Mindfulness-Based Stress Reduction in Breast Cancer Survivors with Chronic Neuropathic Pain: A Randomized Controlled Trial.

Objectives: The purpose of this study was to compare the effects of group-delivered mindfulness-based stress reduction as compared to a waitlist control group among breast cancer survivors living with CNP. Methods: A randomized controlled trial design was applied, and outcomes collected included pain, emotional function, quality of life, and global impression of change. Results: A total of 98 women were randomized and included in analyses. The sample included 49 women in the mindfulness-based stress reduction group, and 49 women in the waitlist control group. The intervention group participants (mean age 51.3 years, standard deviation = 11.4) and waitlist participants (mean age 55.1 years, standard deviation = 9.6) reported an average pain duration of approximately three years. No significant differences were found on the primary outcome of the proportions of women with reduced pain interference scores from the time of randomization to 3 months after the intervention was received. No significant changes were found among secondary outcomes. Conclusion: Our randomized clinical trial did not find significant benefits of group-based mindfulness-based stress reduction for the management of CNP. The current study findings should be replicated and are important to consider given ongoing concerns that nonsignificant results of mindfulness-based stress reduction are often unpublished.

Health-related quality of life in patients with advanced cancer who express a wish to hasten death: A comparative study.

BACKGROUND: Some evidence suggests the wish to hasten death is related to poor health-related quality of life. Deficits in perceived dignity and self-efficacy are risk factors for wish to hasten death that also impact health-related quality of life. AIM: To compare perceived health-related quality of life, dignity and self-efficacy in patients with advanced cancer who either do (case group) or do not (control group) express a wish to hasten death. Cases and controls were matched on sociodemographic and functional characteristics. DESIGN: A comparative cross-sectional study. PARTICIPANTS: A total of 153 adult patients with advanced cancer were assessed for wish to hasten death using the Desire for Death Rating Scale. Scores ⩾1 indicate some degree of wish to hasten death (case group, n = 51), and score = 0 implies no wish to hasten death (control group, n = 102). Assessments included health-related quality of life using the European Organization for Research and Treatment of Cancer Quality-of-Life Core 15-Item Palliative Questionnaire, perceived loss of dignity using the Patient Dignity Inventory and self-efficacy using the General Self-Efficacy Scale. RESULTS: Patients with a wish to hasten death had worse emotional functioning (p < 0.001), greater perceived loss of dignity (p < 0.001) and lower self-efficacy (p = 0.001). There was no difference in most physical symptoms. Perceived overall health-related quality of life was significantly worse for those with a clinically relevant wish to hasten death (p = 0.023) and marginally worse for the case group than the control group (p = 0.052). CONCLUSION: Patients with wish to hasten death showed lower perceived dignity, self-efficacy and emotional quality of life than patients without wish to hasten death without necessarily perceiving worse physical symptoms.

Validation of a Limitations in Daily Activities Scale for Chronic Pain.

Limitations in physical function and participation are important domains of assessment in chronic pain. In 1995, the International Association for the Study of Pain distributed a self-report measure of functional limitations. Although the questionnaire has been used in research studies, it has never been subjected to a thorough investigation of its measurement properties. In this study, 941 patients with chronic pain completed the 16-item Limitations in Daily Activities Scale (LIDAS) at 2 pretreatment and 1 post-treatment assessment points. Individual item analysis favored a 13-item scale. This 13-item LIDAS had a confirmed 3-factor structure consisting of limitations in personal care, global participation, and specific tasks. Reliability analyses for the total scale (α = .90), as well as for each factor individually (αs = .82-.84), indicated good internal consistency, test-retest reliability (intraclass correlations = .65-.88 over varying time intervals), and responsiveness to change with treatment. LIDAS scores correlated as expected with measures of pain intensity, pain cognitions, and depression, as well as with other self-report and clinician-administered measures of functional performance. Using patient global ratings as anchors, a minimal clinically important difference of 5 points was established as a criterion for meaningful individual improvement after treatment. In conclusion, the LIDAS is a reliable, valid, and clinically relevant option for assessing limitations in physical function and participation in patients with chronic pain. PERSPECTIVE: Physical function and participation comprise a core dimension in the assessment of chronic pain. This study demonstrates that the LIDAS is a reliable and valid measure of this dimension, with good applicability for documenting clinically important change with treatment.

Assessment of the wish to hasten death in patients with advanced cancer: A comparison of 2 different approaches.

INTRODUCTION: The Desire for Death Rating Scale (DDRS) and the short form of the Schedule of Attitudes toward Hastened Death (SAHD-5) are different approaches to assessing the wish to hasten death (WTHD). Both have clinical threshold scores for identifying individuals with a meaningfully elevated WTHD. However, the agreement between the 2 measures and patient opinions about assessment of the WTHD are unknown. OBJECTIVES: To compare the DDRS and SAHD-5 and to analyze patient opinions about assessment of the WTHD. METHODS: The WTHD was assessed in 107 patients with advanced cancer using both the DDRS and SAHD-5. Patients were subsequently asked their opinion about this assessment. RESULTS: Correlation between scores on the SAHD-5 and the DDRS was moderate, Spearman rho = 0.67 (P < .01). The SAHD-5 identified 13 patients (12.1%) at risk of the WTHD, and the DDRS identified 6 patients (5.6%) with a moderate-high WTHD (P > .05). Concordance between the DDRS and SAHD-5 in identifying individuals with an elevated WTHD was poor when using recommended cut-off scores, κ = 0.37 (P < 0.01) but could be improved by using different thresholds. Only 4 patients (3.8%) regarded the assessment questions as bothersome, and 90.6% considered it important that health-care professionals inquire about the WTHD. CONCLUSIONS: The SAHD-5 and DDRS appear to be appropriate methods for assessing the WTHD and could provide complementary information in clinical practice: the SAHD-5 to screen for risk of the WTHD and the DDRS as a clinical interview to explore it in greater detail. Assessment of the WTHD is well accepted by palliative care cancer patients.

A Network Analysis of Depressive Symptoms in Individuals Seeking Treatment for Chronic Pain.

OBJECTIVES: Major depression in the context of chronic pain has been conceptualized implicitly as a latent variable, in which symptoms are viewed as manifestations of an underlying disorder. A network approach provides an alternative model and posits that symptoms are causally connected, rather than merely correlated, and that disorders exist as systems, rather than as entities. The present study applied a network analysis to self-reported symptoms of major depression in patients with chronic pain. The goals of the study were to describe the network of depressive symptoms in individuals with chronic pain and to illustrate the potential of network analysis for generating new research questions and treatment strategies. MATERIALS AND METHODS: Patients (N=216) admitted to an interdisciplinary chronic pain rehabilitation program provided symptom self-reports using the Patient Health Questionnaire-9. Well-established network analyses methods were used to illustrate the network of depressive symptoms and determine the centrality of each symptom (ie, the degree of connection with other symptoms in the network). RESULTS: The most central symptoms were difficulty concentrating, loss of interest or pleasure, depressed mood, and fatigue, although the relative position of each symptom varied slightly, depending on the centrality measure considered. DISCUSSION: Consistent with past research with patients undergoing treatment for major depression, the current findings are supportive of a model in which depressive symptoms are causally connected within a network rather than being manifestations of a common underlying disorder. The research and clinical implications of the findings, such as developing treatments targeting the most central symptoms, are discussed.

Self-perceived burden, perceived burdensomeness, and suicidal ideation in patients with chronic pain.

Background: Self-perceived burden and perceived burdensomeness are two apparently related constructs that have arisen independently from research in physical and mental health, respectively. Although both are associated with suicidal ideation in individuals with chronic pain, they have yet to be examined concurrently in the same group of patients. Aims: The aim of this study was to investigate the relationship between the two constructs and their differential prediction of suicidal ideation. Methods: Participants were 260 outpatients of an interdisciplinary chronic pain treatment program. Each participant completed the Self-Perceived Burden Scale (SPBS), the Interpersonal Needs Questionnaire Perceived Burdensomeness Scale (INQPBS), the Beck Scale for Suicide Ideation, and the thoughts of self-harm item of the Patient Health Questionnaire-9. Results: The SPBS and the INQPBS were both unifactorial measures with good internal consistency. They correlated significantly with one another (r = 0.50, P < 0.001), as well as with scores on the two measures of suicidal ideation (rs ranging from 0.29 to 0.62, Ps < 0.001). However, the INQPBS correlated more highly with suicidal ideation than did the SPBS. In regression analyses, the INQPBS predicted unique variance in suicidal ideation after adjusting for the SPBS. Conversely, the SPBS did not contribute uniquely when the INQPBS was entered first. Conclusions: Patients with chronic pain who believe that they have become "a burden to others" are at increased risk for suicidal ideation. The conceptual similarities and differences between the constructs of self-perceived burden and perceived burdensomeness are reviewed to explain why perceived burdensomeness is the stronger predictor of this increased risk.

Contexte: La perception de soi comme un fardeau et le fardeau perçu sont deux construits connexes qui ont respectivement émergé de travaux de recherche en santé physique et en santé mentale, de manière indépendante. Bien qu'ils soient tous deux associés à l'idéation suicidaire chez les individus souffrant de douleur chronique, ils n'ont jamais été évalués simultanément au sein du même groupe de patients. Objectifs: Examiner le lien entre les deux construits et leur prédiction différentielle de l'idéation suicidaire. Méthodes: Le groupe de participants était composé de 260 patients externes d'un programme interdisciplinaire de gestion de la douleur chronique. Chaque participant a rempli le Self-Perceived Burden Scale (SPBS), l'Interpersonal Needs Questionnaire Perceived Burdensomeness Scale (INQPBS), l'Échelle d'idéation suicidaire de Beck et l'énoncé portant sur les pensées d'automutilation du Questionnaire sur la santé des patients-9.Résultats: Tant les mesures du SPBS que celles de l'INQPBS étaient monofactorielles et présentaient une bonne cohérence interne. Elles présentaient une corrélation significative l'une avec l'autre (r = 0,50, p < 0,001) et avec les scores obtenus pour les deux mesures de l'idéation suicidaire (r = de 0,29 à 0,62, p < 0,001), Toutefois, l'INQPBS présentait une plus grande corrélation avec l'idéation suicidaire que le SPBS. Dans les analyses de régression, l'INQPS était un prédicteur de variance unique dans l'idéation suicidaire après rajustement en fonction du SPBS. Inversement, le SPBS ne contribuait pas de manière unique lorsque l'INQPBS était inscrit en premier.Conclusions: Les patients souffrant de douleur chronique qui croient qu'ils sont devenus « un fardeau pour les autres ¼ sont à plus grand risque d'idéation suicidaire. Les similarités et les différences conceptuelles entre les construits de perception de soi comme un fardeau et de fardeau perçu sont examinées afin d'expliquer pourquoi le fardeau perçu est le meilleur prédicteur de ce risque accru.

Balancing give and take between patients and their spousal caregivers in hematopoietic stem cell transplantation.

OBJECTIVE: Hematopoietic stem cell transplantation (HSCT) is a demanding treatment. Spouses of HSCT patients assume caregiving responsibilities that can induce feelings of burden and disrupt relationship equity. On the basis of equity theory, we propose a conceptual framework examining the individual and dyadic experience of HSCT patients and their caregivers. The model includes feelings of inequity, patient self-perceived burden, caregiver burden, and distress. METHODS: The HSCT patients and their spousal caregivers were recruited prior to HSCT between March 2011 and September 2012. Each member of the dyad self-administered a questionnaire package. RESULTS: Seventy-two dyads were included in the path analyses. Our model demonstrated an inadequate statistical fit; however, with one modification, an adequate to good fit was obtained: χ2 (df) = 6.01(5), normed χ2  = 1.20, standardized root mean square residual = 0.048, comparative fit index = 0.99, Tucker-Lewis index = 0.96, and root-mean-square error of approximation = 0.05 (90% CI, 0.00-0.18). As hypothesized, pre-HSCT caregiver burden mediates the relationship between caregiver underbenefit and caregiver distress. However, patient self-perceived burden was not associated with patient distress; rather, patient perception of overbenefit was related to patient distress. In our modified model, the results demonstrate that patient overbenefit influenced caregiver burden; however, there was not a reciprocal influence, because caregiver variables did not affect patient variables. CONCLUSIONS: Our proposed theoretical framework describes patients' and caregivers' individual experience of distress before HSCT but does not as clearly encompass the dyadic experience. Addressing perceived imbalances and providing psycho-education on role changes within HSCT dyads before transplantation may be a useful prehabilitation strategy for preventing distress.

Testing the Interpersonal Theory of Suicide in Chronic Pain.

OBJECTIVE: The interpersonal theory of suicide offers a conceptual framework for understanding suicidal ideation (SI) that may be applicable to individuals with chronic pain. The theory emphasizes the importance of 2 interpersonal constructs as precursors to SI: perceived burdensomeness (the belief that one has become a burden to others) and thwarted belongingness (a lack of social integration or connection). Our objective was to test the interpersonal theory of suicide in people with chronic pain. METHODS: Hierarchical regression analysis was used in a cross-sectional study of 282 patients of an interdisciplinary pain clinic. The Beck Scale for Suicide Ideation was the criterion measure of SI, and independent variables included both general and pain-specific predictors. RESULTS: After adjusting for other known or putative risk factors related to pain and mental health, perceived burdensomeness significantly predicted SI, whereas thwarted belongingness did not. As expected according to theory, the interaction between perceived burdensomeness and thwarted belongingness was also significant; perceived burdensomeness was a strong predictor of SI at high levels of thwarted belongingness, but only marginally at low levels. Other independent predictors were male sex, number of prior suicide attempts, and hopelessness. DISCUSSION: These findings are in line with some, but not all, of the major predictions of the interpersonal theory of suicide. In general, however, they support the relevance of the theory for individuals with chronic pain.

The relationship between mindfulness, pain intensity, pain catastrophizing, depression, and quality of life among cancer survivors living with chronic neuropathic pain.

PURPOSE: This study aims to examine if mindfulness is associated with pain catastrophizing, depression, disability, and health-related quality of life (HRQOL) in cancer survivors with chronic neuropathic pain (CNP). METHOD: We conducted a cross-sectional survey with cancer survivors experiencing CNP. Participants (n = 76) were men (24 %) and women (76 %) with an average age of 56.5 years (SD = 9.4). Participants were at least 1 year post-treatment, with no evidence of cancer, and with symptoms of neuropathic pain for more than three months. Participants completed the Five Facets Mindfulness Questionnaire (FFMQ), along with measures of pain intensity, pain catastrophizing, pain interference, depression, and HRQOL. RESULTS: Mindfulness was negatively correlated with pain intensity, pain catastrophizing, pain interference, and depression, and it was positively correlated with mental health-related HRQOL. Regression analyses demonstrated that mindfulness was a negative predictor of pain intensity and depression and a positive predictor of mental HRQOL after controlling for pain catastrophizing, age, and gender. The two mindfulness facets that were most consistently associated with better outcomes were non-judging and acting with awareness. Mindfulness significantly moderated the relationships between pain intensity and pain catastrophizing and between pain intensity and pain interference. CONCLUSION: It appears that mindfulness mitigates the impact of pain experiences in cancer survivors experiencing CNP post-treatment. IMPLICATIONS FOR CANCER SURVIVORS: This study suggests that mindfulness is associated with better adjustment to CNP. This provides the foundation to explore whether mindfulness-based interventions improve quality of life among cancer survivors living with CNP.

When Someone Dies in the Emergency Department: Perspectives of Emergency Nurses.

UNLABELLED: Emergency nurses work in a clinical area where treatment measures usually are provided quickly, and they have little time to establish relationships. In addition to performing life-saving interventions, emergency nurses provide care for patients who are dying. Little is known about the experiences of emergency nurses who care for patients who die in the emergency department in the Canadian context. METHODS: This study used a qualitative design with an interpretive descriptive approach. Semistructured interviews were conducted with 11 ED nurses from a large Canadian academic health sciences system. RESULTS: In-depth analysis of the data resulted in 3 major themes: "It's not a nice place to die," "I see the grief," and "Needing to know you've done your best." Findings revealed that emergency nurses believed the environment made it difficult to care for dying patients and their families because of unpredictability, busyness, noise, lack of privacy, and the need to manage many patients simultaneously. These nurses were also put in the position of caring for the suddenly bereaved family members, which was viewed as an especially challenging aspect of their role. DISCUSSION: Caring for adults who die in the emergency department is a difficult and challenging aspect of the emergency nursing role. Emergency nurses believed they did their best to provide end-of-life care interventions, which brought a sense of professional satisfaction. Recommended future interventions include advocating for ED design and physical layout to support compassionate end-of-life care, provision of policies and training to support families and family presence, and support of nursing staff.

Loss of Dignity in Severe Chronic Obstructive Pulmonary Disease.

CONTEXT: The maintenance of dignity is an important concept in palliative care, and the loss of dignity is a significant concern among patients with advanced cancer. OBJECTIVES: The goals of this study were to examine whether loss of dignity is also a concern for patients receiving interdisciplinary rehabilitation for Stage III or IV chronic obstructive pulmonary disease. We examined the prevalence and correlates of loss of dignity and determined whether it improves with treatment. METHODS: Inpatients underwent a structured interview inquiry around their sense of dignity and completed measures of pulmonary, physical, and psychological function at admission (n = 195) and discharge (n = 162). RESULTS: Loss of dignity was identified as a prominent ongoing concern for 13% of patients. It was correlated with measures of depression and anxiety sensitivity, but not with pulmonary capacity or functional performance. A robust improvement in loss of dignity was demonstrated, with 88% of those who reported a significant problem at admission no longer reporting one at discharge. CONCLUSION: The prevalence of a problematic loss of dignity among patients with severe chronic obstructive pulmonary disease is at least as high as among those receiving palliative cancer care. Loss of dignity may represent a concern among people with medical illnesses more broadly, and not just in the context of "death with dignity" at the end of life. Furthermore, interdisciplinary care may help to restore a sense of dignity to those individuals who are able to participate in rehabilitation.

Clinically Important Change in Insomnia Severity After Chronic Pain Rehabilitation.

OBJECTIVES: Insomnia is a common problem for people with chronic pain. It is unclear, however, whether interdisciplinary treatment centered on pain management, rather than sleep, confers a benefit in reducing insomnia symptoms. In this study, we examined clinically important change in insomnia severity following participation in an interdisciplinary chronic pain rehabilitation program. METHODS: A total of 140 patients (43 men and 97 women) completed a 4-week outpatient day program for interdisciplinary rehabilitation that incorporated psychoeducation about pain, physical fitness, and group psychotherapy. The Insomnia Severity Index (ISI) was included as an outcome, along with measures of pain, mood, and function. RESULTS: On the ISI before treatment, 20 patients (14.3%) reported no insomnia, 36 (25.7%) had a mild or subthreshold problem, and 84 (60%) had moderate (31.4%) or severe (28.6%) clinical insomnia. After treatment, ISI scores showed a statistically significant improvement overall (P<0.001). Six indices of individual change were examined among those with moderate-severe insomnia at baseline. Depending on the index used, rates of clinically important improvement ranged from 2.4% to 47.6%; however, only 2 patients with insomnia met criteria for full remission. Among patients with no or subthreshold symptoms at baseline, from 0% to 14.3% were worse after treatment, depending on the criterion. DISCUSSION: Insomnia improves overall following interdisciplinary rehabilitation for chronic pain, but most patients with clinical insomnia continue to have a significant sleep problem after treatment, and some patients may get worse. Interventions to alleviate persistent insomnia comorbid with chronic pain are likely to require a more intensive focus on sleep itself.

Mental disorders and the desire for death in patients receiving palliative care for cancer.

OBJECTIVES: The desire for death in terminally ill patients is associated with depression and anxiety, but not all patients who report it meet criteria for mental disorders. We examined the characteristics of subgroups of palliative cancer patients who expressed a desire for death that occurred either with or without a concurrent depressive or anxiety disorder. DESIGN: Cross-sectional survey. SETTING: Eight Canadian palliative care programs. PARTICIPANTS: 377 patients with cancer. MAIN OUTCOME MEASURES: Desire for Death Rating Scale; Structured Interview of Symptoms and Concerns. RESULTS: Most participants (69.5%) had no desire for death. Of the remainder, 69 (18.3%) acknowledged occasional transient thoughts, and 46 (12.2%) reported an apparently genuine desire to die. In the latter group, 24 individuals (52.2%) were diagnosed with a mental disorder and 22 (44.8%) were not. Individuals with no serious desire for death and no mental disorder reported the least distress in physical, social, existential, and psychological symptoms and concerns; those with a mental disorder and a significant desire for death reported the most. The subgroup of patients with a serious desire for death but no concurrent mental disorders still reported increased distress due to physical symptoms and social concerns, as well as a higher prevalence of global suffering. CONCLUSIONS: The expression of a desire for death by a terminally ill patient should raise a suspicion about mental health problems, but is not in itself clearly indicative of one. Nevertheless, it may serve as a catalyst to review the individual's physical symptom management and interpersonal concerns, and overall sense of suffering.

Attachment insecurity predicts responses to an interdisciplinary chronic pain rehabilitation program.

The aim of this study was to examine the hypothesis that attachment insecurity is associated with poorer responses to interdisciplinary treatment for chronic pain. Patients (n = 235) admitted to a 4-week interdisciplinary rehabilitation program were recruited. At pre-treatment, participants completed a battery of questionnaires assessing adult attachment styles and dimensions, as well as pain intensity, disability, self-efficacy, pain catastrophizing, and depressive symptoms. The latter measures were completed again at post-treatment. Nearly two-thirds of participants (65.5 %) reported having an insecure attachment style. Attachment insecurity was unrelated to pre- and post-treatment reports of pain intensity and pain-related disability, but was significantly associated with most other clinical variables at both time points. Regression analyses controlling for pre-treatment functioning indicated that attachment insecurity was associated with less improvement in pain catastrophizing, pain self-efficacy, and depressive symptoms. Further research is warranted to investigate the processes by which attachment characteristics influence patients' responses to chronic pain rehabilitation.

A Breathlessness Catastrophizing Scale for chronic obstructive pulmonary disease.

OBJECTIVE: Catastrophizing about breathlessness may be related to disability in patients with chronic obstructive pulmonary disease (COPD), but assessment options are limited. This study reports the initial validation of a 13-item Breathlessness Catastrophizing Scale (BCS). METHOD: Pulmonary rehabilitation inpatients completed spirometric, functional performance and questionnaire assessments at admission (N=242) and discharge (n=186). RESULTS: The BCS comprised a unifactorial scale that demonstrated excellent internal consistency (Cronbach's alpha=.96) and correlated with measures of anxiety sensitivity, depression, and self-efficacy, but not with performance on walk and stair-climbing tests. BCS scores improved robustly with rehabilitation, approaching a medium effect size (d=.43), and demonstrated a modest association with enhanced performance in a stair-climbing test of exercise tolerance. CONCLUSION: The BCS is a reliable measure of catastrophizing in severe COPD that has good convergent validity and sensitivity to change. Its association with functional performance requires further investigation. However, it appears that a high level of catastrophizing about breathlessness is not a barrier to functional improvement with inpatient pulmonary rehabilitation.

Change in suicidal ideation after interdisciplinary treatment of chronic pain.

OBJECTIVES: To examine suicidal ideation (SI) in individuals with chronic pain, especially change in suicidal thinking after interdisciplinary treatment. MATERIALS AND METHODS: Consecutive patients (n=250) admitted to a 4-week, group-based chronic pain management program completed measures of pain intensity, functional limitations, depressive symptoms, overall distress, pain catastrophizing, self-perceived burden, and SI at pretreatment and posttreatment. RESULTS: Before treatment, 30 (12.0%) participants were classified as having a high level of SI, 56 (22.4%) had a low level of SI, and 164 (65.6%) reported none. After treatment, there was a significant reduction in SI and improvements in all other outcomes, but there were still some individuals with high (n=22, 8.8%) or low (n=28, 11.2%) levels at discharge. Patients with high SI at baseline differed from those with no suicidal thinking on pretreatment and posttreatment measures of depression, distress, catastrophizing, and self-perceived burden, but not on pain intensity or functional limitations. Patients high in SI endorsed greater pain catastrophizing and self-perceived burden than those low in suicidal thinking. Sustained SI after treatment was associated with higher baseline levels of suicidal thinking and self-perceived burden to others, as well as a more limited overall response to treatment. DISCUSSION: SI was common in individuals with chronic pain, although mostly at a low level. Interdisciplinary treatment may result in reduced suicidal thinking; however, some patients continue to express thoughts of self-harm. Future studies could examine processes of change and interventions for treatment-resistant suicidal concerns.

Major depressive disorder and sleep disturbance in patients with chronic pain.

BACKGROUND: Disturbed sleep is a common problem in both chronic pain and major depressive disorder (MDD). Moreover, many patients with chronic pain are depressed. OBJECTIVES: To examine the effects of depression on the sleep behaviour of chronic pain patients by comparing patients who did or did not meet diagnostic criteria for MDD. METHODS: A total of 60 patients with chronic musculoskeletal pain underwent structured diagnostic interviews for MDD and insomnia, and completed questionnaires assessing pain severity, disability, sleep quality, beliefs and attitudes about sleep, and sleep hygiene. For four consecutive days, they also completed a sleep diary, and reported on sleep hygiene practices and presleep arousal. RESULTS: Thirty-three patients (55%) met diagnostic criteria for MDD, most of whom (n=32 [97%]) also fulfilled criteria for insomnia disorder. Insomnia was also common among patients without MDD (21 of 27 [78%]). Participants with MDD had higher self-reports of pain, disability, dysfunctional beliefs about sleep, and, on a prospective basis, greater presleep arousal and poorer sleep hygiene. However, diary assessments of specific sleep parameters (eg, sleep onset latency, total sleep time, sleep efficiency) did not differ between the groups. DISCUSSION: Chronic pain patients with comorbid MDD exhibited more dysfunctional beliefs about sleep, poorer sleep hygiene practices and greater presleep arousal; however, diary-recorded sleep characteristics may not differ from those of patients without MDD. Chronic pain itself may disturb sleep so extensively that MDD introduces little additive effect. CONCLUSION: MDD in chronic pain may be related to the cognitive and behavioural aspects of insomnia, rather than to an incremental disturbance in the initiation or maintenance of sleep.

The Canadian Safe Driving Study-Phase I pilot: Examining potential logistical barriers to the full cohort study.

Multiple organizations and task forces have called for a reliable and valid method to identify older drivers who are medically unfit to drive. The development of a clinical decision rule for this type of screening requires data from a longitudinal prospective cohort of older drivers. The aim of this article is to identify potential design, sampling and data collection barriers to such studies based on an analysis of the Canadian Safe Driving Study-phase I pilot (Candrive I). A convenience sample of 100 active older drivers aged 70 years or more was recruited through the aid of a seniors' organization, 94 of whom completed the full study (retention rate 94%). Data were collected over the course of 1 year on various driving behaviours, as well as on cognitive, physical and mental functioning. Driving patterns were recorded using driving diaries, logs and electronic devices. Driving records from the Ministry of Transportation of Ontario (MTO) were obtained for the 3-year period preceding the study initiation and up to 1 year following study completion. An increased burden of illness was observed as the number of medical diagnoses and medication use increased over the study period. Study participants were involved in a total of five motor vehicle collisions identified through MTO records, which was comparable to the Ontario annual collision rate of 4.1% for drivers aged 75 years or older. In sum, many of the relevant logistical and practical barriers to studying a large sample of older drivers longitudinally have been shown to be addressable, supporting the feasibility of completing a large prospective cohort study of older drivers.

Chronic pain and the interpersonal theory of suicide.

OBJECTIVE: Chronic pain is a known risk factor for suicide. To date, however, few studies of people with chronic pain have tested specific predictions about suicidal ideation that are derived from theory. The interpersonal theory of suicide proposes that the psychological constructs of thwarted belongingness and perceived burdensomeness are unique and independent precursors to suicidal ideation. We tested this hypothesis in a clinical sample of patients with chronic pain. METHOD: A total of 303 patients of a chronic pain rehabilitation program completed measures of pain severity, duration, and disability; cognitive-affective measures of depression and catastrophizing; and interpersonal measures of relationship distress and self-perceived burden to others. The latter measures were included as indices of the belongingness and burdensomeness constructs. Participants also rated two items pertaining to suicidal ideation. RESULTS: In a multiple regression analysis, both distress in interpersonal relations (ß = 0.12, p = .037) and self-perceived burden to others (ß = 0.25, p < .001) were significant predictors of suicidal ideation, even after adjusting statistically for demographic characteristics, pain severity and duration, functional limitations, catastrophizing, and depression. CONCLUSIONS: These findings suggest that the interpersonal theory is relevant to understanding elevated rates of suicidal ideation among people with chronic pain, and may have broader applicability to other populations with chronic illness or disability.

How well do emergency medical dispatch codes predict prehospital medication administration in a diverse urban community?

BACKGROUND: The Medical Priority Dispatch System (MPDS) is an emergency medical dispatch (EMD) system that is widely used to prioritize 9-1-1 calls and optimize resource allocation. MPDS is a computer-based EMD system that uses callers' responses to scripted questions to categorize cases into groups and subgroups, based on complaint and perceived acuity. OBJECTIVE: This study evaluates the ability of MPDS codes to predict prehospital use of medications. METHODS: All transported prehospital patients assigned a subgroup by MPDS from January 1, 2009 to December 31, 2009 in a diverse urban community were matched with their prehospital electronic patient care records. The records of transported patients dispatched through EMD were queried for prehospital interventions and matched to their MPDS classifications. Only MPDS subgroups with 10 or more calls were included in the analysis. RESULTS: A total of 38,005 patients met inclusion criteria. Patients with chest pain, breathing problems, heart problems, and diabetic problems received the most medications. Medications were administered in 19% of all calls. The individual MPDS subgroup with the highest rate of medication administration was 6E1A (breathing problems, 76%). Higher rates of Advanced Life Support (ALS) interventions in higher-acuity categories (e.g., Alpha, Bravo, Charlie) were seen in several EMD categories, including unconscious/fainting, breathing problems, and abdominal pain; but this was not observed in many other categories, including seizure, sick person, traumatic injury, and hemorrhage/lacerations. CONCLUSIONS: Medications were administered in 19% of all calls. There were higher rates of ALS interventions in higher-acuity categories that were not observed in many other categories.