Efficacy of a transdiagnostic, prevention-focused program for at-risk young adults: a waitlist-controlled trial.

BACKGROUND: Prevention programs that are 'transdiagnostic' may be more cost-effective and beneficial, in terms of reducing levels of psychopathology in the general population, than those focused on a specific disorder. This randomized controlled study evaluated the efficacy of one such intervention program called Resilience Training (RT). METHODS: College students who reported mildly elevated depressive or subclinical psychotic symptoms ('psychotic experiences' (PEs)) (n = 107) were randomized to receiving RT (n = 54) or to a waitlist control condition (n = 53). RT consists of a four-session intervention focused on improving resilience through the acquisition of mindfulness, self-compassion, and mentalization skills. Measures of symptoms and these resilience-enhancing skills were collected before and after the 4-week RT/waitlist period, with a follow-up assessment 12-months later. RESULTS: Compared to the waitlist control group, RT participants reported significantly greater reductions in PEs, distress associated with PEs, depression, and anxiety, as well as significantly greater improvements in resilience, mindfulness, self-compassion, and positive affect, following the 4-week RT/waitlist period (all p < 0.03). Moreover, improvements in resilience-promoting skills were significantly correlated with symptom reductions (all p < 0.05). Lastly, the RT-related reductions in PEs and associated distress were maintained at the 12-month follow-up assessment. CONCLUSIONS: RT is a brief, group-based intervention associated with improved resilience and reduced symptoms of psychopathology, with sustained effects on PEs, in transdiagnostically at-risk young adults. Follow-up studies can further assess the efficacy of RT relative to other interventions and test whether it can reduce the likelihood of developing a serious mental illness.

Society of Family Planning Clinical Recommendation: Medication abortion between 14 0/7 and 27 6/7 weeks of gestation: Jointly developed with the Society for Maternal-Fetal Medicine.

The objective of this Clinical Recommendation is to review relevant literature and provide evidence-based recommendations for medication abortion between 14 0/7 and 27 6/7 weeks of gestation, with a focus on mifepristone-misoprostol and misoprostol-only regimens. We systematically reviewed PubMed articles published between 2008 and 2022 and reviewed reference lists of included articles to identify additional publications. See Search Strategy for more details. Several randomized trials of medication abortion between 14 0/7 and 27 6/7 weeks of gestation demonstrate that mifepristone 200 mg orally before misoprostol increases effectiveness (complete abortion at 24 or 48 hours) compared to misoprostol only. Studies continue to evaluate different doses, routes, and dosing intervals for misoprostol. If mifepristone is unavailable, several misoprostol regimens with individual doses of at least 200 mcg or more are effective. Adjunctive osmotic dilators are of limited benefit. It is important to individualize care, with consideration to reducing misoprostol dose in low-resource settings or at 24 0/7 weeks of gestation or later (or equivalent uterine size). Misoprostol in the setting of two or more previous cesarean sections is associated with increased risk of uterine rupture compared to one or none, but risk remains low. Most contraceptives can be started during or immediately following abortion. Appropriately trained and credentialed advanced practice clinicians can provide medication abortion between 14 0/7 and 27 6/7 weeks of gestation with appropriate backup within the confines of local regulations and licensure.

Development of a transdiagnostic, resilience-focused intervention for at-risk adolescents.

BACKGROUND: Environmental adversity and subclinical symptoms of psychopathology in adolescents increase their risk for developing a future psychiatric disorder, yet interventions that may prevent poor outcomes in these vulnerable adolescents are not widely available. AIMS: To develop and test the feasibility and acceptability of a prevention-focused program to enhance resilience in high-risk adolescents. METHOD: Adolescents with subclinical psychopathology living in a predominantly low-income, Latinx immigrant community were identified during pediatrician visits. A group-based intervention focused on teaching emotion recognition and regulation skills was piloted in three cohorts of adolescents (n = 11, 10, and 7, respectively), using a single arm design. The second and third iterations included sessions with parents. RESULTS: Eighty-eight percent of participants completed the program, which was rated as beneficial. Also, from baseline to end of treatment, there was a significant decrease in subclinical symptoms and a significant increase in the adolescents' positive social attribution bias (all p < 0.05). CONCLUSIONS: A resilience-focused intervention administered to high-risk adolescents was found to be feasible and acceptable to participants. Future work is needed to determine whether such a program can reduce the incidence of negative outcomes, such as the development of psychiatric disorders and related disability, in this population.

How Can Nurses Support Patients on Hemodialysis Who Experience Needle Fear? An Online Educational Intervention for Nephrology Nurses.

Nephrology nurses struggle to support patients on hemodialysis who experience needle fear due to absence of adequate programs or guidelines. Therefore, we have designed an educational intervention for nurses to learn techniques and strategies to support patients with needle fear and review best cannulation practices with minimal trauma to improve patients' experience of dialysis. A pre-post design measured self-reported confidence in nurses' ability to support patients on dialysis who have a fear of needles. We found nurses can benefit from targeted educational interventions that provide information and strategies regarding needle fear management. Findings from this study have a potential to be transferred to other chronic disease settings with frequent needle use.

Rates of New Human Papillomavirus Detection and Loss of Detection in Middle-aged Women by Recent and Past Sexual Behavior.

BACKGROUND: Understanding the source of newly detected human papillomavirus (HPV) in middle-aged women is important to inform preventive strategies, such as screening and HPV vaccination. METHODS: We conducted a prospective cohort study in Baltimore, Maryland. Women aged 35-60 years underwent HPV testing and completed health and sexual behavior questionnaires every 6 months over a 2-year period. New detection/loss of detection rates were calculated and adjusted hazard ratios were used to identify risk factors for new detection. RESULTS: The new and loss of detection analyses included 731 women, and 104 positive for high-risk HPV. The rate of new high-risk HPV detection was 5.0 per 1000 woman-months. Reporting a new sex partner was associated with higher detection rates (adjusted hazard ratio, 8.1; 95% confidence interval, 3.5-18.6), but accounted only for 19.4% of all new detections. Among monogamous and sexually abstinent women, new detection was higher in women reporting ≥5 lifetime sexual partners than in those reporting <5 (adjusted hazard ratio, 2.2; 95% confidence interval, 1.2-4.2). CONCLUSION: Although women remain at risk of HPV acquisition from new sex partners as they age, our results suggest that most new detections in middle-aged women reflect recurrence of previously acquired HPV.

Integrated Psychological Care Reduces Health Care Costs at a Hospital-Based Inflammatory Bowel Disease Service.

BACKGROUND & AIMS: Inflammatory bowel diseases (IBD) are associated with high psychosocial burden and economic cost. Integrating psychological care into routine management might lead to savings. We performed a 2-year investigation of the effects of integrated psychological care in reducing healthcare use and costs. METHODS: We performed a prospective study of 335 adult patients treated at a hospital-based IBD service in Australia. Participants were recruited between September 2015 and August 2016 and completed screening instruments to evaluate mental health and quality of life. Data on healthcare use and costs for the previous 12 months were also collected. Patients found to be at risk for mental health issues were offered psychological intervention. Patients were followed up 12 months after screening (between September 2016 and August 2017). RESULTS: A significantly higher proportion of subjects at risk for mental health issues had presented to an emergency department in the 12 months before screening (51/182; 28%) compared to psychologically healthy subjects (28/152; 18%; X2(1) = 4.23; P = .040). Higher levels of depression and general distress (but not anxiety) were related to increased odds of hospital admission (adjusted odds ratios, 1.07 and 1.05, respectively). Among the patients who accepted psychological intervention, the number who presented to emergency departments was reduced significantly in the 12 months after screening (follow-up) compared to the 12 months before screening (P = .047), resulting in a cost saving of AU$30,140 ($20,816 USD). A cost-benefit analysis of the integrated psychological care model revealed a net saving of AU$84,905 ($58,647 USD) over a 2-year period. CONCLUSIONS: Risk for mental health issues is associated with higher healthcare costs in people with IBD. Providing integrated psychological care to individuals at risk for mental health issues can reduce costs, particularly by decreasing visits to emergency departments. Further studies are required to determine the best care to provide to reduce costs.

Waiting in Pain II: An Updated Review of the Provision of Persistent Pain Services in Australia.

OBJECTIVE: To provide an update on Australian persistent pain services (number, structure, funding, wait times, activity). METHODS: An updated national search was conducted. Of those identified, 74 persistent pain services provided detailed responses between July 2016 and February 2018 (64 adult, seven pediatric, two pelvic pain, and one cancer pain). A similar structure to the original Waiting in Pain (WIP) survey was used, and participants chose online or telephone completion. RESULTS: Pediatric pain services had more than doubled but remained limited. Adult services had also increased, with a concurrent decrease in median wait times and an increase in the number of new referrals seen each year. Despite this, some lengthy wait times (≥3 years) persisted. Wait times were longest at clinics using public or combined funding models and offering pain management group programs (PMGPs). Although clinical activity had increased, medical staffing had not, suggesting that clinics were operating differently. Privately funded clinics performed more procedures than publicly funded services. Use of PMGPs had increased, but program structure remained diverse. CONCLUSIONS: Specialist pain services have expanded since the original WIP survey, facilitating treatment access for many. However, wait time range suggested that the most disadvantaged individuals still experienced the longest wait times, often far exceeding the recommended 6-month maximum wait. More needs to be done. Numerous developments (e.g., National Strategic Action Plan for Pain Management, health system changes as a result of the COVID-19 pandemic) will continue to influence the delivery of pain services in Australia, and repeated analysis of service structures and wait times will optimize our health system response to the management of this condition.

Associations between dietary micronutrient intake and molecular-Bacterial Vaginosis.

OBJECTIVES: Bacterial vaginosis (BV), a clinical condition characterized by decreased vaginal Lactobacillus spp., is difficult to treat. We examined associations between micronutrient intake and a low-Lactobacillus vaginal microbiota as assessed by molecular methods (termed "molecular-BV"). METHODS: This cross-sectional analysis utilized data collected at the baseline visit of the Hormonal Contraception Longitudinal Study, a cohort of reproductive-aged women followed over 2 years while initiating or ceasing hormonal contraception (HC). The Block Brief 2000 Food Frequency Questionnaire was administered and micronutrient intakes were ranked. Vaginal microbiota composition was assessed using 16S rRNA gene amplicon sequencing and clustered into community state types (CSTs) based on the types and relative abundance of bacteria detected. Associations between the lowest estimated quartile intake of nutrients and having a low-Lactobacillus CST (molecular-BV) were evaluated by logistic regression. Separate models were built for each nutrient controlling for age, body mass index, behavioral factors, HC use and total energy intake. We also conducted a literature review of existing data on associations between micronutrient intakes and BV. RESULTS: Samples from 104 women were included in this analysis. Their mean age was 25.8 years (SD 4.3), 29.8% were African American, 48.1% were using HC, and 25% had molecular-BV. In adjusted multivariable analyses, the lowest quartile of betaine intake was associated with an increased odds of molecular-BV (aOR 9.2, p value < 0.01, [CI 2.4-35.0]). CONCLUSIONS: This is the first study to assess the association between estimated micronutrient intake and molecular-BV. Lower energy-adjusted intake of betaine was associated with an increased risk of molecular-BV. Betaine might have direct effects on the vaginal microenvironment or may be mediated through the gut microbiota. Additional research is needed to determine reproducibility of this finding and whether improved intake of select micronutrients such as betaine decreases the risk of BV and its sequelae.

Rates of regression of cervical dysplasia between initial biopsy and excisional procedure in routine clinical practice.

PURPOSE: To determine rates and factors associated with regression of cervical intraepithelial neoplasia (CIN) 2 + between colposcopic biopsy and therapeutic excisional procedure in standard practice. METHODS: A retrospective chart review was performed for women undergoing a cervical excisional procedure for CIN 2 + at clinics at three academic institutions over a 3-year period. Cytology, histology, patient age and time-to-excision were analyzed to determine factors influencing rates of regression. RESULTS: Of 356 women undergoing excision for CIN 2 + on colposcopic biopsy, 91 (25.3%) of final pathology diagnoses displayed clinically significant regression. Age and time-to-excision were not associated with regression, but referral cytology and severity of initial biopsy histology were, with ASC-H (aOR 0.1, CI 0.03, 0.8) and CIN 3/AIS (aOR 0.4, CI 0.2, 0.7) being less likely to regress than less severe lesions. CONCLUSIONS: Disease severity by referral cytology or diagnostic biopsy, as opposed to age or length of time-to-excision, is likely the most relevant factor in determination of regression for cervical intraepithelial neoplasia in women undergoing excisional treatment for biopsy-confirmed CIN2 +.

Brief Report: Robo1 Regulates the Migration of Human Subventricular Zone Neural Progenitor Cells During Development.

Human neural progenitor cell (NPC) migration within the subventricular zone (SVZ) of the lateral ganglionic eminence is an active process throughout early brain development. The migration of human NPCs from the SVZ to the olfactory bulb during fetal stages resembles what occurs in adult rodents. As the human brain develops during infancy, this migratory stream is drastically reduced in cell number and becomes barely evident in adults. The mechanisms regulating human NPC migration are unknown. The Slit-Robo signaling pathway has been defined as a chemorepulsive cue involved in axon guidance and neuroblast migration in rodents. Slit and Robo proteins expressed in the rodent brain help guide neuroblast migration from the SVZ through the rostral migratory stream to the olfactory bulb. Here, we present the first study on the role that Slit and Robo proteins play in human-derived fetal neural progenitor cell migration (hfNPC). We describe that Robo1 and Robo2 isoforms are expressed in the human fetal SVZ. Furthermore, we demonstrate that Slit2 is able to induce a chemorepellent effect on the migration of hfNPCs derived from the human fetal SVZ. In addition, when Robo1 expression is inhibited, hfNPCs are unable to migrate to the olfactory bulb of mice when injected in the anterior SVZ. Our findings indicate that the migration of human NPCs from the SVZ is partially regulated by the Slit-Robo axis. This pathway could be regulated to direct the migration of NPCs in human endogenous neural cell therapy. Stem Cells 2017;35:1860-1865.

Female and male decision-making regarding whether to continue or abort an unintended pregnancy: a secondary analysis of the FECOND study.

OBJECTIVE: We aimed to explore partner agreement in unintended pregnancy decisions and to describe predictors of female and male perceived agreement with their partner regarding the decision to continue or terminate the pregnancy. METHODS: This is a secondary analysis of the FECOND study, a population-based probability telephone survey conducted in France in 2010 comprising 8645 respondents aged 15-49 years. Pregnancy data were reported by individuals (not couple-level data). For female- and male-reported unintended pregnancies, we used generalised estimation equation models to estimate the odds of a female-only (disagreement) versus a joint (agreement) decision to continue or terminate an unintended pregnancy. RESULTS: The decision to continue an unintended pregnancy was reported as joint in 82% of female- and 88% of male-reported pregnancies. Pregnancy continuation was more likely to be perceived as female-only versus a joint decision if men perceived initial pregnancy intention disagreement (adjusted odds ratio [aOR] 5.9; 95% confidence intervals [CI] 2.0, 16.9), if women indicated finances were very difficult at the time of conception (aOR 3.0; 95% CI 1.7, 5.2) and if women or men reported an unstable relationship at the time of conception (aOR 10.0; 95% CI 6.1, 16.4; aOR 55.3; 95% CI 15.8, 193.0). The decision to terminate an unintended pregnancy was reported as joint in 61% of female- and 74% of male-reported pregnancies. Pregnancy termination was more likely to be perceived as a female-only decision if women reported an unstable relationship at the time of conception (aOR 3.8; 95% CI 2.3, 6.2). CONCLUSION: Pregnancy intention disagreement and finance/relationship status at the time of conception inform partner agreement about the decision to continue or end an unintended pregnancy.

Race is Associated With Sexual Behaviors and Modifies the Effect of Age on Human Papillomavirus Serostatus Among Perimenopausal Women.

BACKGROUND: Human papillomavirus (HPV) causes oropharyngeal and cervical cancers. Oropharyngeal cancer primarily affects whites, but cervical cancer is more common among blacks. Reasons for this distinct epidemiology are unclear. METHODS: Serum was collected from women aged 35 to 60 years in the HPV in Perimenopause cohort and evaluated for antibodies to 8 HPV types. Demographic and behavioral data were collected by telephone questionnaire. Associations between sexual behaviors, race, age, HPV serostatus, and strength of serologic response to HPV were evaluated. RESULTS: There were 781 women in this analysis, including 620 white (79%) and 161 (21%) black women. Whites were less likely to report 5+ vaginal sex partners (prevalence ratio [PR], 0.86; 95% confidence interval [CI], 0.77-0.97), but more likely to report 5+ oral sex partners (PR, 2.38; 95% CI, 1.62-3.49) compared with blacks. Seropositivity to most individual HPV types and at least 3 types was significantly lower in whites than in blacks (PR, 0.62; 95% CI, 0.47-0.80). Human papillomavirus seropositivity was independently associated with younger age among blacks, but with sexual exposures among whites. Furthermore, strength of serologic response to most HPV types significantly decreased with older age among blacks, but not among whites. CONCLUSIONS: Racial differences in immune markers of HPV exposure and the epidemiology of HPV-related cancers may be linked to differences in patterns of sexual behaviors.

Maternal Affective Illness in the Perinatal Period and Child Development: Findings on Developmental Timing, Mechanisms, and Intervention.

Maternal mental illness is one of the most reliable risks for clinically significant child adjustment difficulties. The research literature in this area is very large and broad and dates back decades. In this review, we consider recent research findings on maternal mental illness and child development by focusing particularly on affective illness the perinatal period. We do this because maternal affective illness in the perinatal period is common; recent evidence suggests that pre- and postpartum maternal depression may have lasting effects on child behavioral and somatic health; research in the perinatal period raises acute and compelling questions about mechanisms of transmission and effect; and perinatal-focused interventions may offer distinct advantages for benefitting mother and child and gaining insights into developmental mechanisms. Throughout the review, we attend to the increasing integration of psychological and biological models and the trans-disciplinary approach now required for clinical investigation.

Does a Brief Educational Session Produce Positive Change for Individuals Waiting for Tertiary Chronic Pain Services?

OBJECTIVES: To examine: 1) whether a single brief pre-clinic educational session improved the well-being and quality of life of individuals entering the wait-list for a tertiary chronic pain (CP) service; and 2) the impact of waiting for services on these outcomes. METHODS: Participants were 346 adults, with basic English skills and non-urgent triage codes, who were recruited on referral to a tertiary Australian metropolitan CP unit. Participants were randomized across two conditions: "treatment as usual" (normal wait-list) and "experimental" (normal wait-list plus a 3-hour CP educational session). The educational session encouraged self-management and life engagement despite pain. Multiple outcomes (pain acceptance, pain-related interference, psychological distress, health care utilization [frequency, types], quality of life, health knowledge/beliefs), as well as pain severity and symptom exaggeration, were assessed at intake and again at 2 weeks and 6 months post-educational session (or equivalent for the wait-list group). RESULTS: Satisfaction with the educational session was moderate-to-high, but attendance was not associated with improved outcomes. At 2 weeks, all study participants reported significant improvements in pain acceptance (willingness, overall acceptance), health care utilization (frequency) and quality of life (physical), which were maintained/enhanced at 6 months. Use of psychological and physical therapies increased significantly by 6 months. There was no functional deterioration while wait-listed. CONCLUSIONS: Attending a brief pre-clinic education session did not improve function. There was no deterioration in wait-listed participants who agreed to be involved in research and who completed study measures at 2 and 6 months, but referral was associated with short-term functional improvements. This is the first study to link positive change with referral to, rather than treatment by, a tertiary CP service.

Changes in Acceptance in a Low-Intensity, Group-Based Acceptance and Commitment Therapy (ACT) Chronic Pain Intervention.

BACKGROUND: Acceptance and commitment therapy has shown to be effective in chronic pain rehabilitation, and acceptance has been shown to be a key process of change. The influence of treatment dose on acceptance is not clear, and in particular, the effectiveness of a non-intensive treatment (<20 h) in a tertiary pain clinic is required. PURPOSE: The purpose of the study was to assess the effectiveness of a low-intensity, acceptance and commitment therapy (ACT) group program for chronic pain. The study sought to compare, at both groups and individual patient levels, changes in acceptance with changes observed in previous ACT studies. METHODS: Seventy-one individuals with chronic pain commenced a 9-week ACT-based group program at an outpatient chronic pain service. In addition to acceptance, outcomes included the following: pain catastrophizing, depression, anxiety, quality of life, and pain-related anxiety. To compare the current findings with previous research, effect sizes from seven studies were aggregated using the random-effects model to calculate benchmarks. Reliable change indices (RCIs) were applied to assess change on an individual patient-level. RESULTS: The ACT intervention achieved a statistically significant increase in acceptance and medium effect size (d = 0.54) at a group level. Change in acceptance was of a similar magnitude to that found in previous ACT studies that examined interventions with similar treatment hours (<20 h). Results across other outcome measures demonstrated small to medium effect sizes (d = 0.01 to 0.48, mean = 0.26). Reliable improvement in acceptance occurred in approximately one-third (37.2, 90% CI) of patients. Approximately three-quarters (74.3, 90% CI) demonstrated reliable change in at least one of the outcome measures. CONCLUSIONS: The low-intensity, group-based ACT intervention was effective at a group level and showed a similar magnitude of change in acceptance to previous ACT studies employing low-intensity interventions. Three-quarters of patients reported reliable change on at least one outcome measure.

Observed parent-child relationship quality predicts antibody response to vaccination in children.

BACKGROUND: Quality of the parent-child relationship is a robust predictor of behavioral and emotional health for children and adolescents; the application to physical health is less clear. METHODS: We investigated the links between observed parent-child relationship quality in an interaction task and antibody response to meningococcal conjugate vaccine in a longitudinal study of 164 ambulatory 10-11 year-old children; additional analyses examine associations with cortisol reactivity, BMI, and somatic illness. RESULTS: Observed Negative/Conflict behavior in the interaction task predicted a less robust antibody response to meningococcal serotype C vaccine in the child over a 6 month-period, after controlling for socio-economic and other covariates. Observer rated interaction conflict also predicted increased cortisol reactivity following the interaction task and higher BMI, but these factors did not account for the link between relationship quality and antibody response. CONCLUSIONS: The results begin to document the degree to which a major source of child stress exposure, parent-child relationship conflict, is associated with altered immune system development in children, and may constitute an important public health consideration.

Update on medical abortion: simplifying the process for women.

PURPOSE OF REVIEW: Medical abortion using mifepristone and misoprostol comprises a growing proportion of abortions performed in the United States. Simplifying the process of medical abortion can optimize use of resources and improve care for women. RECENT FINDINGS: Medical abortion using evidence-based protocols is effective through 70 days' gestation. The requirement of a follow-up office visit with a transvaginal ultrasound to ensure completion of medical abortion is safely and effectively replaced with self-administered low-sensitivity or semiquantitative urine pregnancy tests and remote communication with women. Most contraceptive options can be initiated the same day as mifepristone administration to improve contraceptive use after medical abortion. State legislatures continue to pass laws that threaten evidence-based medical abortion practices. Such efforts ultimately limit access to well-tolerated and effective medical abortion services. SUMMARY: Research supports simplification of the follow-up protocol for medical abortion, and provision of the contraceptive implant and progestin injectable for postabortion contraception the same day as mifepristone administration. With disregard to its documented safety and efficacy, legislative challenges persist as significant challenges to provision of evidence-based medical abortion.

An analysis of multidisciplinary staffing levels and clinical activity in Australian tertiary persistent pain services.

OBJECTIVE: To document staffing (medical, nursing, allied health [AH], administrative) in Australian multidisciplinary persistent pain services and relate them to clinical activity levels. METHODS: Of the 68 adult outpatient persistent pain services approached (Dec'08-Jan'10), 45 agreed to participate, received over 100 referrals/year, and met the contemporaneous International Association for the Study of Pain criteria for Level 1 or 2 multidisciplinary services. Structured interviews with Clinical Directors collected quantitative data regarding staff resources (disciplines, amount), services provided, funding models, and activity levels. RESULTS: Compared with Level 2 clinics, Level 1 centers reported higher annual demand (referrals), clinical activity (patient numbers) and absolute numbers of medical, nursing and administrative staff, but comparable numbers of AH staff. When staffing was assessed against activity levels, medical and nursing resources were consistent across services, but Level 1 clinics had relatively fewer AH and administrative staff. Metropolitan and rural services reported comparable activity levels and discipline-specific staff ratios (except occupational therapy). The mean annual AH staffing for pain management group programs was 0.03 full-time equivalent staff per patient. CONCLUSIONS: Reasonable consistency was demonstrated in the range and mix of most disciplines employed, suggesting they represented workable clinical structures. The greater number of medical and nursing staff within Level 1 clinics may indicate a lower multidisciplinary focus, but this needs further exploration. As the first multidisciplinary staffing data for persistent pain clinics, this provides critical information for designing and implementing clinical services. Mapping against clinical outcomes to demonstrate the impact of staffing patterns on safe and efficacious treatment delivery is required.

Psychological functioning of people living with chronic pain: a meta-analytic review.

OBJECTIVES: Chronic pain (CP; >3 months) is a common condition that is associated with significant psychological problems. Many people with CP do not fit into discrete diagnostic categories, limiting the applicability of research that is specific to a particular pain diagnosis. This meta-analysis synthesized the large extant literature from a general CP, rather than diagnosis-specific, perspective to systematically identify and compare the psychological problems most commonly associated with CP. METHODS: Four databases were searched from inception to December 2013 (PsychINFO, The Cochrane Library, Scopus, and PubMed) for studies comparing the psychological functioning of adults with CP to healthy controls. Data from 110 studies were meta-analysed and Cohen's d effect sizes calculated. RESULTS: The CP group reported experiencing significant problems in a range of psychological domains (depression, anxiety, somatization, anger/hostility, self-efficacy, self-esteem and general emotional functioning), with the largest effects observed for pain anxiety/concern and somatization; followed by anxiety and self-efficacy; and then depression, anger/hostility, self-esteem and general emotional functioning. CONCLUSIONS: This study demonstrates, for the first time, that individuals with CP are more likely to experience physically focussed psychological problems than other psychological problems and that, unlike self-efficacy, fear of pain is intrinsically tied to the CP experience. This challenges the prevailing view that, for individuals with CP, problems with depression are either equal to, or greater than, problems with anxiety, thereby providing important information to guide therapeutic targets. PRACTITIONER POINTS: Positive clinical implications: This is the first time that the CP literature has been synthesized from a general perspective to examine psychological functioning in the presence of CP and provide practical recommendations for assessment and therapy. Individuals with CP were most likely to experience psychological problems in physically focussed areas - namely pain anxiety/concern and somatization. Although fear of pain was intrinsically tied to the CP experience, self-efficacy was not. CP was more strongly associated with anxiety than with depression. Limitations The study focuses on the general CP literature, adults and research-utilizing self-report measures. Meta-analyses are limited by the empirical literature on which they are based.