Does Screening for Pain Correspond to High Quality Care for Veterans?

Routine numeric screening for pain is widely recommended, but its association with overall quality of pain care is unclear. To assess adherence to measures of pain management quality and identify associated patient and provider factors. A cross-sectional visit-based study. One hundred and forty adult VA outpatient primary care clinic patients reporting a numeric rating scale (NRS) of moderate to severe pain (four or more on a zero to ten scale). Seventy-seven providers completed a baseline survey regarding general pain management attitudes and a post-visit survey regarding management of 112 participating patients. We used chart review to determine adherence to four validated process quality indicators (QIs) including noting pain presence, pain character, and pain control, and intensifying pharmacological intervention. The average NRS was 6.7. Seventy-three percent of charts noted the presence of pain, 13.9% the character, 23.6% the degree of control, and 15.3% increased pain medication prescription. Charts were more likely to include documentation of pain presence if providers agreed that “patients want me to ask about pain” and “pain can have negative consequences on patient’s functioning”. Charts were more likely to document character of pain if providers agreed that “patients are able to rate their pain”. Patients with musculoskeletal pain were less likely to have chart documentation of character of pain. Despite routine pain screening in VA, providers seldom documented elements considered important to evaluation and treatment of pain. Improving pain care may require attention to all aspects of pain management, not just screening

Cortical pruning and the development of schizophrenia: A computer model. Schizophrenia Bulletin

Abstract Schizophrenic patients tend to demonstrate reduced cerebral metabolism in frontal areas. Studies of human brain development reveal that synapses in the cerebral cortex are progressively reduced throughout childhood and adolescence, with parallel reductions in cerebral metabolism. This relationship is not surprising, since synaptic density is a primary factor determining regional metabolic requirements. The elimination of synapses in prefrontal cortex continues for a particularly long period of time, extending well into adolescence. Thus, reduced frontal metabolism in schizophrenic patients could be due to a developmental process-namely, elimination of synapses-gone too far. Animal studies indicate that developmentally induced reductions in synaptic density are due to the pruning of axonal collaterals rather than the death of neurons, which raises a critical question: Does excessive axonal pruning have specific pathological effects on cortical information processing? To answer this question, computer simulations of neural information processing systems were subjected to axonal pruning which reduced synaptic density. If pruning was conducted overzealously, cognitive pathology was induced that could, in humans, lead to the conscious experience of hallucinations, delusions, and Schneiderian symptoms

Reaching Those at Risk for Psychiatric Disorders and Suicidal Ideation: Facebook Advertisements to Recruit Military Veterans

Background: Younger military veterans are at high risk for psychiatric disorders and suicide. Reaching and engaging veterans in mental health care and research is challenging. Social media platforms may be an effective channel to connect with veterans. Objective: This study tested the effectiveness of Facebook advertisements in reaching and recruiting Iraq and Afghanistan-era military veterans in a research study focused on mental health. Methods: Facebook ads requesting participation in an online health survey ran for six weeks in 2017. Ads varied imagery and headlines. Validated instruments were used to screen for psychiatric disorders and suicidality. Outcomes included impressions, click-through rate, survey completion, and cost per survey completed. Results: Advertisements produced 827,918 impressions, 9,527 clicks, and 587 survey completions. Lack of enrollment in Veterans Affairs health care (193/587, 33%) and positive screens for current mental health problems were common, including posttraumatic stress disorder (266/585, 45%), problematic drinking (243/584, 42%), major depression (164/586, 28%), and suicidality (132/585, 23%). Approximately half of the survey participants (285/587, 49%) were recruited with just 2 of the 15 ads, which showed soldiers marching tied to an “incentive” or “sharing” headline. These 2 ads were also the most cost-effective, at US $4.88 and US$5.90 per participant, respectively. Among veterans with current suicidal ideation, the survey-taking image resulted in higher survey completion than the soldiers marching image (P=.007). Conclusions: Facebook advertisements are effective in rapidly and inexpensively reaching military veterans, including those at risk for mental health problems and suicidality, and those not receiving Veterans Affairs health care. Advertisement image and headlines may help optimize the effectiveness of advertisements for specific subgroups

The Importance of “Being There”: A Qualitative Study of What Veterans with Depression Want in Social Support

Background: Social connectedness exerts strong influences on health, including major depression and suicide. A major component of social connectedness is having individual relationships with close supports, romantic partners and other trusted members of one’s social network. Objective: The objective of this study was to understand how individuals’ relationships with close supports might be leveraged to improve outcomes for primary care patients with depression and at risk for suicide. Design: In this qualitative study, a semi-structured interview guide was used to probe patient experiences, views, and preferences related to social support. Participants: We conducted interviews with 30 primary care patients at a Veterans Health Administration (VA) medical center who had symptoms of major depression and a close support. Approach: Thematic analysis of qualitative interview data examined close supports’ impact on patients. We iteratively developed a codebook, used output from codes to sort data into themes, and selected quotations that exemplified themes for inclusion in this manuscript. Key Results: “Being there” as an important quality of close supports emerged as a key concept. “Being there” was defined in three ways: physical proximity, frequent or responsive contact, or perceived availability. Close supports who were effective at “being there” possessed skills in intuitively sensing the patient’s emotional state and communicating indirectly about depression. Three major barriers to involving close supports in depression care were: concerns of overburdening the close support, a perception that awareness of the patient’s depression would make the close support unnecessarily worried, and a desire and preference among patients to handle depression on their own. Conclusions: “Being there” represents a novel, patient-generated way to conceptualize and talk about social support. Suicide prevention initiatives such as population-level communication campaigns might be improved by incorporating language used by patients and addressing attitudinal barriers to allowing help and involvement close supports

VA Healthcare Costs of a Collaborative Intervention for Chronic Pain in Primary Care

Background: Chronic pain is costly to individuals and the healthcare system, and is often undertreated. Collaborative care models show promise for improving treatment of patients with chronic pain. The objectives of this article are to report the incremental benefit and incremental health services costs of a collaborative intervention for chronic pain from a veterans affairs (VA) healthcare perspective. Methods: Data on VA treatment costs incurred by participants were obtained from the VA\u27s Decision Support System for all utilization except certain intervention activities which were tracked in a separate database. Outcome data were from a cluster-randomized trial of a collaborative intervention for chronic pain among 401 primary care patients at a VA medical center. Intervention group participants received assessments and care management; stepped-care components were offered to patients requiring more specialized care. The main outcome measure was pain disability-free days (PDFDs), calculated from Roland-Morris Disability Questionnaire scores. Results: Participants in the intervention group experienced an average of 16 additional PDFDs over the 12-month follow-up window as compared with usual care participants; this came at an adjusted incremental cost of $364 per PDFD for a typical participant. Important predictors of costs were baseline medical comorbidities, depression severity, and prior year\u27s treatment costs. Conclusion: This collaborative intervention resulted in more pain disability-free days and was more expensive than usual care. Further research is necessary to identify if the intervention is more cost-effective for some patient subgroups and to learn whether pain improvements and higher costs persist after the intervention has ended

Sex Differences in the Medical Care of VA Patients with Chronic Non-Cancer Pain

Objective Despite a growing number of women seeking medical care in the veterans affairs (VA) system, little is known about the characteristics of their chronic pain or the pain care they receive. This study sought to determine if sex differences are present in the medical care veterans received for chronic pain. Design Retrospective cohort study using VA administrative data. Subjects The subjects were 17,583 veteran patients with moderate to severe chronic non-cancer pain treated in the Pacific Northwest during 2008. Methods Multivariate logistic regression assessed for sex differences in primary care utilization, prescription of chronic opioid therapy, visits to emergency departments for a pain-related diagnosis, and physical therapy referral. Results Compared with male veterans, female veterans were more often diagnosed with two or more pain conditions, and had more of the following pain-related diagnoses: fibromyalgia, low back pain, inflammatory bowel disease, migraine headache, neck or joint pain, and arthritis. After adjustment for demographic characteristics, pain diagnoses, mental health diagnoses, substance use disorders, and medical comorbidity, women had lower odds of being prescribed chronic opioid therapy (adjusted OR [AOR] 0.67, 95% CI 0.58–0.78), greater odds of visiting an emergency department for a pain-related complaint (AOR 1.40, 95% CI 1.18–1.65), and greater odds of receiving physical therapy (AOR 1.19, 95% CI 1.05–1.33). Primary care utilization was not significantly different between sexes. Conclusions Sex differences are present in the care female veterans receive for chronic pain. Further research is necessary to understand the etiology of the observed differences and their associations with clinical outcomes

Does Mode of Contact with Different Types of Social Relationships Predict Depression in Older Adults? Evidence from a Nationally Representative Survey

OBJECTIVES: To determine associations between use of three different modes of social contact (in person, telephone, written or e-mail), contact with different types of people, and risk of depressive symptoms in a nationally representative, longitudinal sample of older adults. DESIGN: Population-based observational cohort. SETTING: Urban and suburban communities throughout the contiguous United States. PARTICIPANTS: Individuals aged 50 and older who participated in the Health and Retirement Survey between 2004 and 2010 (N = 11,065). MEASUREMENTS: Frequency of participant use of the three modes of social contact with children, other family members, and friends at baseline were used to predict depressive symptoms (measured using the eight-item Center for Epidemiologic Studies Depression Scale) 2 years later using multivariable logistic regression models. RESULTS: Probability of having depressive symptoms steadily increased as frequency of in-person—but not telephone or written or e-mail contact—decreased. After controlling for demographic, clinical, and social variables, individuals with in-person social contact every few months or less with children, other family, and friends had a significantly higher probability of clinically significant depressive symptoms 2 years later (11.5%) than those having in-person contact once or twice per month (8.1%; P \u3c .001) or once or twice per week (7.3%; P \u3c .001). Older age, interpersonal conflict, and depression at baseline moderated some of the effects of social contact on depressive symptoms. CONCLUSION: Frequency of in-person social contact with friends and family independently predicts risk of subsequent depression in older adults. Clinicians should consider encouraging face-to-face social interactions as a preventive strategy for depression