Acute Pain and Depressive Symptoms: Independent Predictors of Insomnia Symptoms among Adults with Sickle Cell Disease

An Examination of John Henryism in Adults Living with Sickle Cell Disease

BACKGROUND

John Henryism (JH) is a behavioral predisposition for high-effort coping with adversity. JH has been associated with hypertension in Black Americans with low socioeconomic status (SES) and is also found to be associated with psychological well-being. Sickle cell disease (SCD), a rare genetic disease largely affecting Black Americans in the United States, presents as a chronic condition that may benefit from a deeper understanding of the impact of JH on overall health.

PURPOSE

This study examined the association between high and low JH and diastolic blood pressure, systolic blood pressure, hypertension prevalence, and sleep function. We relied on the biopsychosocial transaction model to adjust for relevant clinical and sociodemographic variables.

METHODS

This was a cross-sectional secondary analysis of 274 adults with SCD living in the United States and recruited between 2014 and 2020. Study visits consisted of physical examinations, medical history, demographic, and psychosocial questionnaires. Adjusted linear regressions estimated associations between high and low JH and diastolic and systolic blood pressure as well as self-reported sleep function. Multivariable logistic regression was used to examine associations with hypertension prevalence.

RESULTS

High JH was significantly associated with lower diastolic blood pressure (β =  - 2.98; 95% confidence interval =  - 5.92, - 0.04) but higher sleep dysfunction (β = 2.76; 95% confidence interval = 1.45, 4.07).

CONCLUSIONS

Overall, we found positive psychological coping resources associated with high JH, with the exception of sleep.

TRIAL REGISTRATION

CLINICALTRIALS

gov Identifier: NCT02156102.

Psychiatric comorbidities in adults with sickle cell disease: A narrative review

Although descriptions of quality of life and patient reports of mood in sickle cell disease (SCD) have become more common in the literature, less is known about psychiatric illness prevalence, presentation, and treatment, particularly for adults. We provide a narrative review of what is known about common and debilitating psychiatric conditions such as depression, anxiety, and cognitive impairment, specifically for adults with SCD. We discuss the limitations of the current evidence, make provisional recommendations, and identify opportunities for research and improved care.

Depressive and Insomnia Symptoms Sequentially Mediate the Association Between Racism-Based Discrimination in Healthcare Settings and Clinical Pain Among Adults With Sickle Cell Disease

Racism-based discrimination in healthcare settings has been associated with clinical pain in adults living with sickle cell disease; however, no studies have examined depressive and insomnia symptoms as mechanisms that may drive this relationship. This secondary data analysis examined associations between depressive and insomnia symptoms, racism-based discrimination, and clinical pain. Seventy-one adults with sickle cell disease (70% female, Mage = 38.79) provided baseline reports of racism-based discrimination, depressive symptoms, insomnia symptoms, and pain (severity, interference, catastrophizing), and they completed daily diaries of pain severity and interference over 3 months. In a sequential mediation model, baseline depressive (1st) and insomnia symptoms (2nd) significantly mediated the association between racism-based discrimination and baseline pain interference, average daily diary pain severity, and average daily diary pain interference. Although the mediation model with baseline pain severity as the outcome was significant, the total and direct effects were not. Results indicate that discrimination in healthcare settings contributes to depression, which may act on pain through sleep disturbance. Findings support the need for systemic and structural changes to eliminate discrimination in healthcare settings and behavioral mood and sleep interventions to reduce the impact of discrimination on clinical pain. PERSPECTIVE: The relationship between discrimination in healthcare settings and pain in adults with sickle cell disease may be driven by depression and sleep disturbance, modifiable risk factors and potential treatment targets. Results suggest that systemic, structural, and institutional changes must be implemented to promote better patient care and health outcomes.

Sleep quality and pain in adolescents and young adults with sickle cell disease

STUDY OBJECTIVES

This study evaluated sleep quality in relation to pain and pain-related impairment in adolescents and young adults with sickle cell disease. The purpose was to examine whether increased age was associated with poorer sleep quality and pain and to examine the sleep quality-pain association in this age group.

METHODS

Eighty-nine adolescents and young adults with sickle cell disease between the ages of 13 and 25 completed ratings of sleep quality, overall pain, and 2 measures of pain-related impairment (pain impact and pain burden) as part of their clinical care. Retrospective chart reviews were completed to match ratings to demographic and medical characteristics. Correlations and multiple regression were used to examine associations between age, sleep quality, and pain variables, including an exploratory analysis of the sleep-pain association by age.

RESULTS

Increased age was associated with poorer sleep quality, worse overall pain, and higher pain burden. Poorer sleep quality was also associated with worse overall pain and pain burden. Using multiple regression, a small, but not statistically significant trend was observed for the interaction of increased age and strengthening of the sleep quality-pain burden association.

CONCLUSIONS

Sleep quality and pain are important challenges for adolescents and young adults with sickle cell disease that may persist or worsen with increased age. Early identification of these difficulties in pediatric populations as well as continued screening and intervention as adolescents transition into adult care is important. Additional longitudinal research is needed to better understand the progression of the sleep-pain relationship over time.

CITATION

Schlenz AM, Thomas SJ, Gloston G, Lebensburger J, Maxwell SL, Kanter J. Sleep quality and pain in adolescents and young adults with sickle cell disease. J Clin Sleep Med. 2022;18(12):2845-2853.

An evaluation of patient-reported outcomes in sickle cell disease within a conceptual model

PURPOSE

To examine the relations between patient-reported outcomes (PROs) within a conceptual model for adults with sickle cell disease (SCD) ages 18 - 45 years enrolled in the multi-site Sickle Cell Disease Implementation Consortium (SCDIC) registry. We hypothesized that patient and SCD-related factors, particularly pain, and barriers to care would independently contribute to functioning as measured using PRO domains.

METHODS

Participants (N = 2054) completed a 48-item survey including socio-demographics and PRO measures, e.g., social functioning, pain impact, emotional distress, and cognitive functioning. Participants reported on lifetime SCD complications, pain episode frequency and severity, and barriers to healthcare.

RESULTS

Higher pain frequency was associated with higher odds of worse outcomes in all PRO domains, controlling for age, gender and site (OR range 1.02-1.10, 95% CI range [1.004-1.12]). Reported history of treatment for depression was associated with 5 of 7 PRO measures (OR range 1.58-3.28 95% CI range [1.18-4.32]). Fewer individual barriers to care and fewer SCD complications were associated with better outcomes in the emotion domain (OR range 0.46-0.64, 95% CI range [0.34-0.86]).

CONCLUSIONS

Study results highlight the importance of the biopsychosocial model to enhance understanding of the needs of this complex population, and to design multi-dimensional approaches for providing more effective interventions to improve outcomes.

Development and testing of a standardized pain interview assessment for use in post-acute care

OBJECTIVES

Pain is highly prevalent among patients in post-acute care (PAC) settings and can affect quality of life, treatment outcomes, and transitions in care. Routine, accurate assessment of pain across settings is important for pain management and care planning; however, existing PAC assessment instruments do not assess patient pain in a standardized manner.

METHODS

We developed and tested a set of pain interview data elements for use across PAC settings (skilled nursing facilities, inpatient rehabilitation facilities, long term care hospitals, home health agencies) as part of a larger effort undertaken by the Centers for Medicare & Medicaid Services to develop standardized assessment data elements to meet the requirements of the IMPACT Act of 2014. The interview assessed six pain constructs: presence; frequency; interference with sleep; interference with rehabilitation therapies [if applicable]; interference with daily activities; worst pain; and pain relief from treatments/medications). A total of 3031 PAC patients at 143 PAC settings (across 14 U.S. geographic/metropolitan areas in 10 states) participated in a national field test of standardized data elements from November 2017 to August 2018. We assessed item response distributions, time to complete interviews, inter-assessor agreement, and, for a subset of patients, change in responses between admission and discharge assessments. We also conducted focus groups with nurse assessors about their experiences administering the items.

RESULTS

For patients reporting any pain, average time to complete the pain interview was 3.1 min (SD = 1.3), and interrater reliability was excellent for all data elements (kappa range: 0.95-0.99). Findings were similar across types of PAC settings. Qualitative data from nurses emphasized ease of administration and high perceived clinical utility.

CONCLUSION

Findings provide support for feasibility of implementing a standardized pain interview assessment in PAC settings. This tool can support tracking of patient needs across settings and interoperability of data in electronic medical records.

Prevalence of clinical manifestations suggestive of depression in patients with sickle cell disease: a review

ABSTRACT Objective: To assess the prevalence of clinical manifestations suggestive of depression in patients with sickle cell disease. Methods: A systematic search was performed in the electronic databases PubMed®, LILACS and SciELO, with the following inclusion criteria: cross-sectional studies that assessed the prevalence of depression in patients with sickle cell disease, published in English or Portuguese in the last 10 years. The selection of the articles was performed in two stages by two independent researchers following the PRISMA (Preferred reporting items for systematic reviews and meta-analyses) recommendations. The first stage consisted on screening the titles and abstracts, and in the second stage the full text was appraised, both following the pre-defined inclusion and exclusion criteria. Results: From the 42 articles available, nine were included in this review. Seven instruments were used to screen for depression with different cutoff points, and the Patient Health Questionnaire-9 (PHQ-9) was the most used instrument. The worldwide prevalence of clinical manifestations suggestive of depression ranged from 11 to 40%, according to several variables. Conclusion: The prevalence of clinical manifestations suggestive of depression in patients with sickle cell disease is higher compared to the prevalence of depression in the general population. Thus, the multidisciplinary follow-up for these people, with a focus on mental health, is of great importance.

The Experiences and Determinants of Sleep Problems of Immigrant and Canadian-Born Older Adults-Analysis of Canadian Longitudinal Study on Aging Baseline Data

BACKGROUND

Although prevalent, limited knowledge is available on the experience of sleep problems (i.e., disturbance in sleep latency and in sleep maintenance) and their determinants in immigrant older adults.

PURPOSE

To compare immigrant and Canadian-born older adults' experiences of: 1) sleep problems, 2) determinants of sleep problems, categorized into precipitating and perpetuating factors, and 3) determinants most significantly contributing to each sleep problem.

METHODS

Baseline data obtained by the comprehensive cohort of the Canadian Longitudinal Study on Aging were analyzed. Participants 55+ years of age and with complete data on their country of birth comprised the sample, with 18,245 Canadian-born and 4,257 immigrant older adults. Single or multiple items were used to assess the precipitating (chronic condition, sleep disorders, pain, depressive symptoms, psychological distress, education, marital and socio-economic status) and perpetuating (smoking, alcohol consumption, physical activity) factors. Chi-square test and independent sample t-test were used in the comparison and multiple regression was applied to determine the most significant determinant of each sleep problem in each group of older adults.

RESULTS

Despite differences in a few determinants of sleep problems, the set of factors contributing to disturbance in sleep latency and maintenance was comparable for Canadian-born and immigrant older adults, and included: having a sleep disorder and high level of depressive symptoms and psychological distress.

CONCLUSION

The findings highlight the importance of public health campaigns to increase older adults' awareness of sleep problems, the factors that may contribute to disturbance in sleep, and strategies to prevent and/or manage sleep problems.

Indirect Economic Burden of Sickle Cell Disease

OBJECTIVE

This study aimed to quantify the indirect costs of sickle cell disease in the United States.

METHODS

Adult patients from a sickle cell disease clinic at an urban academic healthcare system completed an adapted Institute for Medical Technology Assessment Productivity Cost Questionnaire related to the impact of their disorder on absenteeism, presenteeism, ability to contribute through unpaid work outside of employment, and other aspects of life. Additional data were collected from patient records about each participant's genotype, total hemoglobin level, and pain level.

RESULTS

Of the 192 individuals, 187 who completed the survey reported experiencing vaso-occlusive crisis pain events during the last year that negatively affected their productivity at work and in daily roles. Three-fourths of respondents reported impairment in their ability to complete everyday tasks, such as caring for children, running errands, doing housework, shopping for groceries, and volunteer (unpaid) work. Only 30% of respondents reported being employed or self-employed. Of those employed, estimated costs of absenteeism and presenteeism attributable to pain events averaged $15 103 per person annually. Estimated total annual losses in unpaid work productivity averaged $3 145 862 for the study respondents and another $2 870 652 for their caregivers.

CONCLUSIONS

Sickle cell disease affected the work productivity, nonwork productivity, and the daily lives of adults seen with the disorder in an academic medical center.

Identifying Clinical and Research Priorities in Sickle Cell Lung Disease. An Official American Thoracic Society Workshop Report

Background: Pulmonary complications of sickle cell disease (SCD) are diverse and encompass acute and chronic disease. The understanding of the natural history of pulmonary complications of SCD is limited, no specific therapies exist, and these complications are a primary cause of morbidity and mortality.Methods: We gathered a multidisciplinary group of pediatric and adult hematologists, pulmonologists, and emergency medicine physicians with expertise in SCD-related lung disease along with an SCD patient advocate for an American Thoracic Society-sponsored workshop to review the literature and identify key unanswered clinical and research questions. Participants were divided into four subcommittees on the basis of expertise: 1) acute chest syndrome, 2) lower airways disease and pulmonary function, 3) sleep-disordered breathing and hypoxia, and 4) pulmonary vascular complications of SCD. Before the workshop, a comprehensive literature review of each subtopic was conducted. Clinically important questions were developed after literature review and were finalized by group discussion and consensus.Results: Current knowledge is based on small, predominantly observational studies, few multicenter longitudinal studies, and even fewer high-quality interventional trials specifically targeting the pulmonary complications of SCD. Each subcommittee identified the three or four most important unanswered questions in their topic area for researchers to direct the next steps of clinical investigation.Conclusions: Important and clinically relevant questions regarding sickle cell lung disease remain unanswered. High-quality, multicenter, longitudinal studies and randomized clinical trials designed and implemented by teams of multidisciplinary clinician-investigators are needed to improve the care of individuals with SCD.

AAAPT Diagnostic Criteria for Acute Sickle Cell Disease Pain

Acute pain episodes are the most common complication in patients with sickle cell disease (SCD). Classically attributed to vaso-occlusion, recent insights suggest that chronic pain may also contribute to the pathogenesis of acute pain episodes, which adds complexity to their diagnosis and management. A taxonomy, or classification system, for acute pain in patients with SCD would aid research efforts and enhance clinical care. To meet this need, the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks public-private partnership with the U.S. Food and Drug Administration, the American Pain Society, and the American Academy of Pain Medicine formed the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks-American Pain Society-American Academy of Pain Medicine Pain Taxonomy initiative. One of the goals of this initiative was to develop taxonomies for acute pain disorders, including SCD. To accomplish this, a working group of experts in SCD and pain was convened. Based on available literature and expert opinion, the working group used a 5-dimenional structure (diagnostic criteria, common features, modulating factors, impact/functional consequences, and putative mechanisms) to develop an acute pain taxonomy that is specific to SCD. As part of this, a set of 4 diagnostic criteria, with 2 modifiers to account for the influence of chronic pain, are proposed to define the types of acute pain observed in patients with SCD. PERSPECTIVE: This article presents a taxonomy for acute pain in patients with SCD. This taxonomy could help to standardize definitions of acute pain in clinical studies of patients with SCD.

Brief Pain Inventory: A proposal to extend its clinical application

BACKGROUND

This study presents an adaptation of the Brief Pain Inventory (BPI) extending its use in clinical/epidemiological contexts and the evaluation of the properties of BPI (short form) in a sample of Brazilian adults.

METHODS

Part of item 1 of this instrument was removed because it prevented the participation of individuals with usual pain. In addition to the reference period of original response "last 24 hr," a new period "last pain experience" was proposed. Individuals responded about the presence/lack and onset of pain. Individuals who reported pain in the last 24 hr before the interview answered the BPI considering both reference periods. Confirmatory factor analysis was performed to check the fit of five theoretical BPI models.

RESULTS

A total of 1,176 adults participated (79.0% women; 38.7 (SD = 10.8) years), 29.2% did not report pain in the last 24 hr, 33.6% reported pain <3 months and 37.2% pain ≥3 months. All theoretical BPI models presented adequate fit indices (GFI ≥ 0.9; RMSEA < 0.1; α ≥ 0.7) when both reference periods were used. In conclusion, the adaptations proposed can contribute to extend the use of BPI.

CONCLUSIONS

The reference period of responses and the theoretical model used must be chosen according to the needs of the researcher and/or physician.

SIGNIFICANCE

This study presents evidence related to the validity of applying the Brief Pain Inventory (BPI) in adults with and without pain considering the present pain or memory of pain, enabling the clinician to collect additional information that may be relevant to the clinical management of pain.

Sleep Problem Risk for Adolescents With Sickle Cell Disease: Sociodemographic, Physical, and Disease-related Correlates

The aims of the current study were to investigate whether SCD incurs an additional risk for poor sleep over and above the influence of sociodemographic factors (ie, race and sex) during adolescence, and to explore the relationships between sociodemographic, physical (ie, age and pubertal status), and disease-related factors (ie, SCD genotype and hydroxyurea use) on sleep problem risk during adolescence. Black adolescents (age, 12 to 17 y) with SCD (n=53) were recruited from regional pediatric SCD clinics in the southeast and a sample of healthy black adolescents (n=160) were recruited from middle and high schools. Regression analyses indicated that SCD was uniquely related to sleeping more, and worse sleep quality over and above the influence of sociodemographic factors. Having a more severe SCD genotype was related to worse sleep quality and higher pubertal status was related to sleeping longer during the week. Results indicate the need for systematic assessments of sleep problems, with more a focus on youth with more severe genotypes and higher pubertal status. Future research should focus on characterizing trajectories of sleep problems in this population, identifying key risk factors, and elucidating mechanisms linking risk factors to sleep problem risk to aid in tailoring interventions for this population.

Prevalence and correlates of major depression among Nigerian adults with sickle cell disease

Objective To ascertain the current and lifetime prevalence of depression among adults with sickle cell disease and identify relevant socio-demographic and clinical correlates. Method A cross-sectional study of 205 stable adult out-patient attendees at a treatment center in southern Nigeria between April and September, 2014. A socio-demographic questionnaire, the depression module of Mini International Neuropsychiatric Interview, and the eight-item Morisky Medication Adherence Scale were administered. Categorical and continuous variables associated with a diagnosis of depression were tested using chi-squared and t-tests respectively. Level of significance was set a priori at P < 0.05. Results Prevalence of current depression was 16.6%, while lifetime prevalence was 29.8%. Current depression was significantly associated with frequent analgesic use ( P < 0.03), unemployment ( P = 0.04), low income ( P < .04), low educational status ( P < 0.01), and subjective pain ( P < 0.001). Subjective pain was nearly twice as likely to predict a current depressive episode (AOR: 1.81, 95%CI: 1.42-2.02, P < 0.03). Conclusions Depression is common among adults with sickle cell disease and is significantly associated with severity of subjective pain.