Meaning in Life Among Patients With Chronic Pain and Suicidal Ideation: Mixed Methods Study

Examining the Relationship Between Chronic Pain and Mortality in U.S. Adults

Chronic pain (CP) significantly impacts quality of life and increases noncommunicable disease risk, with recent U.S. data showing a 6.3% incidence rate, surpassing diabetes, depression, and hypertension. International studies suggest higher mortality in CP populations, yet prior U.S. data are inconclusive. To investigate CP's mortality risk, we analyzed National Health Interview Survey and National Death Index data. We hypothesized that individuals with CP and high-impact CP (HICP [≥1 activity limitation]) would exhibit higher mortality rates. National Health Interview Survey provided demographics, pain reporting, lifestyle, and psychosocial data matched with National Death Index mortality records. Chi-square analyses explored the relationships between CP/HICP and demographics, lifestyle factors, psychosocial variables, and mortality. Cox proportional hazards models assessed mortality risk between groups. The weighted sample was 245,899,776; 20% reported CP and 8% HICP, both groups exhibiting higher mortality rates than pain-free individuals (CP: 5.55%, HICP: 8.79%, total: 2.82%). Hazard ratios indicated nearly double the mortality risk for CP and 2.5 times higher risk for HICP compared to those without these conditions. Adjusting for lifestyle and psychosocial factors reduced mortality risk but remained elevated compared with non-CP individuals. Heart disease, malignant neoplasms, and chronic lower respiratory diseases accounted for a higher percentage of deaths in CP cases. CP individuals showed higher rates of smoking, alcohol consumption, obesity, inactivity, depression, anxiety, emotional problems, and sleep disturbances. CP and HICP significantly influence mortality outcomes, leading to excess deaths compared with pain-free individuals. Given the relationship between pain, lifestyle, psychosocial variables, and mortality, further investigations are needed into CP causation and prevention strategies. PERSPECTIVE: This article presents evidence regarding the relationship between CP, HICP, and mortality. Additional findings are discussed regarding the impact of demographics, lifestyle, and psychosocial variables on mortality in those with versus without CP and HICP. These findings are crucial for informing future research, prevention, and healthcare management strategies.

Associations of Gender Role and Pain in Musculoskeletal Disorders: A Mixed-Methods Systematic Review

Previous studies have investigated the association of gender roles with pain outcomes in healthy individuals. However, little is known about this association in those with musculoskeletal (MSK) disorders. Therefore, this mixed-methods systematic review aimed to investigate the association of sociocultural gender roles on pain outcomes in adults with MSK disorders. Literature from Medline, CINAHL, Web of Science, and Embase was reviewed from inception to February 2023. Eligibility criteria included studies of adults with an MSK pain disorder that explored the relationship between gender roles and pain for all primary qualitative and quantitative study designs. Exclusion criteria were gray literature, review articles, case studies, and conference proceedings. Risk of bias was assessed via the Quality Appraisal for Diverse Studies for quantitative studies and the McMaster Quality Appraisal Tool for qualitative studies. Eleven studies were included, 9 qualitative, and 2 quantitative with a total of 540 participants (19.6% women, 80.4% men) with various MSK disorders. The convergent integrated approach was used to synthesize data from the qualitative and quantitative studies resulting in 3 themes and 7 subthemes. Our findings identified differences in the way individuals explained the cause of their pain, were treated for their pain in a social and systemic context, and in describing the effect pain had on their lives based on gender roles. There is a need for pain management to evolve to acknowledge the individual pain experience through exploration of an individual's gender identity and roles. PERSPECTIVE: This article demonstrates that gender roles have a multidimensional influence on the pain experience in those with MSK disorders. These findings support the development of gender-sensitive, patient-centered approaches to pain management, acknowledging each individual's important roles and identities.

A Prospective Multicenter Longitudinal Analysis of Suicidal Ideation among Long-COVID-19 Patients

Long coronavirus disease 19 (COVID-19) is an emerging multifaceted illness with the pathological hallmarks of chronic inflammation and neuropsychiatric symptoms. These pathologies have also been implicated in developing suicidal behaviors and suicidal ideation (SI). However, research addressing suicide risk in long COVID-19 is limited. In this prospective study, we aim to characterize SI development among long-COVID-19 patients and to determine the predictive power of inflammatory markers and long-COVID-19 symptoms-including those of psychiatric origin-for SI. During this prospective, longitudinal, multicenter study, healthy subjects and long-COVID-19 patients will be recruited from the University Hospital of Geneva, Switzerland, the University of Genova, the University of Rome "La Sapienza", and the University of San Francisco. Study participants will undergo a series of clinic visits over a follow-up period of 1 year for SI assessment. Baseline and SI-onset levels of inflammatory mediators in plasma samples, along with 12 long-COVID-19 features (post-exertional malaise, fatigue, brain fog, dizziness, gastrointestinal disturbance, palpitations, changes in sexual desire/capacity, loss/change of smell/taste, thirst, chronic cough, chest pain, and abnormal movements) will be collected for SI risk analysis. The proposed enrollment period is from 15 January 2024 to 15 January 2026 with targeted recruitment of 100 participants for each study group. The anticipated findings of this study are expected to provide important insights into suicide risk among long-COVID-19 patients and determine whether inflammation and psychiatric comorbidities are involved in the development of SI in these subjects. This could pave the way to more effective evidence-based suicide prevention approaches to address this emerging public health concern.

From existential uncertainty to a new mindset promoting recovery: Exploring the development of uncertainty experience in women with vulvar neoplasia - A qualitative longitudinal study

BACKGROUND

Women with vulvar neoplasia continue to experience uncertainty up to six months post-surgery. Uncertainty in illness is considered a significant psychosocial stressor, that negatively influences symptom distress, self-management strategies and quality of life. According to the Reconceptualized Uncertainty in Illness Theory, the appraisal of uncertainty changes positively over time in chronic illness. We aimed at exploring whether and how the experience of uncertainty develops in women with vulvar neoplasia.

METHODS

We selected a purposive sample of seven women diagnosed with vulvar neoplasia in four Swiss and one Austrian women's clinic. By means of a qualitative longitudinal study, we conducted 30 individual interviews at five points of time during one year after diagnosis. We applied Saldaña's analytical questions for longitudinal qualitative research.

RESULTS

First, participants experienced uncertainty as an existential threat, then an inherent part of their illness, and finally a certainty. Women initially associated the existential threat with a high risk for suffering from severe health deteriorations. Participants that could reduce their individually assessed risk by adopting health promoting behaviors, accepted the remaining uncertainty. From now on they reframed uncertainty into a certainty. This new mindset was based on a belief of promoting recovery and reducing the risk of recurrence.

CONCLUSIONS

The long-lasting and oscillating nature of uncertainty should receive attention in supportive oncology care. Uncertainty concerning existential issues is of special importance since it can inhibit a positive development of uncertainty experience.

Incorporating personal narratives in positive psychology interventions to manage chronic pain

In this perspective paper, we argue for incorporating personal narratives in positive psychology interventions for chronic pain. Narratives refer to the telling and retelling of events. Narratives detail accounts of events and provide rich, in-depth information on human interactions, relationships, and perspectives. As such, narratives have been used to understand people's experiences with pain and pain coping mechanisms-as well as to facilitate therapeutic outcomes. Furthermore, narrative research has shown that narration can help restore and promote relief, calm, hope, self-awareness, and self-understanding in chronic pain sufferers. Positive psychology interventions have been successful in improving the lives of people living with chronic pain, but these psychology interventions do not typically incorporate personal narratives. Still, narrative, and positive psychology scholarship foci overlap, as both aim to enhance people's quality of life, happiness, and well-being, and to promote the understanding of psychosocial strengths and resources. In this article, we provide a rationale for incorporating personal narratives as an agentic form of positive psychology intervention. To that aim, we outline areas of convergence between positive psychology and narrative research and show how combining positive psychology exercises and narration can have additive benefits for pain sufferers. We also show how integrating narration in positive psychology intervention research can have advantages for healthcare research and policy.

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.

Health-promoting behavior to enhance perceived meaning and control of life in chronic disease patients with role limitations and depressive symptoms: a network approach

The association between health-related role limitations in the mental and physical subdomains and clinical status (i.e., chronic disease and comorbid depressive symptoms) is mediated by health-promoting behaviors. To enhance health-promoting behaviors in adults with chronic disease, it is necessary to identify item-level associations among targets of health-related monitoring and management. Therefore, the current study used a network approach to examine associations among health-related role limitations, depressive symptoms, existential well-being, socioeconomic position, and health-promoting behavior in adults with chronic disease. A total of 535 adults (mean ± SD age = 62.9 ± 11.9 years; males, n = 231, females, n = 304) who were regularly visiting an outpatient clinic for chronic disease treatment participated in this cross-sectional study. Data on participant demographics, chronic disease diagnoses, socioeconomic status, health-related role limitations (12-item short form survey scores), depressive symptoms (patient health questionnaire-9 scores), existential well-being (scores for four items of the McGill quality of life questionnaire-Revised), and health-promoting behavior (Healthy Habits Questionnaire scores) were acquired. "Undirected regularized partial correlations" and "directional joint probability distributions" among these variables were calculated using a mixed graphical model (MGM) and directed acyclic graph (DAG). In the MGM, the most influential nodes were emotional well-being, feelings of failure, and health-related limitations affecting usual role and physical activities. According to both the MGM and DAG, the relationship between emotional well-being and feelings of failure mediated the relationships of health-related role limitations with concentration difficulty and suicidal ideation. A positive mindset was dependent on the probability distributions of suicidal ideation, controllability of life, and positive self-image. Both the meaning of life and a positive mindset had direct associations with proactive living. Specifically, proactive living was associated with a balanced diet, regular exercise, volunteering in the community, and nurturing intimacy in social interactions. The meaning and controllability of life in individuals with chronic diseases could mediate the relationships of health-promoting behavior with health-related limitations related to usual role activities, physical activities, and depressive symptoms. Thus, interventions targeting health-promoting behaviors should aim to enhance the meaning and controllability of life (as it pertains to limitations in usual role and physical activities), as well as promote proactive screening and timely psychiatric treatment of depressive symptoms including feelings of failure, concentration difficulties, and suicidal ideation.

The Association between Dysbiosis and Neurological Conditions Often Manifesting with Chronic Pain

The prevalence of neurological conditions which manifest with chronic pain is increasing globally, where the World Health Organisation has now classified chronic pain as a risk factor for death by suicide. While many chronic pain conditions have a definitive underlying aetiology, non-somatic conditions represent difficult-to-diagnose and difficult-to-treat public health issues. The interaction of the immune system and nervous system has become an important area in understanding the occurrence of neuroinflammation, nociception, peripheral and central sensitisation seen in chronic pain. More recently, however, the role of the resident microbial species in the human gastrointestinal tract has become evident. Dysbiosis, an alteration in the microbial species present in favour of non-beneficial and pathogenic species has emerged as important in many chronic pain conditions, including functional somatic syndromes, autoimmune disease and neurological diseases. In particular, a decreased abundance of small chain fatty acid, e.g., butyrate-producing bacteria, including Faecalibacterium, Firmicutes and some Bacteroides spp., is frequently evident in morbidities associated with long-term pain. Microbes involved in the production of neurotransmitters serotonin, GABA, glutamate and dopamine, which mediate the gut-brain, axis are also important. This review outlines the dysbiosis present in many disease states manifesting with chronic pain, where an overlap in morbidities is also frequently present in patients.

Demoralization and Suicidal Ideation in Chronic Pain Patients

The literature has clearly stressed that patients suffering from chronic pain are at high risk of suicidal behavior (SB). Hence the need to improve the characterization of this behavior risk profile in these patients. Some findings indicate a possible relationship between demoralization and pain, with functional disability found to be correlated with demoralization. The primary objective of this study was to investigate the relationship between demoralization and suicidal ideation (SI) in patients with chronic pain. The secondary objective was to verify whether demoralization can occur independently of depression in these patients. Inclusion criteria were patients with chronic pain, with SI or not, matched for age and gender, aged > 18 years. Seventy patients with SI and 70 patients without SI were included. Between-group difference was statistically significant (F=1.064; t= 7.21, p<0.001, d=1.22), confirming the presence of numerous and intense depressive symptoms in the patients of the SI group. Regarding the Demoralization Scale (DS), the difference between the two groups was statistically highly significant (F=1.49; t=9.44; p<0.001, d=1.6). There was also a strong positive correlation between DS and Beck Depression Inventory (BDI-II) (R=0.749; p<0.001 for the study group and R=0.704; p<0.001 for the control group). Furthermore, there was a strong positive correlation between the DS and the Scale for Suicide Ideation (SSI) in the SI patients group, meaning that high demoralization is associated with higher suicidal ideation as well. Our findings did not allow us to distinguish between the notions of depression and demoralization, since the two constructs show almost the same strong positive correlation with suicidal thoughts, the two also being strongly correlated with each other.

ARMADILLO REGULATES NOCICEPTIVE SENSITIVITY IN THE ABSENCE OF INJURY

Abnormal pain has recently been estimated to affect ∼50 million adults each year within the United States. With many treatment options for abnormal pain, such as opioid analgesics, carrying numerous deleterious side effects, research into safer and more effective treatment options is crucial. To help elucidate the mechanisms controlling nociceptive sensitivity, the Drosophila melanogaster larval nociception model has been used to characterize well-conserved pathways through the use of genetic modification and/or injury to alter the sensitivity of experimental animals. Mammalian models have provided evidence of β-catenin signaling involvement in neuropathic pain development. By capitalizing on the conserved nature of β-catenin functions in the fruit fly, here we describe a role for Armadillo, the fly homolog to mammalian β-catenin, in regulating baseline sensitivity in the primary nociceptor of the fly, in the absence of injury, using under- and over-expression of Armadillo in a cell-specific manner. Underexpression of Armadillo resulted in hyposensitivity, while overexpression of wild-type Armadillo or expression of a degradation-resistant Armadillo resulted in hypersensitivity. Neither underexpression nor overexpression of Armadillo resulted in observed dendritic morphological changes that could contribute to behavioral phenotypes observed. These results showed that focused manipulation of Armadillo expression within the nociceptors is sufficient to modulate baseline response in the nociceptors to a noxious stimulus and that these changes are not shown to be associated with a morphogenetic effect.

Possible Contribution of Meaning in Life in Patients With Chronic Pain and Suicidal Ideation: Observational Study

Background

Chronic pain is associated with an elevated risk of suicidal ideation (SI).

Objective

We aimed to examine if the presence or the search for Meaning in Life (MiL) are associated with less SI and explore whether MiL profiles emerge in our cohort. These profiles can be described as high presence–high search, high presence–low search, low presence–low search, and low presence–high search.

Methods

In this observational study, we recruited 70 patients who were referred to the Multidisciplinary Pain Center of the Geneva University Hospitals and who answered positively to question 9 on the Beck Depression Inventory, 2nd Edition, investigating SI. Patients who agreed to participate in the study were further investigated; they participated in a structured diagnostic interview to screen for psychiatric diagnoses. During this interview, they completed the Meaning in Life Questionnaire and the semistructured Scale for Suicide Ideation (SSI) to assess the characteristics and severity of SI.

Results

There was a statistically significant correlation between the presence of MiL subscale and the SSI. These 2 scales had a negative and statistically highly significant correlation (R=–.667; P<.001). The results also showed a negative and statistically highly significant correlation between the score of the search for MiL and the SSI (R=–.456; P<.001). The results thus pointed to the presence of MiL as a potential protective factor against the severity of SI, while the search for MiL is also a possible resiliency factor, although to a lesser extent. The profile low presence–low search grouped the vast majority (47%) of the patients; in these patients, the mean SSI score was 14.36 (SD 5.86), much higher compared with that of the other subgroups.

Conclusions

This study’s results point to MiL as a concept of interest regarding devising psychotherapeutic interventions for chronic pain patients in order to reduce the suicidal risk and more accurately determine patients’ suffering.

Meaning in Life and Pain: The Differential Effects of Coherence, Purpose, and Mattering on Pain Severity, Frequency, and the Development of Chronic Pain

Objective

Meaning in life is consistently associated with better health outcomes across a range of mental and physical domains. However, meaning in life is a complex construct involving three distinct facets: coherence, purpose, and mattering. While these facets have been studied individually in relation to pain, they have not been assessed concurrently to parse out their potential distinct contributions to pain outcomes. We sought to identify the unique relationships of these individual facets of meaning with pain experiences and specify the components associated with pain-related resilience.

Methods

The associations of coherence, purpose, and mattering with pain outcomes were examined across three studies. Study 1 used data from the Midlife in the United States National Survey to determine associations between facets and the frequency of various recently experienced pains, and the development of chronic pain nine years later. Study 2 cross-sectionally observed the association between facets and recent pain severity in young adults. Using a diary-type approach, Study 3 captured fluctuations of pain severity in relation to the facets across the span of four weeks.

Results

Coherence was uniquely associated with less headache, backache, joint, and extremities pain frequency in Study 1, over and above purpose and mattering, controlling for other health variables. Coherence was also associated with lower odds of developing chronic pain. In Study 2, coherence was associated with less pain severity and fully mediated the relationship between global meaning in life and pain. Study 3 found that coherence predicted the most unique variance in weekly pain fluctuations.

Conclusion

Across three studies and timescales, coherence was uniquely associated with fewer and less severe pain experiences over and above purpose and mattering. These findings provide support for the value of coherence as a resilience factor in the context of pain and suggest a potential benefit for coherence-specific interventions in clinical settings.