Parental Self-Efficacy and Personal Time Help Explain Impact of Parent-Staff Interactions on Parental Distress and Bonding in the Neonatal Intensive Care Unit.

OBJECTIVES: To identify factors that help explain associations between parent-staff interactions and: (1) parental depression, anxiety, and post-traumatic stress; and (2) parent-child bonding in the neonatal intensive care unit. STUDY DESIGN: Our cross-sectional mixed methods survey investigated the ways in which parental-staff interactions relate to parental distress and parent-child bonding. Parents with babies in the neonatal intensive care unit (n = 165) completed validated measures and open-ended questions about their experiences with staff. Using a sequential explanatory approach, we examined: (1) whether and how parental self-efficacy and personal time mediated parent-staff interactions on distress and bonding; and (2) parental written accounts of experiences with staff. RESULTS: Multiple mediation analyses revealed that parent-staff interactions exhibited an: (1) indirect effect on parental depression (b = -0.05, SE = 0.02, CI [-0.10, -0.01]), anxiety (b = -0.08, SE = 0.04, CI [-0.16, -0.02]), and parent-child bonding (b = -0.26, SE = 0.08, CI [-0.43, -0.11]) through parental self-efficacy; and (2) indirect effect on parental post-traumatic stress (b = -0.08, SE = 0.04, CI [-0.17, -0.00], completely standardized indirect effect = -0.06) through parental personal time. Thematic analyses revealed that emotional and instructional support from staff helped build parental self-efficacy. Trust with staff helped parents feel comfortable leaving the bedside and engage in basic needs (eg, eat, sleep). CONCLUSIONS: Family-staff dynamics are the foundation for high quality family-centered care. Staff who empower parents to participate in care, engage in parenting tasks, and take care of themselves may reduce their distress and improve relationships among staff, parents, and babies.

The impact of a virtual mind-body program on symptoms of depression and anxiety among international English-speaking adults with neurofibromatosis.

The neurofibromatoses (NFs) are a set of incurable genetic disorders that predispose individuals to nervous system tumors. Although many patients experience anxiety and depression, there is little research on psychosocial interventions in this population. The present study examined the effects of a mind-body intervention on depression and anxiety in adults with NF. This is a secondary analysis of the Relaxation Response Resiliency Program for NF (3RP-NF), an 8-week virtual group intervention that teaches mind-body skills (e.g., relaxation, mindfulness) to improve quality of life. Participants were randomized to 3RP-NF or the Health Enhancement Program for NF (HEP-NF) consisting of health informational sessions and discussion. We evaluated depression (PHQ-9) and anxiety (GAD-7) at posttreatment, 6 months, and 12 months. Both groups improved in depression and anxiety between baseline and posttest, 6 months, and 12 months. The 3RP-NF group showed greater improvements in depression scores from baseline to 6 months compared with HEP-NF and with lower rates of clinically significant depressive symptoms. There were no between-group differences for anxiety. Both interventions reduced distress and anxiety symptoms for individuals with NF. The 3RP-NF group may be better at sustaining these improvements. Given the rare nature of NF, group connection may facilitate reduced distress.

Diverse learners: learning disabilities and quality of life following mind-body and health education interventions for adults with neurofibromatosis.

PURPOSE: Neurofibromatosis (NF) is associated with low quality-of-life (QoL). Learning disabilities are prevalent among those with NF, further worsening QoL and potentially impacting benefits from mind-body and educational interventions, yet research on this population is scarce. Here, we address this gap by comparing NF patients with and without learning disabilities on QoL at baseline and QoL-related gains following two interventions. METHODS: Secondary analysis of a fully-powered RCT of a mind-body program (Relaxation Response Resiliency Program for NF; 3RP-NF) versus an educational program (Health Enhancement Program for NF; HEP-NF) among 228 adults with NF. Participants reported QoL in four domains (Physical Health, Psychological, Social Relationships, and Environmental). We compare data at baseline, post-treatment, and 12-month follow-up, controlling for intervention type. RESULTS: At baseline, individuals with NF and learning disabilities had lower Psychological (T = -3.0, p = .001) and Environmental (T = -3.8, p < .001) QoL compared to those without learning disabilities. Both programs significantly improved all QoL domains (ps < .0001-0.002) from baseline to post-treatment, regardless of learning disability status. However, those with learning disabilities exceeded the minimal clinically important difference in only one domain (Psychological QoL) compared to three domains in individuals without learning disabilities. Moreover, those with learning disabilities failed to sustain statistically significant gains in Psychological QoL at 12-months, while those without learning disabilities sustained all gains. CONCLUSION: Adults with NF and learning disabilities have lower Psychological and Environmental QoL. While interventions show promise in improving QoL regardless of learning disabilities, additional measures may bolster clinical benefit and sustainability among those with learning disabilities.

Flexibly Incorporating the Dyad into Psychosocial Intervention: Considerations for Neuropalliative Care.

This paper reviews dyadic psychosocial intervention approaches that flexibly incorporate both dyad members despite challenges to equitable involvement due to cognitive limitations or limited availability. We provide an overview, analysis, and examples for the following dyadic intervention approaches: (1) shared interventions that involve each dyad member equitably (i.e., higher care recipient cognition, higher care-partner availability); (2) patient-focused interventions that primarily engage care recipients with early stages of neurocognitive disorders, yet include care-partners in select sessions and target dyadic and relationship needs (i.e., higher care recipient cognition, lower care-partner availability); and (3) care-partner focused interventions that primarily engage care-partners, yet still address care recipient and relationship needs (i.e., lower care recipient cognition, higher care-partner availability). In our review, we propose a flexible definition of dyadic psychosocial intervention that considers the continuum of individuals' involvement, measurement, content, and conceptual background. We conclude with a discussion of implications for neuropalliative care.

Minimal clinically important difference in the World Health Organization Quality of Life Brief (WHOQOL-BREF) for adults with neurofibromatosis.

PURPOSE: This study aimed to estimate minimal clinically important difference (MCID) values for the World Health Organization Quality of Life Brief version (WHOQOL-BREF) among adults with neurofibromatosis (NF). An MCID is needed to demonstrate clinical meaningfulness of interventions for NF. METHODS: We estimated MCID for the WHOQOL-BREF: the quality of life (QoL) measure recommended by the Response Evaluation in Neurofibromatosis and Schwannomatosis International Collaboration. We used data from 228 clinical trial participants with NF type 1, NF type 2-related schwannomatosis, or schwannomatosis (SCHWN) who completed 10 weeks of a virtual group mind-body program targeting resiliency or a time- and attention-matched control. Following established guidelines, we estimated MCIDs using both anchor-based and distribution-based methods for physical, psychological, social relationships, and environmental domains of the WHOQOL-BREF. RESULTS: MCID results varied across method and QoL domain. Three anchor-based methods, average change (AC), change difference (CD), and regression (REG), yielded the most consistent and comparable MCID across QoL domains. Based on these methods, we recommend ranges for each QoL domain: Physical QoL (3.9-7.3), Psychological QoL (4.7-8.1), Social QoL (2.6-5.9), and Environmental QoL (4.1-6.6). CONCLUSION: Establishing a rigorous MCID for QoL in NF is a critical step toward evaluating meaningful change in response to psychosocial interventions.

PTSD symptoms, pain catastrophizing, and pain outcomes after acute orthopedic injury.

BACKGROUND: PTSD is associated with greater incidence of chronic pain. Pain catastrophizing often accounts for this association. Less is known about these relationships during the acute phase (1-2 months) following orthopedic traumatic injuries. We sought to understand which orthopedic traumatic injury-related PTSD symptoms were associated with acute pain and physical dysfunction and whether pain catastrophizing accounted for these associations. METHODS: This secondary analysis uses baseline data from a multisite randomized controlled trial of an intervention for individuals with heightened pain catastrophizing or pain anxiety following acute orthopedic injury. We used partial correlations to examine associations between PTSD symptom clusters (re-experiencing, avoidance, negative alterations in cognitions and mood, and hyperarousal) and pain outcomes (pain intensity and physical dysfunction) controlling for pain catastrophizing. We used hierarchical regressions to evaluate unique associations between PTSD clusters and pain outcomes. In exploratory analysis, we examined the indirect effects of PTSD symptoms on pain outcomes through catastrophizing. RESULTS: Hierarchical linear regressions indicated that hyperarousal was uniquely associated with greater pain intensity with activity (ß = 0.39, p < 0.001, ΔR2 =0.06) and physical dysfunction (ß = 0.22, p = 0.04 ΔR2 =0.02). PTSD symptoms were still associated with pain with activity even with pain catastrophizing included in the models, and catastrophizing did not have a significant indirect effect on the relationship between PTSD and physical dysfunction (b=0.06, SEBoot=0.04, 95% CIBoot = [-0.003, 0.14]). Pain catastrophizing did largely account for the association between re-experiencing, avoidance, and negative alterations in cognitions and mood symptoms and pain at rest. CONCLUSIONS: Pain catastrophizing interventions may be best suited for limiting the impact of PTSD symptoms on pain at rest, but catastrophizing alone may not fully explain the relationship between PTSD symptoms and physical dysfunction after acute orthopedic injury. To prevent the negative association of PTSD symptoms, especially hyperarousal, on physical outcomes in acute pain populations, interventions may require more than solely targeting pain catastrophizing.

Perspectives of adults with neurofibromatosis regarding the design of psychosocial trials: Results from an anonymous online survey.

BACKGROUND/AIMS: Individuals with neurofibromatosis, including neurofibromatosis 1 (NF1), neurofibromatosis 2 (NF2)-related schwannomatosis (SWN), and other forms of SWN, often experience disease manifestations and mental health difficulties for which psychosocial interventions may help. An anonymous online survey of adults with neurofibromatosis assessed their physical, social, and emotional well-being and preferences about psychosocial interventions to inform clinical trial design. METHODS: Neurofibromatosis clinical researchers and patient representatives from the Response Evaluation in Neurofibromatosis and Schwannomatosis International Collaboration developed the survey. Eligibility criteria included age ≥ 18 years, self-reported diagnosis of NF1, NF2, or SWN, and ability to read and understand English. The online survey was distributed internationally by the Neurofibromatosis Registry and other neurofibromatosis foundations from June to August 2020. RESULTS: Surveys were completed by 630 adults (18-81 years of age; M = 45.5) with NF1 (78%), NF2 (14%), and SWN (8%) who were mostly White, not Hispanic/Latino, female, and from the United States. The majority (91%) reported that their neurofibromatosis symptoms had at least some impact on daily life. In the total sample, 51% endorsed a mental health diagnosis, and 27% without a diagnosis believed they had an undiagnosed mental health condition. Participants indicated that neurofibromatosis affected their emotional (44%), physical (38%), and social (35%) functioning to a high degree. Few reported ever having participated in a drug (6%) or psychosocial (7%) clinical trial, yet 68% reported they "probably" or "definitely" would want to participate in a psychosocial trial if it targeted a relevant concern. Top treatment targets were anxiety, healthier lifestyle, and daily stress. Top barriers to participating in psychosocial trials were distance to clinic, costs, and time commitment. Respondents preferred interventions delivered by clinicians via individual sessions or a combination of group and individual sessions, with limited in-person and mostly remote participation. There were no significant group differences by neurofibromatosis type in willingness to participate in psychosocial trials (p = 0.27). Regarding interest in intervention targets, adults with SWN were more likely to prefer psychosocial trials for pain support compared to those with NF1 (p < 0.001) and NF2 (p < 0.001). CONCLUSION: This study conducted the largest survey assessing physical symptoms, mental health needs, and preferences for psychosocial trials in adults with neurofibromatosis. Results indicate a high prevalence of disease manifestations, psychosocial difficulties, and untreated mental health problems in adults with neurofibromatosis and a high degree of willingness to participate in psychosocial clinical trials. Patient preferences should be considered when designing and implementing psychosocial interventions to develop the most feasible and meaningful studies.

"I Wish I Had That!": A Qualitative Analysis of Psychosocial Treatment Preferences Among Young Adults With Recent Concussion and Anxiety.

OBJECTIVE: To assess psychosocial treatment preferences and factors that may affect treatment participation among young adults with a recent concussion and co-occurring anxiety. DESIGN: In-depth, semi-structured individual qualitative interviews, followed by thematic analysis using a hybrid deductive-inductive approach. SETTING: Academic medical center in the US Northeast. PARTICIPANTS: Seventeen young adults (18-24y) who sustained a concussion within the past 3-10 weeks and reported at least mild anxiety (≥5 on the Generalized Anxiety Disorder-7 questionnaire). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Primary outcomes include preferences for program content (eg, topics and skills), delivery modality, format, and barriers and facilitators to participation. RESULTS: We identified 4 domains characterizing participants' perceptions of and preferences for treatment. (1) Program content: Participants preferred a program early after injury that included psychoeducation and coping skills (eg, activity pacing, deep breathing, mindfulness). (2) Therapeutic processes: Participants preferred a person-centered approach in which clinicians normalized anxiety postconcussion and reassured them of recovery. (3) Program logistics: Participants endorsed that a brief, virtual program would be acceptable. They preferred access to program components through multiple modalities (eg, audio, video) and accommodations to manage concussion symptoms. (4) Barriers and facilitators to participation: Barriers included acute concussion symptoms (eg, screen sensitivity), time constraints, and forgetting sessions. Facilitators included a program that is flexible (format, scheduling), personalized (self-chosen mode for reminders, measure of accountability), and accessible (ie, advertising through health care professionals or social media). CONCLUSIONS: Participants need psychosocial support that normalizes their experiences and provides education and coping tools. Treatments should be accessible, flexible, and person centered. Psychosocial treatments meeting these preferences may help optimize the recovery of young adults with recent concussion and anxiety.

Anxiety, pain catastrophizing, and pain outcomes among older adults with chronic orofacial pain.

Although chronic orofacial pain (COFP) is common among older adults, the role of psychological factors in pain outcomes among this population has received limited attention. This study examined the role of anxiety and pain catastrophizing, two corelates of pain in other populations, in pain intensity and interference among 166 older adults with COFP (79% female, Mage = 68.84, SD = 5.56). Participants completed an online survey including measures of anxiety, pain catastrophizing, and pain intensity/interference. We applied mediation analyses to test indirect associations between anxiety and pain outcomes via pain catastrophizing. Results indicated that anxiety was positively associated with pain intensity and pain interference (bs = .70-1.12, ps < .05). There was also an indirect association between anxiety and pain interference through pain catastrophizing (b = .35, 95% CI [.0383, .7954]), indicating pain catastrophizing partially accounts for this relationship. Assessing and addressing anxiety and pain catastrophizing has the potential to improve treatment outcomes in this population.

Perceived discrimination and pain outcomes among black adults with chronic musculoskeletal pain: identifying modifiable psychosocial risk factors.

Chronic musculoskeletal pain (CMP) is highly prevalent, frequently associated with negative health outcomes, and disproportionately impacts Black Americans. Perceived racial and ethnic discrimination has emerged as a factor that may influence the experience of chronic pain in this population. Identifying modifiable psychosocial factors that influence the link between perceived discrimination and pain and that can be directly targeted in treatment is vital to reducing the disproportionate burden of CMP among Black individuals. The present study examines the moderating role of five risk factors (i.e., pain avoidance, pain fusion, experiential avoidance, pain catastrophizing, and pain anxiety) on the relationship between perceived discrimination and pain outcomes (i.e., pain intensity and interference) in a sample of 401 Black adults with CMP. We recruited 401 Black individuals (Mage = 35.98, 51.9% female) with self-reported CMP and assessed their self-reported perceived discrimination, pain intensity, pain interference, and pain-related psychosocial risk factors. Results indicated that higher scores on each of the psychosocial risk factors (i.e., pain avoidance, pain fusion, experiential avoidance, pain catastrophizing, and pain anxiety) were significantly associated with greater pain intensity and pain interference (all ps < 0.01). Further, pain avoidance (B = 0.12, p = .006), pain fusion (B = 0.13, p = .002), and pain anxiety (B = 0.13, p = .002) each significantly moderated the relation between perceived discrimination and pain intensity. Greater perceived discrimination was associated with greater pain intensity at higher levels of avoidance and fusion, and was associated with less pain intensity at lower levels of avoidance and pain anxiety. In interaction models predicting pain interference, both pain fusion (B = 0.14, p = .001) and pain anxiety (B = 0.10, p = .01) significantly moderated the relation between perceived discrimination and pain interference. Perceived discrimination was associated with greater pain interference at higher levels of pain fusion and pain anxiety, and was not associated with pain interference at lower levels of pain fusion and pain anxiety. The present findings provide important insights into psychosocial risk factors that moderate the link between perceived discrimination and pain outcomes, providing important clinical implications for the treatment of Black adults with chronic musculoskeletal pain.

Depression Negatively Impacts Dyadic Quality of Life Following Neuro-ICU Admission: A Prospective Study of Cognitively Intact Patients and Caregivers.

BACKGROUND: Admission to a neurological intensive care unit (Neuro-ICU) can increase risk for depressive and anxiety symptoms for both patients and caregivers. To better understand the long-term mental health impact of a Neuro-ICU admission, we examined the dyadic interdependence between depression and anxiety at Neuro-ICU admission with 3-month quality of life (QoL) for patients and caregivers in a longitudinal, observational cohort study. METHOD: We assessed depressive and anxiety symptoms (Hospital Anxiety and Depression Scale; HADS) reported by neurologically intact patients (n = 72) and their caregivers (n = 72) within 2 weeks of Neuro-ICU admission (baseline) and 3-months post-discharge (follow-up). We examined the longitudinal association between dyadic depression and anxiety at Neuro-ICU admission and 3-month QoL (World Health Organization; QOL-BREF) across four domains (Physical, Psychological, Social relationships, and Environmental QoL) in separate actor-partner interdependence models (APIM) for patients and caregivers. RESULTS: In the overall models, patients' own baseline depression levels were negatively associated with their own 3-month QoL in all domains (ß = - 0.53 to - 0.64, p < 0.001), and for caregivers, only in the psychological (ß = - 0.73, p < .001) and social relationships (ß = - 0.56, p < .001) domains. No actor effects were found for one's own baseline anxiety impacting one's own 3-month QoL. Partner effects for one's own depression were significant for caregivers on patients' 3-month psychological (ß = - 0.26, p < .02) and environmental (ß = - 0.29, p < .03) QoL, as well as for patients on caregiver's 3-month psychological QoL (ß = 0.25, p < .02). No partner effects were significant in association with baseline anxiety and 3-month QoL in both patients and caregivers. CONCLUSION: Neuro-ICU patients' and caregivers' baseline depression has significant negative impacts on their own long-term QoL. Caregivers demonstrate significant negative impacts on patient long-term QoL in domains related to emotional distress and caregiver burden. Early identification of mental health symptoms, especially depression, during Neuro-ICU admission may provide an intervention opportunity to improve QoL post-discharge for both dyad members.

A Brief Mind-body Intervention Is Feasible and May Prevent Persistent Pain After Acute Orthopaedic Traumas: A Randomized Controlled Trial.

BACKGROUND: Approximately 20% to 50% of patients develop persistent pain after traumatic orthopaedic injuries. Psychosocial factors are an important predictor of persistent pain; however, there are no evidence-based, mind-body interventions to prevent persistent pain for this patient population. QUESTIONS/PURPOSES: (1) Does the Toolkit for Optimal Recovery after Injury (TOR) achieve a priori feasibility benchmarks in a multisite randomized control trial (RCT)? (2) Does TOR demonstrate a preliminary effect in improving pain, as well as physical and emotional function? METHODS: This pilot RCT of TOR versus a minimally enhanced usual care comparison group (MEUC) was conducted among 195 adults with an acute orthopaedic traumatic injury at risk for persistent pain at four geographically diverse Level 1 trauma centers between October 2021 to August 2023. Fifty percent (97 of 195) of participants were randomized to TOR (mean age 43 ± 17 years; 67% [65 of 97] women) and 50% (98) to MEUC (mean age 45 ± 16 years; 67% [66 of 98] women). In TOR, 24% (23 of 97) of patients were lost to follow-up, whereas in the MEUC, 17% (17 of 98) were lost. At 4 weeks, 78% (76 of 97) of patients in TOR and 95% (93 of 98) in the MEUC completed the assessments; by 12 weeks, 76% (74 of 97) of patients in TOR and 83% (81 of 98) in the MEUC completed the assessments (all participants were still included in the analysis consistent with an intention-to-treat approach). The TOR has four weekly video-administered sessions that teach pain coping skills. The MEUC is an educational pamphlet. Both were delivered in addition to usual care. Primary outcomes were feasibility of recruitment (the percentage of patients who met study criteria and enrolled) and data collection, appropriateness of treatment (the percent of participants in TOR who score above the midpoint on the Credibility and Expectancy Scale), acceptability (the percentage of patients in TOR who attend at least three of four sessions), and treatment satisfaction (the percent of participants in TOR who score above the midpoint on the Client Satisfaction Scale). Secondary outcomes included additional feasibility (including collecting data on narcotics and rescue medications and adverse events), fidelity (whether the intervention was delivered as planned) and acceptability metrics (patients and staff), pain (numeric rating scale), physical function (Short Musculoskeletal Function Assessment questionnaire [SMFA], PROMIS), emotional function (PTSD [PTSD Checklist], depression [Center for Epidemiologic Study of Depression]), and intervention targets (pain catastrophizing, pain anxiety, coping, and mindfulness). Assessments occurred at baseline, 4 and 12 weeks. RESULTS: Several outcomes exceeded a priori benchmarks: feasibility of recruitment (89% [210 of 235] of eligible participants consented), appropriateness (TOR: 73% [66 of 90] scored > midpoint on the Credibility and Expectancy Scale), data collection (79% [154 of 195] completed all surveys), satisfaction (TOR: 99% [75 of 76] > midpoint on the Client Satisfaction Scale), and acceptability (TOR: 73% [71 of 97] attended all four sessions). Participation in TOR, compared with the MEUC, was associated with improvement from baseline to postintervention and from baseline to follow-up in physical function (SMFA, baseline to post: -7 [95% CI -11 to -4]; p < 0.001; baseline to follow-up: -6 [95% CI -11 to -1]; p = 0.02), PROMIS (PROMIS-PF, baseline to follow-up: 2 [95% CI 0 to 4]; p = 0.045), pain at rest (baseline to post: -1.2 [95% CI -1.7 to -0.6]; p < 0.001; baseline to follow-up: -1 [95% CI -1.7 to -0.3]; p = 0.003), activity (baseline to post: -0.7 [95% CI -1.3 to -0.1]; p = 0.03; baseline to follow-up: -0.8 [95% CI -1.6 to -0.1]; p = 0.04), depressive symptoms (baseline to post: -6 [95% CI -9 to -3]; p < 0.001; baseline to follow-up: -5 [95% CI -9 to -2]; p < 0.002), and posttraumatic symptoms (baseline to post: -4 [95% CI -7 to 0]; p = 0.03; baseline to follow-up: -5 [95% CI -9 to -1]; p = 0.01). Improvements were generally clinically important and sustained or continued through the 3 months of follow-up (that is, above the minimum clinically important different [MCID] of 7 for the SMFA, the MCID of 3.6 for PROMIS, the MCID of 2 for pain at rest and pain during activity, the MCID of more than 10% change in depressive symptoms, and the MCID of 10 for posttraumatic symptoms). There were treatment-dependent improvements in pain catastrophizing, pain anxiety, coping, and mindfulness. CONCLUSION: TOR was feasible and potentially efficacious in preventing persistent pain among patients with an acute orthopaedic traumatic injury. Using TOR in clinical practice may prevent persistent pain after orthopaedic traumatic injury. LEVEL OF EVIDENCE: Level I, therapeutic study.

"Pushed to Their Limits": Health Care Provider Perspectives on Barriers and Facilitators to Implementing a Mind-Body and Activity Program for Older Adults With Chronic Pain in a Community Clinic for the Underserved.

Older adults from underserved backgrounds experience chronic pain at a rate of 60% to 75%. Pharmacological treatments have limited efficacy and involve considerable risks. Mind-body interventions hold promise to improve pain outcomes but are typically not implemented in community clinics in which they are needed most, thus contributing to health disparities in chronic pain treatment. We conducted qualitative focus groups and interviews with 20 providers (eg, primary care doctors, nurses, administrators). We sought their perspectives on barriers and facilitators to implementing an evidence based mind-body activity program for older adults with chronic pain at an underserved community health clinic in Massachusetts. Subthemes were identified within 2 superordinate domains (barriers and facilitators) using a hybrid inductive-deductive thematic analysis approach following the Framework Method. Providers discussed facilitators (partner with clinic staff to facilitate referrals and buy-in, integrate referrals through the electronic medical record, offer groups in different languages, post and tailor advertisements) and barriers (limited staff bandwidth, scheduling challenges, inconsistent patient participation). These results will directly inform tailoring and subsequent effectiveness testing and implementation of the pain management program for older underserved adults with chronic pain in this community health care setting.

Peer-Delivered Interventions for Caregivers in the ICU with a Focus on Severe Acute Brain Injury: A Scoping Review.

Approximately 50% of family caregivers of patients with severe acute brain injury (SABI) admitted to intensive care units experience clinically significant anxiety, depression, and posttraumatic stress. Peer-delivered interventions may be a sustainable way to provide social connection, emotional support, and evidence-based coping skills for family caregivers of patients with SABI to improve their mental health and well-being. The aim of this scoping review was to examine existing peer-delivered interventions for family caregivers of adult patients with SABI admitted to neurocritical and other critical care units. We set broad inclusion criteria and identified ten examples of peer-delivered interventions for family caregivers of adult patients with critical illness, of which only two were tailored to the needs of caregivers for patients who had experienced SABI. Our results indicated that (1) very few examples of peer-delivered interventions for this population exist, (2) all existing examples are professional-led (e.g., nurse-led) multifamily support groups, and (3) existing interventions demonstrate mixed results. Future research is needed to develop and evaluate peer-delivered interventions, including testing different models of peer-delivered interventions (e.g., one-to-one peer mentorship), programs that provide skills and support to caregivers after discharge, and skills-based formats that are tailored to the unique needs of SABI caregivers.

Thematic Analysis of Psychosocial Stressors and Adaptive Coping Strategies Among Informal Caregivers of Patients Surviving ICU Admission for Coma.

BACKGROUND: Family caregivers of patients with severe acute brain injury (SABI) admitted to intensive care units (ICUs) with coma experience heightened emotional distress stemming from simultaneous stressors. Stress and coping frameworks can inform psychosocial intervention development by elucidating common challenges and ways of navigating such experiences but have yet to be employed with this population. The present study therefore sought to use a stress and coping framework to characterize the stressors and coping behaviors of family caregivers of patients with SABI hospitalized in ICUs and recovering after coma. METHODS: Our qualitative study recruited a convenience sample from 14 US neuroscience ICUs. Participants were family caregivers of patients who were admitted with ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, traumatic brain injury, or hypoxic-ischemic encephalopathy; had experienced a comatose state for > 24 h; and completed or were scheduled for tracheostomy and/or gastrostomy tube placement. Participants were recruited < 7 days after transfer out of the neuroscience ICU. We conducted live online video interviews from May 2021 to January 2022. One semistructured interview per participant was recorded and subsequently transcribed. Recruitment was stopped when thematic saturation was reached. We deductively derived two domains using a stress and coping framework to guide thematic analysis. Within each domain, we inductively derived themes to comprehensively characterize caregivers' experiences. RESULTS: We interviewed 30 caregivers. We identified 18 themes within the two theory-driven domains, including ten themes describing practical, social, and emotional stressors experienced by caregivers and eight themes describing the psychological and behavioral coping strategies that caregivers attempted to enact. Nearly all caregivers described using avoidance or distraction as an initial coping strategy to manage overwhelming emotions. Caregivers also expressed awareness of more adaptive strategies (e.g., cultivation of positive emotions, acceptance, self-education, and soliciting social and medical support) but had challenges employing them because of their heightened emotional distress. CONCLUSIONS: In response to substantial stressors, family caregivers of patients with SABI attempted to enact various psychological and behavioral coping strategies. They described avoidance and distraction as less helpful than other coping strategies but had difficulty engaging in alternative strategies because of their emotional distress. These findings can directly inform the development of additional resources to mitigate the long-term impact of acute psychological distress among this caregiver population.

Positive affect expression during a play interaction and psychological health among older adults living with cognitive impairment and their adult children.

OBJECTIVES: We examined the extent to which positive affect expression in play interactions between adult children and their parents living with cognitive impairment was associated with lower depressive symptoms and mental health difficulties for both dyad members. Gender differences in positive affect expression were also examined. METHOD: Dyads (N = 126) self-reported their depressive symptoms and mental health difficulties. Dyad members later engaged in a video-recorded play interaction together, and their positive affect expression was observationally coded by trained coders in terms of 'enjoyment', 'laughter', and 'positive affect towards partner'. RESULTS: Findings from mixed models using the Actor Partner Interdependence Model showed that one's partner's positive affect was associated with one's own lower depressive symptoms. There were no significant actor effects or effects of role (parent vs. child). Results also revealed that women expressed more positive affect and had greater mental health difficulties, but not depressive symptoms. We found that one's partner's positive affect expressions were more associated with women's mental health than men's mental health. CONCLUSION: Positive affect expression may be a useful indicator of psychological health in parent-child relationships in which the parent has cognitive impairment. Positive affect may be useful to target in supportive, dyadic, psychosocial interventions.

Graded exposure therapy for adults with persistent symptoms after mTBI: A historical comparison study.

Fear avoidance behaviour is associated with slow recovery from mild traumatic brain injury (mTBI). This study is a preliminary evaluation of graded exposure therapy (GET), which directly targets fear avoidance behaviour, for reducing post-concussion symptoms (PCS) and disability following mTBI. In a historical comparison design, we compared two groups from independent randomized trials. The GET + UC group (N = 34) received GET (delivered over 16 videoconference sessions) in addition to usual care (UC). The historical comparison group (N = 71) received UC only. PCS severity (Rivermead Post Concussion Symptoms Questionnaire; RPQ) and disability (World Health Organization Disability Assessment Schedule; WHODAS 2.0 12-item) were measured at clinic intake (M = 2.7, SD = 1.1 months after injury) and again at M = 4.9 (SD = 1.1) months after injury. Between-group differences were estimated using linear mixed effects regression, with a sensitivity analysis controlling for injury-to-assessment intervals. The estimated average change on the RPQ was -14.3 in the GET + UC group and -5.3 in the UC group. The estimated average change on the WHODAS was -5.3 in the GET + UC group and -3.2 in the UC group. Between-group differences post-treatment were -5.3 on the RPQ and -1.5 on the WHODAS. Treatment effects were larger in sensitivity analyses. Findings suggest that a randomized controlled trial is warranted.

Does gender moderate resiliency variables and posttraumatic stress symptoms in informal caregivers of neurocritical care patients? An exploratory study.

We examined gender differences between resiliency factors (i.e. mindfulness, self-efficacy, coping, intimate care, and caregiver preparedness) and posttraumatic stress symptoms (PTSS) in informal caregivers of patients in the neuroscience intensive care unit (Neuro-ICU). Ninety-two informal caregivers were enrolled during patients' hospitalization and completed resiliency measures at baseline, and a PTSS measure at baseline, 3 and 6 months. We conducted five ANCOVAs to explore gender and resiliency on PTSS. No significant main effects of gender on PTSS were observed across time points. However, main effects were seen for resiliency on PTSS at baseline for informal caregivers with high (vs. low) mindfulness, coping, and self-efficacy. Gender moderated the association between mindfulness and PTSS (i.e. high mindfulness at baseline was associated with lower PTSS in males compared to females at 3 months) and intimate care and PTSS (high intimate care at baseline was associated with lower PTSS in males than females at 6 months; high intimate care at baseline for females was associated with lower PTSS at 6 months than females with low intimate care). Overall, we observed associations among informal caregivers' gender, resiliency, and PTSS, with males particularly benefitting from mindfulness and intimate care. These findings hold value for future inquiry into gender differences in this population with possible clinical implications.

Mindfulness, coping, and optimism as mechanisms of change in the 3RP-NF intervention.

INTRODUCTION: Neurofibromatosis (NF) is chronic neurogenetic condition that increases risk for poor quality of life, depression, and anxiety. Given the lack of biomedical treatments, we developed the "Relaxation Response Resiliency for NF" (3RP-NF) program to improve psychosocial outcomes among adults with NF. OBJECTIVE: To move toward effectiveness testing, we must understand mechanisms that explained treatment effects. We tested whether our hypothesized mechanisms of change-mindfulness, coping, and optimism-mediated improvements in quality of life, depression, and anxiety among adults in the 3RP-NF program (N = 114; ages 18-70; 72.80% female; 81.58% White). METHODS: We conducted mixed-effects models to assess whether these mechanisms uniquely mediated outcomes. RESULTS: Improvements in quality of life were most explained by coping, (b = 0.97, SE = 0.28, CI [0.45, 1.56]), followed by mindfulness (b = 0.46, SE = 0.17, CI [0.15, 0.82]) and optimism (b = 0.39, SE = 0.12, CI [0.17, 0.65]). Improvements in depression and anxiety were most explained by mindfulness (b = -1.52, SE = 0.38, CI [-2.32, -0.85], CSIE = -0.26; b = -1.29, SE = 0.35, CI [-2.04, -0.67], CSIE = -0.23), followed by optimism (b = 0.39, SE = 0.12, CI [0.17, 0.65]; b = -0.49, SE = 0.20, CI [-0.91, -0.13]), but were not explained by coping (b = 0.22, SE = 0.43, CI [-0.62, 1.07]; b = 0.06, SE = 0.46, CI [-0.84, 0.97]), respectively. CONCLUSIONS: Targeting mindfulness, coping, and optimism in psychosocial interventions may be a promising way to improve the lives of adults with NF.

Breaking the Disability Spiral: A Case Series Report Illustrating the Delivery of a Brief Skills Based Coaching Intervention to Prevent Chronic Dysfunction and Pain After Orthopedic Injury.

Orthopedic traumas are common, costly, and burdensome - particularly for patients who transition from acute to chronic pain. Psychosocial factors, such as pain catastrophizing and pain anxiety, increase risk for poor outcomes after injury. The Toolkit for Optimal Recovery (TOR) is a novel multi-component mind-body intervention informed by the fear-avoidance model to promote re-engagement in daily activities and prevent transition toward chronic pain and physical dysfunction. The current case series aims to 1) describe the intervention and 2) showcase the treatment course of three TOR completers from diverse geographic locations in the U.S. with distinct injury types and varying personal identities to illustrate how the intervention can be delivered flexibly. Results indicate pre-to-post program improvement in physical function, pain severity, pain catastrophizing, pain anxiety, and other relevant outcomes targeted by the intervention (i.e., depression, mindfulness, coping). Experiences of our three TOR completers suggest that integrating TOR with standard orthopedic care may promote physical recovery after injury.