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Solá VP, Montes JM, Calvo ET, Gasull V, Campayo JG, Diez JMO, Berrocoso E, Mico JA, Agüera L. Consensus on the detection and management of patients with depression and pain as an associated somatic symptom. SPANISH JOURNAL OF PSYCHIATRY AND MENTAL HEALTH 2023:S2950-2853(23)00055-8. [PMID: 37952640 DOI: 10.1016/j.sjpmh.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 09/13/2023] [Accepted: 10/16/2023] [Indexed: 11/14/2023]
Abstract
INTRODUCTION Globally, depression is the most common psychiatric disorder and is frequently associated with somatic symptom disorders, including pain as a physical symptom. There is a current need to improve the detection and management of the individuals in which depression and pain coexist. Hence, the aim of this document is to provide recommendations in the diagnosis and management of patients with major depressive disorder (MDD) who have pain as a physical symptom (PPS), in order to reduce the variability of clinical practice. MATERIAL AND METHODS The methodology used is based on the internationally recognized RAND/UCLA consensus method. The scientific committee, consisted of a group of eight multidisciplinary experts, defined 12 clinically relevant questions. After the systematic review of the literature, the scientific committee assessed the evidence and developed recommendations. The panel group with 15 participants validated these recommendations using a single Delphi round. To conclude, there was a final consensus meeting held to redefine with minor modifications the final recommendations. RESULTS The scientific committee developed a total of 19 recommendations on the diagnosis and detection, impact of PPS in MDD, treatment of MDD with associated PPS, use of healthcare resources, additional recommendations, and care coordination of these patients. Globally, a substantial level of agreement (≥80%) was reached on all items during the Delphi round. All the 19 achieved consensus, seven of them (37%) were agreed with unanimity during the Delphi round. The recommendations with higher consensus were in relation to diagnosis, impact of PPS in MDD, treatment and use of healthcare resources. CONCLUSIONS Currently, the evidence base for patients with MDD and PPS is still being developed and this consensus statement aims to bridge that gap by providing practical recommendations.
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Affiliation(s)
- Víctor Pérez Solá
- Institut de Neuropsiquiatria i Addiccions, Parc de salut mar, Barcelona, Spain; CIBERSAM, Madrid, Spain; Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain; Department of Medicine and Life Sciences (MELIS), Universitat Pompeu Fabra, Barcelona, Spain.
| | - José Manuel Montes
- Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain; Universidad de Alcalá, Alcala de Henares, CIBERSAM, Spain
| | - Eva Trillo Calvo
- Medicina de Familia, Centro de Salud Campo de Belchite, Belchite, Zaragoza, Spain
| | - Vicente Gasull
- Medicina de Familia, Centro de Salud Torrent II, Valencia, Spain
| | | | - Jose Manuel Olivares Diez
- Servicio de Psiquiatría del Area Sanitaria de Vigo, Director del Area de Neurociencias, Instituto de Investigación Sanitaria Galicia Sur (IISGS, Cibersam), Spain
| | - Esther Berrocoso
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Madrid, Spain; Department of Psychology, University of Cadiz, Spain; Biomedical Research and Innovation Institute of Cádiz (INiBICA), Spain
| | - Juan Antonio Mico
- Departamento de Neurociencias, Farmacología y Psiquiatría, Centro de Investigación Biomédica en Red de Salud Mental, Instituto de Salud Carlos III (CIBERSAM), Universidad de Cádiz, Cádiz, Spain
| | - Luis Agüera
- Servicio de Psiquiatría del Hospital Universitario 12 de Octubre, Madrid, Spain; Associate Professor of the Faculty of Medicine, Universidad Complutense, Madrid, Spain
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Trivedi C, Vadukapuram R, Chaudhari G, Ashraf S, Tazin F, Mansuri Z, Jain S. Risk of Suicide in Patients With Bipolar Disorder Having Comorbid Chronic Pain Disorders: Insights From the Nationwide Inpatient Sample Data From 2016 to 2018. J Nerv Ment Dis 2022; 210:564-569. [PMID: 35394970 DOI: 10.1097/nmd.0000000000001506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Bipolar disorders (BDs) are associated with significant risk of suicide. BD patients (age ≥18 years) admitted to the hospital were identified from the National Inpatient Sample dataset. Based on the secondary diagnosis of chronic pain disorder (CPD), patients were stratified into two groups (1) BD with CPD (BD + CPD) and (2) BD without CPD (BD - CPD). Groups were matched (1:1) for the type of BD and compared for baseline characteristics and suicidal ideation/attempt (SI/SA). Compared with BD - CPD, most patients in the BD + CPD group were older (mean age, 47.6 vs. 40.4 years), female (58.4% vs. 55.2%), and white (77.2% vs. 66.7%). After adjusting for covariates, compared with the BD - CPD group, the BD + CPD group had 21% more risk of SI/SA (odds ratio, 1.21, p < 0.001). CPD is independently associated with the increased risk of suicide among patients with BD. Thus, comorbid CPD among patients admitted for BD can be an essential risk factor for suicide.
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Affiliation(s)
- Chintan Trivedi
- Texas Tech University Health Science Center at Permian Basin, Midland, Texas
| | | | - Gaurav Chaudhari
- Texas Tech University Health Science Center at Permian Basin, Midland, Texas
| | | | - Faria Tazin
- East Liverpool City Hospital, East Liverpool, Ohio
| | - Zeeshan Mansuri
- Boston Children's Hospital/Harvard Medical School, Boston, Massachusetts
| | - Shailesh Jain
- Texas Tech University Health Science Center at Permian Basin, Midland, Texas
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Risch N, Dubois J, M’bailara K, Cussac I, Etain B, Belzeaux R, Dubertret C, Haffen E, Schwan R, Samalin L, Roux P, Polosan M, Leboyer M, Courtet P, Olié E. Self-Reported Pain and Emotional Reactivity in Bipolar Disorder: A Prospective FACE-BD Study. J Clin Med 2022; 11:jcm11030893. [PMID: 35160345 PMCID: PMC8836480 DOI: 10.3390/jcm11030893] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 01/24/2022] [Accepted: 02/01/2022] [Indexed: 02/05/2023] Open
Abstract
In patients with bipolar disorder (BD), pain prevalence is close to 30%. It is important to determine whether pain influences BD course and to identify factors associated with pain in BD in order to guide BD management. This naturalistic, prospective study used data on 880 patients with BD from the French FACE-BD cohort who were divided into two groups according to the presence or absence of pain. Multivariate models were used to test whether pain was associated with affective states and personality traits while controlling for confounders. Then, multivariate models were used to test whether pain at baseline predicted global life functioning and depressive symptomatology at one year. At baseline, 22% of patients self-reported pain. The pain was associated with depressive symptomatology, levels of emotional reactivity in a quadratic relationship, and a composite variable of personality traits (affective lability, affective intensity, hostility/anger, and impulsivity). At one year, the pain was predictive of depression and lower global life functioning. Pain worsens mental health and well-being in patients with BD. The role of emotions, depression, and personality traits in pain has to be elucidated to better understand the high prevalence of pain in BD and to promote specific therapeutic strategies for patients experiencing pain.
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Affiliation(s)
- Nathan Risch
- Institute of Functional Genomics, University of Montpellier, CNRS, INSERM, 34094 Montpellier, France; (J.D.); (P.C.); (E.O.)
- Department of Emergency Psychiatry and Post-Acute Care, CHU Montpellier, 34295 Montpellier, France
- Clinique de la Lironde, Clinea Psychiatrie, 34980 Saint-Clément-de-Rivière, France
- Correspondence: ; Tel.: +33-46-733-8581
| | - Jonathan Dubois
- Institute of Functional Genomics, University of Montpellier, CNRS, INSERM, 34094 Montpellier, France; (J.D.); (P.C.); (E.O.)
- Department of Emergency Psychiatry and Post-Acute Care, CHU Montpellier, 34295 Montpellier, France
| | - Katia M’bailara
- Fondation FondaMental, 94000 Créteil, France; (K.M.); (I.C.); (B.E.); (R.B.); (C.D.); (E.H.); (R.S.); (L.S.); (P.R.); (M.P.); (M.L.)
- LabPsy, University of Bordeaux, EA 4139, F-33000 Bordeaux, France
- Department of Clinical and Academic Psychiatry, Charles-Perrens Hospital, 33076 Bordeaux, France
| | - Irena Cussac
- Fondation FondaMental, 94000 Créteil, France; (K.M.); (I.C.); (B.E.); (R.B.); (C.D.); (E.H.); (R.S.); (L.S.); (P.R.); (M.P.); (M.L.)
- Psychiatric Center, Hospital Princesse Grace, 1 Ave. Pasteur, 98000 Monaco, Monaco
| | - Bruno Etain
- Fondation FondaMental, 94000 Créteil, France; (K.M.); (I.C.); (B.E.); (R.B.); (C.D.); (E.H.); (R.S.); (L.S.); (P.R.); (M.P.); (M.L.)
- AP-HP, GHU Paris Nord, DMU Neurosciences, Hôpital Fernand Widal, 75010 Paris, France
- INSERM UMRS 1144-Université de Paris, 75006 Paris, France
| | - Raoul Belzeaux
- Fondation FondaMental, 94000 Créteil, France; (K.M.); (I.C.); (B.E.); (R.B.); (C.D.); (E.H.); (R.S.); (L.S.); (P.R.); (M.P.); (M.L.)
- Pôle de Psychiatrie, Assistance Publique Hôpitaux de Marseille, 13005 Marseille, France
- INT-UMR 7289, CNRS Aix-Marseille Université, 13385 Marseille, France
| | - Caroline Dubertret
- Fondation FondaMental, 94000 Créteil, France; (K.M.); (I.C.); (B.E.); (R.B.); (C.D.); (E.H.); (R.S.); (L.S.); (P.R.); (M.P.); (M.L.)
- Department of Psychiatry, University of Paris, AP-HP, Louis Mourier Hospital, INSERM UMR 1266 Paris, 92700 Colombes, France
| | - Emmanuel Haffen
- Fondation FondaMental, 94000 Créteil, France; (K.M.); (I.C.); (B.E.); (R.B.); (C.D.); (E.H.); (R.S.); (L.S.); (P.R.); (M.P.); (M.L.)
- Service de Psychiatrie de l’Adulte, CIC-1431 INSERM, CHU de Besançon, Laboratoire de Neurosciences, Université de Franche-Comté, UBFC, 25000 Besançon, France
| | - Raymund Schwan
- Fondation FondaMental, 94000 Créteil, France; (K.M.); (I.C.); (B.E.); (R.B.); (C.D.); (E.H.); (R.S.); (L.S.); (P.R.); (M.P.); (M.L.)
- Université de Lorraine, Centre Psychothérapique de Nancy, Pôle Hospitalo-Universitaire de Psychiatrie d’Adultes du Grand Nancy, INSERM U1254, 54000 Nancy, France
| | - Ludovic Samalin
- Fondation FondaMental, 94000 Créteil, France; (K.M.); (I.C.); (B.E.); (R.B.); (C.D.); (E.H.); (R.S.); (L.S.); (P.R.); (M.P.); (M.L.)
- CHU Clermont-Ferrand, Department of Psychiatry, University of Clermont Auvergne, UMR 6602 Institut Pascal (IP), 63178 Clermont-Ferrand, France
| | - Paul Roux
- Fondation FondaMental, 94000 Créteil, France; (K.M.); (I.C.); (B.E.); (R.B.); (C.D.); (E.H.); (R.S.); (L.S.); (P.R.); (M.P.); (M.L.)
- Centre Hospitalier de Versailles, Service de Psychiatrie et D’addictologie Adulte, Le Chesnay, EA 4047 HANDIReSP, UFR des Sciences de la Santé Simone Veil, Université Versailles Saint-Quentin-en-Yvelines, Versailles, France and Université Paris-Saclay, UVSQ, Inserm, CESP, Equipe “PsyDev”, 94807 Villejuif, France
| | - Mircea Polosan
- Fondation FondaMental, 94000 Créteil, France; (K.M.); (I.C.); (B.E.); (R.B.); (C.D.); (E.H.); (R.S.); (L.S.); (P.R.); (M.P.); (M.L.)
- Université Grenoble Alpes, Inserm U1216, Grenoble Institut de Neurosciences, CHU de Grenoble, F-38000 Grenoble, France
| | - Marion Leboyer
- Fondation FondaMental, 94000 Créteil, France; (K.M.); (I.C.); (B.E.); (R.B.); (C.D.); (E.H.); (R.S.); (L.S.); (P.R.); (M.P.); (M.L.)
- Université Paris Est Creteil (UPEC), AP-HP, Hôpitaux Universitaires «H. Mondor», DMU IMPACT, INSERM, IMRB, Translational Neuropsychiatry, Fondation FondaMental, F-94010 Creteil, France
| | - Philippe Courtet
- Institute of Functional Genomics, University of Montpellier, CNRS, INSERM, 34094 Montpellier, France; (J.D.); (P.C.); (E.O.)
- Department of Emergency Psychiatry and Post-Acute Care, CHU Montpellier, 34295 Montpellier, France
- Fondation FondaMental, 94000 Créteil, France; (K.M.); (I.C.); (B.E.); (R.B.); (C.D.); (E.H.); (R.S.); (L.S.); (P.R.); (M.P.); (M.L.)
| | - Emilie Olié
- Institute of Functional Genomics, University of Montpellier, CNRS, INSERM, 34094 Montpellier, France; (J.D.); (P.C.); (E.O.)
- Department of Emergency Psychiatry and Post-Acute Care, CHU Montpellier, 34295 Montpellier, France
- Fondation FondaMental, 94000 Créteil, France; (K.M.); (I.C.); (B.E.); (R.B.); (C.D.); (E.H.); (R.S.); (L.S.); (P.R.); (M.P.); (M.L.)
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Fernández-Sevillano J, Alberich S, Zorrilla I, González-Ortega I, López MP, Pérez V, Vieta E, González-Pinto A, Saíz P. Cognition in Recent Suicide Attempts: Altered Executive Function. Front Psychiatry 2021; 12:701140. [PMID: 34366931 PMCID: PMC8339467 DOI: 10.3389/fpsyt.2021.701140] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 06/01/2021] [Indexed: 12/27/2022] Open
Abstract
Background: Neuropsychological alterations can lead to inaccurate perception, interpretation, and response to environmental information, which could be a risk factor for suicide. Methods: Ninety-six subjects were recruited from the Psychiatry Department of the Araba University Hospital-Santiago, including 20 patients with a recent attempt and diagnosis of major depressive disorder (MDD) according to DSM-V, 33 MDD patients with history of attempted suicide, 23 non-attempter MDD patients, and 20 healthy controls. All participants underwent a clinical interview and neuropsychological assessment on the following cognitive domains: working memory, processing speed, decision-making, executive function, and attention. Backward multiple regressions were performed adjusting for significant confounding variables. For group comparisons, ANOVA and Bonferroni post-hoc tests were performed with a p < 0.05 significance level. Results: The patient groups did not differ regarding severity of depression and stressful events in the last 6 months. In comparison to healthy controls, depressed patients with lifetime suicide attempts had more general trauma (p = 0.003), emotional abuse (p = 0.003), emotional negligence (p = 0.006), and physical negligence (p = 0.009), and depressed patients with recent suicide attempts had experienced more child sexual abuse (p = 0.038). Regarding neuropsychological assessment, all patient groups performed significantly worse than did healthy controls in processing speed, decision-making, and attention. Comparisons between patient groups indicated that recent suicide attempters had poorer performance on executive function in comparison to both depressed lifetime attempters and depressed non-attempters (B = 0.296, p = 0.019, and B = 0.301, p = 0.028, respectively). Besides, women with recent attempts had slightly better scores on executive function than males. Regarding the rest of the cognitive domains, there were no significant differences between groups. Conclusion: Executive function performance is altered in recent suicide attempts. As impaired executive function can be risk factor for suicide, preventive interventions on suicide should focus on its assessment and rehabilitation.
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Affiliation(s)
- Jessica Fernández-Sevillano
- Department of Neuroscience, Universidad del País Vasco/Euskal Herriko Unibertsitatea, Bilbao, Spain
- Department of Psychiatry, Bioaraba Research Institute, Araba University Hospital, Vitoria-Gasteiz, Spain
- Biomedical Research Networking Centre in Mental Health (CIBERSAM), Madrid, Spain
| | - Susana Alberich
- Department of Psychiatry, Bioaraba Research Institute, Araba University Hospital, Vitoria-Gasteiz, Spain
- Biomedical Research Networking Centre in Mental Health (CIBERSAM), Madrid, Spain
| | - Iñaki Zorrilla
- Department of Neuroscience, Universidad del País Vasco/Euskal Herriko Unibertsitatea, Bilbao, Spain
- Department of Psychiatry, Bioaraba Research Institute, Araba University Hospital, Vitoria-Gasteiz, Spain
- Biomedical Research Networking Centre in Mental Health (CIBERSAM), Madrid, Spain
| | - Itxaso González-Ortega
- Department of Psychiatry, Bioaraba Research Institute, Araba University Hospital, Vitoria-Gasteiz, Spain
- Biomedical Research Networking Centre in Mental Health (CIBERSAM), Madrid, Spain
| | - María Purificación López
- Department of Neuroscience, Universidad del País Vasco/Euskal Herriko Unibertsitatea, Bilbao, Spain
- Department of Psychiatry, Bioaraba Research Institute, Araba University Hospital, Vitoria-Gasteiz, Spain
- Biomedical Research Networking Centre in Mental Health (CIBERSAM), Madrid, Spain
| | - Víctor Pérez
- Biomedical Research Networking Centre in Mental Health (CIBERSAM), Madrid, Spain
- Institut Hospital del Mar d'Investigacions Mèdiques (IMIM) Department of Psychiatry, Institut de Neuropsiquiatria i Addicions, Hospital del Mar, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Eduard Vieta
- Biomedical Research Networking Centre in Mental Health (CIBERSAM), Madrid, Spain
- Hospital Clinic, Institute of Neuroscience, University of Barcelona, Institut D'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Ana González-Pinto
- Department of Neuroscience, Universidad del País Vasco/Euskal Herriko Unibertsitatea, Bilbao, Spain
- Department of Psychiatry, Bioaraba Research Institute, Araba University Hospital, Vitoria-Gasteiz, Spain
- Biomedical Research Networking Centre in Mental Health (CIBERSAM), Madrid, Spain
| | - Pilar Saíz
- Biomedical Research Networking Centre in Mental Health (CIBERSAM), Madrid, Spain
- Department of Psychiatry, Universidad de Oviedo, Instituto de Investigación Sanitaria del Principado de Asturias, Servicio de Salud del Principado de Asturias, Oviedo, Spain
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Olgun G, Nabi A, Tastan O. NoRCE: non-coding RNA sets cis enrichment tool. BMC Bioinformatics 2021; 22:294. [PMID: 34078267 PMCID: PMC8170991 DOI: 10.1186/s12859-021-04112-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 03/30/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND While some non-coding RNAs (ncRNAs) are assigned critical regulatory roles, most remain functionally uncharacterized. This presents a challenge whenever an interesting set of ncRNAs needs to be analyzed in a functional context. Transcripts located close-by on the genome are often regulated together. This genomic proximity on the sequence can hint at a functional association. RESULTS We present a tool, NoRCE, that performs cis enrichment analysis for a given set of ncRNAs. Enrichment is carried out using the functional annotations of the coding genes located proximal to the input ncRNAs. Other biologically relevant information such as topologically associating domain (TAD) boundaries, co-expression patterns, and miRNA target prediction information can be incorporated to conduct a richer enrichment analysis. To this end, NoRCE includes several relevant datasets as part of its data repository, including cell-line specific TAD boundaries, functional gene sets, and expression data for coding & ncRNAs specific to cancer. Additionally, the users can utilize custom data files in their investigation. Enrichment results can be retrieved in a tabular format or visualized in several different ways. NoRCE is currently available for the following species: human, mouse, rat, zebrafish, fruit fly, worm, and yeast. CONCLUSIONS NoRCE is a platform-independent, user-friendly, comprehensive R package that can be used to gain insight into the functional importance of a list of ncRNAs of any type. The tool offers flexibility to conduct the users' preferred set of analyses by designing their own pipeline of analysis. NoRCE is available in Bioconductor and https://github.com/guldenolgun/NoRCE .
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Affiliation(s)
- Gulden Olgun
- Department of Computer Engineering, Bilkent University, Ankara, Turkey.,Cancer Data Science Lab, National Cancer Institute, National Institute of Health, Bethesda, MD, USA
| | - Afshan Nabi
- Faculty of Engineering and Natural Sciences, Sabanci University, 34956, Istanbul, Turkey
| | - Oznur Tastan
- Faculty of Engineering and Natural Sciences, Sabanci University, 34956, Istanbul, Turkey. .,Cancer Data Science Lab, National Cancer Institute, National Institute of Health, Bethesda, MD, USA.
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Characteristics of somatic symptoms among Chinese patients diagnosed with major depressive episode. Arch Psychiatr Nurs 2021; 35:27-33. [PMID: 33593512 DOI: 10.1016/j.apnu.2020.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 10/02/2020] [Accepted: 11/08/2020] [Indexed: 11/22/2022]
Abstract
PURPOSE This study aimed to describe the clinical features of somatic symptoms among Chinese patients diagnosed with major depressive episode (MDE). METHODS A total of 213 inpatients with MDE from two mental health hospitals were recruited and investigated using the Somatic Symptom Inventory (SSI), Hamilton rating scale for depression, Hamilton rating scale for anxiety, and a demographic questionnaire. RESULTS The participants included 142 patients with unipolar depression and 71 patients with bipolar depression. The mean SSI score of all participants was 49.30 (SD = 14.80). "Feeling fatigued, weak, or tired all over" was found to be the most common somatic symptom (61.0% reported moderate levels or above), followed by "feeling of being not in as good physical health as most of your friends" (56.3%), and "feeling weak in parts of the body" (49.3%). "Headache" and "soreness in muscles" were common painful symptoms. Both patients with unipolar and bipolar depression had similar somatic symptoms, including painful and non-painful ones. The somatic symptoms of all participants were closely correlated with the severity of depression and anxiety (P < 0.01). Patients with anxiety, older age, low education, and negative life events in the last year had more somatic symptoms. CONCLUSIONS Inpatients with MDE of somatic symptoms are common, which were significantly correlated with the severity of depression and anxiety. Further efforts should focus on early recognition and integrated care model management of patients based on their characteristics to improve their quality of life and treatment outcomes.
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Travaglini LE, Kuykendall L, Bennett ME, Abel EA, Lucksted A. Relationships between chronic pain and mood symptoms among veterans with bipolar disorder. J Affect Disord 2020; 277:765-771. [PMID: 33065815 DOI: 10.1016/j.jad.2020.08.069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 07/13/2020] [Accepted: 08/25/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Chronic pain is highly prevalent among individuals with mood disorders. While much is known about the relationship between pain and unipolar depression, little is known about pain experiences among people with bipolar disorder. This pilot study addresses this gap by examining pain and its relationship to mood and functioning in a sample of US military veterans with bipolar disorder. METHODS Qualitative interviews were conducted with 15 veterans with bipolar disorder and chronic pain who were recruited from outpatient services within a Veterans Affairs medical center. RESULTS Veterans reported a bidirectional relationship between pain and bipolar depression. When discussing manic episodes, individuals' experiences varied between notable reductions in pain (usually in euphoric states), increases in pain (usually in angry/irritable states), and feeling disconnected from pain. Many reported that increased activity when manic contributed to worse pain after an episode. Veterans clearly articulated how these connections negatively affected their functioning and quality of life. LIMITATIONS This was a small, retrospective study that included a non-random sample of veteran participants from one VA medical center. All veterans were engaged in outpatient mental health care, so the majority reported that their mood has been well-stabilized through medications and/or psychotherapy. CONCLUSIONS Chronic pain experiences appear to be related to depressive and manic mood states and significantly affects functioning and quality of life in Veterans with bipolar disorder. This study highlights the need to assess chronic pain among veterans with bipolar disorder, as changes in mood could have significant implications for functioning and pain management.
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Affiliation(s)
- Letitia E Travaglini
- VA Capital Healthcare Network Mental Illness, Research, Education, and Clinical Center (MIRECC), Baltimore, MD 21201, United States.
| | - Lorrianne Kuykendall
- VA Capital Healthcare Network Mental Illness, Research, Education, and Clinical Center (MIRECC), Baltimore, MD 21201, United States
| | - Melanie E Bennett
- VA Capital Healthcare Network Mental Illness, Research, Education, and Clinical Center (MIRECC), Baltimore, MD 21201, United States; Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD 21201, United States
| | - Erica A Abel
- VA Connecticut Healthcare System, Pain Research, Informatics, Multimorbidities and Education (PRIME) Center, West Haven, CT 06516, United States; Department of Psychiatry, Yale School of Medicine, New Haven, CT 06511, United States
| | - Alicia Lucksted
- VA Capital Healthcare Network Mental Illness, Research, Education, and Clinical Center (MIRECC), Baltimore, MD 21201, United States; Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD 21201, United States
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Owen-Smith A, Stewart C, Sesay MM, Strasser SM, Yarborough BJ, Ahmedani B, Miller-Matero LR, Waring SC, Haller IV, Waitzfelder BE, Sterling SA, Campbell CI, Hechter RC, Zeber JE, Copeland LA, Scherrer JF, Rossom R, Simon G. Chronic pain diagnoses and opioid dispensings among insured individuals with serious mental illness. BMC Psychiatry 2020; 20:40. [PMID: 32005200 PMCID: PMC6995196 DOI: 10.1186/s12888-020-2456-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 01/22/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Individuals with major depressive disorder (MDD) and bipolar disorder (BD) have particularly high rates of chronic non-cancer pain (CNCP) and are also more likely to receive prescription opioids for their pain. However, there have been no known studies published to date that have examined opioid treatment patterns among individuals with schizophrenia. METHODS Using electronic medical record data across 13 Mental Health Research Network sites, individuals with diagnoses of MDD (N = 65,750), BD (N = 38,117) or schizophrenia or schizoaffective disorder (N = 12,916) were identified and matched on age, sex and Medicare status to controls with no documented mental illness. CNCP diagnoses and prescription opioid medication dispensings were extracted for the matched samples. Multivariate analyses were conducted to evaluate (1) the odds of receiving a pain-related diagnosis and (2) the odds of receiving opioids, by separate mental illness diagnosis category compared with matched controls, controlling for age, sex, Medicare status, race/ethnicity, income, medical comorbidities, healthcare utilization and chronic pain diagnoses. RESULTS Multivariable models indicated that having a MDD (OR = 1.90; 95% CI = 1.85-1.95) or BD (OR = 1.71; 95% CI = 1.66-1.77) diagnosis was associated with increased odds of a CNCP diagnosis after controlling for age, sex, race, income, medical comorbidities and healthcare utilization. By contrast, having a schizophrenia diagnosis was associated with decreased odds of receiving a chronic pain diagnosis (OR = 0.86; 95% CI = 0.82-0.90). Having a MDD (OR = 2.59; 95% CI = 2.44-2.75) or BD (OR = 2.12; 95% CI = 1.97-2.28) diagnosis was associated with increased odds of receiving chronic opioid medications, even after controlling for age, sex, race, income, medical comorbidities, healthcare utilization and chronic pain diagnosis; having a schizophrenia diagnosis was not associated with receiving chronic opioid medications. CONCLUSIONS Individuals with serious mental illness, who are most at risk for developing opioid-related problems, continue to be prescribed opioids more often than their peers without mental illness. Mental health clinicians may be particularly well-suited to lead pain assessment and management efforts for these patients. Future research is needed to evaluate the effectiveness of involving mental health clinicians in these efforts.
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Affiliation(s)
- Ashli Owen-Smith
- Health Policy and Behavioral Sciences, School of Public Health, Georgia State University, Urban Life Building, 140 Decatur Street, Suite 434, Atlanta, GA, 30303, USA. .,Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, USA.
| | - Christine Stewart
- 0000 0004 0615 7519grid.488833.cHealth Research Institute, Kaiser Permanente Washington, Seattle, USA
| | - Musu M. Sesay
- 0000 0000 9957 7758grid.280062.eCenter for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, USA
| | - Sheryl M. Strasser
- 0000 0004 1936 7400grid.256304.6Health Policy and Behavioral Sciences, School of Public Health, Georgia State University, Urban Life Building, 140 Decatur Street, Suite 434, Atlanta, GA 30303 USA
| | - Bobbi Jo Yarborough
- 0000 0000 9957 7758grid.280062.eCenter for Health Research, Kaiser Permanente Northwest, Portland, USA
| | - Brian Ahmedani
- 0000 0000 8523 7701grid.239864.2Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, USA ,0000 0000 8523 7701grid.239864.2Depart Behavioral Health Services, Henry Ford Health System, Detroit, USA
| | - Lisa R. Miller-Matero
- 0000 0000 8523 7701grid.239864.2Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, USA ,0000 0000 8523 7701grid.239864.2Depart Behavioral Health Services, Henry Ford Health System, Detroit, USA
| | - Stephen C. Waring
- 0000 0004 0449 6525grid.428919.fEssentia Institute of Rural Health, Duluth, USA
| | - Irina V. Haller
- 0000 0004 0449 6525grid.428919.fEssentia Institute of Rural Health, Duluth, USA
| | - Beth E. Waitzfelder
- 0000 0000 9957 7758grid.280062.eCenter for Health Research, Kaiser Permanente Hawaii, Honolulu, USA
| | - Stacy A. Sterling
- 0000 0000 9957 7758grid.280062.eDivision of Research, Kaiser Permanente Northern California, Oakland, USA
| | - Cynthia I. Campbell
- 0000 0000 9957 7758grid.280062.eDepartment of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, USA
| | - Rulin C. Hechter
- 0000 0000 9957 7758grid.280062.eDepartment of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, USA
| | - John E. Zeber
- 0000 0001 2184 9220grid.266683.fSchool of Public Health & Health Sciences, University of Massachusetts Amherst, Amherst, USA
| | | | - Jeffrey F. Scherrer
- 0000 0004 1936 9342grid.262962.bDepartment of Family and Community Medicine, Saint Louis University School of Medicine, Saint Louis, USA
| | - Rebecca Rossom
- 0000 0004 0461 4886grid.280625.bHealth Partners Institute, Minneapolis, USA
| | - Greg Simon
- 0000 0004 0615 7519grid.488833.cHealth Research Institute, Kaiser Permanente Washington, Seattle, USA
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9
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Abstract
BACKGROUND There is a knowledge gap regarding factors that influence the intensity of pain associated with pressure injuries. OBJECTIVES We examined the influence of age, gender, race, and comorbidity on the relationships between pressure injuries, psychological distress, and pain intensity in hospitalized adults. METHODS This study was a cross-sectional, retrospective secondary analysis using data from a regional acute hospital's electronic health records from 2013 to 2016. A sample of 454 cases met the inclusion criteria and were analyzed using path analysis. RESULTS The hypothesized model (Model A) and two alternative models (Models B and C) were tested and demonstrated adequate model fit. All tested models demonstrated statistically significant independent direct effects of age on the severity of pressure injury (p < .001) and pain intensity (p = .001), as well as independent direct effects of gender (p ≤ .005), race (p < .001), and comorbidity (p = .001) on psychological distress. DISCUSSION Pain management for individuals with pressure injuries should include not only the treatment of wounds but also the individual characteristics of the patient such as demographics, comorbidity, and psychological status that may affect pain. Given the limitations of secondary analyses, further studies are suggested to validate these findings.
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10
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Kim J, Lyon D, Weaver MT, Keenan G, Chen XJ. The role of psychological distress in the relationship between the severity of pressure injury and pain intensity in hospitalized adults. J Adv Nurs 2019; 75:1219-1228. [PMID: 30456856 DOI: 10.1111/jan.13913] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 10/02/2018] [Indexed: 12/01/2022]
Abstract
AIMS To examine the effect of psychological distress in mediating the relationship between the severity of pressure injury and pain intensity in hospitalized adults. BACKGROUND Despite the prevalence of pressure injury (previously known as pressure ulcers) in hospitalized adults, the current knowledge of pain associated with pressure injury is limited and findings are inconsistent. There is also a lack of understanding of the relationship between psychological distress and pain from pressure injury. DESIGN Retrospective cross-sectional secondary analysis of data from electronic health records. METHODS The data were retrieved from the third day of admission in the period between 2013 - 2016 through the Integrated Data Repository (IDR). Electronic health records were reviewed to collect data as needed. The mediation effect was tested by using path analysis implemented through Mplus. RESULTS Path analysis revealed that the severity of pressure injuries and psychological distress have significant direct effects on pain intensity in hospitalized adults. However, the relationship between the severity of pressure injury and pain intensity was not significantly mediated by psychological distress. CONCLUSION Hospitalized adults who have more severe pressure injury and more treatments for psychological distress experienced greater pain intensity. Healthcare providers must pay attention to treating psychological distress among hospitalized adults to manage pain. Further study is needed to validate these findings and it should incorporate more appropriate measures of psychological distress. The lack of standardized nursing documentation in electronic health records severely limits the usefulness of data from electronic health records for nursing research.
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Affiliation(s)
- Junglyun Kim
- Department of Family, Community and Health System Science, College of Nursing, University of Florida, Gainesville, Florida
| | - Debra Lyon
- Department of Biobehavioral Nursing, College of Nursing, University of Florida, Gainesville, Florida
| | - Michael T Weaver
- Department of Biobehavioral Nursing, College of Nursing, University of Florida, Gainesville, Florida
| | - Gail Keenan
- Department of Family, Community and Health System Science, College of Nursing, University of Florida, Gainesville, Florida
| | - Xinguang Jim Chen
- Department of Epidemiology, College of Public Health and Health Professions & College of Medicine, University of Florida, Gainesville, Florida
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11
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Saxena AK, Jain PN, Bhatnagar S. The Prevalence of Chronic Pain among Adults in India. Indian J Palliat Care 2018; 24:472-477. [PMID: 30410260 PMCID: PMC6199848 DOI: 10.4103/ijpc.ijpc_141_18] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background The prevalence of chronic pain (CP) is well described in Europe, America, and Australia. However, little knowledge is available of the prevalence of CP within Asia or Southeast Asia. Given the cultural and genetic variation in pain causation, manifestation, and reporting, the findings of previous western studies cannot be extrapolated to Asian countries. A prevalence study was needed to be carried out to quantify the magnitude and impact of CP in the adult population in India. Methods Two sets of questionnaires were designed. The first, a screening questionnaire was used telephonically to identify the prevalence of CP, and should there be CP; the second, a detailed questionnaire was administered, to characterize the features and impact of pain. The interviews were carried out face-to-face. Results A total of 4326 Indian patients were screened, and 836 completed a detailed pain questionnaire during 2006. The prevalence of CP was found to be 19.3% (n = 836). There was a higher prevalence in females (25.2%). Pain prevalence increased steeply beyond the age of 65 years old. There was a significant impact of CP on work and daily function. Conclusion This Indian adults' population survey about CP found a higher prevalence of CP as compared to other Asian pain prevalence studies; however, the impact of pain was just as significant. In a rapidly aging population, CP is emerging as a significant healthcare problem which may likely to exert an increasing toll on the existing social infrastructure within the next two decades.
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Affiliation(s)
- Ashok Kumar Saxena
- Department of Anaesthesia and Pain Medicine, UCMS and GTB Hospital, Delhi, India
| | - Parmanand N Jain
- Department of Anaesthesiology, Critical Care and Pain, Division of Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Sushma Bhatnagar
- Department of Anesthesiology, Pain and Palliative Care, Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
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12
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Stubbs B, Eggermont L, Mitchell AJ, De Hert M, Correll CU, Soundy A, Rosenbaum S, Vancampfort D. The prevalence of pain in bipolar disorder: a systematic review and large-scale meta-analysis. Acta Psychiatr Scand 2015; 131:75-88. [PMID: 25098864 DOI: 10.1111/acps.12325] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/10/2014] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To conduct a meta-analysis investigating the prevalence of pain in people with bipolar disorder (BD). METHOD A systematic review and random effects meta-analysis searching major electronic databases from inception till 01/2014 in accordance with the PRISMA statement. We included articles reporting quantitative data on the prevalence of pain in people with BD with or without a healthy control group. Two independent authors conducted searches, extracted data, and completed methodological quality assessment. RESULTS Twenty two cross-sectional studies were included, representing 12,375,644 individuals (BD n=171,352, n controls=12,204,292). The prevalence of pain in people with BD was 28.9% (95% CI=16.4-43.4%, BD n=171,352). The relative risk (RR) of pain in BD compared to controls was 2.14 (95% CI=1.67-2.75%, n=12,342,577). The prevalence of migraine was 14.2% (95% CI=10.6-18.3%, BD n=127,905), and the RR was 3.30 (95% CI=2.27-4.80%, n=6,732,220).About 23.7% (95% CI=13.1-36.3%, n=106,214) of people with BD experienced chronic pain. Age, percentage of males, methodological quality, and method of BD classification did not explain the observed heterogeneity. CONCLUSION People with BD experience significantly increased levels of pain (particularly chronic pain and migraine). The assessment and treatment of pain should form an integral part of the management of BD.
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Affiliation(s)
- B Stubbs
- Department of Health and Social Care, Greenwich, London, UK
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13
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Nicholl BI, Mackay D, Cullen B, Martin DJ, Ul-Haq Z, Mair FS, Evans J, McIntosh AM, Gallagher J, Roberts B, Deary IJ, Pell JP, Smith DJ. Chronic multisite pain in major depression and bipolar disorder: cross-sectional study of 149,611 participants in UK Biobank. BMC Psychiatry 2014; 14:350. [PMID: 25490859 PMCID: PMC4297369 DOI: 10.1186/s12888-014-0350-4] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Accepted: 11/24/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chronic pain has a strong association with major depressive disorder (MDD), but there is a relative paucity of studies on the association between chronic multisite pain and bipolar disorder (BD). Such studies are required to help elucidate the complex biological and psychological overlap between pain and mood disorders. The aim of this study is to investigate the relationship between chronic multisite pain and mood disorder across the unipolar-bipolar spectrum. METHODS We conducted a cross-sectional study of 149,611 UK Biobank participants. Self-reported depressive and bipolar features were used to categorise participants into MDD and BD groups and a non-mood disordered comparison group. Multinomial logistic regression was used to establish whether there was an association between extent of chronic pain (independent variable) and mood disorder category (dependent variable), using no pain as the referent category, and adjusting for a wide range of potential sociodemographic, lifestyle and comorbidity confounders. RESULTS Multisite pain was significantly more prevalent in participants with BD and MDD, for example, 4-7 pain sites: BD 5.8%, MDD 4.5%, and comparison group 1.8% (p < 0.001). A relationship was observed between extent of chronic pain and risk of BD and persisted after adjusting for confounders (relative to individuals with no chronic pain): 2-3 sites RRR of BD 1.84 (95% CI 1.61, 2.11); 4-7 sites RRR of BD 2.39 (95% CI 1.88, 3.03) and widespread pain RRR of BD 2.37 (95% CI 1.73, 3.23). A similar relationship was observed between chronic pain and MDD: 2-3 sites RRR of MDD 1.59 (95% CI 1.54, 1.65); 4-7 sites RRR of MDD 2.13 (95% CI 1.98, 2.30); widespread pain RRR of MDD 1.86 (95% CI 1.66, 2.08). CONCLUSIONS Individuals who report chronic pain and multiple sites of pain are more likely to have MDD and are at higher risk of BD. These findings highlight an important aspect of comorbidity in MDD and BD and may have implications for understanding the shared neurobiology of chronic pain and mood disorders.
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Affiliation(s)
- Barbara I Nicholl
- Institute of Health & Wellbeing, University of Glasgow, Glasgow, Scotland, UK.
| | - Daniel Mackay
- Institute of Health & Wellbeing, University of Glasgow, Glasgow, Scotland, UK.
| | - Breda Cullen
- Institute of Health & Wellbeing, University of Glasgow, Glasgow, Scotland, UK.
| | - Daniel J Martin
- Institute of Health & Wellbeing, University of Glasgow, Glasgow, Scotland, UK.
| | - Zia Ul-Haq
- Institute of Health & Wellbeing, University of Glasgow, Glasgow, Scotland, UK.
| | - Frances S Mair
- Institute of Health & Wellbeing, University of Glasgow, Glasgow, Scotland, UK.
| | - Jonathan Evans
- Institute of Health & Wellbeing, University of Glasgow, Glasgow, Scotland, UK.
| | | | - John Gallagher
- Institute of Health & Wellbeing, University of Glasgow, Glasgow, Scotland, UK.
| | - Beverly Roberts
- Centre for Cognitive Ageing and Cognitive Epidemiology, Department of Psychology, University of Edinburgh, Edinburgh, UK.
| | - Ian J Deary
- Centre for Cognitive Ageing and Cognitive Epidemiology, Department of Psychology, University of Edinburgh, Edinburgh, UK.
| | - Jill P Pell
- Institute of Health & Wellbeing, University of Glasgow, Glasgow, Scotland, UK.
| | - Daniel J Smith
- Institute of Health & Wellbeing, University of Glasgow, Glasgow, Scotland, UK.
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14
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Rahman T, Campbell A, O'Connell CR, Nallapula K. Carbamazepine in bipolar disorder with pain: reviewing treatment guidelines. Prim Care Companion CNS Disord 2014; 16:14r01672. [PMID: 25667814 DOI: 10.4088/pcc.14r01672] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 06/20/2014] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVE To determine if any monotherapy drug treatment has robust efficacy to treat comorbid bipolar disorder and chronic pain. DATA SOURCES The American Psychiatric Association (APA) treatment guidelines for bipolar mood disorder and the 2012 Cochrane database for pain disorders. STUDY SELECTION We relied on the treatment guides to determine if the drugs that are APA guideline-supported to treat bipolar disorder have supporting data from the Cochrane database for chronic pain. DATA SYNTHESIS No single drug was mentioned by either guideline to treat this comorbidity. However, carbamazepine was the only drug that has guideline-supported robust efficacy in the management of each condition separately. CONCLUSIONS Carbamazepine was found to have strong preclinical data for the treatment of comorbid bipolar mood disorder and chronic pain disorders. While requiring more studies in this population, we propose that this treatment modality may benefit patients.
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Affiliation(s)
- Tahir Rahman
- Department of Psychiatry, University of Missouri, Columbia
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15
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Erten E, Funda Uney A, Saatçioğlu Ö, Özdemir A, Fıstıkçı N, Çakmak D. Effects of childhood trauma and clinical features on determining quality of life in patients with bipolar I disorder. J Affect Disord 2014; 162:107-13. [PMID: 24767014 DOI: 10.1016/j.jad.2014.03.046] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Revised: 02/13/2014] [Accepted: 03/19/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND We explored how childhood trauma (CHT) affects the clinical expression of disorder and quality of life in patients with bipolar I (BP-I) disorder. METHODS Euthymic patients (n=116) who subsequently received a diagnosis of BP-I disorder were consecutively included and were interviewed using the following sociodemographic and clinical data forms; Young Mania Rating Scale (YMRS), Hamilton Depression Rating Scale (HDRS), Childhood Abuse and Neglect Questionnaire (CANQ) and the 36-item Medical Outcome Study Short Form Health Survey (SF-36). The quality of life of BP-I patients with and without a history of CHT were examined. RESULTS The percentage of trauma was 61.2%. Patients who had CHT had higher frequencies of depressive episodes (t=-2.38, p=0.019), total episodes (t=-2.25, p=0.026), attempted suicide more often (χ(2)=18.12, p=0.003) and had lower scores on the pain subscale of the SF-36 (z=-2.817, p=0.005). In patients with mixed or rapid-cycling episodes, SF-36 subscale scores except general health and pain were found to be lower. LIMITATIONS Our sample may fail to reflect the general BD population; the patients were included consecutively and consisted of a majority of female patients. CONCLUSIONS CHT plays an important role in the clinical expression of BP-I disorder and having mixed/rapid-cycling episodes negatively affects both physical and mental components, as measured by the SF-36. While both males and females reported experiencing sexual abuse, female BP-I patients complained about pain more often. It is suggested that treatment of BP-I patients with a history of CHT should differ from that provided for patients with no CHT history.
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Affiliation(s)
- Evrim Erten
- Bakirkoy Research and Training Hospital for Psychiatry, Neurology and Neurosurgery, Istanbul, Turkey.
| | | | | | - Armağan Özdemir
- Bakirkoy Research and Training Hospital for Psychiatry, Neurology and Neurosurgery, Istanbul, Turkey
| | - Nurhan Fıstıkçı
- Bakirkoy Research and Training Hospital for Psychiatry, Neurology and Neurosurgery, Istanbul, Turkey
| | - Duran Çakmak
- Istanbul AREL University, Psychology Department, Istanbul, Turkey
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