First Provider Seen for an Acute Episode of Low Back Pain Influences Subsequent Health Care Utilization.

OBJECTIVE: Costs associated with low back pain (LBP) continue to rise. Despite numerous clinical practice guidelines, the evaluation and treatments for LBP are variable and largely depend on the individual provider. As yet, little attention has been given to the first choice of provider. Early research indicates that the choice of first provider and the timing of interventions for LBP appear to influence utilization. We sought to examine the association between the first provider seen and health care utilization. METHODS: Using 2015-2018 data from a large insurer, this retrospective analysis focused on patients (29,806) seeking care for a new episode of LBP. The study identified the first provider chosen and examined the following year of medical utilization. Cox proportional hazards models were calculated using inverse probability weighting on propensity scores to evaluate the time to event and the relationship to the first choice of provider. RESULTS: The primary outcome was the timing and use of health care resources. Total health care use was lowest in those who first sought care with chiropractic care or physical therapy. Highest health care use was seen in those patients who chose the emergency department. CONCLUSION: Overall, there appears to be an association between the first choice of provider and future health care use. Chiropractic care and physical therapy provide nonpharmacologic and nonsurgical, guideline-based interventions. The use of physical therapists and chiropractors as entry points into the health system appears related to a decrease in immediate and long-term use of health resources. This study expands the existing body of literature and provides a compelling case for the influence of the first provider on an acute episode of LBP. IMPACT: The first provider seen for an acute episode of LBP influences immediate treatment decisions, the trajectory of a specific patient episode, and future health care choices in the management of LBP.

Feeling left out: depressed adolescents may atypically recruit emotional salience and regulation networks during social exclusion.

Depression is associated with negative attention and attribution biases and maladaptive emotion responsivity and regulation, which adversely impact self-evaluations and interpersonal relationships. Using functional magnetic resonance imaging, we investigated the neural substrates of these impairments. We compared neural activity recruited by 126 clinically depressed and healthy adolescents (ages 11-17 years) during social exclusion (Exclusion > Inclusion) using Cyberball. Results revealed significant interaction effects within left anterior insula (AI)/inferior frontal gyrus and left middle temporal gyrus. Insula hyperresponsivity was associated with peer exclusion for depressed adolescents but peer inclusion for healthy adolescents. In additional, healthy adolescents recruited greater lateral temporal activity during peer exclusion. Complementary effect size analyses within independent parcellations offered converging evidence, as well as highlighted medium-to-large effects within subgenual/ventral anterior cingulate cortex and lateral prefrontal, lateral temporal and lateral parietal regions implicated in emotion regulation. Depressogenic neural patterns were associated with negative self-perceptions and negative information processing biases. These findings suggest a neural mechanism underlying cognitive biases in depression, as reflected by emotional hyperresponsivity and maladaptive regulation/reappraisal of negative social evaluative information. This study lends further support for salience and central executive network dysfunction underlying social threat processing, and in particular, highlights the anterior insula as a key region of disturbance in adolescent depression.

The neurobiology of self face recognition among depressed adolescents.

OBJECTIVE: Depression is linked to alterations in both emotion and self-processing. The current study used functional magnetic resonance imaging (fMRI) to assess neural activation in healthy and depressed youth to a novel task that combined emotion processing with self-face recognition. METHODS: An fMRI study involving 81 adolescents (50.6% females; Mage=14.61, SD=1.65) comprised of depressed (DEP, n=43), and healthy controls (HC, n=38). Participants completed a clinical interview and self-report measures during an initial assessment. In the scanner, adolescents completed a face recognition task, viewing emotional (happy, sad, neutral) images of their own face (self) or the face of another youth (other). RESULTS: DEP youth showed higher activity in the cuneus (F=26.29) and post and precentral gyri (F=20.76), across all conditions compared to HC. Sad faces elicited higher posterior cingulate cortex, precuneus (F=10.36) and inferior parietal cortex activity (F=11.0), and self faces elicited higher precuneus, fusiform (F=16.39), insula and putamen (F=16.82) activity in all youth. DEP showed higher middle temporal activity to neutral faces but lower activity to sad faces compared to HC, who showed the opposite pattern (F=12.86). DEP also showed hypoactive mid-temporal limbic activity relative to controls when identifying their self happy face vs. neutral face, yet showed hyperactivity when identifying the other happy face vs. neutral face, and HC showed the opposite pattern (F=10.94). CONCLUSIONS: The neurophysiology of self-face recognition is altered in adolescent depression. Specifically, depression was associated with decreased activity in neural areas that support emotional and associative processing for positive self-faces and increased processing for neutral self-faces. These results suggest that depression in adolescents is associated with hypoactive emotional processing and encoding of positive self-related visual information. This abnormal neural activity at the intersection of reward and self-processing among depressed youth might have long lasting impact in self-formation and future adult self-representations, given that adolescence is a sensitive period for self-development.

Ventral Striatum Functional Connectivity during Rewards and Losses and Symptomatology in Depressed Patients.

BACKGROUND: The ventral striatum (VS) and striatal network supports goal motivated behavior. Identifying how depressed patients differ in their striatal network during the processing of emotionally salient events is a step towards uncovering biomarkers for diagnosis and treatment. METHODS: 38 depressed and 30 healthy adults completed a task that examined brain activation to the anticipation and receipt of monetary rewards and losses. Data were collected using a 3T Siemens Trio scanner. Functional connectivity differences were examined with seeds in the Left or Right VS. FC estimates were regressed on specific symptoms. RESULTS: Depressed patients displayed higher functional connectivity between the VS and midline cortical areas during loss versus reward trials. Anhedonia and depressed mood were associated to fairly similar striatal circuits but suicidality was associated to a unique VS-midline structures coupling, while depression severity was linked to higher VS to caudate and precuneus connectivity during loss versus reward trials. CONCLUSIONS: Depression is characterized by excessive VS coupling to cognitive control and associative networks during losses versus rewards. High VS to midline cortical structures coupling may index suicidality.

The neurobiology of self-processing in abused depressed adolescents.

Maltreatment is associated with chronic depression, high negative self-attributions, and lifetime psychopathology. Adolescence is a sensitive period for the formation of self-concept. Identifying neurobiomarkers of self-processing in depressed adolescents with and without maltreatment may parse the effects of trauma and depression on self-development and chronic psychopathology. Depressed adolescents (n = 86) maltreated due to omission (DO, n = 13) or commission (DCM, n = 28) or without maltreatment (DC, n = 45), and HCs (HC, n = 37) appraised positive and negative self-descriptors in the scanner. DCM and DO showed hypoactivity in the dorsal anterior cingulate cortex (dACC) while processing positive versus negative self-descriptors compared to DC youth, who in turn showed reduced dACC recruitment versus HC. HC youth showed the highest activation in the dACC and striatum during positive self-descriptors; these regions showed a linear decline in activity across DC, DO, and DCM. Low dACC activity to positive versus negative self-descriptors was linked to inadequate coregulation of children's emotions by parents. Negative self-cognitions prevalent in DCM and DO adolescents may be perpetuated by activity in the dACC and striatum. Reduced activation of the dACC and striatum for positive self-descriptors, coupled with enhanced activity for negative self-descriptors, may heighten the risk for persistent depression.

The neurobiology of self-face recognition in depressed adolescents with low or high suicidality.

This study sought to test whether the neurobiology of self-processing differentiated depressed adolescents with high suicidality (HS) from those with low suicidality (LS) and healthy controls (HC; N = 119, MAGE = 14.79, SD = 1.64, Min = 11.3, Max = 17.8). Participants completed a visual self-recognition task in the scanner during which they identified their own or an unfamiliar adolescent face across 3 emotional expressions (happy, neutral or sad). A 3-group (HS, LS, HC) by 2 within-subject factors (2 Self conditions [self, other] and 3 Emotions [happy, neutral, sad]) GLM yielded (a) a main effect of Self condition with all participants showing higher activity in the right occipital, precuneus and fusiform during the self- versus other-face conditions; (b) a main effect of Group where all depressed youth showed higher dorsolateral prefrontal cortex activity than HC across all conditions, and with HS showing higher cuneus and occipital activity versus both LS and HC; and (c) a Group by Self by Emotion interaction with HS showing lower activity in both mid parietal, limbic, and prefrontal areas in the Happy self versus other-face condition relative to the LS group, who in turn had less activity compared to HC youth. Covarying for depression severity replicated all results except the third finding; In this subsequent analysis, a Group by Self interaction showed that although HC had similar midline cortical structure (MCS) activity for all faces, LS showed higher MCS activity for the self versus other faces, whereas HS showed the opposite pattern. Results suggest that the neurophysiology of emotionally charged self-referential information can distinguish depressed, suicidal youth versus nonsuicidal depressed and healthy adolescents. Neurophysiological differences and implications for the prediction of suicidality in youth are discussed. (PsycINFO Database Record

The neurobiology of self-knowledge in depressed and self-injurious youth.

There is limited information regarding the neurobiology underlying non-suicidal self-injury (NSSI) in clinically-referred youth. However, the salience of disturbed interpersonal relationships and disrupted self-processing associated with NSSI suggests the neural basis of social processes as a key area for additional study. Adolescent participants (N=123; M=14.75 years, SD=1.64) were divided into three groups: NSSI plus depression diagnosis (NSSI), depression only (DEP), healthy controls (HC). In the scanner, participants completed an Interpersonal Self-Processing task by taking direct (own) and indirect (mothers', best friends', or classmates') perspectives regarding self-characteristics. Across all perspectives, NSSI showed higher BOLD activation in limbic areas, and anterior and posterior cortical midline structures versus DEP and HC, while HC showed greater activity in rostrolateral, frontal pole and occipital cortex than NSSI and DEP youth. Moreover, NSSI youth showed heightened responses in amygdala, hippocampus, parahippocampus, and fusiform when taking their mothers' perspective, which were negatively correlated with self-reports of the mother's support of adolescents' emotional distress in the NSSI group. NSSI youth also yielded greater precuneus and posterior cingulate cortex activity during indirect self-processing from their classmates' perspective. Findings suggest a role for disruptions in self- and emotion-processing, and conflicted social relationships in the neurobiology of NSSI among depressed adolescents.