The relationship between pain and suicidal vulnerability in adolescence: a systematic review.

Leading suicide theories and research in adults suggest that pain can exacerbate the suicidal risk of an individual. Although pain and suicidality (including suicidal ideation, behaviour, and death by suicide) both increase in prevalence during adolescence, the relationship between these factors remains unclear. We aimed to systematically review the empirical evidence for such an association in adolescence. We included 25 observational studies published between January 1961 and December 2018, exploring the potential association between pain and suicidality in adolescents aged 10-19 years. Across various samples and manifestations of pain and suicidality, we found that pain approximately doubles the suicidal risk in adolescents, with a few studies suggesting that pain can predict suicidality longitudinally. Although depression was an important factor, it did not fully explain the association between pain and suicidality. Evidence for associations between pain characteristics and suicidality is sparse and inconclusive, and potentially hides developmental differences between adolescents and adults. Identification of psychological mediators and moderators is required to develop interventions tailored to the needs of adolescents experiencing pain. This study is registered with the PROSPERO database, number CRD42018097226.VH is funded by the Oskar-Helene Heim Foundation and the FAZIT foundation. CC is funded by the Wellcome Trust, (107496/Z/14/Z). RB is funded by the Defehr-Neumann foundation. BG is funded by the Faculty of Social Sciences University of Oslo

Does depression moderate the relationship between pain and suicidality in adolescence? A moderated network analysis

BACKGROUND: Whilst growing research suggests that pain is associated with suicidality in adolescence, it remains unclear whether this relationship is moderated by co-morbid depressive symptoms. The present study aimed to investigate whether the pain-suicidality association is moderated by depressive symptoms. METHODS: We performed secondary analyses on cross-sectional, pre-intervention data from the ‘My Resilience in Adolescence’ [MYRIAD] trial (ISRCTN ref: 86619085; N=8072, 11-15 years). Using odds ratio tests and (moderated) network analyses, we investigated the relationship between pain and suicidality, after controlling for depression, anxiety, inhibitory control deficits and peer problems. We investigated whether depression moderates this relationship and explored gender differences. RESULTS: Overall, 20% of adolescents reported suicidality and 22% reported pain, whilst nine percent of adolescents reported both. The experience of pain was associated with a four-fold increased risk of suicidality and vice versa (OR=4.00, 95%-CI=[3.54;4.51]), with no gender differences. This cross-sectional association remained significant after accounting for depression, anxiety, inhibitory control deficits and peer problems (aOR=1.39). Depression did not moderate the pain-suicidality association. LIMITATIONS: The item-based, cross-sectional assessment of pain and suicidality precludes any conclusions about the direction of the effects and which aspects of suicidality and pain may drive this association. CONCLUSIONS: Our findings underscore the need to consider pain as an independent risk correlate of suicidality in adolescents. Longitudinal research should examine how this relationship develops during adolescence. Clinically, our findings emphasise the need to assess and address suicidality in adolescents with pain, even in the absence of depressive symptoms

Count me in: an inclusive approach towards patient recruitment for clinical research studies in the NHS

Background: Participation in clinical research is associated with better patient outcomes and higher staff retention and satisfaction rates. Nevertheless, patient recruitment to mental health studies is challenging due to a reliance on clinician or patient referrals (standard approach). To empower patients and make healthcare research more equitable, we explored a novel researcher-led approach, called ‘Count Me In’ (CMI). Objective: To evaluate a 12-month implementation of CMI in a routine clinical setting. Methods: CMI was launched in August 2021 in a mental health National Health Service (NHS) Trust in England. Patients (aged 18+) learnt about CMI at their initial clinical appointment. Unless they opted out, they became contactable for research (via research informatics searches). Findings: After 12 months, 368 patients opted out and 22 741 became contactable through CMI, including 2716 through the standard approach and 20 025 through electronic searches (637% increase). Of those identified via electronic searches, 738 were contacted about specific studies and 270 consented to participate. Five themes were identified based on patient and staff experiences of CMI: ‘level of awareness and accessibility of CMI’, ‘perceptions of research and perceived engagement with CMI’, ‘inclusive research practice’, ‘engagement and incentives for research participation’, and ‘relationships between clinical and research settings’. Conclusions: CMI (vs standard) led to a larger and diverse patient cohort and was favoured by patients and staff. Yet a shift in the NHS research culture is needed to ensure that this diversity translates to actual research participation. Clinical implications: Through collaboration with other NHS Trusts and services, key funders (National Institute for Health and Care Research) and new national initiatives (Office for Life Sciences Mental Health Mission), CMI has the potential to address recruitment challenges through rapid patient recruitment into time-sensitive country-wide studies

Do adolescents like school-based mindfulness training? Predictors of mindfulness practice and responsiveness in the MYRIAD Trial

Objective We explored what predicts secondary school students’ mindfulness practice and responsiveness to universal school-based mindfulness training (SBMT), and how students experience SBMT. Method A mixed-methods design was used. Participants were 4,232 students (11-13 years of age), in 43 UK secondary schools, who received universal SBMT (ie, “.b” program), within the MYRIAD trial (ISRCTN86619085). Following previous research, student, teacher, school, and implementation factors were evaluated as potential predictors of students’ out-of-school mindfulness practice and responsiveness (ie, interest in and attitudes toward SBMT), using mixed-effects linear regression. We explored pupils’ SBMT experiences using thematic content analysis of their answers to 2 free-response questions, 1 question focused on positive experiences and 1 question on difficulties/challenges. Results Students reported practicing out-of-school mindfulness exercises on average once during the intervention (mean [SD] = 1.16 [1.07]; range, 0-5). Students’ average ratings of responsiveness were intermediate (mean [SD] = 4.72 [2.88]; range, 0-10). Girls reported more responsiveness. High risk of mental health problems was associated with lower responsiveness. Asian ethnicity and higher school-level economic deprivation were related to greater responsiveness. More SBMT sessions and better quality of delivery were associated with both greater mindfulness practice and responsiveness. In terms of students’ experiences of SBMT, the most frequent themes (60% of the minimally elaborated responses) were an increased awareness of bodily feelings/sensations and increased ability to regulate emotions. Conclusion Most students did not engage with mindfulness practice. Although responsiveness to the SMBT was intermediate on average, there was substantial variation, with some youth rating it negatively and others rating it positively. Future SBMT developers should consider co-designing curricula with students, carefully assessing the student characteristics, aspects of the school environment, and implementation factors associated with mindfulness practice and responsiveness. SBMT teacher training is key, as more observed proficiency in SBMT teaching is associated with greater student mindfulness practice and responsiveness to SBMT

Count me in : an inclusive approach towards patient recruitment for clinical research studies in the NHS

Background. Participation in clinical research is associated with better patient outcomes and higher staff retention and satisfaction rates. Nevertheless, patient recruitment to mental health studies is challenging due to a reliance on clinician or patient referrals (standard approach). To empower patients and make healthcare research more equitable, we explored a novel researcher-led approach, called ‘Count Me In’ (CMI). Objective. To evaluate a 12-month implementation of CMI in a routine clinical setting. Methods. CMI was launched in August 2021 in a mental health National Health Service (NHS) Trust in England. Patients (aged 18+) learnt about CMI at their initial clinical appointment. Unless they opted out, they became contactable for research (via research informatics searches). Findings. After 12 months, 368 patients opted out and 22 741 became contactable through CMI, including 2716 through the standard approach and 20 025 through electronic searches (637% increase). Of those identified via electronic searches, 738 were contacted about specific studies and 270 consented to participate. Five themes were identified based on patient and staff experiences of CMI: ‘level of awareness and accessibility of CMI’, ‘perceptions of research and perceived engagement with CMI’, ‘inclusive research practice’, ‘engagement and incentives for research participation’, and ‘relationships between clinical and research settings’. Conclusions. CMI (vs standard) led to a larger and diverse patient cohort and was favoured by patients and staff. Yet a shift in the NHS research culture is needed to ensure that this diversity translates to actual research participation. Clinical implications. Through collaboration with other NHS Trusts and services, key funders (National Institute for Health and Care Research) and new national initiatives (Office for Life Sciences Mental Health Mission), CMI has the potential to address recruitment challenges through rapid patient recruitment into time-sensitive country-wide studies

Calcite-accumulating large sulfur bacteria of the genus Achromatium in Sippewissett Salt Marsh

Large sulfur bacteria of the genus Achromatium are exceptional among Bacteria and Archaea as they can accumulate high amounts of internal calcite. Although known for more than 100 years, they remain uncultured, and only freshwater populations have been studied so far. Here we investigate a marine population of calcite-accumulating bacteria that is primarily found at the sediment surface of tide pools in a salt marsh, where high sulfide concentrations meet oversaturated oxygen concentrations during the day. Dynamic sulfur cycling by phototrophic sulfide-oxidizing and heterotrophic sulfate-reducing bacteria co-occurring in these sediments creates a highly sulfidic environment that we propose induces behavioral differences in the Achromatium population compared with reported migration patterns in a low-sulfide environment. Fluctuating intracellular calcium/sulfur ratios at different depths and times of day indicate a biochemical reaction of the salt marsh Achromatium to diurnal changes in sedimentary redox conditions. We correlate this calcite dynamic with new evidence regarding its formation/mobilization and suggest general implications as well as a possible biological function of calcite accumulation in large bacteria in the sediment environment that is governed by gradients. Finally, we propose a new taxonomic classification of the salt marsh Achromatium based on their adaptation to a significantly different habitat than their freshwater relatives, as indicated by their differential behavior as well as phylogenetic distance on 16S ribosomal RNA gene level. In future studies, whole-genome characterization and additional ecophysiological factors could further support the distinctive position of salt marsh Achromatium

Exploring the relationship between pain and suicidality in adolescence

Across the world, physical pain (‘pain’) and suicidal thoughts and behaviours (‘suicidality’) are major health concerns in adolescents. Emerging research in adults and leading suicide theories recognise pain as an important correlate for suicidality. Although prevalence rates of suicidality and pain increase substantially during adolescence, their relationship in adolescence remains poorly understood. Such knowledge is paramount, as the early delivery of effective care may provide an opportunity to prevent long-term suffering and at its worst mortality. First, I aimed to synthesise the evidence for a relationship between pain and suicidality in adolescence. Second, I aimed to examine this relationship in two independent samples of young people. By using state-of-the-art statistical analyses ((moderated) network analyses and latent class growth analyses), I controlled for shared correlates, explored if specific subgroups may be at an increased risk for this association and how this association may unfold throughout the adolescent years. Third, I aimed to shed light on service use in adolescents with pain and/or suicidality. My systematic review revealed support for the pain-suicidality association in adolescents across community and clinical samples and types of pain and suicidality. However, the sparsity of high-quality evidence emphasised the need for further research. In two independent samples, I have shown that pain and suicidality are common experiences in young people, especially in adolescents, in the United Kingdom. Pain was cross-sectionally associated with a two- to fourfold increased risk of suicidality and vice versa, with no differences between children (aged 5-9 years) and adolescents (aged 10-16 years), and adolescent boys and girls. This association remained significant in network analyses, after shared correlates of pain and suicidality were accounted for and was not moderated by depression. Furthermore, four longitudinal pain trajectories (increasing, decreasing, and persistent/recurrent probability of pain, and no pain) were identified that were associated with distinct sets of correlates. Crucially, only the persistent/recurrent pain trajectory (vs. no pain) was predicted by baseline suicidality and predicted future suicidality, suggesting a bidirectional pain-suicidality association in young people. Together, these findings demonstrate that pain is an independent correlate of suicidality in adolescence and emphasise screening for suicidality even in the absence of depressive symptoms. However, do adolescents with pain and/or suicidality use health and social services? In my final data chapter, I aimed to examine this question in a representative sample of adolescents (11-15 years) in the United Kingdom. I showed that 55 percent of adolescents used health and social services, with general practitioner visits, outpatient appointments for injuries, and contacts with a school nurse being the service units used most frequently. Total service use across settings was highest for adolescents with pain-suicidality comorbidity (74% using services), followed by adolescents with pain (68% using services), suicidality (64% using services) and neither pain nor suicidality (49% using services). As no single setting was used by most adolescents (>50%), awareness of the pain-suicidality association is crucial across primary care, hospital, and school settings to aid early risk identification. Together, my findings have important implications: Theoretically, they inform the development of a working model to uncover risk pathways and mechanisms underpinning the pain-suicidality association in adolescence that may guide future research. Clinically, these findings underscore the need for regular screening and systematic follow-up of vulnerable youth, and the training of healthcare professionals and community staff to recognise suicidal vulnerability in young people with pain or vice versa. In summary, the translational nature of my research leads to valuable recommendations for public mental health initiatives, and clinical research and practice

Thesis chapter 5: MYRIAD network analyses

Analysis code for my thesis chapter 5: Does depression moderate the relationship between pain and suicidality in adolescence? A moderated network analysi

Pain and Suicidality in Adolescence

These files pertain to the publication: The relationship between pain and suicidal vulnerability in adolescence: a systematic review doi: https://doi.org/10.1016/S2352-4642(19)30267-

Thesis chapter 4: BCAMHS longitudinal pain trajectories

Analysis code for my thesis chapter 4: The Longitudinal Relationship between Pain Trajectories and Suicidality in Children and Adolescent