BACKGROUND CONTEXT Psychological factors such as depression, anxiety, and poor coping strategies have been shown to predict negative outcomes after lumbar spine surgery and spinal cord stimulation (SCS). Recent studies have shown that nonlinear burst spinal cord stimulation (NLB-SCS), compared with traditional low-frequency tonic SCS, produces a greater effect on brain targets associated with the affective/emotional aspects of pain processing via the modulation of the medial spinothalamocortical pathways. PURPOSE Herein we present outcomes after NLB-SCS in patients with persistent back pain after lumbar spine surgery who are suffering from high psychological distress. STUDY DESIGN/SETTING Subanalysis from a prospective, multicenter, international, single arm study on nonlinear burst spinal cord stimulation. PATIENT SAMPLE Data for this subanalysis were extracted from an ongoing prospective, multicenter, study on NLB-SCS (ClinicalTrials.gov NCT03082261). OUTCOME MEASURES Catastrophizing Scale (PCS), Patient Health Questionnaire Depression scale (PHQ-9), State Trait Anxiety Index (STAI), Numerical Rating Scale (NRS). METHODS One-year outcomes were evaluated in subjects who presented with severe symptoms at baseline on the Pain Catastrophizing Scale (PCS), Patient Health Questionnaire Depression scale (PHQ-9), or State Trait Anxiety Index (STAI). Severity and responder analyses were performed for each measure, based on individually published standards. Severe symptoms were classified as scores of ≥30 on the PCS, ≥10 on the PHQ-9, and ≥40 on the STAI. Responders were classified as subjects who reported below these severity thresholds. Additional outcomes assessed at the 12-month follow-up visit included the Numeric Pain Rating Scale (NRS) and the EuroQol 5-Dimensions (EQ-5D). The minimal clinical important difference (MCID) for the EQ-5D Index is a 0.074 increase. RESULTS At baseline, 107 subjects reported severe symptoms of anxiety (64%), depression (52%), or catastrophizing (37%). Thirty-six percent reported severe symptoms in all three measures. At one-year post-implant, 69% were no longer catastrophizing, 50% were no longer clinically depressed, and 44% responded on STAI. Moreover, quality of life on EQ-5D improved on average from 0.38 before therapy to 0.62 post-therapy. Pain intensity was significantly decreased at 12 months; 77% reported at least 50% pain relief. CONCLUSIONS Our results demonstrate that NLB-SCS is an effective therapy for patients with persistent back pain who are suffering from high psychological distress. Subjects reported improvements across all psychological measures, reaffirming that NLB-SCS modulates the affective/emotional aspects of pain processing. FDA DEVICE/DRUG STATUS Spinal cord stimulation (Approved for this indication)