Phyllis L. Hendry

Children's mental health emergencies-part 1: Challenges in care: Definition of the problem, barriers to care, screening, advocacy, and resources

Objective: At a time when there has been a reduction in mental health resources nationwide, the incidence of mental health disorders in children has seen a dramatic increase for many reasons. Methods: A review of the literature was done to identify the epidemiology, barriers to care, useful emergency department (ED) screening methods, and resources regarding pediatric mental health disorders in the ED. Results: Although there are many challenges to the provision of care for children with mental health emergencies, some resources are available. Furthermore, ED screening and intervention may be effective in improving patient outcomes. Conclusions: Collaborative efforts with multidisciplinary services can create a continuum of care, promote better identification of children and adolescents with mental health disorders, and promote early recognition and intervention, which are key to effective referral and treatment.

Incidence and predictors of neck and widespread pain after motor vehicle collision among US litigants and nonlitigants

Summary Most individuals with pain sequelae 6 weeks after motor vehicle collision are not engaged in litigation. Evidence supports bidirectional effects between litigation and post–motor vehicle collision musculoskeletal pain outcomes. ABSTRACT Debate continues regarding the influence of litigation on pain outcomes after motor vehicle collision (MVC). In this study we enrolled European Americans presenting to the emergency department (ED) in the hours after MVC (n = 948). Six weeks later, participants were interviewed regarding pain symptoms and asked about their participation in MVC‐related litigation. The incidence and predictors of neck pain and widespread pain 6 weeks after MVC were compared among those engaged in litigation (litigants) and those not engaged in litigation (nonlitigants). Among the 859 of 948 (91%) participants completing 6‐week follow‐up, 711 of 849 (83%) were nonlitigants. Compared to nonlitigants, litigants were less educated and had more severe neck pain and overall pain, and a greater extent of pain at the time of ED evaluation. Among individuals not engaged in litigation, persistent pain 6 weeks after MVC was common: 199 of 711 (28%) had moderate or severe neck pain, 92 of 711 (13%) had widespread pain, and 29 of 711 (4%) had fibromyalgia‐like symptoms. Incidence of all 3 outcomes was significantly higher among litigants. Initial pain severity in the ED predicted pain outcomes among both litigants and nonlitigants. Markers of socioeconomic disadvantage predicted worse pain outcomes in litigants but not nonlitigants, and individual pain and psychological symptoms were less predictive of pain outcomes among those engaged in litigation. These data demonstrate that persistent pain after MVC is common among those not engaged in litigation, and provide evidence for bidirectional influences between pain outcomes and litigation after MVC.

Polymorphisms in the glucocorticoid receptor co-chaperone FKBP5 predict persistent musculoskeletal pain after traumatic stress exposure.

&NA; An association is demonstrated between genetic polymorphisms in the gene coding for a key regulatory molecule in the hypothalamic‐pituitary‐adrenal axis and persistent pain after trauma. &NA; Individual vulnerability factors influencing the function of the hypothalamic‐pituitary‐adrenal axis may contribute to the risk of the development of persistent musculoskeletal pain after traumatic stress exposure. The objective of the study was to evaluate the association between polymorphisms in the gene encoding FK506 binding protein 51, FKBP5, a glucocorticoid receptor co‐chaperone, and musculoskeletal pain severity 6 weeks after 2 common trauma exposures. The study included data from 2 prospective emergency department‐based cohorts: a discovery cohort (n = 949) of European Americans experiencing motor vehicle collision and a replication cohort of adult European American women experiencing sexual assault (n = 53). DNA was collected from trauma survivors at the time of initial assessment. Overall pain and neck pain 6 weeks after trauma exposure were assessed using a 0–10 numeric rating scale. After adjustment for multiple comparisons, 6 FKBP5 polymorphisms showed significant association (minimum P < 0.0001) with both overall and neck pain in the discovery cohort. The association of rs3800373, rs9380526, rs9394314, rs2817032, and rs2817040 with neck pain and/or overall pain 6 weeks after trauma was replicated in the sexual assault cohort, showing the same direction of the effect in each case. The results of this study indicate that genetic variants in FKBP5 influence the severity of musculoskeletal pain symptoms experienced during the weeks after motor vehicle collision and sexual assault. These results suggest that glucocorticoid pathways influence the development of persistent posttraumatic pain, and that such pathways may be a target of pharmacologic interventions aimed at improving recovery after trauma.

Using emergency department-based inception cohorts to determine genetic characteristics associated with long term patient outcomes after motor vehicle collision: Methodology of the CRASH study

BackgroundPersistent musculoskeletal pain and psychological sequelae following minor motor vehicle collision (MVC) are common problems with a large economic cost. Prospective studies of pain following MVC have demonstrated that demographic characteristics, including female gender and low education level, and psychological characteristics, including high pre-collision anxiety, are independent predictors of persistent pain. These results have contributed to the psychological and social components of a biopsychosocial model of post-MVC pain pathogenesis, but the biological contributors to the model remain poorly defined. Recent experimental studies indicate that genetic variations in adrenergic system function influence the vulnerability to post-traumatic pain, but no studies have examined the contribution of genetic factors to existing predictive models of vulnerability to persistent pain.Methods/DesignThe Project CRASH study is a federally supported, multicenter, prospective study designed to determine whether variations in genes affecting synaptic catecholamine levels and alpha and beta adrenergic receptor function augment social and psychological factors in a predictive model of persistent musculoskeletal pain and posttraumatic stress disorder (PTSD) following minor MVC. The Project CRASH study will assess pain, pain interference and PTSD symptoms at 6 weeks, 6 months, and 1 year in approximately 1,000 patients enrolled from 8 Emergency Departments in four states with no-fault accident laws.DiscussionThe results from this study will provide insights into the pathophysiology of persistent pain and PTSD following MVC and may serve to improve the ability of clinicians and researchers to identify individuals at high risk for adverse outcomes following minor MVC.

More Educated Emergency Department Patients are Less Likely to Receive Opioids for Acute Pain

Summary Of patients presenting to an emergency department for evaluation after a motor vehicle collision, those with higher educational attainment are less likely to receive opioids. ABSTRACT Inadequate treatment of pain in United States emergency departments (EDs) is common, in part because of the limited and idiosyncratic use of opioids by emergency providers. This study sought to determine the relationship between patient socioeconomic characteristics and the likelihood that they would receive opioids during a pain‐related ED visit. We conducted a cross‐sectional analysis of ED data obtained as part of a multicenter study of outcomes after minor motor vehicle collision (MVC). Study patients were non‐Hispanic white patients between the ages of 18 and 65 years who were evaluated and discharged home from 1 of 8 EDs in 4 states. Socioeconomic characteristics include educational attainment and income. Of 690 enrolled patients, the majority had moderate or severe pain (80%). Patients with higher education attainment had lower levels of pain, pain catastrophizing, perceived life threat, and distress. More educated patients were also less likely to receive opioids during their ED visit. Opioids were given to 54% of patients who did not complete high school vs 10% of patients with post‐college education (χ2 test P < .001). Differences in the frequency of opioid administration between patients with the lowest educational attainment (39%, 95% confidence interval 22% to 60%) and highest educational attainment (13%, 95% confidence interval 7% to 23%) remained after adjustment for age, sex, income, and pain severity (P = .01). In this sample of post‐MVC ED patients, more educated patients were less likely to receive opioids. Further study is needed to assess the generalizability of these findings and to determine the reason for the difference.

Pain distribution and predictors of widespread pain in the immediate aftermath of motor vehicle collision.

Musculoskeletal pain is common after motor vehicle collision (MVC). The study objective was to evaluate distribution of pain and predictors of widespread musculoskeletal pain in the early aftermath (within 48 h) of collision.

No man is an island: living in a disadvantaged neighborhood influences chronic pain development after motor vehicle collision.

&NA; Pain recovery after trauma is influenced by neighborhood socioeconomic characteristics. These findings are independent of individual characteristics, and moderated by genetic variation in FKBP5. &NA; Living in a lower socioeconomic status neighborhood has been shown to alter stress system function and is associated with a number of adverse health outcomes, but its influence on musculoskeletal pain (MSP) outcomes after traumatic stress exposures such as motor vehicle collision (MVC) has not been assessed. We performed a multicenter, prospective study that enrolled 948 European‐American individuals within 24 hours of MVC who were discharged home after emergency department evaluation. Follow‐up evaluations were completed via telephone or Internet survey 6 weeks, 6 months, and 1 year after MVC on 91%, 89%, and 91% of participants, respectively. A robust aggregate measure of census tract neighborhood disadvantage was derived, and individual‐level characteristics assessed included socioeconomic and demographic characteristics, pain prior to MVC, litigation status, and opioid use. MSP was assessed in the emergency department; MSP and pain interference with daily activity were assessed at 6 weeks, 6 months, and 1 year. After adjustment for individual‐level factors, living in more disadvantaged neighborhoods was associated with increased MSP (P = 0.0009) and increased pain interference with daily function (P < 0.0001). The relationship between neighborhood disadvantage and MSP was moderated by a common single nucleotide polymorphism, rs2817038, 5′ of the gene encoding FKBP5, a functional regulator of glucocorticoid receptor sensitivity (interaction P‐value = 0.0015). These data support the hypothesis that low neighborhood socioeconomic status increases the likelihood of worse MSP outcomes after traumatic stress exposures such as MVC, and that this influence is mediated in part via its influence on stress system function.

Children's mental health emergencies-part 3: special situations: child maltreatment, violence, and response to disasters

Objective: Children may be exposed to or even be the victims of a violent situation, or a disaster, and the likelihood of a childs exposure to a violent situation or a disaster is increasing. Methods: A review of the literature was done to address key mental health issues occurring with child maltreatment, violence in the home, community, in the emergency department, and disasters. Results: Although pediatric mental health issues regarding violence, disasters, and child maltreatment have often been overlooked or unrecognized, the consequences for the child in such situations can be devastating. However, recognition and appropriate treatment can favorably impact the childs recovery from exposure to such violent events or disasters. Conclusions: Recognition and early intervention to address the mental health issues of children in violent situations or disasters can help ameliorate the negative psychological sequelae of such events. The importance of providing mental health and social services to children exposed to disasters was recognized by the Pediatric Institute of Medicine Report.

Chronic widespread pain after motor vehicle collision typically occurs through immediate development and nonrecovery: results of an emergency department-based cohort study.

Abstract Motor vehicle collision (MVC) can trigger chronic widespread pain (CWP) development in vulnerable individuals. Whether such CWP typically develops through the evolution of pain from regional to widespread or through the early development of widespread pain with nonrecovery is currently unknown. We evaluated the trajectory of CWP development (American College of Rheumatology criteria) among 948 European–American individuals who presented to the emergency department (ED) for care in the early aftermath of MVC. Pain extent was assessed in the ED and 6 weeks, 6 months, and 1 year after MVC on 100%, 91%, 89%, and 91% of participants, respectively. Individuals who reported prior CWP at the time of ED evaluation (n = 53) were excluded. Trajectory modeling identified a 2-group solution as optimal, with the Bayes Factor value (138) indicating strong model selection. Linear solution plots supported a nonrecovery model. Although the number of body regions with pain in the non-CWP group steadily declined, the number of body regions with pain in the CWP trajectory group (192/895, 22%) remained relatively constant over time. These data support the hypothesis that individuals who develop CWP after MVC develop widespread pain in the early aftermath of MVC, which does not remit.

Effect of pain location and duration on life function in the year after motor vehicle collision

Summary In this prospective study of 948 subjects, axial and widespread pain had the greatest influence on life interference during the year after motor vehicle collision. ABSTRACT Persistent musculoskeletal pain is common after motor vehicle collision (MVC) and often results in substantial disability. The objective of this study was to identify distributions of post‐MVC pain that most interfere with specific life functions and that have the greatest interference with aggregate life function. Study data were obtained from a prospective longitudinal multicenter emergency department–based cohort of 948 European Americans experiencing MVC. Overall pain (0–10 numeric rating scale [NRS]), pain in each of 20 body regions (0–10 NRS), and pain interference (Brief Pain Inventory, 0–10 NRS) were assessed 6 weeks, 6 months, and 1 year after MVC. After adjustment for overall pain intensity, an axial distribution of pain caused the greatest interference with most specific life functions (R2 = 0.15–0.28, association P values of <.001) and with overall function. Axial pain explained more than twice as much variance in pain interference as other pain distributions. However, not all patients with axial pain had neck pain. Moderate or severe low back pain was as common as neck pain at week 6 (prevalence 37% for each) and overlapped with neck pain in only 23% of patients. Further, pain across all body regions accounted for nearly twice as much of the variance in pain interference as neck pain alone (60% vs 34%). These findings suggest that studies of post‐MVC pain should not focus on neck pain alone.