Post-traumatic stress disorder, drug abuse and migraine: new findings from the National Comorbidity Survey Replication (NCS-R).

BACKGROUND: Post-traumatic stress disorder (PTSD) has been shown to be associated with migraine and drug abuse. METHODS: This was an analysis of data from the National Comorbidity Survey Replication (NCS-R) to evaluate the association of PTSD in those with episodic migraine (EM) and chronic daily headache (CDH). RESULTS: Our sample consisted of 5,692 participants. Lifetime and 12-month prevalence rates of PTSD were increased in those with EM and CDH. After adjustments, the lifetime odds ratio (OR) of PTSD was greater in those with EM (OR 3.07 confidence interval [CI]: 2.12, 4.46) compared to those without headache; was greater in men than women with EM (men: OR 6.86; CI: 3.11, 15.11; women: OR 2.77; CI: 1.83, 4.21); and was comparable or greater than the association between migraine with depression or anxiety. The lifetime OR of PTSD was also increased in CDH sufferers. The OR of illicit drug abuse was not increased in those with EM or CDH unless co-occurring with PTSD or depression. CONCLUSION: The lifetime and 12-month OR of PTSD is increased in those with migraine or CDH, and is greater in men than women with migraine. The lifetime and 12-month OR of illicit drug abuse is not increased in those with migraine or CDH unless co-occurring with PTSD or depression.

Defining racial and ethnic disparities in pain management.

BACKGROUND: Substantial pain prevalence is as high as 40% in community populations. There is consistent evidence that racial/ethnic minority individuals are overrepresented among those who experience such pain and whose pain management is inadequate. QUESTIONS/PURPOSES: The objectives of this paper are to (1) define parameters of and summarize evidence pertinent to racial/ethnic minority disparities in pain management, (2) identify factors contributing to observed disparities, and (3) identify strategies to minimize the disparities. METHODS: Scientific literature was selectively reviewed addressing pain epidemiology, differences in pain management of non-Hispanic whites versus racial/ethnic minority groups, and patient and physician factors contributing to such differences. RESULTS: Racial/ethnic minorities consistently receive less adequate treatment for acute and chronic pain than non-Hispanic whites, even after controlling for age, gender, and pain intensity. Pain intensity underreporting appears to be a major contribution of minority individuals to pain management disparities. The major contribution by physicians to such disparities appears to reflect limited awareness of their own cultural beliefs and stereotypes regarding pain, minority individuals, and use of narcotic analgesics. CONCLUSIONS: Racial/ethnic minority patients with pain need to be empowered to accurately report pain intensity levels, and physicians who treat such patients need to acknowledge their own belief systems regarding pain and develop strategies to overcome unconscious, but potentially harmful, negative stereotyping of minority patients.

Depression and self-rated health are proximal predictors of episodes of sustained change in pain in independently living, community dwelling elders.

OBJECTIVE: To identify, in community dwelling elders, the determinants of sustained pain improvement or worsening. DESIGN: A longitudinal study with two baseline and 11 monthly follow-up interviews was conducted. Pain was assessed monthly using the Parmelee adaptation of the McGill Pain Inventory. SUBJECTS: Subjects included 109 Caucasian and 132 African American, Philadelphia residing Medicare recipients (65-74 years of age). OUTCOME MEASURES: To identify sustained pain change (> or =2 months), the data for each subject were reconfigured to yield 10 overlapping 3-month data segments. Each segment was classified as improved or worsened pain. Other variables included: the Geriatric Depression Scale (GDS), self-rated health (SRH), physical functioning, and number of improved or worsened medical conditions. RESULTS: Pain experienced (over 3-month periods) was typically stable. Sustained improved pain was more likely than worsened pain. Odds ratios obtained through Generalized Estimation Equation analyses showed that a 1-point increase in GDS scores increased the odds of worsened pain by 1.18 (1.11-1.30). Fair/poor SRH, being female, and having medical conditions worsen increased the odds of worsened pain by 4.04 (2.12-7.70), 1.63 (1.11-2.38), and 2.12 (1.42-3.16), respectively. Observed, statistically significant associations between these variables, except gender, and improved pain were in the opposite direction. CONCLUSIONS: With a 1-month time lag between predictor variable assessment and follow-up pain measures, the study supports temporal associations between depressive symptoms and SRH and subsequent pain change. Clinicians providing care to community dwelling elders are advised to evaluate and attend to both the depressive symptoms and SRH of their patients.

Contact tracing for the control of infectious disease epidemics: Chronic Wasting Disease in deer farms.

Contact tracing is a crucial component of the control of many infectious diseases, but is an arduous and time consuming process. Procedures that increase the efficiency of contact tracing increase the chance that effective controls can be implemented sooner and thus reduce the magnitude of the epidemic. We illustrate a procedure using Graph Theory in the context of infectious disease epidemics of farmed animals in which the epidemics are driven mainly by the shipment of animals between farms. Specifically, we created a directed graph of the recorded shipments of deer between deer farms in Pennsylvania over a timeframe and asked how the properties of the graph could be exploited to make contact tracing more efficient should Chronic Wasting Disease (a prion disease of deer) be discovered in one of the farms. We show that the presence of a large strongly connected component in the graph has a significant impact on the number of contacts that can arise.

Total blood mercury levels and depression among adults in the United States: National Health and Nutrition Examination Survey 2005-2008.

BACKGROUND: Mercury is a neurotoxicant linked with psychiatric symptoms at high levels of exposure. However, it is unclear whether an association is present at the low exposure levels in the US adult population. MATERIALS AND METHODS: Cross-sectional associations of total blood mercury and depression were assessed in 6,911 adults age ≥20 in the National Health and Nutrition Examination Survey (NHANES), 2005-2008. The Patient Health Questionnaire-9 was used to assess depression (high likelihood of a depressive spectrum disorder diagnosis; score 5-27). RESULTS: Unadjusted survey weighted logistic regression suggested that higher total blood mercury was associated with lower odds of depression (Odds Ratio  = 0.49, 95% Confidence Interval: 0.36-0.65, comparing the highest and lowest mercury quintiles). This association largely disappeared after adjustment for sociodemographic variables (income-poverty ratio, education, marital status). However, in age-stratified analyses, this inverse relationship remained in older adults (age ≥40) even after adjustment for sociodemographic variables. Simulation analyses adjusting for expected confounding effects of fish intake suggested that the inverse relationship among older adults may be plausibly attributed to residual confounding (Odds Ratio  = 0.75, 95% Confidence Interval: 0.50-1.12, comparing the highest and lowest mercury quintiles). CONCLUSIONS: Higher total blood mercury was not associated with increased odds of depression. The lower odds of depression in older adults with higher total blood mercury may be due to residual confounding.

Preliminary evaluation of the Health Background Questionnaire for Pain and clinical encounter form for pain.

OBJECTIVES: The principal aims of this study were to evaluate the extent to which patients completed, understood, and were satisfied with the Health Background Questionnaire for Pain (HBQ-P), a health and pain history questionnaire that includes a modification of the Medical Outcome Study Short Form-36, the Treatment Outcomes in Pain Survey, and to examine the degree to which the questionnaire produced reliable and valid responses. A secondary aim was to determine the length of time for a physician to complete the Clinician Evaluation Form for Pain (CEF-P), a brief questionnaire designed to obtain key elements resulting from clinical assessment and management decisions. METHODS: This cross-sectional study utilized data from consecutive new patients seen from January to December 2001 in Drexel University College of Medicine's Pain Medicine and Comprehensive Rehabilitation Center at Graduate Hospital in Philadelphia, PA. The HBQ-P and an accompanying brief satisfaction inventory were completed at home by the patient prior to the individual's initial office visit. The CEF-P was completed by the physician after seeing the patient. RESULTS: Ten of 11 comparisons of patient responses to similar questions on the HBQ-P showed significant consistency. Of eight comparisons between the CEF-P and HBQ-P, two pain duration comparisons showed moderate agreement and one depression comparison showed significant association. Patients consistently had difficulty in answering six single questions and two question sets. Overall patient satisfaction was high. The mean time for the physician to complete the CEF-P was 90 seconds. CONCLUSIONS: Analyses indicate patient responses to similar HBQ-P questions have sufficient reliability to support the use of the Health Background Questionnaire for clinically related data collection and for outcome evaluation of treatments for chronic and recurring pain. The consistently missed questions on the HBQ-P should be revised.

The longitudinal occurrence and impact of comorbid chronic pain and chronic depression over two years in continuing care retirement community residents.

OBJECTIVE: To describe the longitudinal course of depressive symptoms and pain experienced by continuing care retirement community (CCRC) residents and to investigate the impact of comorbid chronic activity-limiting pain and chronic high depressive symptoms on physical functioning and health service use. METHODS: This longitudinal study of 169 CCRC residents involved five assessments (baseline and four in-person interviews at 6-month intervals). The Geriatric Depression Scale (GDS), questions drawn from the McGill Pain Questionnaire, and self-report data on physical functioning and health care use were assessed. Individuals reporting activity-limiting pain and those with GDS scores > or =11 at three or more assessments were considered to have chronic pain or chronic depression, respectively. The analysis sample included 169 CCRC residents. Multivariate logistic regression was used to test hypotheses. RESULTS: Pain and depressive symptoms were characterized by longitudinal stability. Of the sample, 37% met the criteria for chronic activity-limiting pain, 21% met the criteria for chronic high depressive symptoms, and 13% were comorbid. Adjusting for age and health conditions, those with chronic activity-limiting pain were five times more likely than those in the lowest pain group to persistently be in the worst two quartiles of physical functioning, as were those with even one GDS score >5. The odds of poor physical functioning were 11.2 times greater in those with comorbid chronic pain and depression. Comparable greater odds were seen in this sample for frequency of medical care visits (adjusted odds ratio AOR]=12.4) and consistently high use of all medical services (AOR=3.5). CONCLUSIONS: Pain and depressive symptoms were both common and appeared remarkably stable over time. Depressive symptoms contributed significantly to the prediction of impairment associated with pain, and identification and treatment of such symptoms, even minor symptoms, could reduce pain-related impairment and health care costs in the elderly.