A pilot trial of collaborative care with motivational interviewing to reduce opioid risk and improve chronic pain management.

BACKGROUND AND AIMS: Opioid use and chronic pain are prevalent in the veteran population. Collaborative care enhances coordination between patients and their care teams, and motivational interviewing (MI) is a communication style designed to facilitate behavior change. This study evaluated the use of collaborative care with MI (CCMI) with patients with chronic pain and high-risk prescription opioid use. DESIGN: Small pilot study of a randomized controlled trial. SETTING: An urban Veterans Affairs (VA) Medical Center in the United States. PARTICIPANTS: One hundred adult veterans with chronic pain currently enrolled into primary care and receiving long-term opioid therapy. INTERVENTION AND COMPARATOR: During an initial 1-hour visit with a study primary-care physician (PCP), all veterans (n = 100) developed a personalized pain care plan, after which they were randomized to receive four sessions (at 4, 6, 8 and 12 weeks) of either CCMI (n = 51) or attention control psychoeducation (ACP; n = 49). Subsequently, participants had 30-minute follow-up visits with study PCPs and post-treatment assessment at 12 weeks. MEASUREMENTS: Co-primary outcomes measures assessed opioid risk and pain interference; secondary measures assessed pain severity, PCP rating of opioid risk and pain management goals. FINDINGS: At 12 weeks, intent-to-treat (ITT) analyses using multivariate mixed-effects linear regression were inconclusive regarding the between-group differences in primary and secondary outcomes at post-intervention (12 weeks). Bayes factors for opioid risk, pain interference, pain severity and PCP ratings were 1.96, 1.36, 0.45 and 0.82, respectively. Veterans in the CCMI group reported implementing more complementary integrative health (CIH) goals (e.g. yoga) than did those in the ACP group (d = 0.54). CONCLUSIONS: US veterans with chronic pain who received collaborative care with motivational interviewing reduced their high-risk opioid use and showed improved pain interference and severity after an intake with a primary-care provider involving shared decision-making and the creation of a personalized pain care plan.

Fat Reduction Efforts: A 24-Month Longitudinal Comparison of a Large Sample of Maintainers, Relapsers, and Non-Changers.

This research examined dynamic transtheoretical model (TTM) constructs for dietary fat reduction. This secondary data analysis pooled three large population-based TTM-tailored school, worksite, medical, and home-based intervention studies and examined use of constructs across three groups organized by longitudinal progress (dynatypes): Maintainers, Relapsers, and Stable Non-Changers. The criteria for successful change, at the time, were that less than 30% of calories came from fat. A total of 2,718 adults met criteria for an unhealthy diet at baseline. The majority of participants were female, White, married, and middle-aged. Demographics, Stage of Change, Processes of Change, Decisional Balance, and Temptations were measured. Dynatype groups were assessed with reliable and valid scales assessing constructs at baseline and 6, 12, and 24 months. Analyses included a multivariate analysis of variance followed by a series of analyses of variance, with Tukey follow-up tests assessing differences in use of TTM constructs across the three groups at each time point. Relapsers and Maintainers were similar in their use of all TTM Processes of Change at baseline, with the exception of Self-Liberation (η(2) = 0.15, p < .001) and Reinforcement Management (η(2) = 0.01, p < .001). Although Relapsers reverted to an unhealthy diet, their overall greater use of Processes of Change suggests that their behaviors and strategy use remain better than that of the Stable Non-Changer group. Results suggest that specific cognitive and behavioral constructs may contribute differentially to intervention outcomes.

Predictors of relapse among smokers: transtheoretical effort variables, demographics, and smoking severity.

The present longitudinal study investigates baseline assessments of static and dynamic variables, including demographic characteristics, smoking severity, and Transtheoretical Model of Behavior Change (TTM) effort variables (Decisional Balance (i.e. Pros and Cons), Situational Temptations, and Processes of Change) of relapse among individuals who were abstinent at 12months. The study sample (N=521) was derived from an integrated dataset of four population-based smoking cessation interventions. Several key findings included: Participants who were aged 25-44 and 45-64 (OR=.43, p=.01 and OR=.40, p=.01, respectively) compared to being aged 18-24 were less likely to relapse at follow-up. Participants in the control group were more than twice as likely to relapse (OR=2.17, p=.00) at follow-up compared to participants in the treatment group. Participants who reported higher Habit Strength scores were more likely to relapse (OR=1.05, p=.02). Participants who had higher scores of Reinforcement Management (OR=1.05, p=.04) and Self-Reevaluation (OR=1.08, p=.01) were more likely to relapse. Findings add to one assumption that relapsers tend to relapse not solely due to smoking addiction severity, but due to immediate precursor factors such as emotional distress. One approach would be to provide additional expert guidance on how smokers can manage stress effectively when they enroll in treatment at any stage of change.

Transtheoretical Principles and Processes for Adopting Physical Activity: A Longitudinal 24-Month Comparison of Maintainers, Relapsers, and Nonchangers.

This study examined longitudinal differences in use of transtheoretical model (TTM) behavior change constructs in maintainers (who reached and maintained exercise guidelines), relapsers (who reached guidelines, then regressed), and nonchangers (who did not reach guidelines). Data from two population-based TTM-tailored randomized trial intervention groups targeting exercise behavior (N = 1050) were pooled, and analyses assessed differences in TTM constructs between the three groups at baseline, 12 months, and 24 months. Findings indicated that relapsers tended to use TTM variables similarly to maintainers with the exception of self-efficacy, consciousness raising, and most behavioral processes of change, at 24 months. Nonchangers, however, used all TTM variables less than maintainers at nearly every time point. Findings suggest that relapsers remain more active than nonchangers in terms of use of change processes. Poor response to interventions (nonchangers) may be predicted by low baseline engagement in change processes. Although relapsers reverted to physical inactivity, their overall greater use of TTM constructs suggests that their efforts to change remain better than those of the stable nonchanger group. Future research can focus on treatment engagement strategies to help the stable nonchangers initiate change and to help relapsers to maintain treatment gains.

Mixed effects of deep brain stimulation on depressive symptomatology in Parkinson's disease: a review of randomized clinical trials.

Although ~50% of patients with Parkinson's disease (PD) experience depression, treatment for this important and debilitating comorbidity is relatively understudied. Deep brain stimulation (DBS) has been increasingly utilized for the management of tremors in progressive PD. Several preliminary studies have shown the potential benefit of DBS for non-motor PD symptoms such as depression. Here, we critically evaluate seven recent randomized clinical trials of the effectiveness of DBS in reducing depressive symptomatology among individuals with PD. Findings are mixed for the effectiveness of DBS as a treatment for depression in PD. Our review suggests that this is due, in large part, to the anatomical and methodological variation across the DBS studies. We provide a comprehensive discussion of these variations and highlight the need to conduct larger, more controlled studies aimed specifically at evaluating the treatment of depression in PD patients.

Results of a transtheoretical model-based alcohol, tobacco and other drug intervention in middle schools.

BACKGROUND: Early use of alcohol, tobacco, and other drugs threatens the physical and mental well-being of students and continued use negatively affects many areas of development. An internet-based, tailored intervention based on the Transtheoretical Model of Behavior Change was delivered to middle school students to reduce alcohol, tobacco, and other drug use. This internet-based approach requires very little faculty and staff time, which is efficient given curricular demands. METHODS: Twenty-two middle schools in the United States were matched and randomly assigned to either the intervention or control conditions (N=1590 students who had ever used substances). Participants received one pre-test assessment, three thirty-minute intervention sessions over three months, and two post-test assessments (3 and 14 months after pre-test, respectively). RESULTS: Random effects logistic models showed significant treatment effects for the intervention group when compared to the control group at the 3-month post-test. CONCLUSIONS: This program has the potential to be applied as stand-alone practice or as part of more intensive interventions to promote substance use cessation.

Factors associated with attrition from a randomized controlled trial of meaning-centered group psychotherapy for patients with advanced cancer.

OBJECTIVE: The generalizability of palliative care intervention research is often limited by high rates of study attrition. This study examined factors associated with attrition from a randomized controlled trial comparing meaning-centered group psychotherapy (MCGP), an intervention designed to help advanced cancer patients sustain or enhance their sense of meaning to the supportive group psychotherapy (SGP), a standardized support group. METHODS: Patients with advanced solid tumor cancers (n = 153) were randomized to eight sessions of either the MCGP or SGP. They completed assessments of psychosocial, spiritual, and physical well-being pretreatment, midtreatment, and 2 months post-treatment. Attrition was assessed in terms of the percent of participants who failed to complete these assessments, and demographic, psychiatric, medical, and study-related correlates of attrition were examined for the participants in each of these categories. RESULTS: The rates of attrition at these time points were 28.1%, 17.7%, and 11.1%, respectively; 43.1% of the participants (66 of 153) completed the entire study. The most common reason for dropout was patients feeling too ill. Attrition rates did not vary significantly between study arms. The participants who dropped out pretreatment reported less financial concerns than post-treatment dropouts, and the participants who dropped out of the study midtreatment had poorer physical health than treatment completers. There were no other significant associations between attrition and any demographic, medical, psychiatric, or study-related variables. CONCLUSIONS: These findings highlight the challenge of maintaining advanced cancer patients in longitudinal research and suggest the need to consider alternative approaches (e.g., telemedicine) for patients who might benefit from group interventions but are too ill to travel.

Descriptive characteristics of a colon disease family registry at an urban hospital.

BACKGROUND: Hospital registries are an important component of cancer screening efforts of individuals and communities. This paper describes the structure and goals of a Colon Disease Family Registry at a metropolitan hospital. Patient characteristics, differences between gastrointestinal diseases among probands, subjective distress in relation to perception of colorectal cancer, and quality of life were examined. METHODS: Participants were patients with colorectal cancer (CRC), familial adenomatous polyposis (FAP), hereditary nonpolyposis colorectal carcinoma (HNPCC) and inflammatory bowel disease ulcerative colitis (UC) and Crohn's disease representing a range of colonic diseases. A total of 630 probands were recruited into the registry and administered a questionnaire. RESULTS: Of the 630 probands, 198 (31.4%) were diagnosed with CRC, 36 (5.3%) with FAP or HNPCC and 272 (43.2%) with UC or Crohn's. The majority of all three groups had some level of college education, was white, and reported a household income greater then $70,000. The Impact of Event Scale score was found to be of notable significance when categorized by relation to proband (p<0.01) and proband diagnoses (p ≤ 0.000). On the quality of life item, the largest difference was between FAP or HNPCC and UC or Crohn's without CRC. CONCLUSION: Subjective distress scores were higher for CRC probands in comparison to probands with other colorectal diseases. Quality of life was relatively high for all probands. Psychological distress should be explored in more depth and more frequently to screen for any concomitant psychiatric disorders like post-traumatic symptoms that have been linked to a cancer diagnosis.

Concomitant Hodgkin's lymphoma and gastric adenocarcinoma: a rare coincidence.

Gastric adenocarcinomas may be seen together with colon, prostate, breast, liver, lung and gynecological malignancies as synchronous or metachronous cancer. However, Hodgkin's lymphoma (HL) is rarely diagnosed with solid tumors. Herein, a 72-year-old man with both gastric adenocarcinoma and HL has been presented. Mass lesions far away from the primary tumor in cancer patients can be not only the sign of distant metastasis but also another primary malignancy. In the English literature, synchronous gastric adenocarcinoma and HL has been rarely reported, and as far as we know, this is the third case to be reported.

An Internet-Based Computer-Tailored Intervention to Promote Responsible Drinking: Findings from a Pilot Test with Employed Adults.

This paper describes pilot test findings of an Internet-based, Transtheoretical Model-based, computer tailored intervention for adults who exceed national guidelines for low-risk drinking. In a pilot test, 166 adults recruited from worksites completed one session and evaluated the program. Pre and post assessments indicate intention to make behavioral changes. Importantly, 94.3% of participants indicated that they would recommend the program. Ratings were positive with the majority of participants 'agreeing' or 'strongly agreeing' with all 14 evaluation items. Feasibility was demonstrated by recruiting and engaging employed adults. This program is a cost-effective prevention program promoting responsible drinking to adults.

A review of panic and suicide in bipolar disorder: does comorbidity increase risk?

INTRODUCTION: Bipolar mood disorder carries a serious suicide risk. Panic disorder, which also confers an independent risk of suicide and psychiatric comorbidity, in general has been found to amplify suicidality in mood-disordered patients. This article assesses the available literature on how panic and suicide relate to each other in bipolar mood-disordered patients. METHODS: We conducted a search on Medline and PsycINFO using the keywords "anxiety", "attempted suicide", "completed suicide", "mortality", "self-harm" in combination with "bipolar", "manic depression" and "panic". Twenty-four articles were included in the evaluation. RESULTS: 14 papers support increased risk, 9 papers do not support increased risk, and 3 papers are inconclusive. CONCLUSIONS: The presence of comorbid panic disorder in individuals with bipolar disorder may confer an increased risk of suicide risk. Some papers' reviewed have conflicting conclusions but the majority of papers support an increased risk. This is consistent with a recent (2008) literature review supporting increased risk of suicide in bipolar patients with comorbid anxiety disorders. Future research should study specific bipolar subgroups, focus on anxiety and panic symptoms rather than diagnosis, and look at the role of specific pharmacological treatment in patients with comorbid mood and anxiety disorders.