Identifying patterns of pain, depression, anxiety, interpersonal trauma exposure, and nonmedical prescription opioid use: Latent class analysis among patients with chronic pain.

BACKGROUND: Chronic pain in the context of certain factors may be associated with potential for nonmedical prescription opioid use; however, identifying this risk can be challenging and complex. Several variables alone have been associated with non-prescribed opioid use, including depression, anxiety, pain interference, and trauma exposure. Prior research has often failed to integrate these assessments together, which is important as these factors may cluster together in important and complex ways. The current study aimed to identify classes of patients with chronic pain who have differential risk for use of nonmedical prescription opioid use, depression and anxiety, and pain severity, interference, and catastrophizing, and interpersonal violence exposure. METHODS: Self-report and medical record data from patients (N = 211; Mage = 48, 69.0% women, 69.0% white) at a pain management center were collected. RESULTS: Latent class analysis revealed 3 classes with (1) low probability of clinically significant depression, anxiety, pain, and nonmedical prescription opioid use (44.7%), (2) high probability of clinically significant depression, anxiety, pain, pain catastrophizing, trauma, and nonmedical prescription opioid use (41.3%), and (3) high probability of severe pain and nonmedical prescription opioid use (14.0%). CONCLUSIONS: High-risk classes had either high levels of depression and anxiety, pain catastrophizing, and interpersonal violence exposure, or pain severity and interference. Future research should continue to explore these classes in large, diverse samples, and prospective study designs. Finally, results underscore that opioid use is complex, not easily identified by a single factor, and may be motivated by complex unmet clinical needs.

Exploring the Impact of Book Club Participation on Clinicians' Empathy and Reflection on Empathetic Practice: A Wake-Up Call.

INTRODUCTION:  Empathy is associated with desirable outcomes in healthcare, including improved patient-clinician rapport, fewer patient complications, and reduced clinician burnout. Despite these benefits, research suggests empathy declines during professional training. This study aimed to explore the impact of book club participation on clinicians' and trainees' empathy and perspectives on empathetic patient care. METHODS:  In this mixed-methods study, anesthesiology clinicians and trainees were invited to respond to a baseline online empathy survey followed by an invitation to read a book and to participate in one of four facilitated book club sessions. Post-intervention empathy was measured. The primary outcome of the quantitative analysis was a change in empathy scores as measured by the Toronto Empathy Questionnaire. A thematic analysis of book club sessions and open-ended comments in the post-intervention survey was conducted. RESULTS:  Participants included 74 responders to the baseline survey and 73 responders to the post-intervention survey. Empathy score change in the book club participants was not statistically significant from those who did not participate in any book club sessions (F(2, 39) = 0.42, p=0.66). Thematic analysis of the book club sessions revealed four themes that highlight how the book club enhanced empathy awareness among trainees and clinicians: 1) a wake-up call, 2) deciding whether to take action, 3) learning and nurturing empathy, and 4) changing the culture. CONCLUSION:  There were no significant changes in empathy scores associated with book club participation. Thematic analysis highlighted barriers toward empathetic patient care, areas for improvement, and voiced intentions to practice with heightened empathy. Book clubs may be a viable venue to nurture a culture of increased self-awareness and motivation to counteract loss of empathy, but just one experience may not be sufficient.

Impacts of Cognitive Behavioral Therapy for Insomnia and Pain on Sleep in Women with Gynecologic Malignancies: A Randomized Controlled Trial.

Insomnia is an adverse cancer outcome impacting mood, pain, quality of life, and mortality in cancer patients. Cognitive Behavioral Therapy (CBT) is an evidence-based treatment for diverse psychophysiological disorders, including pain and insomnia. Primarily studied in breast cancer, there is limited research on CBT within gynecology oncology. This study examined CBT effects on subjective and behavioral sleep outcomes: Sleep Efficiency (SE), Sleep Quality (SQ), Total Wake Time (TWT), Sleep Onset Latency (SOL), and Wake After Sleep Onset (WASO). Thirty-five women with insomnia status/post-surgery for gynecologic cancer were randomized to CBT for insomnia and pain (CBTi.p., N = 18) or Psychoeducation (N = 17). Sleep was assessed via sleep diaries and wrist-worn actigraphy at baseline (T1), post-intervention (T2), and two-month follow-up (T3). Intent-to-treat analyses utilizing mixed linear modeling examined longitudinal group differences on sleep controlling for age and advanced cancer. All participants demonstrated improved (1) subjective SE (0.5, p < .01), SOL (-1.2, p < .01), TWT (-1.2, p < .01), and (2) behavioral SE (0.1, p = .02), TWT (-1.2, p = .03), WASO (-0.8, p < .01) across time. Group-level time trends were indicative of higher subjective SE (6.8, p = .02), lower TWT (-40.3, p = .01), and lower SOL (-13.0, p = .05) in CBTi.p. compared to Psychoeducation. Supplemental analyses examining clinical significance and acute treatment effects demonstrated clinical improvements in SE (T1), TWT (T2, T3), and SOL (T3). Remaining effects were not significant. Despite lacking power to detect interaction effects, CBTi.p. clinically improved sleep in women with gynecologic cancers and insomnia during the active treatment phase. Future research will focus on developing larger trials within underserved populations.

Associations Among Sleep Latency, Subjective Pain, and Thermal Pain Sensitivity in Gynecologic Cancer.

OBJECTIVE: Pain is common among women with gynecologic cancer and contributes to depressed mood, sleep disturbances, and likelihood of future chronic pain. Little is known about how psychosocial factors are associated with central sensitization of pain in gynecologic cancer. This study examined relations among depressive symptoms, sleep, subjective pain, and aftersensation pain (a proxy for central sensitization of pain) in gynecologic cancer. METHODS: Participants were 42 women (mean age [SD] = 59.60 [10.11] years) enrolled in a randomized clinical trial examining psychological intervention effects on sleep, pain, mood, and stress hormones/cytokines in gynecologic cancer. Six to eight weeks after surgery, participants completed an assessment of depressive symptoms, sleep, and subjective pain and a temporal summation of pain protocol via quantitative sensory testing (QST). RESULTS: Controlling for recent chemotherapy, history of chronic pain, and analgesic medication use, regression analyses revealed that longer sleep onset latency (SOL; B = 3.112, P = 0.039, bias-corrected and accelerated (BCa) 95% confidence interval [CI] = 0.371 to 6.014) and greater sensory pain (B = 0.695, P = 0.023, BCa 95% CI = 0.085 to 1.210) were associated with greater aftersensation pain at 15 seconds. Greater sensory pain scores were associated with greater aftersensation pain at 30 seconds (B = 0.286, P = 0.045, BCa 95% CI = 0.008 to 0.513). Depression was not associated with aftersensation pain. The overall models accounted for 44.5% and 40.4% of the variance in aftersensation pain at 15 and 30 seconds, respectively. Conclusions. Longer SOL and higher subjective sensory pain were related to greater aftersensation of experimentally induced pain in women postsurgery for gynecologic cancers. Interventions that improve sleep and subjective sensory pain during the perisurgical period may reduce risk for central sensitization of pain.

Predictors of Admission After the Implementation of an Enhanced Recovery After Surgery Pathway for Minimally Invasive Gynecologic Surgery.

BACKGROUND: Enhanced recovery after surgery (ERAS) pathways in gynecologic surgery have been shown to decrease length of stay with no impact on readmission, but no study has assessed predictors of admission in this population. The purpose of this study was to identify predictors of admission after laparoscopic hysterectomy (LH) and robotic-assisted hysterectomy (RAH) performed under an ERAS pathway. METHODS: This is a prospective observational study of women undergoing LH/RAH for benign indications within an ERAS pathway. Data collected included same-day discharge, reason for admission, incidences of urgent clinic and emergency room (ER) visits, readmissions, reoperations, and 9 postulated predictors of admission listed below. Patient demographics, markers of baseline health, and clinical outcomes were compared between groups (ERAS patients discharged on the day of surgery versus admitted) using Fisher exact and Student t tests. Multivariable logistic regression was used to assess the potential risk factors for being admitted, adjusting for age, race, body mass index, American Society of Anesthesiologists (ASA) physical status score, preoperative diagnosis indicative of hysterectomy, preoperative chronic pain, completion of a preprocedure pain-coping skills counseling session, procedure time, and compliance to the ERAS pathway. RESULTS: There were 165 patients undergoing LH/RAH within an ERAS pathway; 93 (56%) were discharged on the day of surgery and 72 were admitted. There were no significant differences in ER visits, readmissions, and reoperations between groups (ER visits: discharged 13% versus admitted 13%, P = .99; 90-day readmission: discharged 4% versus admitted 7%, P = .51; and 90-day reoperation: discharged 4% versus admitted 3%, P = .70). The most common reasons for admission were postoperative urinary retention (n = 21, 30%), inadequate pain control (n = 21, 30%), postoperative nausea and vomiting (n = 7, 10%), and planned admissions (n = 7, 10%). Increased ASA physical status, being African American, and increased length of procedure were significantly associated with an increased risk of admission (ASA physical status III versus ASA physical status I or II: odds ratio [OR], 3.12; 95% confidence interval [CI], 1.36-7.16; P = .007; African American: OR, 2.47; 95% CI, 1.02-5.96; P = .04; and length of procedure, assessed in 30-minute increments: OR, 1.23; 95% CI, 1.02-1.50; P = .04). CONCLUSIONS: We were able to define predictors of admission for patients having LH/RAH managed with an ERAS pathway. Increased ASA physical status, being African American, and increased length of procedure were significantly associated with admission after LH/RAH performed under an ERAS pathway. In addition, the incidences of urgent clinic and ER visits, readmissions, and reoperations within 90 days of surgery were similar for patients who were discharged on the day of surgery compared to those admitted.

Interleukin-6 and body mass index, tobacco use, and sleep in gynecologic cancers.

OBJECTIVE: Elevated body mass index (BMI), tobacco use, and sleep disturbance are common health concerns among women with gynecologic cancers. The extent to which these factors are associated with systemic inflammation in gynecologic cancers is unknown. This is a significant literature gap given that (a) chronic, systemic inflammation may mediate relationships between behavioral health factors and cancer outcomes; and (b) elevated BMI, tobacco use, and sleep disturbances can be modified via behavioral interventions. This study examined Interleukin-6 (IL-6) relations with BMI, tobacco use history, and sleep disturbances in patients undergoing surgery for suspected gynecologic cancer. METHOD: Participants were 100 women (M age = 58.42 years, SD = 10.62 years) undergoing surgery for suspected gynecologic cancer. Smoking history was determined by participant self-report. Sleep quality/disturbance was assessed via the Pittsburgh Sleep Quality Index. BMI was abstracted from electronic health records. Presurgical serum IL-6 concentrations were determined using Enzyme-Linked Immunosorbent Assay. RESULTS: Controlling for the cancer type and stage, regression analyses revealed higher BMI, ß = 0.258, p = .007, and former/current smoking status, ß = 0.181, p = .046, were associated with higher IL-6. IL-6 did not differ between former and current smokers, ß = 0.008, p = .927. Global sleep quality, sleep latency, and sleep efficiency were not associated with IL-6. CONCLUSIONS: Higher BMI and any history of tobacco use predicted higher IL-6 among women undergoing surgery for suspected gynecologic cancers. Cognitive-behavioral interventions targeting primary and secondary obesity and tobacco use prevention may reduce systemic inflammation and optimize cancer outcomes in this population. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Cancer-related PTSD symptoms in a veteran sample: association with age, combat PTSD, and quality of life.

OBJECTIVE: The diagnosis and treatment of cancer is a potentially traumatic experience that may evoke posttraumatic stress symptoms (PTSS) among survivors. This paper describes the rates of endorsement of cancer-related PTSS along with the relationship of demographic, cancer, and combat variables on PTSS and quality of life. METHODS: Veterans (N = 166) with head and neck, esophageal, gastric, or colorectal cancers were recruited through tumor registries at two regional Veterans Administration Medical Centers. Standardized scales were used to assess self-report of PTSS, combat, and quality of life. RESULTS: Most participants (86%) reported experiencing at least some cancer-related PTSS; 10% scored above a clinical cutoff for probable PTSD. In linear regressions, younger age and current combat PTSS were associated with cancer-related PTSS, whereas disease and treatment characteristics were not; in turn, cancer-related PTSS were negatively associated with physical and social quality of life. CONCLUSIONS: Individual characteristics and psychosocial factors may play a larger role than disease-related variables in determining how an individual responds to the stress of cancer diagnosis and treatment. Given the rates of reported cancer-related PTSS in this sample, and other non-veteran samples, clinicians should consider screening these following diagnosis and treatment, particularly in younger adults and those with previous trauma histories.

Depressive symptoms and cortisol variability prior to surgery for suspected endometrial cancer.

Endometrial cancer (EC) is the most common type of gynecologic cancer affecting women; however, very little research has examined relationships between psychological factors and hypothalamic-pituitary-adrenal (HPA) axis dysregulation in this population. The current study examined relations between depressive/anxious symptoms and salivary cortisol diurnal rhythm and variability in women undergoing surgery for suspected endometrial cancer. Depressive and anxious symptoms were measured prior to surgery using the Structured Interview Guide for the Hamilton Depression Inventory (SIGH-AD). Saliva was collected four times a day for the 3 days prior to surgery and then assayed by ELISA to obtain cortisol concentrations. Cortisol slopes and intraindividual variability were then calculated across subjects. Relations between depressive/anxious symptoms and cortisol indices were examined using multilevel modeling and linear regression analyses. Participants were 82 women with nonmetastatic endometrial cancer. Anxious symptoms were not associated with either cortisol slope or intraindividual variability, and depressive symptoms were unrelated to cortisol slope. However, after controlling for presence of poorer prognosis cancer subtypes, greater depressive symptoms (excluding symptoms possibly/definitely due to health/treatment factors) in the week preceding surgery were significantly related to greater cortisol intraindividual variability (ß=.214; p<.05). These results suggest that depressive symptoms prior to surgery for suspected endometrial cancer are related to greater cortisol intraindividual variability, which is suggestive of more erratic HPA axis arousal. Future research should examine whether mood symptoms may be associated with compromised health outcomes via erratic HPA axis arousal in this population.

Spiritual absence and 1-year mortality after hematopoietic stem cell transplant.

Religiosity and spirituality have been associated with better survival in large epidemiologic studies. This study examined the relationship between spiritual absence and 1-year all-cause mortality in allogeneic hematopoietic stem cell transplant (HSCT) recipients. Depression and problematic compliance were examined as possible mediators of a significant spiritual absence-mortality relationship. Eighty-five adults (mean = 46.85 years old, SD = 11.90 years) undergoing evaluation for allogeneic HSCT had routine psychologie evaluation prior to HSCT admission. The Millon Behavioral Medicine Diagnostic was used to assess spiritual absence, depression, and problematic compliance, the psychosocial predictors of interest. Patient status at 1 year and survival time in days were abstracted from medical records. Cox regression analysis was used to examine the relationship between the psychosocial factors of interest and mortality after adjusting for relevant biobehavioral factors. Twenty-nine percent (n = 25) of participants died within 1 year of HSCT. After covarying for disease type, individuals with the highest spiritual absence and problematic compliance scores were significantly more likely to die 1-year post-HSCT (hazard ratio [HR] = 2.49, P = .043 and HR = 3.74, P = .029, respectively), particularly secondary to infection, sepsis, or graft-versus-host disease (GVHD) (HR = 4.56, P = .01 and HR = 5.61, P = .014), relative to those without elevations on these scales. Depression was not associated with 1-year mortality, and problematic compliance did not mediate the relationship between spiritual absence and mortality. These preliminary results suggest that both spiritual absence and problematic compliance may be associated with poorer survival following HSCT. Future research should examine these relations in a larger sample using a more comprehensive assessment of spirituality.

Understanding prognostic benefits of exercise and antidepressant therapy for persons with depression and heart disease: the UPBEAT study--rationale, design, and methodological issues.

BACKGROUND: Depression is relatively common in patients with coronary heart disease (CHD) and is associated with worse prognosis. Recently there has been interest in evaluating the impact of treating depression on clinical outcomes. Anti-depressant medications have been shown to be safe and efficacious for many patients; exercise also may be effective for treating depression and may also improve cardiopulmonary functioning. However, methodological limitations of previous studies have raised questions about the value of exercise, and no study has compared the effects of exercise with standard anti-depressant medication in depressed cardiac patients. PURPOSE: UPBEAT is a randomized clinical trial (RCT) funded by NHLBI to evaluate the effects of sertraline or exercise compared to placebo on depression and biomarkers of cardiovascular risk in patients with CHD and elevated depressive symptoms. METHODS: The UPBEAT study includes 200 stable CHD patients with scores on the Beck Depression Inventory (BDI) > or =9 randomized to 4 months of treatment with aerobic exercise, sertraline, or placebo. The primary outcomes include depressive symptoms determined by clinical ratings on the Hamilton Rating Scale for Depression (HAM-D) and measures of heart rate variability (HRV), baroreflex control (BRC), vascular function (i.e., flow-mediated dilation (FMD)), and measures of inflammation and platelet aggregation. RESULTS: This article reviews the rationale and design of UPBEAT and addresses several key methodologic issues that were carefully considered in the development of this protocol: the use of a placebo control condition in depressed cardiac patients, study design, and selection of intermediate endpoints or biomarkers of cardiovascular risk. LIMITATIONS: This study is not powered to assess treatment group differences in CHD morbidity and mortality. Intermediate endpoints are not equivalent to 'hard' clinical events and further studies are needed to determine the clinical significance of these biomarkers. CONCLUSIONS: The UPBEAT study is designed to assess the efficacy of exercise in treating depression in cardiac patients and evaluates the impact of treating depression on important biomarkers of cardiovascular risk.