Suicide Attempts in US Veterans with Chronic Headache Disorders: A 10-Year Retrospective Cohort Study

Headache Disorders in VHA Primary Care: Prevalence, Psychiatric Comorbidity, and Health Care Utilization

Military veterans are at increased risk for headache disorders compared to the general population, yet the prevalence and burden associated with headache disorders among veterans is not yet well understood. In this electronic medical record study, we examined the prevalence of headache disorders among veterans seen in a northeastern network of Veterans Health Administration (VHA) primary care during 2017-2018. We also examined rates of psychiatric comorbidity and health care utilization of veterans with headache disorders for the year following the date of the first headache code in the medical record. Of the total population of veterans in the network, 1.3% had a headache disorder and another 3.5% had a possible headache disorder. Migraine and chronic migraine represented the majority of cases. Posttraumatic stress disorder was the most frequent psychiatric comorbidity. Having a headache disorder was associated with higher rates of primary care, neurology, pain clinic, and mental health service use but not higher rates of emergency department or Whole Health (e.g., patient-centered, holistic health services) use. Prevalence findings are comparable to those previously found among veterans, but a substantial proportion of veterans may have been misdiagnosed. Veterans with headache disorders have high rates of psychiatric comorbidity and use several types of health services at higher rates. Findings highlight the need for interdisciplinary care and further education and support for primary care providers. Primary care settings that integrate evidence-based behavioral and Whole Health services may be an optimal way of providing more holistic care for headache disorders.

Pain Care Disparities and the Use of Virtual Care Among Racial-Ethnic Minority Groups During COVID-19

BACKGROUND AND OBJECTIVE

COVID-19 led to an unprecedented reliance on virtual modalities to maintain care continuity for patients living with chronic pain. We examined whether there were disparities in virtual specialty pain care for racial-ethnic minority groups during COVID-19.

DESIGN AND PARTICIPANTS

This was a retrospective national cohort study with two comparison groups: primary care patients with chronic pain seen immediately prior to COVID-19 (3/1/19-2/29/20) (N = 1,649,053) and a cohort of patients seen in the year prior (3/1/18-2/28-19; n = 1,536,954).

MAIN MEASURES

We assessed use of telehealth (telephone or video) specialty pain care, in-person care specialty pain care, and any specialty pain care for both groups at 6 months following cohort inclusion. We used quasi-Poisson regressions to test associations between patient race and ethnicity and receipt of care.

KEY RESULTS

Prior to COVID-19, there were Black-White (RR = 0.64, 95% CI [0.62, 0.67]) and Asian-White (RR = 0.63, 95% CI [0.54, 0.75]) disparities in telehealth use, and these lessened during COVID-19 (Black-White: RR = 0.75, 95% CI [0.73, 0.77], Asian-White: RR = 0.81, 95% CI [0.74, 0.89]) but did not disappear. Individuals identifying as American Indian/Alaska Native used telehealth less than White individuals during early COVID-19 (RR = 0.98, 95% CI [0.85, 1.13] to RR = 0.87, 95% CI [0.79, 0.96]). Hispanic/Latinx individuals were less likely than non-Hispanic/Latinx individuals to use telehealth prior to COVID-19 but more likely during early COVID-19 (RR = 0.70, 95% CI [0.66, 0.75] to RR = 1.06, 95% CI [1.02, 1.09]). Disparities in virtual pain care occurred over the backdrop of overall decreased specialty pain care during the early phase of the pandemic (raw decrease of n = 17,481 specialty care encounters overall from pre-COVID to COVID-era), including increased disparities in any VA specialty pain care for Black (RR = 0.81, 95% CI [0.80, 0.83] to RR = 0.79, 95% CI [0.77, 0.80]) and Asian (RR = 0.91, 95% CI [0.86, 0.97] to RR = 0.88, 95% CI [0.82, 0.94]) individuals.

CONCLUSIONS

Disparities in virtual specialty pain care were smaller during the early phases of the COVID-19 pandemic than prior to the pandemic but did not disappear entirely, despite the rapid growth in telehealth. Targeted efforts to increase access to specialty pain care need to be concentrated among racial-ethnic minority groups.

Mental Defeat and Suicidality in Chronic Pain: A Prospective Analysis

Living with chronic pain has been identified as a significant risk factor for suicide. Qualitative and cross-sectional studies have reported an association between mental defeat and suicidal thoughts and behavior in patients with chronic pain. In this prospective cohort study, we hypothesized that higher levels of mental defeat would be associated with increased suicide risk at a 6-month follow-up. A total of 524 patients with chronic pain completed online questionnaires measuring variables related to suicide risk, mental defeat, sociodemographic, psychological, pain, activity, and health variables. At 6 months, 70.8% (n = 371) of respondents completed the questionnaires again. Weighted univariate and multivariable regression models were run to predict suicide risk at 6 months. The clinical suicide risk cutoff was met by 38.55% of the participants at baseline and 36.66% at 6 months. Multivariable modeling revealed that mental defeat, depression, perceived stress, head pain, and active smoking status significantly increased the odds of reporting higher suicide risk, while older age reduced the odds. Receiver operating characteristic (ROC) analysis showed that assessment of mental defeat, perceived stress, and depression is effective in discriminating between 'low' and 'high' suicide risk. Awareness of the prospective links from mental defeat, depression, perceived stress, head pain, and active smoking status to increased suicide risk in patients with chronic pain may offer a novel avenue for assessment and preventative intervention. PERSPECTIVE: Results from this prospective cohort study suggest that mental defeat is a significant predictor of increased suicide risk among patients with chronic pain, along with depression, perceived stress, head pain, and active smoking status. These findings offer a novel avenue for assessment and preventative intervention before risk escalates.

Drug Safety and Suicidality Risk of Chronic Pain Medications

Chronic pain is one of the main leading causes of disability in the world at present. A variety in the symptomatology, intensity and duration of this phenomenon has led to an ever-increasing demand of pharmacological treatment and relief. This demand for medication, ranging from well-known groups, such as antidepressants and benzodiazepines, to more novel drugs, was followed by a rise in safety concerns of such treatment options. The validity, frequency, and diversity of such concerns are discussed in this paper, as well as their possible effect on future prescription practices. A specific caution is provided towards the psychological safety and toll of these medications, regarding suicidality and suicidal ideation. Most significantly, this paper highlights the importance of pharmacovigilance and underscores the necessity of surveillance programs when considering chronic pain medication.

Prevalence of suicidal behavior in patients with chronic pain: a systematic review and meta-analysis of observational studies

Objective

Chronic pain is a leading cause of disability, severely impairing an individual's daily activity and quality of life. In addition, this condition may contribute to suicidal thoughts by leading to neuropsychological impairments, a perceived lack of meaning in life, and pain-related catastrophizing. This systematic review aimed to comprehensively investigate the prevalence and associated factors of suicidal behaviors (SBs) including suicidal ideation (SI) and suicide attempt (SA) or its complete, in individuals with chronic pain.

Methods

Five electronic databases were searched up to October 4, 2022. Only observational studies investigating the prevalence of SB in individuals with chronic pain were included. The methodological quality of the included studies was assessed using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement. A meta-analysis was conducted to quantify the prevalence of SB in the population, and the command "Metaprop" was used in STATA/MP 16. In addition, factors explaining the association between chronic pain and SB identified through regression analysis were investigated.

Results

A total of 19 studies were included in this review (N = 3,312,343). The pooled lifetime prevalence of SI and SA was 28.90% (95% confidence interval, 17.95 to 41.26%) and 10.83% (5.72 to 17.30%), respectively, in a mixed sample comprising various chronic pain conditions. Importantly, the pooled prevalence of past 2-week SI was as high as 25.87% (18.09 to 34.50%). The methodological quality of the included studies was not optimal, and studies using validated SB assessment tools were lacking. Potential protective factors against SB in this population included pain coping and self-efficacy, older age, certain race/ethnicity groups, and marriage.

Conclusion

This systematic review and meta-analysis demonstrated the high prevalence of SB in individuals with chronic pain. Specifically, around 1 in 4 individuals with chronic pain had SI within the last 2 weeks. However, there was considerable heterogeneity in the pooled prevalence of SB in this population.

Examining the Relationship Between Sleep Apnea Diagnosis and Suicide Risk in Veterans With Traumatic Brain Injury: A VA TBI Model Systems Study

OBJECTIVE

Obstructive sleep apnea (OSA) is a common sleep disorder in people with traumatic brain injury (TBI). Although sleep disturbances have been associated with an increased risk of suicide compared with the general population, the relationship between OSA and suicide risk after TBI is not well documented. In this study, we hypothesized that OSA diagnosis would predict suicide risk in veterans with TBI.

SETTING

Five Veterans Affairs (VA) Polytrauma Rehabilitation Centers.

PARTICIPANTS

Participants were drawn from the VA TBI Model Systems study, with follow-up interviews at year 1 ( n = 392), year 2 ( n = 444), year 5 ( n = 498), or year 10 ( n = 252) post-TBI (7.8%-14.5% follow-up attrition).

DESIGN

This was a retrospective analysis from observational data using logistic regression with repeated measurements. Suicide ideation and suicide attempts were examined as outcomes at each follow-up to evaluate the relationship between OSA and suicide risk after adjusting for other risk factors determined a priori via literature review.

MAIN MEASURES

Suicidal ideation (Patient Health Questionnaire-9 item 9), suicide attempt during the past year (self-reported), and OSA diagnosis (self-reported).

RESULTS

Contrary to study hypotheses, OSA diagnosis had no statistically significant association with suicide ideation or attempt after accounting for known predictors. However, greater depression symptoms, headache severity, and pre-TBI suicidal ideation and attempts predicted suicide risk at follow-up after accounting for other predictors.

CONCLUSIONS

Results of this study did not support a relationship between OSA and suicide risk, possibly due to methodological limitations of OSA measurement. Future research on this topic should include objective measures of OSA severity and OSA treatment including adherence. Although suicide is a low base rate occurrence, the impact is disastrous and further research is needed to mitigate suicide risk.

Remotely supervised at-home tDCS for veterans with persistent post-traumatic headache: a double-blind, sham-controlled randomized pilot clinical trial

Background

Currently, there are no FDA approved therapies for persistent post-traumatic headache (PPTH) secondary to traumatic brain injury (TBI). As such neither headache nor TBI specialists have an effective means to manage PPTH. Thus, the objective of the present pilot trial was to evaluate the feasibility and preliminary efficacy of a four-week at-home remotely supervised transcranial direct current stimulation (RS-tDCS) intervention for veterans with PPTH.

Methods

Twenty-five (m = 46.6 ± 8.7 years) veterans with PPTH were randomized into two groups and received either active (n = 12) or sham (n = 13) RS-tDCS, with anodal stimulation over left dlPFC and cathodal over occipital pole. Following a four-week baseline, participants completed 20-sessions of active or sham RS-tDCS with real-time video monitoring over a period of four-weeks. Participants were assessed again at the end of the intervention and at four-weeks post-intervention. Primary outcomes were overall adherence rate (feasibility) and change in moderate-to-severe headache days per month (efficacy). Secondary outcomes were changes in total number of headache days, and PPTH-related functional outcomes.

Results

Adherence rate was high with 88% of participants (active = 10/12; sham = 12/13) fully completing tDCS interventions. Importantly, there was no significant difference in adherence between active and sham groups (p = 0.59). Moderate-to-severe headache days were significantly reduced within the active RS-tDCS group (p = 0.004), compared to sham during treatment (-2.5 ± 3.5 vs. 2.3 ± 3.4), and 4-week follow-up (-3.9 ± 6.4 vs. 1.2 ± 6.5). Total number of headache days was significantly reduced within the active RS-tDCS (p = 0.03), compared to sham during-treatment (-4.0 ± 5.2 vs. 1.5 ± 3.8), and 4-week follow-up (-2.1 ± 7.2 vs. -0.2 ± 4.4).

Conclusion

The current results indicate our RS-tDCS paradigm provides a safe and effective means for reducing the severity and number of headache days in veterans with PPTH. High treatment adherence rate and the remote nature of our paradigm indicate RS-tDCS may be a feasible means to reduce PPTH, especially for veterans with limited access to medical facilities.Clinical Trial Registration: ClinicalTrials.gov, identifier [NCT04012853].

Risks of suicide in migraine, non-migraine headache, back, and neck pain: a systematic review and meta-analysis

Objective

To conduct a systematic review and meta-analysis on suicidal ideation, attempts, and death in patients with head, neck, and back pain.

Method

Search was performed using PubMed, Embase, and Web of Science from the date of the first available article through September 31, 2021. A random effects model was used to estimate the pooled odds ratios (ORs) and 95% confidence intervals (95% CI) for the association between suicidal ideation and/or attempt and head, back/neck pain conditions. Articles describing non-migraine headache disorders and death by suicide were also reviewed but not included in the meta-analysis due to an insufficient number of studies.

Results

A total of 20 studies met criteria for systemic review. A total of 186,123 migraine patients and 135,790 of neck/back pain patients from 11 studies were included in the meta-analysis. The meta-analysis showed that the estimated risk of combined suicidal ideation and attempt in migraine [OR 2.49; 95% CI: 2.15-2.89] is greater than that in back/neck pain pain [OR 2.00; 95% CI: 1.63-2.45] compared to non-pain control groups. Risk of suicide ideation/planning is 2 folds higher [OR: 2.03; 95% CI: 1.92-2.16] and risk of suicide attempt is more than 3 folds higher [OR: 3.47; 95% CI: 2.68-4.49] in migraine as compared to healthy controls.

Conclusion

There is an elevated risk of suicidal ideation and attempt in both migraine and neck/back pain patients in comparison to healthy controls, and this risk is particularly higher among migraine patients. This study underscores the critical need for suicide prevention in migraine patients.

Testing the Decision Support Tool for Responsible Pain Management for Headache and Facial Pain Diagnosis with Opioid-Risk-Stratified Treatment

In primary and urgent care, headache and facial pain are common and challenging to diagnose and manage, especially with using opioids appropriately. We therefore developed the Decision Support Tool for Responsible Pain Management (DS-RPM) to assist healthcare providers in diagnosis (including multiple simultaneous diagnoses), workup (including triage), and opioid-risk-informed treatment. A primary goal was to supply sufficient explanations of DS-RPM's functions allowing critique. We describe the process of iteratively designing DS-RPM adding clinical content and testing/defect discovery. We tested DS-RPM remotely with 21 clinician-participants using three vignettes-cluster headache, migraine, and temporal arteritis-after first training to use DS-RPM with a trigeminal-neuralgia vignette. Their evaluation was both quantitative (usability/acceptability) and qualitative using semi-structured interviews. The quantitative evaluation used 12 Likert-type questions on a 1-5 scale, where 5 represented the highest rating. The mean ratings ranged from 4.48 to 4.95 (SDs ranging 0.22-1.03). Participants initially found structured data entry intimidating but adapted and appreciated its comprehensiveness and speed of data capture. They perceived DS-RPM as useful for teaching and clinical practice, making several enhancement suggestions. The DS-RPM was designed, created, and tested to facilitate best practice in management of patients with headaches and facial pain. Testing the DS-RPM with vignettes showed strong functionality and high usability/acceptability ratings from healthcare providers. Risk stratifying for opioid use disorder to develop a treatment plan for headache and facial pain is possible using vignettes. During testing, we considered the need to adapt usability/acceptability evaluation tools for clinical decision support, and future directions.

Delivery of a Mental Health Intervention for Chronic Pain Through an Artificial Intelligence-Enabled App (Wysa): Protocol for a Prospective Pilot Study

BACKGROUND

Patients with chronic pain often suffer from coexisting, long-term and debilitating mental health comorbidities such as depression and anxiety. Artificial Intelligence Supported Cognitive Behavioral Therapy or AI-CBT interventions could offer cost-effective, accessible, and potentially effective resources to tackle this problem. However, there is not enough research conducted about the efficacy of AI-CBT interventions for chronic pain.

OBJECTIVE

This prospective cohort study aims to examine the efficacy and usage of an AI-CBT intervention for chronic pain (Wysa for Chronic Pain app), using a conversational agent (with no human intervention). To the best of our knowledge, this is the first such study for chronic pain using a fully-automated, free-text-based conversational agent (CA).

METHODS

Participants with self-reported chronic pain (N = 500) will be recruited online on a rolling basis from April 2022 through posts on US-based internet communities within this prospective cohort. Informed consent is taken from the participants within the app and the Wysa intervention is delivered remotely for 8 weeks. Outcome measures including NPRS (Numeric Pain Rating Scale), PROMIS PI (Patient-Reported Outcomes Measurement Information System Pain Interference), GAD-7 (Generalized Anxiety Disorder), and PHQ-9 (Patient Health Questionnaire) questionnaires will be administered to test the effectiveness of the intervention on reducing levels of pain interference, depression, and anxiety. The therapeutic alliance created with the conversational agent will be assessed through the WAI-SR (Working Alliance Inventory-Short Revised). Retention and usage statistics will be observed for adherence and engagement.

RESULTS

The study will open for recruitment in April 2022 and data collection is expected to be completed by August 2022. The results for the primary outcomes are expected to be published by late-2022.

CONCLUSIONS

Mental health conversational agents driven by artificial intelligence (AI) could be effective in helping patients with chronic pain learn to self-manage their pain and deal with common comorbidities like depression and anxiety. The Wysa for Chronic Pain app is one such digital intervention that can potentially serve as a solution to the problems of affordability and scalability associated with interventions with a human therapist in loop. This prospective study examines the efficacy of the app as a treatment solution for chronic pain. It aims to inform future practices and digital mental health interventions for individuals with chronic pain.

CLINICALTRIAL