among young people in Lebanon—a non-WEIRD nation affected by ongoing conflict and recurring crises. By focusing on Lebanon, our study aims to deepen understanding of physical pain and its mental health associations within diverse cultural settings, ultimately contributing to a more inclusive global perspective on the relationship between physical and mental health in underrepresented populations.

One major finding from this review is the strong bidirectional relationship between various types of physical pain, particularly among university students in Lebanon, and mental health issues like depression, anxiety, and stress [25,42]. This pattern aligns with previous research conducted in Switzerland [63] and India [64] which also showed similar relationships among university students. In some studies, mental health issues such as stress, depression, and anxiety were identified as predictors of physical pain [25, 42, 53, 54] while in others, they appeared to result from physical pain [31, 32, 34, 41]. These findings resonate with broader research indicating that chronic pain and mental health often interact in a cyclical way, where pain worsens mental health issues, and vice versa [58–62].

Approximately 36% of the studies included in this review focused specifically on university students aged 18–26 [22, 28, 30]. Among these students, the most common forms of pain reported were musculoskeletal pain [24, 53], neck and lower back pain [35, 42, 48], migraine [28, 52], and menstrual pain [41, 54]. The prevalence of these types of pain highlights unique vulnerabilities within this demographic, potentially stemming from academic stress, lifestyle factors, or societal expectations [65, 66]. The remaining 64% of studies [5, 23, 44] involved individuals with chronic pain and healthcare professionals, like nurses, who might experience high levels of work-related stress and physical strain [67, 68].

A notable finding from these studies is the demographic focus, as 81% of studies had a majority of female participants [32, 36, 37]. This gender disparity in the experience and reporting of pain is consistent with previous literature, which often suggests that women tend to report higher levels of both acute and chronic pain [69–71]. Various factors may contribute to this trend, including biological differences, such as hormonal fluctuations that can influence pain sensitivity [72, 73], as well as psychosocial factors, such as differing gender norms related to expressing pain [74, 75]. In many cultures, including Lebanon, women may feel more socially permitted to express pain and seek help [76], while men may face societal expectations to endure pain quietly due to norms around masculinity [77]. Additionally, research suggests that women are more likely to experience somatic symptoms associated with mental health conditions, such as depression and anxiety, which could further explain the higher reported prevalence of physical pain among females [78–81]. These findings underscore the importance of considering gender-specific factors when assessing and treating physical pain and mental health issues among young people, as this can lead to more targeted and effective interventions.

Furthermore, the 83.3% of the studies predominantly used quantitative self-report measures to assess physical pain and mental health [24,40,41]. The measurement tools to assess and mental health problems included scales such as the PSST [54], A-DSSS [40], BDS-10 [25], PCS-A [39], PHQ-9 [47], NRS [42, 44, 48], BPI-A [39, 48], MAIA-2 [22], SF-36 [27, 38], DN4 [39, 48], MIDAS [25, 28], WPI [32] and SSS [32]. These tools provide standardized metrics for assessing pain levels and mental health symptoms, although the review points out a lack of culturally validated tools for use in Lebanese populations. Only a few studies used the culturally validated versions of established tools like the A-DSSS, BDS-10, PCS-A, and BPI-A [25, 39, 40, 48], emphasizing a significant gap in culturally appropriate assessment methods. In addition, these quantitative measures, may not fully capture the culturally specific experiences of pain and mental health [82]. Pain can be expressed differently across cultures [83, 84] and relying solely on quantitative methods or tools designed for WEIRD populations risks overlooking culturally nuanced experiences of pain and mental health issues [85]. In the context of Lebanon, a non-WEIRD population, there is a crucial need for culturally adapted instruments. Moreover, incorporating qualitative methods would provide a more in-depth understanding of how pain is experienced and expressed within this cultural context [86], potentially leading to more accurate and relevant assessments. This gap underscores the importance of expanding research methodologies to ensure the tools used are both culturally sensitive and inclusive, particularly when addressing mental health and pain in diverse populations.

An intriguing finding was the emergence of mindfulness meditation as a potential protective factor, identified in only one study [44]. Despite extensive literature supporting mindfulness as effective in reducing chronic pain and improving mental health outcomes [87–89] this approach appears underexplored in the Lebanese context. This suggests that mindfulness could represent an untapped resource for managing comorbid physical and mental health conditions among Lebanese youth, warranting further investigation.

In summary, this scoping review highlights a substantial association between physical pain and mental health problems among young adults in Lebanon. It also reveals limitations in current methodologies and stresses the need for culturally validated tools. By adopting a more holistic, gender-sensitive, and culturally inclusive approach, future research can better capture the complex experiences of physical pain and mental health in Lebanon, ultimately leading to more effective and targeted mental health strategies for these populations.

Limitations

Despite its contributions, this scoping review merits limitations. First, most studies focused on quantitative measures, limiting the depth of understanding regarding the lived experiences of pain among youth in Lebanon. The lack of qualitative research also hampers the ability to explore culturally specific expressions of pain. Second, while this review highlights gender differences in the experience of pain, it does not account for other important factors, such as socioeconomic status, that could influence these experiences. Third, due to indexing limitations, studies examining associations between mental health and physical pain that did not include specific keywords in their titles or abstracts may have been overlooked. Additionally, the search strategy was not formally validated or reviewed by a librarian. However, the search terms were carefully developed based on relevant keywords and were guided by the specific aims of the review. Furthermore, we acknowledge that our inclusion criteria did not explicitly differentiate between clinical and community studies or consider grey literature and unpublished studies. This decision was made with the primary aim of understanding the relationship between physical pain and mental health within the Lebanese context, rather than focusing on study setting or type, and to maintain rigor and reliability in the data. Future reviews could address this limitation by expanding the search strategy to include a broader range of pain-related measures or by incorporating grey literature to capture a wider array of relevant studies. Fourth, we did not conduct a formal calibration exercise for data abstraction questions, nor did we calculate the kappa agreement between the two reviewers. While both reviewers independently screened the studies, any disagreements were resolved through discussion and consensus. The absence of a formal kappa calculation may limit the ability to quantify the level of agreement between reviewers. In future reviews, we would like to implement a calibration process and calculate Cohen’s kappa to ensure greater consistency and reliability in the data abstraction process.

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