Pain Catastrophizing as a Mediator of the Relationship between Pain Intensity and Depression: Evidence from Chronic Pain Patients in Gaza

Abstract Background: Chronic pain represents a major global public health issue. It is associated with wideranging psychosocial consequences, including depression and anxiety. Extensive evidence has demonstrated that pain catastrophizing contributes to the bidirectional association between chronic pain and psychological distress. The present study aims to explore the psychological and cognitive correlates of chronic pain among individuals living in Gaza, a region marked by protracted conflict, socioeconomic hardship, and limited healthcare services. Methods: A cross-sectional study was conducted among 272 adults with chronic musculoskeletal pain. Validated Arabic versions of the Numerical Rating Scale (NRS), Pain Catastrophizing Scale (PCS), and Depression Anxiety Stress Scale-21 (DASS-21) were administered. Spearman’s correlations assessed associations between pain intensity, catastrophizing, and depressive symptoms. Multiple regression and bootstrapped mediation analyses (5,000 resamples, PROCESS macro) evaluated predictors and the mediating role of catastrophizing in the pain–depression relationship. Results: Pain intensity was positively correlated with depression (r = 0.28, p < 0.001) and catastrophizing (r = 0.39, p < 0.001). A stronger correlation was found between catastrophizing and depression (r = 0.54, p < 0.001). Mediation analysis demonstrated that catastrophizing fully mediated the association between pain intensity and depression (indirect effect = 0.95, 95% CI [0.65–1.29]). Conclusion: Pain catastrophizing is a key psychological mechanism linking pain intensity and depression among patients with chronic pain in Gaza. Integrating cognitive-behavioural therapy, mindfulness, and emotion regulation strategies into pain management may improve mental health outcomes in conflict-affected settings.