Impact of mental health on seeking pain care among veterans with serious mental illness.

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Published in final edited form as: Gen Hosp Psychiatry. 2021 Jul 27;75:92–93. doi: 10.1016/j.genhosppsych.2021.07.008 Impact of mental health on seeking pain care among veterans with serious mental illness Natasha A Tonge a, b, * , Letitia E Travaglini c , Clayton H Brown a, d , Anjana Muralidharan a, b , Richard W Goldberg a, b Author information Article notes Copyright and License information a VA Capitol Healthcare Network (VISN 5) Mental Illness Research, Education, and Clinical Center (MIRECC), 10 N. Greene St., Annex Building 7th Fl., Baltimore, MD 21201, USA b University of Maryland School of Medicine, Department of Psychiatry, 737 W. Lombard St., Baltimore, MD 21201, USA c VA Maryland Health Care System, Department of Neurology, Chronic Pain Service, 10 N. Greene St., Baltimore, MD 21201, USA d Department of Epidemiology and Public Health, University of Maryland School of Medicine, 660 W. Redwood St., Baltimore, MD 21201, United States of America Author contributions Natasha A. Tonge: conceptualization, data curation, formal analysis, methodology, writing (original draft, review, editing). Letitia E. Travaglini: conceptualization, data curation, formal analysis, methodology, writing (original draft, review, editing). Clayton H. Brown: conceptualization, data curation, formal analysis, methodology, writing (review and editing). Anjana Muralidharan: conceptualization, methodology, project administration, resources, writing (review and editing). Richard W. Goldberg: conceptualization, methodology, funding acquisition, investigation, project administration, resources, writing (review and editing). * Corresponding author at: Notre Dame of Maryland University, 4701 N Charles St, Baltimore, MD 21211, USA. Natasha.Tonge@va.gov , ntonde@ndm.edu (N.A. Tonge) Issue date 2022 Mar-Apr. PMC Copyright notice PMCID: PMC13224098  NIHMSID: NIHMS2159354  PMID: 34839929 The publisher's version of this article is available at Gen Hosp Psychiatry Letter to the editor Chronic pain is prevalent in the United States, impairs physical, psychological, and social functioning, and is associated with mental health concerns including depression, anxiety, and trauma [ 1 , 2 ]. Chronic pain is a leading reason for seeking health care in the United States [ 1 ], and increased pain severity and/or psychological distress (i.e., depression, anxiety) is associated with greater help-seeking behavior in general adult populations [ 3 , 4 ]. Individuals with serious mental illness (SMI; schizophrenia spectrum, bipolar disorder, chronic post-traumatic stress disorder, severe depression) also have high rates of debilitating chronic pain [ 2 , 5 ]. Although positive relationships between pain and depression are well-documented, the relationship between psychosis and pain is less clear [ 6 , 7 ]. Furthermore, it is unknown how psychological distress in SMI populations impacts help-seeking when pain is also present. The current investigation explored how mental health symptoms (depression, psychosis, insomnia) interact with pain severity to affect help-seeking for pain in a subsample of Veterans with SMI and joint pain from a larger intervention study [ 8 ]. We hypothesized that greater pain severity would be associated with greater mental health symptoms. We then hypothesized that the interaction of psychosis and pain would decrease likelihood of treatment for chronic pain, but that pain interactions with depression and insomnia would increase the likelihood of treatment for chronic pain. Study procedures were approved by the University of Maryland IRB and relevant VA research oversight committees. Data were obtained from baseline self-report questionnaires from participants across both conditions of a randomized controlled trial examining a group-based intervention for Veterans with SMI to improve physical health behaviors [ 8 ]. Participants included 184 veterans with SMI (per medical record) and self-reported current joint pain. Demographics and BMI were collected as part of the parent study (see Supplemental Table 1 ). Pain severity was based on the average of four pain numeric rating scale (PNRS) ratings: current, usual, worst, and least pain ratings in the past week. Scores ranged from 0 ( no pain ) to 10 ( worst pain ). Depression and psychotic symptoms were assessed using the Behavioral and Symptom Identification Scale (BASIS-24) [ 9 ], with scores ranging from 0 to 4 (higher scores denote greater severity) in the past week. Insomnia was assessed using the Insomnia Severity Index (ISI) [ 10 ], with higher scores (ranges 0–28) indicating greater insomnia severity in the past two weeks. We used self-reported treatment by a VA provider for chronic pain in the past six months to indicate help-seeking. We examined correlations among average pain rating, sleep, depression, psychosis, BMI, age, race, gender, education, and marital status (see Supplemental Table 2 ). We then tested the effect of pain severity on the odds of a being treated for chronic pain, then tested the interaction between pain severity and the mental health symptom variables using mean-centered variables using logistic regression. We found significant correlations between pain severity and depression ( r = 0.394, p < .001), insomnia ( r = 0.382, p < .001), and psychosis ( r = 0.163, p = .035) but not age, gender, race, education, marital status, or BMI ( p s = .05–.14). In logistic regressions, pain severity alone did not significantly increase odds (OR = 1.13 [95% CI: 1.00, 1.29], p = .051) of help-seeking. Interactions with pain severity and insomnia (OR = 0.99 [95% CI: 0.97, 1.00], p = .176) or psychosis (OR = 0.92 [95% CI: 0.81, 1.03], p = .150) were non-significant, as were all lower order terms ( p s > .081). However, there was a significant interaction between depression and pain severity (B = − 0.175, Z = − 2.13, OR = 0.84 [95% CI: 0.71, 0.98], p = .033; see Fig. 1 ). Fig. 1. Open in a new tab Interaction of Depression and Average Pain Rating Predicting Probability of Seeing a Pain Physician. The figure demonstrates the interaction effect of depression and average pain with average pain rating on the x-axis, represented at 5 levels of depression on the probability of seeing a pain physician. Average pain at low-to-moderate depression levels predicted increased probability of seeking treatment, as did high levels of depression in the absence of pain. The probability of treatment for pain was lowest for those reporting high levels of both pain and depression. In a Veteran SMI population, mental health symptoms were positively correlated with self-reported pain severity, similar to non-SMI populations [ 2 ]. Against hypotheses, interactions of pain and depression, but not insomnia or psychosis, impacted help-seeking. In contrast with the general population in which depression and pain severity are associated with increased help-seeking [ 3 , 4 ], more severely depressed SMI participants with chronic pain had less help-seeking. Our findings suggest that providers should pay attention to depression symptoms co- occurring with pain in an SMI population. Limitations of our study include having an outpatient sample already engaged in mental health treatment; use of self-report; majority male Veterans; and response scales on different time frames. Further, our study did not investigate causes of help-seeking directly and we defined help-seeking as care within the VA healthcare system. Although 87% of patients in our sample reported that they received primary care through VA providers, we were unable to account for seeking care for pain outside the VA. Future work should determine causal barriers to help-seeking with greater specificity and in other healthcare systems. In conclusion, our study demonstrated that veterans with SMI experience pain which may be exacerbated by depression and impact pain care. Providers should carefully monitor depression in addition to other mental health variables as these could impact identification and treatment of pain conditions in SMI. Supplementary Material Supplemental Table 1 NIHMS2159354-supplement-Supplemental_Table_1.docx (15.6KB, docx) Supplemental Table 2 NIHMS2159354-supplement-Supplemental_Table_2.docx (16.1KB, docx) Acknowledgements This research was supported by the VA Health Services Research and Development Service (IIR 11-216; awarded to RWG, principal investigator), the VA Rehabilitation Research and Development Service (CDA IK2RX002339,; awarded to AM, principal investigator; CDA 1IK2RX003069-01A2 awarded to LET, and the Department of Veterans Affairs Office of Academic Affiliations Advanced Fellowship Program in Mental Illness Research and Treatment (NAT, LET, AM). It is the result of work supported with resources and the use of facilities at the VA Maryland Healthcare System, the VISN 5 MIRECC, and the University of Maryland School of Medicine Department of Psychiatry. This article reflects the authors’ personal views and in no way represents the official view of the Department of Veterans Affairs of the U.S. Government. All study procedures were approved by the University of Maryland Institutional Review Board Institutional Review Board and the related VA research oversight committees. Role of the funder/sponsor The funding source was not involved in the design or conduct of the study; collection, management, analysis, or interpretation of the data; and preparation, review, or approval of the manuscript. Appendix A. Supplementary data Supplementary data to this article can be found online at https://doi.org/10.1016/j.genhosppsych.2021.07.008 . Footnotes Declaration of Competing Interest None reported. References [1]. Institute of Medicine. Relieving pain in America: a blueprint for transforming prevention, care, education and research. Washington, DC: Institute of Medicine; 2011. [ Google Scholar ] [2]. Stubbs B, Koyanagi A, Thompson T, et al. The epidemiology of back pain and its relationship with depression, psychosis, anxiety, sleep disturbances, and stress sensitivity: data from 43 low- and middle income countries. Gen Hosp Psychiatry 2016;43:63–70. [ DOI ] [ PubMed ] [ Google Scholar ] [3]. Cornally N, McCarthy G. (2011). Help-seeking behaviour for the treatment of chronic pain. Br J Community Nurs 2011;16(2):90–8. [ DOI ] [ PubMed ] [ Google Scholar ] [4]. Huysmans E, Leemans L, Beckwée D, et al. The relationship between cognitive and emotional factors and healthcare and medication use in people experiencing pain: a systematic review. J Clin Med 2020. Aug 3;9(8):2486. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] [5]. Birgenheir DG, Ilgen MA, Bohnert AB, Abraham KM, Bowersox NW, Austin K, et al. Pain conditions among veterans with schizophrenia or bipolar disorder. Gen Hosp Psychiatry 2013;35(5):480–4. 10.1016/j.genhosp-psych.2013.03.019.5. [ DOI ] [ PubMed ] [ Google Scholar ] [6]. Travaglini LE, Cosgrave J, Klingaman EA. The impact of pain and sleep problems on quality of life among veterans with serious mental illness. Psychiatr Rehabil J 2019;42(3):229–37. [ DOI ] [ PubMed ] [ Google Scholar ] [7]. Engels G, Francke AL, van Meijel B, et al. Clinical pain in schizophrenia: a systematic review. J Pain 2014;15(5):457–67. [ DOI ] [ PubMed ] [ Google Scholar ] [8]. Muralidharan A, Brown CL, Peer JE, et al. Living well: an intervention to improve medical illness self-management among individuals with serious mental illness. Psychiatr Serv 2019;70(1):19–25. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] [9]. Eisen SV, Gerena M, Ranganathan G, Esch D, Idiculla T. Reliability and validity of the BASIS-24© mental health survey for whites, African-Americans, and Latinos. J Behav Health Serv Res 2006;33(3):304–23. [ DOI ] [ PubMed ] [ Google Scholar ] [10]. Bastien CH, Vallières A, Morin CM. Validation of the insomnia severity index as an` outcome measure for insomnia research. Sleep Med 2001;2(4):297–307. [ DOI ] [ PubMed ] [ Google Scholar ] Associated Data This section collects any data citations, data availability statements, or supplementary materials included in this article. Supplementary Materials Supplemental Table 1 NIHMS2159354-supplement-Supplemental_Table_1.docx (15.6KB, docx) Supplemental Table 2 NIHMS2159354-supplement-Supplemental_Table_2.docx (16.1KB, docx) ACTIONS View on publisher site PDF (142.6 KB) Cite Collections Permalink RESOURCES Similar articles Cited by other articles Links to NCBI Databases Follow NCBI NCBI on X (formerly known as Twitter) NCBI on Facebook NCBI on LinkedIn NCBI on GitHub NCBI RSS feed Connect with NLM NLM on X (formerly known as Twitter) NLM on Facebook NLM on YouTube National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894 Web Policies FOIA HHS Vulnerability Disclosure Help Accessibility Careers NLM NIH HHS USA.gov Back to Top

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