Frequent Occurrence of Pain and Prescription Opioid Use for Treatment of Pain Among Women with and at Risk for HIV Infection.

Pain is frequent and underreported among HIV+ women. We determined occurrence and severity of pain, and types of pain treatments used among HIV+ and HIV- women. Cross-sectional analyses of pain as measured by the Brief Pain Inventory Short Form, and related pain therapies nested in the Women's Interagency HIV Study (WIHS). Multiple variable linear regression models examined differences by HIV status in pain severity and pain interference in general activity, mood, ability to walk, work, relationships with others, sleep, and enjoyment of life. Among 1393 HIV+ and 587 HIV- participants with median age 47-48 years, there was no statistically significant difference in pain reported within the past week by HIV status (HIV+ 50% vs. 49% HIV-, p = 0.70). Ratings of pain severity and interference were similar between HIV+ and HIV- women, as was receipt of pain medication (58% HIV+ vs. 56% HIV-). Pain medications most frequently used were: NSAIDS (90% HIV+, 96% HIV-), opioids (65% HIV+, 67% HIV-), topical anesthetics (46% HIV+, 56% HIV-), muscle relaxants (23% HIV+, 14% HIV-), and anticonvulsants (23% HIV+, 14% HIV-). Nearly half of predominantly low income, minority women reported pain in the past week, and two-thirds reported opioid use for pain management. The occurrence, severity, and treatment of pain did not differ by HIV status, nor did report of pain interference with mood or function. Additional research is needed to better characterize pain etiology among HIV+ women in the era of potent antiretroviral therapy, and determine the extent to which pain severity and type of medication used for pain treatment impact HIV disease outcomes.

Parental Bonding in Adolescents With and Without Chronic Pain.

Objective: Parental responses influence children's pain; however, the specific role of parental bonding in pediatric pain has not been examined. Depressive symptomology is frequently reported in children with chronic pain (CP) and may play a role in the relationship between parental bonding and pain. This study examined the connections between maternal/paternal bonding (perceived care and control) and symptoms of pain and depression in adolescents with CP and in healthy adolescents. Method: Participants included 116 adolescents (aged 12-17) with CP (n = 55) and without (n = 61). Adolescents completed the Parental Bonding Instrument separately for their mother and father, as well as measures of depression and pain. Results: Significant associations between parental bonding and adolescent pain and depression emerged in the pain group, but not in the healthy group. There were no differences in the impact of maternal versus paternal bonding on adolescent pain and depression. Mediation analyses revealed adolescent depression was a mediator of the relationship between maternal care and adolescent pain, and paternal control and adolescent pain in the group with CP. Conclusions: This study highlights the importance of considering parental bonding and adolescent depression in pediatric CP, suggesting that high paternal control and low maternal care contribute to increased pain in adolescents through heightened adolescent depressive symptoms. The findings emphasize the need for family-based treatment for CP that addresses parent behaviors and adolescent mental health.

Pain Catastrophizing Predicts Menstrual Pain Ratings in Adolescent Girls with Chronic Pain.

OBJECTIVES: The current study aimed to explore relationships among self-reported menstrual pain ratings, acute laboratory pain, pain catastrophizing, and anxiety sensitivity in a sample of girls without pain (No Pain group) and girls with a chronic pain condition (Chronic Pain group). SETTING: A laboratory at an off-campus Medical School office building. SUBJECTS: Eighty-four postmenarchal girls (43 No Pain, 41 Chronic Pain) ages 10-17 participated in the study. METHODS: All participants completed self-report questionnaires assessing menstrual pain, pain catastrophizing, and anxiety sensitivity and completed a cold pressor task. Pain intensity during the task was rated on a 0 (no pain) to 10 (worst pain possible) numeric rating scale. RESULTS: After controlling for age, average menstrual pain ratings (without medication) were significantly correlated with cold pressor pain intensity for the No Pain group only. In the Chronic Pain group, menstrual pain ratings were significantly correlated with pain catastrophizing and anxiety sensitivity. In a multiple linear regression analysis, after controlling for age, only pain catastrophizing emerged as a significant predictor of menstrual pain ratings in the Chronic Pain group. CONCLUSION: Results demonstrate differences in relationships among menstrual pain, acute laboratory pain, and psychological variables in girls with no pain compared with girls with chronic pain. In addition, pain catastrophizing may be a particularly salient factor associated with menstrual pain in girls with chronic pain that warrants further investigation.

Iyengar yoga for adolescents and young adults with irritable bowel syndrome.

OBJECTIVES: Irritable bowel syndrome (IBS) is a chronic, disabling condition that greatly compromises patient functioning. The aim of this study was to assess the impact of a 6-week twice per week Iyengar yoga (IY) program on IBS symptoms in adolescents and young adults (YA) with IBS compared with a usual-care waitlist control group. METHODS: Assessments of symptoms, global improvement, pain, health-related quality of life, psychological distress, functional disability, fatigue, and sleep were collected pre- and posttreatment. Weekly ratings of pain, IBS symptoms, and global improvement were also recorded until 2-month follow-up. A total of 51 participants completed the intervention (yoga = 29; usual-care waitlist = 22). RESULTS: Baseline attrition was 24%. On average, the yoga group attended 75% of classes. Analyses were divided by age group. Relative to controls, adolescents (14-17 years) assigned to yoga reported significantly improved physical functioning, whereas YA (18-26 years) assigned to yoga reported significantly improved IBS symptoms, global improvement, disability, psychological distress, sleep quality, and fatigue. Although abdominal pain intensity was statistically unchanged, 44% of adolescents and 46% of YA reported a minimally clinically significant reduction in pain following yoga, and one-third of YA reported clinically significant levels of global symptom improvement. Analysis of the uncontrolled effects and maintenance of treatment effects for adolescents revealed global improvement immediately post-yoga that was not maintained at follow-up. For YA, global improvement, worst pain, constipation, and nausea were significantly improved postyoga, but only global improvement, worst pain, and nausea maintained at the 2-month follow-up. CONCLUSIONS: The findings suggest that a brief IY intervention is a feasible and safe adjunctive treatment for young people with IBS, leading to benefits in a number of IBS-specific and general functioning domains for YA. The age-specific results suggest that yoga interventions may be most fruitful when developmentally tailored.

Experimental pain responses in children with chronic pain and in healthy children: how do they differ?

BACKGROUND: Extant research comparing laboratory pain responses of children with chronic pain with healthy controls is mixed, with some studies indicating lower pain responsivity for controls and others showing no differences. Few studies have included different pain modalities or assessment protocols. OBJECTIVES: To compare pain responses among 26 children (18 girls) with chronic pain and matched controls (mean age 14.8 years), to laboratory tasks involving thermal heat, pressure and cold pain. Responses to cold pain were assessed using two different protocols: an initial trial of unspecified duration and a second trial of specified duration. METHODS: Four trials of pressure pain and of thermal heat pain stimuli, all of unspecified duration, were administered, as well as the two cold pain trials. Heart rate and blood pressure were assessed at baseline and after completion of the pain tasks. RESULTS: Pain tolerance and pain intensity did not differ between children with chronic pain and controls for the unspecified trials. For the specified cold pressor trial, 92% of children with chronic pain completed the entire trial compared with only 61.5% of controls. Children with chronic pain exhibited a trend toward higher baseline and postsession heart rate and reported more anxiety and depression symptoms compared with control children. CONCLUSIONS: Contextual factors related to the fixed trial may have exerted a greater influence on pain tolerance in children with chronic pain relative to controls. Children with chronic pain demonstrated a tendency toward increased arousal in anticipation of and following pain induction compared with controls.

Yoga for youth in pain: the UCLA pediatric pain program model.

Children, adolescents, and young adults do not typically feature in clinics, studies, and mainstream notions of chronic pain. Yet many young people experience debilitating pain for extended periods of time. Chronic pain in these formative years may be especially important to treat in order for young patients to maintain life tasks and to prevent protracted disability. The Pediatric Pain Program at the University of California, Los Angeles, is a multidisciplinary treatment program designed for young people with chronic pain and their families. We offer both conventional and complementary medicine to treat the whole individual. This article describes the work undertaken in the clinic and our newly developed Yoga for Youth Research Program. The clinical and research programs fill a critical need to provide service to youth with chronic pain and to scientifically study one of the more popular complementary treatments we offer, Iyengar yoga.

A Unified, Transdiagnostic Treatment for Adolescents With Chronic Pain and Comorbid Anxiety and Depression.

Chronic pain disorders represent a significant public health concern, particularly for children and adolescents. High rates of comorbid anxiety and unipolar mood disorders often complicate psychological interventions for chronic pain. Unified treatment approaches, based on emotion regulation skills, are applicable to a broad range of emotional disorders and suggest the possibility of extending these interventions to chronic pain and pain-related dysfunction. This case report describes the use of a unified protocol for treatment of an adolescent boy with chronic daily headache and social anxiety and an adolescent girl with whole body pain and depression. Following weekly, 50-minute individual treatment sessions, the boy demonstrated notable improvement in emotional symptoms, emotion regulation skills, somatization, and functional disability. The girl showed some improvement on measures of anxiety and depression, although there appeared to be a worsening of pain symptoms and somatization. However, both patients demonstrated improvement over follow-up. This case study illustrates the potential utility of a unified treatment approach targeting pain and emotional symptoms from an emotion regulation perspective in an adolescent population.

The impact of group drumming on social-emotional behavior in low-income children.

Low-income youth experience social-emotional problems linked to chronic stress that are exacerbated by lack of access to care. Drumming is a non-verbal, universal activity that builds upon a collectivistic aspect of diverse cultures and does not bear the stigma of therapy. A pretest-post-test non-equivalent control group design was used to assess the effects of 12 weeks of school counselor-led drumming on social-emotional behavior in two fifth-grade intervention classrooms versus two standard education control classrooms. The weekly intervention integrated rhythmic and group counseling activities to build skills, such as emotion management, focus and listening. The Teacher's Report Form was used to assess each of 101 participants (n = 54 experimental, n = 47 control, 90% Latino, 53.5% female, mean age 10.5 years, range 10-12 years). There was 100% retention. ANOVA testing showed that intervention classrooms improved significantly compared to the control group in broad-band scales (total problems (P < .01), internalizing problems (P < .02)), narrow-band syndrome scales (withdrawn/depression (P < .02), attention problems (P < .01), inattention subscale (P < .001)), Diagnostic and Statistical Manual of Mental Disorders-oriented scales (anxiety problems (P < .01), attention deficit/hyperactivity problems (P < .01), inattention subscale (P < .001), oppositional defiant problems (P < .03)), and other scales (post-traumatic stress problems (P < .01), sluggish cognitive tempo (P < .001)). Participation in group drumming led to significant improvements in multiple domains of social-emotional behavior. This sustainable intervention can foster positive youth development and increase student-counselor interaction. These findings underscore the potential value of the arts as a therapeutic tool.

Healthcare utilization for pain in children and adolescents: a prospective study of laboratory and non-laboratory predictors of care-seeking.

BACKGROUND: Few studies have focused on identifying predictors of medical consultation for pain in healthy children and adolescents. OBJECTIVE: This investigation sought to identify parent and child laboratory and non-laboratory predictors of pediatric healthcare utilization for pain problems. STUDY GROUP: Participants were 210 healthy children and adolescents (102 girls), aged 8-17 years who took part in a laboratory pain session. METHODS: Three months after the laboratory session, participants were contacted by telephone to ascertain whether they had experienced pain and whether they had seen a healthcare professional for pain. Zero-order correlations among sociodemographic status, child laboratory pain responses, parent physical/mental health status and medical consultation for pain were conducted to identify relevant correlates of pediatric healthcare utilization; these correlates were subjected to multivariate analyses. RESULTS: Bivariate analyses indicated that higher anticipated pain and bother for the cold pressor task, as well as poorer parent physical health status, were associated with pediatric medical consultation for pain, but only among girls. Sequential logistic regression analyses controlling for child age indicated that only parent physical health status, not the laboratory indicators, significantly predicted healthcare consultation for pain among girls. No parent or child correlates of care-seeking for pain emerged for boys. CONCLUSION: The findings suggest that parents' perceived physical health plays a role in determining whether medical care is sought for pain complaints in healthy girls. These results suggest that interventions to assist parents in managing their own physical health problems could lead to reductions in medical consultation for girls' pain.

Sex differences in pain and misuse of prescription analgesics among persons with HIV.

OBJECTIVE: Women represent the largest percentage of new HIV infections globally. Yet, no large-scale studies have examined the experience of pain and its treatment in women living with HIV. DESIGN: This study used structural equation modeling to examine sex differences in pain and the use and misuse of prescription analgesics in a representative sample of HIV+ persons in the United Stated within a prospective, longitudinal design. OUTCOME MEASURES: Bodily pain subscale of the Short-Form 36 and Modified Short Form of the World Health Organization's Composite International Diagnostic Interview (opioid misuse). RESULTS: Women reported more pain than men over a roughly 6-month period regardless of mode of HIV transmission or prior drug use history. Men acknowledged more misuse of prescription analgesics over an approximate 1-year period compared with women, after taking into account pain, use of analgesics specifically for pain, and drug use history. Weaker associations between pain and use of analgesics specifically for pain that persisted over time were found among women compared with men. For both men and women, pain was stable over time. Problem drug use history exerted significant direct and indirect effects on pain, opioid misuse, and pain-specific analgesic use across sex. CONCLUSION: The current findings are consistent with prior evidence indicating female pain predominance as well as the undertreatment of pain among women with HIV. Efforts should be made to improve the assessment and long-term management of pain in HIV+ persons.

"I can't be what I want to be": children's narratives of chronic pain experiences and treatment outcomes.

BACKGROUND: Chronic or recurrent nonmalignant pain is a significant problem for many children and adolescents and often limits the child's participation in normal physical, academic, and social activities. OBJECTIVE: To better understand the impact of chronic or recurrent pain on children within the context of their own lives and experiences, using qualitative analysis, and to suggest the applications of the narrative method to clinical practice. DESIGN: Grounded theory and narrative analysis of in-depth semi-structured interviews conducted at baseline and 6-12 months following clinic intake. SETTING: Subject homes. PATIENTS: Fifty-three children ages 10-17 presenting with recurrent pain to a university-based pain clinic. This sample did not differ significantly from the overall clinic population during the study period. RESULTS: Five common themes were identified; these suggested that isolation, changed self-perception, activity limitations, concerns about barriers to future goals, and lack of medical validation were important to the children's perceived impact of pain on their lives. Five narratives were identified, each of which provided a coherent, integrated description of the factors and perspectives presented by a specific subset of children at baseline. These narratives were then compared against the children's reports of improvement in pain and functioning at 6-12 months; from this comparison, a sixth narrative of therapeutic change emerged for some of the children. CONCLUSIONS: The authors suggest that physicians and parents who take the initiative to elicit the child's narrative can help the child to rewrite the story to promote therapeutic change, a better outcome, and higher satisfaction.

Psychosocial outcomes and health-related quality of life in adult childhood cancer survivors: a report from the childhood cancer survivor study.

PURPOSE: Psychological outcomes, health-related quality of life (HRQOL), and life satisfaction are compared between 7,147 adult childhood cancer survivors and 388 siblings from the Childhood Cancer Survivor Study, examining demographic and diagnosis/treatment outcome predictors. METHODS: Psychological distress, HRQOL, and life satisfaction were measured by the Brief Symptom Inventory-18, the Medical Outcomes Survey Short Form-36, and Cantril Ladder of Life, respectively. A self-report questionnaire provided demographic/health information and medical record abstraction provided cancer/treatment data. Siblings' and survivors' scores were compared using generalized linear mixed models, and predictor effects of demographic and cancer/treatment variables were analyzed by multivariate logistic regression. RESULTS: Although survivors report greater symptoms of global distress (mean, 49.17; SE, 0.12) than do siblings (mean, 46.64; SE, 0.51), scores remain below population norms, indicating that survivors and siblings remain psychologically healthy. Survivors scored worse than siblings on overall physical (51.30 +/- 0.10 versus 54.98 +/- 0.44; P < 0.001) but not emotional aspects of HRQOL, but effect sizes were small, other than in vitality. Most survivors reported present (mean, 7.3; SD, 0.02) and predicted future (mean, 8.6; SD, 0.02) life satisfaction. Risk factors for psychological distress and poor HRQOL were female gender, lower educational attainment, unmarried status, annual household income <$20,000, unemployment, lack of medical insurance, having a major medical condition, and treatment with cranial radiation. CONCLUSION: Compared with population norms, childhood cancer survivors and siblings report positive psychological health, good HRQOL, and life satisfaction. The findings identify targeted subgroups of survivors for intervention.

Complementary and alternative medicine for acute procedural pain in children.

Pain may cause physical and emotional distress in children experiencing medical procedures. Complementary and alternative medical (CAM) therapies have become increasingly important in treating children's painful conditions, yet it is still unclear whether CAM has a place in acute pediatric pain analgesia. This review aims to present an overview of the available published evidence. Most research has examined the efficacy of hypnosis, which has emerged as useful in alleviating acute pain associated with a number of medical procedures. Music therapy also has gained some attention and for the most part shows promise in the pediatric acute pain setting. Acupuncture, laughter therapy, and massage also may prove beneficial. Despite the promise of many of these modalities, we conclude that further empirical research into safety and efficacy using well-designed studies and large samples is required before guidelines can be established. In addition, further work is needed in standardizing interventions, creating treatment manuals, and determining treatment efficacy as a function of the child's development, his or her individual characteristics, and the type of procedure the child is undergoing.

Efficacy of acupuncture for health conditions in children: a review.

Acupuncture has been used to treat a variety of childhood problems; however, the efficacy and safety of pediatric acupuncture remains unclear. This article reviews the existing empirical literature relating to the use of acupuncture for medical conditions in children. A systematic search of the literature revealed that acupuncture has been used to treat five main conditions in children, including pain, nocturnal enuresis, postoperative nausea/vomiting, laryngospasm/stridor, and neurological disorders. Despite a number of methodological issues, including limited sample sizes, lack of randomization, and inappropriate control groups, it is concluded that acupuncture represents a promising intervention for a variety of pediatric health conditions. To further address the safety, effectiveness, and acceptability of acupuncture in children, large-scale randomized controlled trials are needed.

Anxiety sensitivity and health-related quality of life in children with chronic pain.

UNLABELLED: Anxiety sensitivity (AS), or the fear of anxiety sensations, has been shown to independently predict poorer health-related quality of life (HRQOL) in adults with chronic pain. Specifically, AS was found to contribute to decrements in psychological well-being and social functioning but not to decrements in physical functioning. Existing studies have not examined the relationship between AS and HRQOL in children with chronic pain. The present study used multivariate regression analysis to test the association between AS and self-reported HRQOL in 87 children (62 girls; mean age = 14.4 years +/-2.3) presenting for treatment at a tertiary, multidisciplinary clinic specializing in pediatric chronic pain. After controlling for key sociodemographic and pain-related characteristics, higher AS was associated with poorer perceived general and mental health, greater impairment in family activities, lower self-esteem, increased behavior problems, and more social/academic limitations due to emotional problems. AS accounted for 4% to 28% of incremental variance in these HRQOL domains above and beyond the demographic and pain-related variables. However, AS was not significantly associated with physical functioning or with academic/social limitations due to physical health. Additional research is required to delineate possible mechanisms by which AS may influence certain aspects of children's HRQOL but not others. PERSPECTIVE: The present findings support the evaluation of AS in pediatric chronic pain patients as part of a comprehensive assessment battery. The links between AS and multiple HRQOL domains suggest that treatment components aimed at reducing AS may lead to enhanced psychosocial well-being in children with chronic pain.

Coping predictors of children's laboratory-induced pain tolerance, intensity, and unpleasantness.

UNLABELLED: This study examined coping predictors of laboratory-induced pain tolerance, intensity, and unpleasantness among 244 healthy children and adolescents (50.8% female; mean age, 12.73 +/- 2.98 years; range, 8-18 years). Participants were exposed to separate 4-trial blocks of pressure and thermal (heat) pain stimuli, as well as 1 trial of cold pain stimuli. Strategies for coping with pain were measured using the Pain Coping Questionnaire (PCQ). Linear regression analyses were conducted to examine the associations between the 8 PCQ subscales and pain responses (pain tolerance, intensity, and unpleasantness) to all 3 pain tasks, controlling for age and sex. We found that internalizing/catastrophizing predicted higher pain intensity across the 3 pain tasks and higher cold pain unpleasantness; seeking emotional support predicted lower pressure pain tolerance; positive self-statements predicted lower pressure pain intensity and lower cold pain intensity and unpleasantness; and behavioral distraction predicted higher pressure pain tolerance and lower heat pain unpleasantness. These results suggest that in healthy children, internalizing/catastrophizing, and seeking emotional support may be conceptualized as pain-prone coping strategies, and positive self-statements and behavioral distraction as pain-resistant coping strategies within the context of laboratory pain. PERSPECTIVE: These results support investigation of interventions with children that aim to reduce acute pain responses by modifying coping to reduce seeking of emotional support and catastrophizing and enhance the use of positive self statements and behavioral distraction.

Sleep Quality, Affect, Pain, and Disability in Children With Chronic Pain: Is Affect a Mediator or Moderator?

Sleep problems have been identified as a potential antecedent of chronic pain and pain-related disability in pediatric populations. In adult studies, affect has been implicated in these relationships. This study sought to better understand the relationships between sleep quality, negative and positive affect, and pain and functioning in children with chronic pain. Participants included 213 children and adolescents (aged 7-17 years) presenting to a tertiary pain clinic with chronic pain. Children completed questionnaires measuring sleep quality, positive and negative affect, pain intensity, and functional disability. Results indicated that 74% of children reported disordered sleeping and that poor sleep quality was significantly associated with increased pain, disability, negative affect, and decreased positive affect. Our hypotheses were partially supported, with negative affect (but not positive affect) mediating the relationship between poor sleep and increased pain; and positive as well as negative affect mediating the relationship between poor sleep and increased functional disability. There was no evidence for affect as a moderator. This study adds to the growing literature demonstrating the effect of poor sleep quality on children's pain and functioning, highlighting the need to develop further longitudinal research to confirm the causal roles of these variables. PERSPECTIVE: This article examines the relationship between poor sleep quality, affect (negative as well as positive), pain, and disability in children with chronic pain. The findings have the potential to better understand the processes involved in how poor sleep may lead to increased pain and pain-related disability.

Parent and child anxiety sensitivity: relationship to children's experimental pain responsivity.

UNLABELLED: Anxiety sensitivity (AS) or fear of anxiety sensations has been linked to childhood learning history for somatic symptoms, suggesting that parental AS may impact children's responses to pain. Using structural equation modeling, we tested a conceptual model in which parent AS predicted child AS, which in turn predicted a hypothesized latent construct consisting of children's pain intensity ratings for 3 laboratory pain tasks (cold pressor, thermal heat, and pressure). This conceptual model was tested in 211 nonclinical parent-child pairs (104 girls, 107 boys; mean age 12.4 years; 178 mothers, 33 fathers). Our model was supported in girls only, indicating that the sex of the child moderated the hypothesized relationships. Thus, parent AS was related to child laboratory pain intensity via its contribution to child AS in girls but not in boys. In girls, 42% of the effect of parent AS on laboratory pain intensity was explained via child AS. In boys, there was no clear link between parent AS and child AS, although child AS was predictive of experimental pain intensity across sex. Our results are consistent with the notion that parent AS may operate via healthy girls' own fear of anxiety symptoms to influence their responses to laboratory pain stimuli. PERSPECTIVE: The present study highlights sex differences in the links among parent and child anxiety sensitivity (fear of anxiety sensations) and children's experimental pain responses. Among girls, childhood learning history related to somatic symptoms may be a particularly salient factor in the development of anxiety sensitivity and pain responsivity.

Sex, gender, and age: contributions to laboratory pain responding in children and adolescents.

UNLABELLED: A cross-sectional design across late childhood and adolescence examined the influence of sex, gender socialization, and age on responses to controlled laboratory pain tasks. Healthy children and adolescents (n = 240, 50% female, age 8 to 18 years) completed the Child Sex Role Inventory, a self-report measure of identification with stereotypically masculine and feminine personality traits, as an index of gender socialization and participated in pressure, cold pressor, and heat pain tasks. Pain tolerance, pain intensity, and bothersomeness of each pain task were assessed. Masculinity correlated with lower heat pain ratings in boys but not girls. Logistic regression indicated cold pain intensity ratings were predicted by sex, gender score, and the age-by-gender score interaction. Heat pain intensity was predicted by age, gender score, age-by-gender score interaction, and sex-by-gender score. PERSPECTIVE: The current findings support closer examination of the influence of gender socialization on young people's pain responses and highlight the importance of a multifactorial, developmental approach to studying the impact of gender socialization on the emergence of sex differences in pain responses after puberty.

Posttraumatic stress disorder in rural primary care: improving care for mental health following bioterrorism.

CONTEXT: Recent bioterrorism attacks have highlighted the critical need for health care organizations to prepare for future threats. Yet, relatively little attention has been paid to the mental health needs of rural communities in the wake of such events. A critical aspect of bioterrorism is emphasis on generating fear and uncertainty, thereby contributing to increased needs for mental health care, particularly for posttraumatic stress disorder, which has been estimated to occur in 28% of terrorism survivors. PURPOSE: Prior experience with natural disasters suggests that first responders typically focus on immediate medical trauma or injury, leaving rural communities to struggle with the burden of unmet mental health needs both in the immediate aftermath and over the longer term. The purpose of the present article is to draw attention to the greater need to educate rural primary care providers who will be the frontline providers of mental health services following bioterrorism, given the limited availability of tertiary mental health care in rural communities. METHODS: We reviewed the literature related to bioterrorism events and mental health with an emphasis on rural communities. FINDINGS AND CONCLUSIONS: Public health agencies should work with rural primary care providers and mental health professionals to develop educational interventions focused on posttraumatic stress disorder and other mental disorders, as well as algorithms for assessment, referral, and treatment of post-event psychological disorders and somatic complaints to ensure the availability, continuity, and delivery of quality mental health care for rural residents following bioterrorism and other public health emergencies.