Self-efficacy and paradoxical dependence in chronic back pain: A qualitative analysis.

Objectives Patients with chronic back pain encounter considerable psychological and social challenges. In particular, the ever-evolving relationship between chronic back pain, sense of self-efficacy, and perceived role in interpersonal relationships merits further investigation. Methods We conducted in-person semi-structured interviews with 20 adult patients attending a specialized interventional spine pain clinic. The interview transcripts were subjected to inductive thematic analysis, and themes were labeled descriptively. Participant responses were intentionally not analyzed within the context of an existing theoretical framework, so that the content of participant responses would directly drive the emphasis of the findings. Results Participants described chronic back pain as a lonely struggle amid diminished capacity to work, enjoy leisure time, and contribute to social relationships. Feelings of needing to handle pain independently contrasted with the reality of having to rely on others for help, and this tension was a source of anxiety. Discussion The experience of chronic back pain was characterized by a conflict between the desire for self-efficacy, a sense of isolation, and the paradoxical need to rely on others. Interventions that allow patients to navigate this struggle by seeking help for their diminished capability, while retaining a sense of autonomy and self-worth, are indicated.

Two cases of delayed-onset suicidal ideation, dysphoria and anxiety after ketamine infusion in patients with obsessive-compulsive disorder and a history of major depressive disorder.

Ketamine is a non-competitive N-methyl-D-aspartate receptor antagonist that is Food and Drug Administration-approved in the United States for anesthesia due to its sedative effects with low risk of severe respiratory depression. Subanesthetic dose intravenous ketamine has rapidly acting antidepressant effects in treatment-resistant unipolar and bipolar depression. We recently reported an open-label trial of ketamine in 10 subjects with treatment-refractory obsessive-compulsive disorder, seven of whom had active comorbid depression. Although ketamine had no sustained anti-obsessive effect, four of the seven subjects with comorbid depression experienced an acute antidepressant effect. However, we unexpectedly observed delayed-onset dysphoria, worsening anxiety and suicidal thinking in two of the three subjects with obsessive-compulsive disorder and extensive psychiatric comorbidity but minimal depressive symptoms at the start of infusion. The implications of these adverse neuropsychiatric effects in two patients with similar psychiatric comorbidity are discussed. We conclude that there remains insufficient data on therapeutic ketamine in the presence of comorbid psychiatric disorders to promote its off-label use in a non-research milieu.