Pain and depression: an integrative review of neurobiological and psychological factors

Influence of Anxiety and Depression, Self-Rated Return-to-Work Problems, and Unemployment on the Outcome of Outpatient Rehabilitation After Shoulder Arthroscopy

OBJECTIVE

The aim of this study was to research the influence of psychosocial confounders on outpatient rehabilitation after arthroscopic shoulder surgery.

DESIGN

This retrospective study included patients who underwent such rehabilitation in a single center between January 2014 and October 2016. Shoulder function (Constant Shoulder Score) and pain (visual analog scale), improvements in these scores, and patient satisfaction were evaluated with regard to anxiety and depression (Hospital Anxiety and Depression Scale), self-rated return-to-work problems (Würzburg screening), and employment status.

RESULTS

The analysis included 176 patients. The mean (SD) Constant Shoulder Score and visual analog scale improved from 53.9 (18) to 75.4 (16.5) and 4.6 (2.1) to 2.9 (2.4) cm, respectively. A total of 84.1% of the patients were satisfied with the outcome. Unemployed patients (P = 0.001) and Hospital Anxiety and Depression Scale-positive ones (P = 0.014) were less satisfied than their counterparts. Patients with a Würzburg screening-positive screening showed less improvement in pain (P = 0.015), function (P = 0.016), and satisfaction (P = 0.002) than those without. Unemployed reported more pain (P = 0.008) than employed patients when starting rehabilitation. At the end of rehabilitation, all psychosocial scores (Hospital Anxiety and Depression Scale, P = 0.002; Würzburg screening, P = 0.001; unemployment, P < 0.001) negatively influenced pain, Würzburg screening (P = 0.007), and unemployment (P = 0.008) function.

CONCLUSIONS

Because we identified psychosocial factors that influence the success of outpatient shoulder rehabilitation, rehabilitation setup should be adjusted in patients with such problems.

Child Abuse and Neglect as Risk Factors for Comorbidity Between Depression and Chronic Pain in Adulthood

It is estimated that comorbidity between depression and chronic pain reaches more than half of the depressed adult patients around the world. Evidence indicates that some stressors, such as early-life stress (ELS), mediate the co-occurrence of depression and chronic pain. This study aimed to assess whether ELS or any of its subtypes could be considered as risk factors for comorbidity between depression and chronic pain. For this purpose, 44 patients in depressive episode were evaluated, in which 22 were diagnosed with depression and chronic pain, and the other 22 patients were diagnosed with depression but without chronic pain. Results had shown that ELS occurrence is more significant among depressive patients with chronic pain compared with those without pain. When subtypes of ELS were evaluated, the group of depressive patients with pain showed significantly higher prevalence of emotional neglect than those depressive participants without pain. Data analysis has shown that severity of the depressive symptoms has a significant impact on the total score of childhood trauma, emotional abuse, physical abuse, emotional neglect, and physical neglect, and that emotional abuse, sexual abuse, and physical neglect have significant impact on the severity of depression. In conclusion, our findings indicate that ELS can be considered as a risk factor for the comorbidity between depression and chronic pain.

Pain and Depression: A Systematic Review

BACKGROUND

Pain comorbid with depression is frequently encountered in clinical settings and often leads to significant impaired functioning. Given the complexity of comorbidities, it is important to address both pain and depressive symptoms when evaluating treatment options.

AIM

To review studies addressing pain comorbid with depression, and to report the impact of current treatments.

METHOD

A systematic search of the literature databases was conducted according to predefined criteria. Two authors independently conducted a focused analysis of the full-text articles and reached a consensus on 28 articles to be included in this review.

RESULTS

Overall, studies suggested that pain and depression are highly intertwined and may co-exacerbate physical and psychological symptoms. These symptoms could lead to poor physical functional outcomes and longer duration of symptoms. An important biochemical basis for pain and depression focuses on serotonergic and norepinephrine systems, which is evident in the pain-ameliorating properties of serotonergic and norepinephrine antidepressants. Alternative pharmacotherapies such as ketamine and cannabinoids appear to be safe and effective options for improving depressive symptoms and ameliorating pain. In addition, cognitive-behavioral therapy may be a promising tool in the management of chronic pain and depression.

CONCLUSION

The majority of the literature indicates that patients with pain and depression experience reduced physical, mental, and social functioning as opposed to patients with only depression or only pain. In addition, ketamine, psychotropic, and cognitive-behavioral therapies present promising options for treating both pain and depression.

Prevalence & correlates of chronic perinatal pain - a study from India

Objectives: To study the prevalence of chronic perinatal pain among mothers who had infants between the ages of 13-25 months in the State of Kerala, India and to report its correlates in the socio-demographic, obstetric and psychological domains. Methods: A total of 9305 mothers selected by cluster random sampling were assessed cross-sectionally for chronic perinatal pain using a questionnaire by Junior Public Health Nurses (JPHNs). In addition, information regarding socio-demographic profile, obstetric history, infant details and perinatal depression were collected. Results: Of the 8302 (89.3%) valid responses, 552 (6.6%) mothers reported chronic perinatal pain. Among those with pain, 142 (25.6%) reported pain during pregnancy, 314 (56.7%) during postpartum and 96 (17.7%) during both periods. The commonest sites of pain reported were back 280 (51%) and pelvic region 110 (19%). Mothers with chronic perinatal pain were more likely to be younger, less educated, employed and from an urban background. Chronic perinatal pain was associated with obstetric complications, delivery by instrumental/caesarean section, non-exclusive breast feeding and higher maternal depression scores. Conclusion: Chronic pain is common among mothers in India during the perinatal period and greater attention needs to be given for it to be recognised and treated early.

Abnormalities in Inflammatory Cytokines Confer Susceptible to Chronic Neuropathic Pain-related Anhedonia in a Rat Model of Spared Nerve Injury

Objective

Patients with chronic neuropathic pain (CNP) have a higher incidence to develop depression. However, its pathogenesis has not yet been fully elucidated. Here we aimed to investigate the role of inflammatory cytokines in CNP-related anhedonia, which is a core symptom of depression, and to explore the effects of ketamine and parecoxib on pain and anhedonia.

Methods

A rat model of spared nerve injury (SNI) was constructed to mimic CNP. Hierarchical cluster analysis of sucrose preference test (SPT) was applied to classify the SNI rats into anhedonia susceptible and unsusceptible. Inflammatory cytokines in medial prefrontal cortex (mPFC) of brain, serum and L2–5 spinal cord were measured. Moreover, effects of ketamine or parecoxib on mechanical withdrawal test (MWT) and SPT in anhedonia susceptible rats were detected.

Results

Tumor necrosis factor (TNF)-α was increased in mPFC, serum and and spinal cord of anhedonia susceptible rats. Furthermore, anhedonia susceptible and unsusceptible rats both increased the interleukin (IL)-1β level in mPFC, serum and spinal cord. IL-6 was altered in serum and spinal cord, but not in mPFC. IL-10 was significantly altered in mPFC and serum, but not in spinal cord. Additionally, ketamine treatment significantly attenuated the decreased results of MWT and SPT in anhedonia susceptible rats, and that parecoxib significantly improved the MWT score, but failed to alter the result of SPT.

Conclusion

These findings suggest that abnormalities in inflammatory cytokines confer susceptible to anhedonia in a rat model of SNI. Ketamine, a fast-acting antidepressant, has pharmacological benefits to alleviate pain and anhedonia symptoms.

Pain and symptoms of depression: international comparative study on selected factors affecting the quality of life of elderly people residing in institutions in Europe

BACKGROUND

As the number of elderly people is on the rise in societies throughout the world, providing them with optimal care is becoming a major demand, especially in the context of rising interest in institutional care. Quality of life is multidimensional notion and its perception depends highly on pain and mood levels. The aim of this study was to perform a comparative analysis of pain and depression symptoms in elderly people living in nursing homes in France, Germany, and Poland.

METHODS

The research carried out in years 2014-2016 involved female residents of nursing homes in France, Germany, and Poland: 190 women from each country, aged over 65 years and not previously diagnosed with advanced dementia, were included. Collection of medical, demographic, and anthropomorphic data from medical documentation was followed by interviews with each senior and her caregiver. A questionnaire of authors' own devising was used, along with the Beck Depression Inventory (BDI) and the scale of Behavioral Pain Assessment in the Elderly (DOLOPLUS). The results were subjected to statistical analysis, p < 0.05 was accepted as threshold of statistical significance.

RESULTS

The main health complaints of nursing homes' residents were constipation, diarrhea, back pain and dizziness. 44,38% of the residents self-assessed their health status as bad and complained of suffering pain (83,33%) and sleeping problems (72,98%) within the last month. According to BDI the average score was 17.01 points and 44,38% of seniors were free from depression or depressed mood. The average DOLOPLUS result was 8.86 points.

CONCLUSION

There are no significant differences, neither in prevalence of pain and symptoms of depression nor in average levels of quality of life, in elderly residents in institutions in the three studied European countries. The decrease in quality of life is mainly due to various complaints and pain and there is a close relationship between health status and quality of life. Further research should be performed in order to study interdependencies between the occurrence of pain and depression, including primary reasons leading to both phenomena. The recognition of factors that induce pain complaints and mood depression in elderly people will contribute to improving their comfort.

Understanding the Relationship Between Spiritual Well-Being and Depression in Chronic Pain Patients: The Mediating Role of Pain Catastrophizing

BACKGROUND

It is well established that there is an association between chronic pain and depression.

AIMS

The present study aimed to identify whether pain catastrophizing and spiritual well-being may influence depression in chronic pain patients when other variables are controlled for (sociodemographic characteristics and pain intensity). Furthermore, it investigated possible mechanisms by which spiritual well-being can influence depression in these patients.

DESIGN

The present study employed a cross-sectional design.

SETTINGS AND PARTICIPANTS

This study was performed with a convenience sample of 300 consecutive patients with different types of chronic pain (defined as recurrent or persistent pain over >3 months), referred to clinics affiliated with Shiraz university of Medical Sciences between March and October 2017.

METHODS

Patients completed validated self-report questionnaires: Spiritual Well-being Questionnaire, Patient Health Questionnaire, Pain Catastrophizing Scale, and Numeric Rating Scale.

RESULTS

Hierarchical multiple regression analysis indicated that a significant portion of the variance in depression scores can be explained by catastrophizing and spiritual well-being. In Multiple Mediation Procedure, pain catastrophizing could negatively mediate the relationship between spiritual well-being and depression when controlling for sociodemographic characteristics and pain intensity.

CONCLUSIONS

The findings add some evidence to further support the influence of spiritual well-being on depression levels through diminished pain catastrophizing. The present results could help clinicians to determine which variables should be emphasized for a successful treatment of depression in pain patients. Clinical interventions that increase meaningfulness and purpose in life may allow patients with chronic pain to overcome the maladaptive cognitions associated with pain, thereby reducing depressive symptoms.

Prevalence of depressive symptoms in overweight and obese children and adolescents in mainland China: A meta-analysis of comparative studies and epidemiological surveys

BACKGROUND

Obesity is associated with a higher risk of depression in children and adolescents. This is a meta-analysis of studies examining depressive symptoms in overweight and obese children and adolescents in China.

METHODS

A systematic literature search was performed independently in both English (PubMed, EMBASE, Web of Science and Medline Complete) and Chinese (China National Knowledge Internet, WANFANG Data and WeiPu VIP) databases from their commencement date to December 31, 2018. The pooled prevalence of depressive symptoms was calculated using a random-effects model. Data analyses were performed with STATA Version 12.0, R Version 3.3.0 and R Studio Version 0.99.903.

RESULTS

Twenty-two epidemiological and 18 comparative studies were included in the meta-analysis. The overall prevalence of depressive symptoms was 24.02% (95% CI: 15.92%-33.16%) in obese children and adolescents and 22.61% (95% CI: 14.87%-31.34%) in overweigh children and adolescents. Obese children and adolescents were more likely to suffer from depressive symptoms (OR = 1.877, 95% CI: 1.459-2.415, P < 0.001) than their non-obese counterparts. The use of different screening scales for depressive symptoms was significantly associated with the prevalence of depressive symptoms.

CONCLUSIONS

Depressive symptoms are common in overweight and obese children and adolescents in China. Obese, but not overweight children and adolescents had higher risk of depressive symptoms. In order to lessen the risk of depressive symptoms, regular screening and effective interventions should be implemented to reduce obesity and overweight in this population.

Sex/gender disparities in health outcomes of individuals with long-term disabling conditions

BACKGROUND

Women with disabling conditions experience health disparities relative to nondisabled women, but few studies have compared women and men with disabling conditions.

OBJECTIVES

To investigate gender differences in physical functioning and emotional health among individuals with long-term disabling conditions, that is, neuromuscular disease, multiple sclerosis, postpolio syndrome, or spinal cord injury.

METHOD

From a mailed survey of 1,862 adults with long-term disabling conditions, we used the 12-item Patient-Reported Outcomes Measurement Information System (PROMIS) physical functioning to assess physical limitations in activities and Patient Health Questionnaire-9 (PHQ-9) for emotional health and severity of secondary conditions (rated 0-10). Least square means models were used to estimate marginal mean PHQ-9 scores and severity of secondary conditions by age and sex adjusted for diagnosis. Generalized linear models were performed to determine the association between sex/gender and PROMIS physical function t score, controlling for age and diagnostic group with potential Age × Sex interaction.

RESULTS

Women reported more fatigue than men (5.48 ± .08 vs. 5.13 ± .11, p = .01) and more pain (3.99 ± .08 vs. 3.67 ± .11, p = .03). Women aged 45-54 had higher average PHQ-9 scores than men aged 45-54 (M = 8.05, SE = .33 vs. M = 6.35, SE = .42, p < .007) adjusted for diagnosis. Younger women had higher physical functioning than younger men while older women had lower physical functioning than older men adjusted for diagnostic group (p = .0003 for the interaction term).

CONCLUSION

Middle-aged and older women with long-term disabling conditions experience considerable health disparities in physical functioning and emotional health compared with middle-aged and older men with similar conditions. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Pain Processing in Psychiatric Conditions: A Systematic Review

Pain is a universal, multidimensional experience with sensory, emotional, cognitive, and social components, which is fundamental to our environmental learning when functioning typically. Understanding pain processing in psychiatric conditions could provide unique insight into the underlying pathophysiology or psychiatric disease, especially given the psychobiological overlap with pain processing pathways. Studying pain in psychiatric conditions is likely to provide important insights, yet, there is a limited understanding beyond the work in depression and anxiety. This is a missed opportunity to describe psychiatric conditions in terms of neurobiological alterations. To examine the research into the pain experiences of these groups and the extent to which a-typicality is present, a systematic review was conducted. An electronic search strategy was developed and conducted in several databases. The current systematic review included 46 studies covering five Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) disorders: autism, attention-deficit hyperactivity disorder (ADHD), schizophrenia, personality disorder, and eating disorders, confirming tentative evidence of altered pain and touch processing. Specifically, hyposensitivity is reported in schizophrenia, personality disorder and eating disorder, hypersensitivity in ADHD, and mixed results for autism. Review of the research highlights a degree of methodological inconsistency in the utilization of comprehensive protocols, the lack of which fails to allow us to understand whether a-typicality is systemic or modality specific.

Assessing Beliefs Underlying Rumination About Pain: Development and Validation of the Pain Metacognitions Questionnaire

Metacognitions, which are beliefs about our own thinking processes, can modulate worry and rumination and thereby influence emotional distress. This study aimed to develop a self-report measure of unhelpful pain-related metacognitions which might serve as a clinical and research tool to better understand pain catastrophizing, a significant risk factor for adverse pain outcomes. Two phases of validation are presented. Phase 1 reports on how the Pain Metacognitions Questionnaire (PMQ) was empirically developed through a qualitative study of 20 people with chronic back (n = 15) or knee (n = 5) pain in secondary or tertiary care and then validated in a large internet sample of people experiencing pain (N = 864). Rasch analysis yielded a 21-item scale with two dimensions (positive and negative metacognition) assessing how useful and problematic people believe rumination about pain to be, respectively. In Phase 2, further validation using a new sample (N = 510) replicated initial findings. Both PMQ subscales have good retest reliability (r = 0.76, r = 0.72) and internal consistency (0.86, 0.87). They correlate negatively with mindfulness and positively with pain intensity, disability, anxiety, depression, catastrophizing, rumination, and metacognition. The PMQ also predicts unique variance in catastrophizing when other variables are controlled and predicts 'patient' status for pain catastrophizing. Sensitivity analysis yielded preliminary suggestions for clinically meaningful cut-offs. Unhelpful pain metacognitions can be validly and reliably measured using a self-report instrument. Future studies using the PMQ might shed new light on pain-related thinking processes to develop better interventions for people prone to worry and rumination about their pain.

Pain characteristics and incidence of functional disability among community-dwelling older adults

This study examined the association between pain characteristics and the incidence of functional disability among community-dwelling older adults. This prospective cohort study included 4,365 older adults (mean age 74.7 years, 53.5% female) living in community settings. Pain characteristics, including severity and duration of pain, were assessed in participants who also underwent monthly follow-up assessment of functional disability for 24 months based on the national long-term care insurance system. Among the 4,365 participants, 2,149 (48.7%) reported pain, regardless of severity and duration. Of the 2,149 participants with pain, 950 (44.2%) reported moderate to severe pain and 1,680 (78.2%) reported chronic pain. Based on the univariate analyses, participants with moderate (hazard ratio [95% confidence interval]: 1.48 [1.05–2.09]) or severe (2.84 [1.89–4.27]) pain and chronic pain (1.50 [1.15–1.95]) showed significantly higher risk of disability incidence than did those without pain. After adjusting for covariates, severe pain remained a significant predictor (hazard ratio [95% confidence interval]: 1.66 [1.05–2.62]), but moderate (1.00 [0.69–1.47]) and chronic pain (1.04 [0.77–1.40]) did not. Our results established that moderate to severe pain or chronic pain affects functional disability; in particular, severe pain was independently associated with the incidence of disability. Subjective complaints of pain do not always correspond to physical causes; however, simplified questions regarding pain characteristics could be useful predictors of functional disability in community-dwelling older people.

Repeated Sigma-1 Receptor Antagonist MR309 Administration Modulates Central Neuropathic Pain Development After Spinal Cord Injury in Mice

Up to two-thirds of patients affected by spinal cord injury (SCI) develop central neuropathic pain (CNP), which has a high impact on their quality of life. Most of the patients are largely refractory to current treatments, and new pharmacological strategies are needed. Recently, it has been shown that the acute administration of the σ1R antagonist MR309 (previously developed as E-52862) at 28 days after spinal cord contusion results in a dose-dependent suppression of both mechanical allodynia and thermal hyperalgesia in wild-type CD-1 Swiss female mice. The present work was addressed to determine whether MR309 might exert preventive effects on CNP development by repeated administration during the first week after SCI in mice. To this end, the MR309 (16 or 32 mg/kg i.p.) modulation on both thermal hyperalgesia and mechanical allodynia development were evaluated weekly up to 28 days post-injury. In addition, changes in pro-inflammatory cytokine (TNF-α, IL-1β) expression and both the expression and activation (phosphorylation) of the N-methyl-D-aspartate receptor subunit 2B (NR2B-NMDA) and extracellular signal-regulated kinases (ERK1/2) were analyzed. The repeated treatment of SCI-mice with MR309 resulted in significant pain behavior attenuation beyond the end of the administration period, accompanied by reduced expression of central sensitization-related mechanistic correlates, including extracellular mediators (TNF-α and IL-1β), membrane receptors/channels (NR2B-NMDA) and intracellular signaling cascades (ERK/pERK). These findings suggest that repeated MR309 treatment after SCI may be a suitable pharmacologic strategy to modulate SCI-induced CNP development.

Cognitive rigidity in patients with depression and fibromyalgia

Background/Objective

The comorbidity of depression and fibromyalgia chronic syndrome has been well documented in the literature; however, the cognitive structure of these patients has not been assessed. Previous results reported variability in cognitive rigidity in depressive patients, the key for this might be the presence of chronic physical pain such as fibromyalgia. The present study explores and compares the cognitive rigidity and differentiation, between patients with depression with and without fibromyalgia syndrome.

Method

Thirty one patients with depression and fibromyalgia were matched, considering age, sex and number of depressive episodes, with 31 patients with depression but without fibromyalgia diagnosis. Cognitive rigidity and differentiation were measured with the repertory grid technique.

Results

The results indicated that depressed patients with fibromyalgia presented higher levels of depressive symptoms, greater cognitive rigidity and lower cognitive differentiation than those without fibromyalgia.

Conclusions

The results might inform future treatments to address the cognitive structure of these patients.

Who benefits from multimodal rehabilitation - an exploration of pain, psychological distress, and life impacts in over 35,000 chronic pain patients identified in the Swedish Quality Registry for Pain Rehabilitation

BACKGROUND

Chronic pain patients frequently suffer from psychological symptoms. There is no consensus concerning the prevalence of severe anxiety and depressive symptoms and the strength of the associations between pain intensity and psychological distress. Although an important aspect of the clinical picture is understanding how the pain condition impacts life, little is known about the relative importance of pain and psychological symptoms for individual's life impact. The aims of this study were to identify subgroups of pain patients; to analyze if pain, psychological distress, and life impact variables influence subgrouping; and to investigate how patients in the subgroups benefit from treatments.

METHODS

Background variables, pain aspects (intensity/severity and spreading), psychological distress (depressive and anxiety symptoms), and two life impact variables (pain interference and perceived life control) were obtained from the Swedish Quality Registry for Pain Rehabilitation for chronic pain patients and analyzed mainly using advanced multivariate methods.

RESULTS

Based on >35,000 patients, 35%-40% had severe anxiety or depressive symptoms. Severe psychological distress was associated with being born outside Europe (21%-24% vs 6%-8% in the category without psychological distress) and low education level (20.7%-20.8% vs 26%-27% in the category without psychological distress). Dose relationships existed between the two psychological distress variables and pain aspects, but the explained variances were generally low. Pain intensity/severity and the two psychological distress variables were significantly associated (R 2=0.40-0.48; P>0.001) with the two life impact variables (pain interference and life control). Two subgroups of patients were identified at baseline (subgroup 1: n=15,901-16,119; subgroup 2: n=20,690-20,981) and the subgroup with the worst situation regarding all variables participated less in an MMRP (51% vs 58%, P<0.001) but showed the largest improvements in outcomes.

CONCLUSION

The results emphasize the need to assess both pain and psychological distress and not take for granted that pain involves high psychological stress in the individual case. Not all patients benefit from MMRP. A better matching between common clinical pictures and the content of MMRPs may help improve results. We only partly found support for treatment resistance in patients with psychological distress burden.

Pain and affective distress in arthritis: relationship to immunity and inflammation

INTRODUCTION

Most arthritides are associated with pain and psychological distress (clinically significant depression and anxiety). Pain and depression are mutually exacerbating; both may continue even when joint involvement appears well controlled. Area covered: There is strong evidence that arthritis-related stress impacts the central nervous system and, together with peripheral inflammatory changes, can cause central sensitization that can lead to chronic pain and worsening of affective distress. Cytokines and chemokines participate both in joint inflammation and in central sensitization. We review evidence of these relationships in five arthritides, namely rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, gout, and in osteoarthritis of the hips and knees. Central sensitization in these conditions results in long-lasting pain and psychological distress. Expert commentary: Chronic pain and depression are important but often neglected in the clinical assessment and treatment of arthritis. The potential role of biologic cytokines and Janus kinase inhibitors in dealing with these symptoms needs further study.

Downregulated spinal IRF8 and BDNF in NAC are involved in neuropathic pain-induced depression relief via pulsed radiofrequency on dorsal root ganglion in rat SNI model

Pulsed radiofrequency (PRF) on the dorsal root ganglion (DRG), which produces remarkable analgesia through high-frequency electromagnetic energy, has become a main therapy for chronic neuropathic pain. The chronic neuropathic pain in patients is frequently accompanied by depression. However, the underlying neurophysiological mechanisms of the treatment of PRF on DRG for the neuropathic pain-induced depression remain unclear. This study was designed to explore the effect of PRF on DRG on the neuropathic pain-induced depression in rats with spared nerve injury (SNI). Here, we found that PRF on DRG or intrathecal injection of the interferon regulatory factor 8 (IRF8) siRNA prevented the increase of mechanical allodynia and depression-like behaviors of rats after receiving SNI. Meanwhile, Western blot, immunohistochemistry, and RT-PCR revealed that PRF on DRG or intrathecal injection of IRF8 siRNA inhibited IRF8 overexpression in the spinal cord and brain-derived neurotrophic factor (BDNF) in NAc. These results suggest that neuropathic pain-induced depression could be attenuated by PRF applied to DRG in SNI rats. The suppressed overexpression of the spinal IRF8 and BDNF in NAc may play an important role and contribute considerably to effectiveness of the therapy by PRF on DRG.

Telephone-delivered cognitive behavioral therapy for veterans with chronic pain following traumatic brain injury: Rationale and study protocol for a randomized controlled trial study

BACKGROUND AND OBJECTIVES

Chronic pain is a highly prevalent and potentially disabling condition in Veterans who have had a traumatic brain injury (TBI) and access to non-pharmacological pain treatments such as cognitive behavioral therapy is limited and variable. The purpose of this randomized controlled trial (RCT) is to evaluate the efficacy of a telephone-delivered cognitive behavioral therapy (T-CBT) for pain in Veterans with a history of TBI.

METHODS

Veterans with a history of TBI and chronic pain of at least six months duration (N = 160) will be randomized to either T-CBT or a telephone-delivered pain psychoeducational active control condition (T-Ed). The eight-week T-CBT intervention builds on other efficacious CBT interventions for chronic pain in the general population but is novel in that it is conducted via telephone and adapted for Veterans with a history of TBI. Outcome variables will be collected pre, mid-, and post-treatment, and 6 months following randomization (follow-up).

PROJECTED OUTCOMES

In addition to evaluating the effects of the interventions on pain intensity (primary outcome), this study will determine their effects on pain interference, sleep, depression, and life satisfaction. We will also examine potential moderators of treatment outcomes such as cognition, PTSD, and alcohol and drug use. This non-pharmacologic one-on-one therapeutic intervention has the potential to reduce pain and pain-related dysfunction, improve access to care, and reduce barriers associated with geography, finances, and stigma, without the negative effects on physical and cognitive performance and potential for addiction as seen with some pharmacologic treatments for pain. This trial is registered at ClinicalTrials.gov, protocol NCT01768650.

Towards a palliative care approach in psychiatry: do we need a new definition?

Psychiatry today is mainly practised within a curative framework. However, many mental disorders are persistent and negatively affect quality of life as well as life expectancy. This tension between treatment goals and the actual illness trajectory has evoked a growing academic interest in 'palliative psychiatry', namely the application of a palliative care approach in patients with severe persistent mental illness. Recently, Trachsel et al presented a working definition of palliative psychiatry. This first official attempt to capture the concept is based on WHO's widely accepted definition of palliative care but modified and limited to include only severe persistent psychiatric illness. While this is a welcome step in the discussion on palliative care approaches in psychiatry, it also opens up for new questions. One of the most evident is whether psychiatry actually needs its own definition of palliative care or, put differently, whether there is something about mental disorders that differs so radically from other medical conditions that it calls for a separate definition. We acknowledge the need to discuss the goals of psychiatric care in patients with severe persistent psychiatric illness. However, we question whether a separate definition of palliative care exclusive to psychiatry is the right way to go. In this paper, we discuss why.

Improvements in Depressive Symptoms and Affect During Cardiac Rehabilitation: PREDICTORS AND POTENTIAL MECHANISMS

PURPOSE

Depression is indicative of poor prognosis in cardiac patients. Reductions in depression have been observed following cardiac rehabilitation (CR). Whether similar improvements in positive and negative affect occur is unknown. Greater understanding of depressive symptom and affect change is needed to enhance facilitators of emotional improvement after a cardiac event.

METHODS

Cardiac rehabilitation attendees (n = 637) completed measures of depressive symptoms, affect, health status, and social support at CR intake and discharge. Body mass index, metabolic equivalents, and blood pressure were also measured. Relationships between changes in psychosocial and physical health indicators and depressive symptoms, positive affect, and negative affect were examined.

RESULTS

From intake to discharge, depressive symptoms (d = 0.40, P < .001) and negative affect (d = 0.26, P < .001) decreased. Positive affect increased (d = 0.34, P < .001). In multivariate regression, predictors of depressive symptom reduction were increased vitality (β = -.26) and decreased bodily pain (β = -.08). Predictors of positive affect increase were increased vitality (β = .25), social support (β = .16), and physical role functioning (β = .09). Predictors of negative affect reduction were increased vitality (β = -.23) and social support (β = -.10). Changes in indicators of physical health were not related to depressive symptom or affect change.

CONCLUSIONS

Depressive symptom and affect improvements following CR were observed and most strongly associated with improvements in vitality and social support. Future research should explore how enhancement of these mechanisms may further improve depressive symptom and affect during CR.

Predictors of pain severity trajectory in older adults: a 10.7-year follow-up study

OBJECTIVES

To identify distinct pain trajectories over 10.7 years and to examine predictors of identified pain trajectories in an older population and those with radiographic knee osteoarthritis (ROA).

METHODS

963 participants (aged 50-80 years) from a population-based cohort had baseline demographic, psychological, lifestyle and comorbidities data collected. T1-and T2-weighted magnetic resonance imaging (MRI) of the right knee was performed to measure knee structural pathology-cartilage defects, bone marrow lesions (BMLs) and effusion-synovitis. Group-based trajectory modelling (GBTM) was applied to identify trajectories of knee pain over 10.7 years measured by Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC).

RESULTS

Three distinct pain trajectories were defined: 'Minimal pain' (n = 501, 52%), 'Mild pain' (n = 329, 34%) and 'Moderate pain' (n = 165, 14%). In multivariable analysis, having cartilage defects, BMLs and effusion-synovitis were associated with an increased risk of being in the 'Mild pain' (relative risk [RR]: 1.40 to 1.92) and 'Moderate pain' trajectory (RR: 1.72 to 2.26), compared with the 'Minimal pain' trajectory. Being obese and having more painful sites were associated with 'Mild pain' and 'Moderate pain' trajectories, while unemployment, lower education level and presence of emotional problems were associated with 'Moderate pain' trajectory group. Similar results were found for those with ROA.

CONCLUSION

Distinct pain trajectories identified suggest that homogeneous subgroups exist, which might be useful for phenotypic assessment for pain management, particularly in knee osteoarthritis. Structural pathology was associated with worse pain trajectories, suggesting that peripheral stimuli are critical for the development and maintenance of pain severity. Environmental and psychological factors may exacerbate pain perception.

Pelvic Pain and Apical Prolapse Surgery: A Population-Based Retrospective Cohort Study

OBJECTIVES

The aims of this study were to evaluate the association of preoperative pelvic pain with operative characteristics and the association of patient and operative characteristics with postoperative pain.

METHODS

This is a retrospective cohort study utilizing Clinformatics DataMart, a large national commercial insurance database. We collected data for patients older than 18 years who underwent apical prolapse surgery between January 2005 and December 2014. We stratified data by preoperative (prior) pain and analyzed for associations of prior and postoperative pain. Logistic regression analysis was performed using SAS software.

RESULTS

A total of 14,440 patients met inclusion criteria and were analyzed. Patients with prior pain were more likely to have an abdominal (open or laparoscopic) approach, a concomitant hysterectomy, but less likely to have additional repairs or a mesh insertion (P < 0.001). Postoperative pain was less with a concomitant hysterectomy, whether they had prior pain (odds ratio [OR], 0.56; 95% confidence interval [CI], 0.41-0.77) or not (OR, 0.68; 95% CI, 0.56-0.82). Additional vaginal repairs were associated with more postoperative pain for those without prior pain (OR, 1.63; 95% CI, 1.3-2.04). Age older than 45 years was associated with less pain. Length of hospital stay of more than 2 days was associated with more pain.

CONCLUSIONS

Patients with prior pain were more likely to undergo an abdominal approach and have a concomitant hysterectomy. Postoperative pain was less with a concomitant hysterectomy, but more with additional vaginal repairs. There is a need to include pain as an outcome in future studies, particularly clinical trials.

The burden of depressive disorders in South Asia, 1990-2016: findings from the global burden of disease study

BACKGROUND

Globally, depressive disorders are one of the most common forms of mental illness. Using data from the most recent Global Burden of Disease, Injury, and Risk Factor Study 2016 (GBD 2016), we aimed to describe the burden of disease attributable to depressive disorders in terms of prevalence and disability-adjusted life years (DALYs) in South Asia countries (namely India, Pakistan, Bangladesh, Nepal and Bhutan).

METHODS

GBD 2016 used epidemiological data on depressive disorders (major depression and dysthymia) from South Asia and a Bayesian meta-regression tool (DisMod-MR 2.1) to model prevalence and DALYs of depressive disorders by age, sex, country and year. DALYs were calculated from the years lived with disability (YLDs), derived from the prevalence of depressive disorders and disability weights, obtained from a community and internet-based surveys. The analyses adjusted for comorbidity, data sources and multiple modelling, and estimates were presented with 95% uncertainty intervals (UI).

RESULTS

In 2016, the age-standardised prevalence of depressive disorders in South Asia was 3.9% (95% UI: 3.6-4.2%), 4.4% (95% UI: 4.4-4.8%) in Bangladesh, 3.9% (95% UI: 3.6-4.2%) in India, 3.0% (95% UI: 2.8-3.3%) in Pakistan, 4.0% (95% UI: 3.7-4.3%) in Nepal and 3.7% (95% UI: 3.4-4.1%) in Bhutan. In South Asia, depressive disorders accounted for 9.8 million DALYs (95% UI: 6.8-13.2 million) or 577.8 (95% UI: 399.9-778.9) per 100,000 population in 2016. Of these, major depressive disorders (MDD) accounted for 7.8 million DALYs (95% UI: 5.3-10.5 million). India generated the largest numbers of DALYs due to depressive disorders and MDD, followed by Bangladesh and Pakistan. DALYs due to depressive disorders were highest in females and older adults (75-79 years) across all countries.

CONCLUSION

Our findings show the substantial public health burden of depressive disorders in South Asian populations and healthcare systems. Given the scale of depressive disorders, improvement in overall population health is possible if South Asian countries prioritise the prevention and treatment of depressive disorders.

Prevalence, characteristics and treatment of chronic pain in elderly patients hospitalized in internal medicine wards

BACKGROUND

Chronic pain is a frequent characteristic of elderly people and represents an actual and still poorly debated topic.

OBJECTIVE

We investigated pain prevalence and intensity, and its pharmacological therapy in elderly patients hospitalized in 101 internal medicine wards.

METHODS

Taking advantage of the "REgistro POliterapie Società Italiana Medicina Interna" (REPOSI), we collected 2535 patients of whom almost a quarter was older than 85 years old. Among them, 582 patients were affected by pain (either chronic or acute) and 296 were diagnosed with chronic pain.

RESULTS

Patients with pain showed worse cognitive status, higher depression and comorbidities, and a longer duration of hospital stay compared to those without pain (all p < .0366). Patients with chronic pain revealed lower level of independency in their daily life, worse cognitive status and higher level of depression compared to acute pain patients (all p < .0156). Moreover, most of them were not treated for pain at admission (73.4%) and half of them was not treated with any analgesic drug at discharge (50.5%). This difference affected also the reported levels of pain intensity. Patients who received analgesics at both admission and discharge remained stable (p = .172). Conversely, those not treated at admission who received an analgesic treatment during the hospital stay decreased their perceived pain (p < .0001).

CONCLUSIONS

Our results show the need to focus more attention on the pharmacological treatment of chronic pain, especially in hospitalized elderly patients, in order to support them and facilitate their daily life after hospital discharge.

Course and characteristics of work disability 3 years before and after lumbar spine decompression surgery- a national population-based study

Despite decompression surgery being a widespread intervention for patients with dorsopathies (i.e. back pain) affecting the lumbar spine, the scientific knowledge on patterns and characteristics of work disability before and after the surgery is limited. Sickness absence (SA) and disability pension (DP) were examined three years before and after surgery in 8558 patients aged 25–60 years who underwent lumbar spine decompression surgery in Sweden. They were compared to individuals with diagnosed dorsopathies but no surgery and individuals from the general population as matched comparison groups. According to Group Based Trajectory models, in patients with decompression surgery, 39% had low levels of SA/DP during the entire study period and 15% started with low levels of SA/DP, which increased in the year before, and declined to almost zero in the second year after surgery. Three trajectory groups (12%, 17%, and 18%) started at different levels of SA/DP, which increased in the years before, and declined in the third year after surgery. The trajectory groups in the comparison groups showed lower levels of work disability. Sex, education, and the use of antidepressants and analgesics the year before surgery played an important role to explain the variance of trajectory groups in patients with surgery.

Comorbid symptoms of depression and musculoskeletal pain and risk of long term sickness absence

Background

Symptoms of depression and musculoskeletal pain have both been found to be associated with increased risk of long term sickness absence (LTSA). The comorbidity between depression and pain i.e. simultaneous presence of both symptoms, is well established in the literature. The aim for the current investigation was to investigate whether the presence of comorbid pain influences the associations between depressive symptoms and LTSA or if the presence of comorbid depressive symptoms influences associations between musculoskeletal pain and LTSA.

Methods

A sample of 6572 Danish female health care workers responding to a questionnaire about health and working conditions were followed up in a national register of social transfer payments (DREAM) for 550 days. We estimated the risk for LTSA of four weeks or more, associated with depressive symptoms and number of musculoskeletal pain locations using a Cox proportional hazards model allowing multiple observations per individual. We conducted a test for multiplicative interaction between musculoskeletal pain locations and depressive symptoms, and presented stratified regression models to facilitate the interpretation of the results.

Results

The severity of depressive symptoms was correlated with the number of pain locations reported (Spearman’s rho = .24, p < 0.001). We found a significant multiplicative interaction between depressive symptoms and musculoskeletal pain in predicting the risk of LTSA. Depressive symptoms and number of musculoskeletal pain locations were associated with increased risk of LTSA for individuals who did not have comorbid symptoms. However, we found no significant associations between the two predictors and LTSA among participants who reported comorbid symptoms.

Conclusions

The risk of LTSA associated with depressive symptoms and musculoskeletal pain appears to be moderated by the presence of comorbid symptoms. The modified risk for LTSA among workers with comorbid symptoms requires further investigation.

Pressure Pain Phenotypes in Women Before Breast Cancer Treatment

OBJECTIVES

To explore associations between quantitative sensory testing (QST) and pretreatment pain, physical, and psychological characteristics in women with breast cancer.

SAMPLE & SETTING

41 women with treatment-naive stage 0-III breast cancer at the University of Michigan Comprehensive Cancer Center in Ann Arbor.

METHODS & VARIABLES

Participants completed self-report surveys and QST within the month before breast surgery. Pressure pain thresholds (PPTs) were measured bilaterally at each trapezius with a manual QST algometer. PPT values were split, yielding low, moderate, and high pain sensitivity subgroups. Subgroup self-reported characteristics were compared using Spearman's correlation, chi-square, and one-way analysis of variance.

RESULTS

Lower PPT (higher sensitivity) was associated with higher levels of pain interference and maladaptive pain cognitions. The high-sensitivity group reported higher pain severities, interference, and catastrophizing and lower belief in internal locus of pain control than the low-sensitivity group.

IMPLICATIONS FOR NURSING

Individualized interventions for maladaptive pain cognitions before surgery may reduce pain sensitivity and the severity of chronic pain developed after surgery.

Pain and quality of life of children and adolescents with osteogenesis imperfecta over a bisphosphonate treatment cycle

The objective was to describe the pain and quality of life among children and adolescents with any osteogenesis imperfecta (OI) type over one intravenous bisphosphonate treatment cycle from a child and parental perspective. A prospective, observational study was conducted, where children and adolescents evaluated their pain intensity, location, and quality, as well as quality of life before, 1 week after treatment, and 6 months later. Quality of life was also evaluated from the parental perspective at the same three time points. Thirty-three child/parent dyads participated. The results showed that pain intensity on the 0-10 self-report scale after the Zoledronate infusion (median = 0, range = 0-6) was not different from pre (median = 2, range = 0-10) and 6-months post-scores (median = 2, range = 0-8) (p = 0.170). Children and adolescents with OI reported experiencing pain mainly in the ankles and the anterior and posterior shoulders. They selected evaluative pain descriptors such as uncomfortable (n = 16, 48%) and annoying (n = 13, 39%). Children and adolescents' functioning and quality of life did not change significantly across the bisphosphonate treatment cycle (p = 0.326), parents perceived an improvement immediately after the treatment compared to before (p = 0.016).

CONCLUSION

Children and adolescents with OI experience mild, yet complex pain localized across several body areas. There is little fluctuation in the pain intensity and functioning of children with OI undergoing bisphosphonate treatment. What is Known: • Acute and chronic musculoskeletal pain remains a major issue in OI. • Pain has a negative impact on quality of life. What is New: • New and unpublished methods and findings describing the pain and quality of life of children and adolescents with OI over one intravenous bisphosphonate treatment cycle from a child- and parental-proxy perspective. • Children and adolescents with OI experience pain intensity that is mild, yet complex in quality and localized across several body areas.

Performance of four diagnostic approaches to depression in adults with cancer

OBJECTIVE

The potentially confounding influence of somatic symptoms in identifying depression in medically ill patients has long been of concern, resulting in several proposed alternative diagnostic approaches. These approaches have been compared in the cancer setting, but the strengths and weaknesses of the alternative approaches have rarely been examined. The purpose of the current study was to examine the performance of four approaches to depression assessment among ambulatory cancer patients.

METHOD

Outpatients were recruited from a large cancer center (N = 611). Participants had to be 40 years or older, English-speaking, and have a cancer diagnosis. All participants completed a sociodemographic questionnaire and a modified Patient Health Questionnaire-9 with additional items targeting the Endicott and Cavanaugh substitutive criteria.

RESULTS

Depression prevalence varied significantly by diagnostic approach, with the inclusive approach identifying the largest proportion as depressed (9.3%, n = 57), followed by the Endicott-substitutive (6.2%, n = 38), exclusive (4.6%, n = 28), and Cavanaugh-substitutive approach (1.8%, n = 11). Somatic items were significantly elevated across all four approaches.

CONCLUSIONS

The inclusive approach that retains use of somatic symptoms is appropriate when screening cancer patients for depression. The fact that somatic symptoms were more prevalent across approaches suggests that they may not inflate the prevalence of depression as much as some have feared. Rather, somatic items may explain variance in depressive symptoms beyond that explained by the presence of cancer and its treatment. Additionally, the Endicott items appeared useful for capturing depressive symptoms that are not included in the existing DSM criteria, and may have a place in clinical and research settings.

The interrelationships among pain interference, depressive symptoms, loneliness, and employment status: a moderated mediation study

OBJECTIVE

To explore the mediating effect of loneliness on the relationship between pain interference and depressive symptoms and to determine whether this mechanism is contingent on employment status.

DESIGN

Cross-sectional study.

SUBJECTS

A total of 876 adult caregivers of adolescents living in extremely impoverished conditions.

ANALYSIS

Mediation and moderated mediation analyses using standard path-analytic approaches.

RESULTS

The mean age of the sample was 39.0 (SD = 12.8) years and 80.7% ( n = 707) identified as female. Almost half (48.9%, n = 425) of the participants did not report any pain, while 32.5% ( n = 285) reported non-disabling pain, and 19.0% ( n = 166) reported disabling pain. The mean depressive symptoms score was 16.20 (SD = 10.6), and the mean loneliness score was 40.09 (SD = 10.5). Loneliness mediated the effect of both non-disabling and disabling pain on depressive symptoms. However, the indirect effect of pain interference on depressive symptoms through loneliness was more pronounced among participants reporting disabling pain (coefficient, 2.11; Boot 95% confidence interval (CI) (1.25-3.01)) than non-disabling pain (coefficient, 0.99; Boot 95% CI (0.25-1.76)). Moderated mediation results showed that the indirect effect of pain interference on depressive symptoms, via loneliness varied in magnitude as a function of employment status among participants reporting disabling pain but not those reporting non-disabling pain.

CONCLUSION

Loneliness provides an important link in the relationship between depressive symptoms and pain interference. Furthermore, employment status is an important factor to consider, especially among individuals reporting disabling pain with comorbid depressive symptoms.

Pain, Racial Discrimination, and Depressive Symptoms among African American Women

African American women with osteoarthritis (OA) are at high risk of experiencing pain. They report more pain than non-Hispanic White women and men of other racial/ethnic groups. This pain can limit independence and diminish their quality of life. Despite the detrimental effects that pain can have on older African American women with OA, there is a dearth of literature examining factors beyond the OA pathology that are associated with pain outcomes within this population. The purpose of this study was to examine the relationships between racial discrimination and depressive symptoms with pain intensity in African American women with OA. The sample comprised of 120 African American women, aged 50-80 years, with OA, from Texas and New Mexico. The women completed survey booklets to answer study questionnaires. We used multiple linear regression to test associations between racial discrimination, depressive symptoms, and pain intensity. We tested whether depressive symptoms mediated the relationship between racial discrimination and pain intensity by using bootstrapping. Results indicated that racial discrimination was significantly associated with pain intensity and that this relationship was mediated by depressive symptoms, even after controlling for body mass index, years of education, and length of time with OA. Both depressive symptoms and racial discrimination may be modifiable. If these modifiable factors are addressed in this population, there may be decreased pain in middle-aged and older African American women.

Tackling Pain Associated with Rheumatoid Arthritis: Proton-Sensing Receptors

Rheumatoid arthritis (RA), characterized by chronic inflammation of synovial joints, is often associated with ongoing pain and increased pain sensitivity. Chronic pain that comes with RA turns independent, essentially becoming its own disease. It could partly explain that a significant number (50%) of RA patients fail to respond to current RA therapies that focus mainly on suppression of joint inflammation. The acute phase of pain seems to associate with joint inflammation in early RA. In established RA, the chronic phase of pain could be linked to inflammatory components of neuron-immune interactions and noninflammatory components. Accumulating evidence suggests that the initial inflammation and autoimmunity in RA (preclinical RA) begin outside of the joint and may originate at mucosal sites and alterations in the composition of microbiota located at mucosal sites could be essential for mucosal inflammation, triggering joint inflammation. Fibroblast-like synoviocytes in the inflamed joint respond to cytokines to release acidic components, lowering pH in synovial fluid. Extracellular proton binds to proton-sensing ion channels, and G-protein-coupled receptors in joint nociceptive fibers may contribute to sensory transduction and release of neurotransmitters, leading to pain and hyperalgesia. Activation of peripheral sensory neurons or nociceptors further modulates inflammation, resulting in neuroinflammation or neurogenic inflammation. Peripheral and central nerves work with non-neuronal cells (such as immune cells, glial cells) in concert to contribute to the chronic phase of RA-associated pain. This review will discuss actions of proton-sensing receptors on neurons or non-neuronal cells that modulate RA pathology and associated chronic pain, and it will be beneficial for the development of future therapeutic treatments.

The impact of fibromyalgia symptoms on brain morphometry

Fibromyalgia (FMS) is a complex clinical syndrome that includes many symptoms beyond chronic pain. The studies that have addressed brain morphometry in FMS have had very heterogeneous results. Thus, the question of which specific FMS symptoms and clinical features-pain, but also psychological distress, sleep-related problems, health status, and medication intake-impact on brain morphometry remains open. Here, we wanted to determine if brain changes in FMS are "symptom-related" more than "diagnostic-related". We performed an observational study of 46 premenopausal women (23 FMS patients and 23 age-matched healthy participants). Magnetic resonance images were analyzed using voxel-based morphometry and subcortical segmentation. We used multiple regression models to assess the associations between total and local brain volumes and FMS clinical characteristics. Furthermore, we calculated associations between subcortical structures' shapes and volumes and FMS clinical characteristics. Larger psychological distress, anxiety, and sleepiness, and higher analgesic consumption accounted for 38 % of FMS patients' smaller total gray matter volume (GMV). For both groups, local decrements of GMV in the medial orbitofrontal cortex were associated to larger psychological distress. Local increases of GMV were positively related to pain scores (superior frontal gyrus), psychological distress (cerebellum), anxiety (medial orbitofrontal cortex), and sleepiness (frontal superior medial cortex). FMS clinical characteristics were also associated to deformations in subcortical structures and volumes changes. This study reveals that total and local GMV changes in FMS go beyond the traditional "pain matrix" alterations. We demonstrated that brain morphology is altered by pain, but also by clinical characteristics that define the FMS experience.

Psychometric properties revised reinforcement sensitivity theory (r-RST) scale in chronic pain patients

OBJECTIVE

The aim of present study was to evaluate the psychometric properties of the Reinforcement Sensitivity Questionnaire (RSQ) in patients with chronic pain.

METHODS

For this purpose, 312 (first study) and 70 (second study) patients with chronic pain were selected, and the Reinforcement Sensitivity Theory Personality Questionnaire (RST-PQ) and Pain Beliefs and Perceptions Inventory (PBPI) were distributed among them for their response. The reliability of the questionnaire was evaluated by Cronbach's alpha, retest, and split-half coefficient; then, the criterion validity with other questionnaires was evaluated to determine the psychometric properties of the RSQ. The factor structure was assessed via confirmatory factor analysis.

RESULTS

The results of the factor analysis indicated that the RSQ has five factors, and checking the validity by using Cronbach's alpha, retest, and split-half coefficient reflected the stability of the scale; the criterion validity of the RSQ with other questionnaires showed desirable discriminant and convergent validity.

CONCLUSION

Overall, the findings indicated that the RSQ has good psychometric properties in chronic pain samples, and the tool can be used in studies of chronic pain. It seems that the RSQ is a good predictor for pain in patients with chronic pain.

Behavioral inhibition, maladaptive pain cognitions, and function in patients with chronic pain

BACKGROUND AND AIMS

Trait behavioral inhibition represents a tendency to react with negative emotions - primarily worry - to cues which signal potential threats. This tendency has been hypothesized by a two-factor model of chronic pain to have direct effects on psychological and physical function in individuals with chronic pain, as well as to influence the associations between pain-related maladaptive cognitions and function. Our aim was to test these hypothesized associations in a sample of individuals who were being screened for possible interdisciplinary chronic pain treatment.

METHODS

Eighty-eight patients referred to an interdisciplinary chronic pain management program were administered measures of average pain intensity, trait behavioral inhibition, kinesiophobia, pain catastrophizing, depressive symptoms, and pain interference. We then performed two linear regression analyses to evaluate the direct effects of trait behavioral inhibition on depressive symptoms and pain interference and the extent to which behavioral inhibition moderated the associations between kinesiophobia and pain catastrophizing, and the criterion variables.

RESULTS

In partial support of the study hypotheses, the results showed significant (and independent) direct effects of trait behavioral inhibition on depressive symptoms, and behavioral inhibition moderated the association between kinesiophobia and depression, such that there were stronger associations between kinesiophobia and depressive symptoms in those with higher dispositional sensitivity to fear-inducing stimuli. However, neither direct nor moderating effects of behavioral inhibition emerged in the prediction of pain interference.

CONCLUSIONS

If replicated in additional studies, the findings would indicate that chronic pain treatments which target both reductions in maladaptive cognitions (to decrease the direct negative effects of these on depressive symptoms) and the individual's tendency to respond to pain with worry (as a way to buffer the potential effects of maladaptive cognitions on depressive symptoms) might be more effective than treatments that targeted only one of these factors.

IMPLICATIONS

Additional research is needed to further evaluate the direct and moderating effects of pain-related behavioral inhibition on function, as well as the extent to which treatments which target behavioral inhibition responses provide benefits to individuals with chronic pain.

How are socio-demographic and psycho-social factors associated with the prevalence and chronicity of severe pain in 14 different body sites? A cross-sectional population-based survey

BACKGROUND

Severe pain and chronic pain have a high impact on individuals and society. Body location of pain is important with regard to perception, articulation, and underlying biological, mental or social causes of pain.

METHODS

A cross-sectional survey was performed in the general Austrian population with 15,474 personally interviewed subjects aged 15 years and older.

RESULTS

The 1‑year period prevalence of severe pain in any body site was 38.6% and of chronic pain 24.9%. In all, 8.1% had pain in at least three body sites. Subjects aged 65 years and older (52.2%), those with low education (43.4%), unemployed subjects (50.4%), retired subjects (52.4%), those with anxiety/depression (67.7%), and subjects with lack of social support (49.6%) were sub-populations with high pain prevalence. In multivariate analyses, depression/anxiety was associated with prevalence and chronicity of severe pain in all body sites (range of ORs 1.89-5.01), while such associations were found for lack of social support (range of ORs 1.33-1.65), female sex (range of ORs 1.38-2.34), higher age (range of ORs 1.09-1.18 for 5 year intervals), as well as low educational (range of ORs 1.47-2.06 primary vs. tertiary education) and unemployment status (range of ORs 1.50-2.62) in most body sites. Being born in non-EU or EFTA states was associated with pain in many body sites (range of ORs 1.38-2.10).

CONCLUSIONS

Psychosocial factors are associated with pain presence in similar ways irrespective of location. Regarding socio-demographic factors, differences towards the magnitude and the direction in the association with pain frequency and chronicity in different body sites emerged.

Regional brain functions in the resting state indicative of potential differences between depression and chronic pain

Complex relationships between depression and chronic pain have been reported in previous studies. However, only a few neuroimaging studies have investigated similarities and differences in neural systems underlying them. We examined the brain functions in the resting state of 43 patients with depression, 41 patients with chronic pain (somatoform pain disorder) and 41 healthy controls, by using regional homogeneity (ReHo) and functional connectivity analysis. Depressive symptoms were assessed by using the Beck Depression Inventory-Second Edition (BDI-II). ReHo values for the dorsolateral prefrontal cortex (DLPFC) significantly decreased for chronic pain patients, and functional connectivity between the DLPFC and thalamus decreased only for these patients. These findings are indicative of distinct brain functions related to depression and chronic pain. Understanding these differences would further elucidate the pathophysiology of these conditions.

A Nationally Scaled Telebehavioral Health Program for Chronic Pain: Characteristics, Goals, and Psychological Outcomes

BACKGROUND

Millions of U.S. adults suffer from chronic pain with a high prevalence of comorbid mental health issues. Telehealth-delivered behavioral therapy for chronic pain has been evaluated in the research setting. The purpose of this study was 1) to describe a nationally scaled, standardized, telebehavioral therapy program for patients with chronic pain and behavioral comorbidities, and 2) evaluate characteristics, goals, and psychosocial outcomes among program participants.

MATERIALS AND METHODS

This was mixed-methods retrospective cohort analysis among consecutive program graduates (mean age 53y; 24% male). The 8-week program was delivered by a licensed therapist and a behavior coach through telephone/secure video and tailored to each participant's behavioral health needs and goals. Participant chief complaints, behavioral goals, and mood triggers were abstracted by deidentified clinical record review using structured qualitative research methods. Depression, anxiety, and stress symptom data were collected at baseline and program graduation using the validated Depression Anxiety Stress Scales 21.

RESULTS

Back pain (42%) and hip/leg/knee pain (28%) comprised the most common chief complaints. Pain management (44%) and weight loss (43%) were the most frequently cited goals. At baseline, approximately half of participants had elevated depression (59%), anxiety (54%), and/or stress (48%) scores. Triggers for depressed, anxious, or stressed mood included severe pain (47%), health concerns (46%), and interpersonal relationship challenges (45%). At graduation, significant improvement in median depression (-54%), anxiety (-50%), and stress (-33%) symptom scores was observed among those with non-normal baseline values (p < 0.001); degree of improvement did not vary by participant age or sex.

CONCLUSIONS

Participants in a nationally scaled telebehavioral health program for chronic pain experienced significant improvement in depression, anxiety, and stress symptoms and shared several complaints, goals, and mood triggers.