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Importance: Medication management and cognitive behavioral therapy (CBT) are commonly used treatments for chronic low back pain (CLBP). However, little evidence is available comparing the effectiveness of these approaches. Objective: To compare collaborative care medication optimization vs CBT on pain intensity, interference, and other pain-related outcomes. Design, Setting, and Participants: The Care Management for the Effective Use of Opioids (CAMEO) trial was a 12-month, comparative effectiveness randomized clinical trial with blinded outcome assessment. Recruitment of veterans with CLBP prescribed long-term opioids occurred at 7 Veterans Affairs primary care clinics from September 1, 2011, to December 31, 2014, and follow-up was completed December 31, 2015. Analyses were based on intention to treat in all randomized participants and were performed from March 22, 2015, to November 1, 2021. Interventions: Patients were randomized to receive either collaborative care with nurse care manager-delivered medication optimization (MED group) (n = 131) or psychologist-delivered CBT (CBT group) (n = 130) for 6 months, with check-in visits at 9 months and final outcome assessment at 12 months. Main Outcomes and Measures: The primary outcome was change in Brief Pain Inventory (BPI) total score, a composite of the pain intensity and interference subscales at 6 (treatment completion) and 12 (follow-up completion) months. Scores on the BPI range from 0 to 10, with higher scores representing greater pain impact and a 30% improvement considered a clinically meaningful treatment response. Secondary outcomes included pain-related disability, pain catastrophizing, self-reported substance misuse, health-related quality of life, depression, and anxiety. Results: A total of 261 patients (241 [92.3%] men; mean [SD] age, 57.9 [9.5] years) were randomized and included in the analysis. Baseline mean (SD) BPI scores in the MED and CBT groups were 6.45 (1.79) and 6.49 (1.67), respectively. Improvements in BPI scores were significantly greater in the MED group at 12 months (between-group difference, -0.54 [95% CI, -1.18 to -0.31]; P = .04) but not at 6 months (between-group difference, -0.46 [95% CI, -0.94 to 0.11]; P = .07). Secondary outcomes did not differ significantly between treatment groups. Conclusions and Relevance: In this randomized clinical trial among US veterans with CLBP who were prescribed long-term opioid therapy, collaborative care medication optimization was modestly more effective than CBT in reducing pain impact during the 12-month study. However, this difference may not be clinically meaningful or generalize to nonveteran populations. Trial Registration: ClinicalTrials.gov Identifier: NCT01236521.
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Terapia Cognitivo-Conductual , Dolor de la Región Lumbar , Veteranos , Masculino , Humanos , Persona de Mediana Edad , Femenino , Dolor de la Región Lumbar/tratamiento farmacológico , Analgésicos Opioides/uso terapéutico , Calidad de VidaRESUMEN
OBJECTIVE: Our objectives were to: 1) assess the relationship between self-reported opioid use and baseline demographics, clinical characteristics and pain outcomes; and 2) examine whether baseline opioid use moderated the intervention effect on outcomes at 9 months. DESIGN: We conducted a secondary analysis of data from the Evaluation of Stepped Care for Chronic Pain (ESCAPE) trial, which found stepped-care to be effective for chronic pain in military veterans. SETTING: A post-deployment clinic and five general medicine clinics at a Veteran Affairs Medical Center. SUBJECTS: In total 241 veterans with chronic musculoskeletal pain; 220 with complete data at 9 months. METHODS: Examination of baseline relationships and multivariable linear regression to examine baseline opioid use as a moderator of pain-related outcomes including Roland Morris Disability Questionnaire (RMDQ), Brief Pain Inventory (BPI) Interference scale, and Graded Chronic Pain Scale (GCPS) at 9 months. RESULTS: Veterans reporting baseline opioid use (n = 80) had significantly worse RMDQ (16.0 ± 4.9 vs. 13.4 ± 4.2, P < .0001), GCPS (68.7 ± 12.0 vs. 65.0 ± 14.4, P = .049), BPI Interference (6.2 ± 2.2 vs. 5.0 ± 2.1, P < .0001), and depression (PHQ-9 12.5 ± 6.2 vs. 10.6 ± 5.7, P = .016) compared to veterans not reporting baseline opioid use. Using multivariable modeling we found that baseline opioid use moderated the intervention effect on pain-related disability (RMDQ) at 9 months (interaction Beta = -3.88, P = .0064) but not pain intensity or interference. CONCLUSIONS: In a stepped-care trial for pain, patients reporting baseline opioid use had greater improvement in pain disability at 9 months compared to patients not reporting opioid use.
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Dolor Crónico , Veteranos , Afganistán , Analgésicos Opioides/uso terapéutico , Dolor Crónico/tratamiento farmacológico , Humanos , IrakRESUMEN
Low back pain is the most common pain condition seen in primary care, with the most common treatment being analgesic medications, including opioids. A dramatic increase in opioid prescriptions for low back pain over the past few decades has led to increased non-medical use and opioid overdose deaths. Cognitive behavioral therapy (CBT) for chronic pain is an evidence-based non-pharmacological treatment for pain with demonstrated efficacy when delivered using collaborative care models. No previous studies have tested CBT compared to analgesic optimization that includes opioid management in primary care. This paper describes the study design and methods of the CAre Management for the Effective use of Opioids (CAMEO) trial, a 2-arm, randomized comparative effectiveness trial in seven primary care clinics. CAMEO enrolled 261 primary care veterans with chronic (6 months or longer) low back pain of at least moderate severity who were receiving long-term opioid therapy and randomized them to either nurse care management focused on analgesic treatment and optimization (MED) or cognitive behavioral therapy (CBT). All subjects undergo comprehensive outcome assessments at baseline, 3, 6, 9, and 12 months by interviewers blinded to treatment assignment. The primary outcome is pain severity and interference, measured by the Brief Pain Inventory (BPI) total score. Secondary outcomes include health-related quality of life, fatigue, sleep, functional improvement, pain disability, pain beliefs, alcohol and opioid problems, depression, anxiety, and stress.
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Analgésicos Opioides , Dolor Crónico , Ensayos Clínicos Controlados Aleatorios como Asunto , Analgésicos , Analgésicos Opioides/uso terapéutico , Dolor Crónico/tratamiento farmacológico , Humanos , Dimensión del Dolor , Calidad de Vida , Ensayos Clínicos Controlados Aleatorios como Asunto/métodosRESUMEN
OBJECTIVE: We aimed to examine 1) the relationship between multifocal pain and clinical characteristics, including demographics, pain outcomes, somatic symptoms, health-related quality of life, depression, and anxiety, and 2) whether multifocal pain was independently associated with treatment response. METHODS: We conducted a secondary data analysis on veterans with chronic pain enrolled in the Evaluation of Stepped Care for Chronic Pain (ESCAPE) trial with complete data at 9 months (n = 222). We examined baseline relationships and used multivariable linear regression to examine whether multifocal pain was independently associated with outcomes that included Brief Pain Inventory (BPI) Interference scale and Graded Chronic Pain Scale (GCPS) scores between baseline and 9 months. RESULTS: The sample had a mean BPI Interference score of 5.3 ± 2.2 and a mean GCPS score of 65.6 ± 13.7, 55% had significant depression (Patient Health Questionnaire 9-item depression scale [PHQ-9] score of ≥10), and 42% had significant anxiety (Generalized Anxiety Disorder Scale [GAD-7] score of ≥10). Veterans reporting three or more pain sites (the "more diffuse pain" group) had significantly less improvement on GCPS (b = 4.6, standard error [SE] = 2.3, P = 0.045), BPI Interference (b = 1.0, SE = 0.2, P = 0.0011), and health-related quality of life (Short-Form 36-item scale, Physical Component Summary) (b = 4.1, SE = 1.0, P < 0.0001) than did veterans reporting fewer than three pain sites (the "less diffuse pain" group). More diffuse pain was not associated with changes in PHQ-9 or GAD-7 scores. CONCLUSIONS: Multifocal pain predicted worse pain outcomes between baseline and 9 months in veterans enrolled in a trial for treating chronic musculoskeletal pain.
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Dolor Crónico , Dolor Musculoesquelético , Veteranos , Análisis de Datos , Humanos , Dolor Musculoesquelético/diagnóstico , Calidad de VidaRESUMEN
OBJECTIVE: To compare pain and psychological outcomes in veterans with chronic musculoskeletal pain and comorbid post-traumatic stress disorder (PTSD) or pain alone and to determine if veterans with comorbidity respond differently to a stepped-care intervention than those with pain alone. DESIGN: Secondary analysis of data from the Evaluation of Stepped Care for Chronic Pain (ESCAPE) trial. SETTING: Six Veterans Health Affairs clinics. SUBJECTS: Iraq and Afghanistan veterans (N = 222) with chronic musculoskeletal pain. METHODS: Longitudinal analysis of veterans with chronic musculoskeletal pain and PTSD or pain alone and available baseline and nine-month trial data. Participants randomized to either usual care or a stepped-care intervention were analyzed. The pain-PTSD comorbidity group screened positive for PTSD and had a PTSD Checklist-Civilian score ≥41 at baseline. RESULTS: T tests demonstrated statistically significant differences and worse outcomes on pain severity, pain cognitions, and psychological outcomes in veterans with comorbid pain and PTSD compared with those with pain alone. Analysis of covariance (ANCOVA) modeling change scores from baseline to nine months indicated no statistically significant differences, controlling for PTSD, on pain severity, pain centrality, or pain self-efficacy. Significant differences emerged for pain catastrophizing (t = 3.10, P < 0.01), depression (t = 3.39, P < 0.001), and anxiety (t = 3.80, P < 0.001). The interaction between PTSD and the stepped-care intervention was not significant. CONCLUSIONS: Veterans with the pain-PTSD comorbidity demonstrated worse pain and psychological outcomes than those with chronic pain alone. These findings indicate a more intense chronic pain experience for veterans when PTSD co-occurs with pain. PTSD did not lead to a differential response to a stepped-care intervention.
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Dolor Crónico , Trastornos por Estrés Postraumático , Veteranos , Campaña Afgana 2001- , Afganistán , Dolor Crónico/epidemiología , Humanos , Irak , Guerra de Irak 2003-2011 , Estudios Longitudinales , Trastornos por Estrés Postraumático/epidemiologíaRESUMEN
PURPOSE: Little research has examined cancer patients' expectations, goals, and priorities for symptom improvement. Thus, we examined these outcomes in metastatic breast cancer patients to provide patients' perspectives on clinically meaningful symptom improvement and priorities for symptom management. METHODS: Eighty women with metastatic breast cancer participated in a survey with measures of comorbidity, functional status, engagement in roles and activities, distress, quality of life, and the modified Patient-Centered Outcomes Questionnaire that focused on 10 common symptoms in cancer patients. RESULTS: On average, patients reported low to moderate severity across the 10 symptoms and expected symptom treatment to be successful. Patients indicated that a 49% reduction in fatigue, 48% reduction in thinking problems, and 43% reduction in sleep problems would represent successful symptom treatment. Cluster analysis based on ratings of the importance of symptom improvement yielded three clusters of patients: (1) those who rated thinking problems, sleep problems, and fatigue as highly important, (2) those who rated pain as moderately important, and (3) those who rated all symptoms as highly important. The first patient cluster differed from other subgroups in severity of thinking problems and education. CONCLUSIONS: Metastatic breast cancer patients report differing symptom treatment priorities and criteria for treatment success across symptoms. Considering cancer patients' perspectives on clinically meaningful symptom improvement and priorities for symptom management will ensure that treatment is consistent with their values and goals.
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Neoplasias de la Mama/psicología , Neoplasias de la Mama/terapia , Prioridades en Salud , Cuidados Paliativos/psicología , Planificación de Atención al Paciente , Percepción , Adulto , Anciano , Neoplasias de la Mama/patología , Dolor en Cáncer/psicología , Dolor en Cáncer/terapia , Fatiga/psicología , Fatiga/terapia , Femenino , Humanos , Persona de Mediana Edad , Motivación , Metástasis de la Neoplasia , Medición de Resultados Informados por el Paciente , Atención Dirigida al Paciente , Calidad de Vida , Encuestas y Cuestionarios , Resultado del TratamientoRESUMEN
Objective: Centrality of pain refers to the degree to which a patient views chronic pain as integral to his or her life or identity. The purpose of this study was to gain a richer understanding of pain centrality from the perspective of patients who live with chronic pain. Methods: Face-to-face interviews were conducted with 26 Veterans with chronic and disabling musculoskeletal pain after completing a stepped care intervention within a randomized controlled trial. Qualitative data were analyzed using an immersion/crystallization approach. We evaluated the role centrality plays in Veterans' lives and examined whether and how their narratives differ when centrality either significantly decreases or increases after participation in a stepped care intervention for chronic pain. Results: Our data identified three emergent themes that characterized pain centrality: 1) control, 2) acceptance, and 3) preoccupation. We identified five characteristics that distinguished patients' changes in centrality from baseline: 1) biopsychosocial viewpoint, 2) activity level, 3) pain communication, 4) participation in managing own pain, and 5) social support. Conclusions: This study highlights centrality of pain as an important construct to consider within the overall patient experience of chronic pain.
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Dolor Crónico/psicología , Dolor Musculoesquelético/psicología , Veteranos/psicología , Campaña Afgana 2001- , Humanos , Guerra de Irak 2003-2011RESUMEN
OBJECTIVE: This study examined symptom-based subgroups of metastatic breast cancer (MBC) patients and the extent to which they differed across key constructs of acceptance and commitment therapy (ACT). METHODS: Eighty women with MBC completed self-report surveys assessing 10 common symptoms and several ACT variables (ie, activity engagement, psychological inflexibility, value obstruction, and value progress) during a single time point. RESULTS: A cluster analysis yielded 3 patient subgroups: low symptoms, low-moderate symptoms, and moderate-high symptoms. Relative to the subgroup with low symptoms, the other subgroups reported less activity engagement. In addition, compared with patients with low symptoms, the subgroup with moderate-high symptoms reported greater psychological inflexibility (ie, avoidance of unwanted internal experiences) and greater difficulty living consistently with their values. CONCLUSIONS: Women with MBC show heterogeneity in their symptom profiles, and those with higher symptom burden are more likely to disengage from valued activities and avoid unwanted experiences (eg, thoughts, feelings, and bodily sensations). Findings are largely consistent with the ACT model and provide strong justification for testing ACT to address symptom interference in MBC patients.
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Terapia de Aceptación y Compromiso , Neoplasias de la Mama/complicaciones , Neoplasias de la Mama/patología , Ajuste Emocional , Calidad de Vida/psicología , Adulto , Anciano , Neoplasias de la Mama/psicología , Emociones , Femenino , Humanos , Persona de Mediana Edad , Autoinforme , Encuestas y CuestionariosRESUMEN
Because posttraumatic stress disorder (PTSD) is both prevalent and underrecognized, routine primary care-based screening for PTSD has been implemented across the Veterans Health Administration. PTSD is frequently complicated by the presence of comorbid chronic pain, and patients with both conditions have increased symptom severity and poorer prognosis. Our objective was to determine whether the presence of pain affects diagnosis and treatment of PTSD among Department of Veterans Affairs (VA) patients who have a positive PTSD screening test. This retrospective cohort study used clinical and administrative data from six Midwestern VA medical centers. We identified 4,244 VA primary care patients with a positive PTSD screen and compared outcomes for those with and without a coexisting pain diagnosis. Outcomes were three clinically appropriate responses to positive PTSD screening: (1) mental health visit, (2) PTSD diagnosis, and (3) new selective serotonin reuptake inhibitor (SSRI) prescription. We found that patients with coexisting pain had a lower rate of mental health visits than those without pain (hazard ratio: 0.889, 95% confidence interval: 0.821-0.962). There were no significant differences in the rate of PTSD diagnosis or new SSRI prescription between patients with and without coexisting pain.
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Dolor Crónico/epidemiología , Servicios de Salud Mental/organización & administración , Manejo del Dolor/métodos , Atención Primaria de Salud/métodos , Trastornos por Estrés Postraumático/epidemiología , United States Department of Veterans Affairs , Veteranos/psicología , Dolor Crónico/diagnóstico , Dolor Crónico/terapia , Comorbilidad , Femenino , Humanos , Masculino , Tamizaje Masivo , Persona de Mediana Edad , Estudios Retrospectivos , Trastornos por Estrés Postraumático/diagnóstico , Trastornos por Estrés Postraumático/terapia , Estados Unidos/epidemiologíaRESUMEN
IMPORTANCE: Despite the prevalence and the functional, psychological, and economic impact of chronic pain, few intervention studies of treatment of chronic pain in veterans have been performed. OBJECTIVE: To determine whether a stepped-care intervention is more effective than usual care, as hypothesized, in reducing pain-related disability, pain interference, and pain severity. DESIGN, SETTING, AND PARTICIPANTS: We performed a randomized clinical trial comparing stepped care with usual care for chronic pain. We enrolled 241 veterans from Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn with chronic (>3 months) and disabling (Roland Morris Disability Scale score, ≥7) musculoskeletal pain of the cervical or lumbar spine or extremities (shoulders, knees, and hips) in the Evaluation of Stepped Care for Chronic Pain (ESCAPE) trial from December 20, 2007, through June 30, 2011. The 9-month follow-up was completed by April 2012. Patients received treatment at a postdeployment clinic and 5 general medicine clinics at a Veterans Affairs medical center. INTERVENTIONS: Step 1 included 12 weeks of analgesic treatment and optimization according to an algorithm coupled with pain self-management strategies; step 2, 12 weeks of cognitive behavioral therapy. All intervention aspects were delivered by nurse care managers. MAIN OUTCOMES AND MEASURES: Pain-related disability (Roland Morris Disability Scale), pain interference (Brief Pain Inventory), and pain severity (Graded Chronic Pain Scale). RESULTS: The primary analysis included 121 patients receiving the stepped-care intervention and 120 patients receiving usual care. At 9 months, the mean decrease from baseline in the Roland Morris Disability Scale score was 1.7 (95% CI, -2.6 to -0.9) points in the usual care group and 3.7 (95% CI, -4.5 to -2.8) points in the intervention group (between-group difference, -1.9 [95% CI, -3.2 to -0.7] points; P=.002). The mean decrease from baseline in the Pain Interference subscale score of the Brief Pain Inventory was 0.9 points in the usual care group and 1.7 points in the intervention group (between-group difference, -0.8 [95% CI, -1.3 to -0.3] points; P=.003). The Graded Chronic Pain Scale severity score was reduced by 4.5 points in the usual care group and 11.1 points in the intervention group (between-group difference, -6.6 [95% CI, -10.5 to -2.7] points; P=.001). CONCLUSIONS AND RELEVANCE: A stepped-care intervention that combined analgesics, self-management strategies, and brief cognitive behavioral therapy resulted in statistically significant reductions in pain-related disability, pain interference, and pain severity in veterans with chronic musculoskeletal pain. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00386243.
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Analgésicos/administración & dosificación , Dolor Crónico/diagnóstico , Dolor Crónico/terapia , Terapia Cognitivo-Conductual/métodos , Dolor Musculoesquelético/fisiopatología , Autocuidado/métodos , Adulto , Campaña Afgana 2001- , Dolor Crónico/fisiopatología , Dolor Crónico/psicología , Terapia Combinada/métodos , Evaluación de la Discapacidad , Femenino , Humanos , Guerra de Irak 2003-2011 , Masculino , Persona de Mediana Edad , Monitoreo Fisiológico/métodos , Proceso de Enfermería , Manejo del Dolor/métodos , Manejo del Dolor/enfermería , Dimensión del Dolor/métodos , Dimensión del Dolor/enfermería , Resultado del Tratamiento , VeteranosRESUMEN
Both posttraumatic stress disorder (PTSD) and depression are highly comorbid with chronic pain and have deleterious effects on pain and treatment outcomes, but the nature of the relationships among chronic pain, PTSD, and depression has not been fully elucidated. This study examined 250 Veterans Affairs primary care patients with moderate to severe chronic musculoskeletal pain who participated in a randomized controlled pain treatment trial. Baseline data were analyzed to examine the independent associations of PTSD and major depression with multiple domains of pain, psychological status, quality of life, and disability. PTSD was strongly associated with these variables and in multivariate models, PTSD and major depression each had strong independent associations with these domains. PTSD demonstrated similar relationships as major depression with psychological, quality of life, and disability outcomes and significant but somewhat smaller associations with pain. Because PTSD and major depression have independent negative associations with pain, psychological status, quality of life, and disability, it is important for clinicians to recognize and treat both mental disorders in patients with chronic pain.
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Dolor Crónico/epidemiología , Dolor Crónico/psicología , Trastorno Depresivo Mayor/psicología , Evaluación de la Discapacidad , Calidad de Vida/psicología , Trastornos por Estrés Postraumático/epidemiología , Trastornos por Estrés Postraumático/psicología , Adulto , Anciano , Dolor Crónico/terapia , Comorbilidad , Trastorno Depresivo Mayor/epidemiología , Trastorno Depresivo Mayor/terapia , Femenino , Humanos , Masculino , Persona de Mediana Edad , Atención Primaria de Salud , Trastornos por Estrés Postraumático/terapia , Veteranos/psicología , Veteranos/estadística & datos numéricosRESUMEN
Chronic pain and posttraumatic stress disorder (PTSD) co-occur at high rates, and Veterans from recent wars in Iraq and Afghanistan may be particularly vulnerable to both conditions. The objective of this study was to identify key aspects of chronic pain, cognitions, and psychological distress associated with comorbid PTSD among this sample of Veterans. Baseline data were analyzed from a randomized controlled trial testing a stepped-care intervention for chronic musculoskeletal pain. Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) Veterans with chronic pain only (n = 173) were compared with those with chronic pain and clinically significant posttraumatic stress symptoms (n = 68). Group differences on pain characteristics, pain cognitions, and psychological distress were evaluated. Results demonstrated that OIF/OEF Veterans with comorbid chronic musculoskeletal pain and PTSD experienced higher pain severity, greater pain-related disability and increased pain interference, more maladaptive pain cognitions (e.g., catastrophizing, self-efficacy, pain centrality), and higher affective distress than those with chronic pain alone. Veterans of recent military conflicts in Iraq and Afghanistan may be particularly vulnerable to the compounded adverse effects of chronic pain and PTSD. These results highlight a more intense and disabling pain and psychological experience for those with chronic pain and PTSD than for those without PTSD.
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Dolor Crónico/epidemiología , Dolor Crónico/psicología , Dolor Musculoesquelético/epidemiología , Dolor Musculoesquelético/psicología , Trastornos por Estrés Postraumático/epidemiología , Trastornos por Estrés Postraumático/psicología , Veteranos/psicología , Adulto , Síntomas Afectivos/etiología , Campaña Afgana 2001- , Anciano , Ansiedad/etiología , Comorbilidad , Depresión/etiología , Evaluación de la Discapacidad , Femenino , Humanos , Guerra de Irak 2003-2011 , Masculino , Salud Mental , Persona de Mediana Edad , Dimensión del Dolor , Percepción del Dolor , Adulto JovenRESUMEN
OBJECTIVE: To examine health care utilization among veterans with both chronic pain and posttraumatic stress symptoms. METHODS: Retrospective cohort study of 40,716 veterans in a VA regional network from January 1, 2002 to January 1, 2007. Veterans were categorized into pain-only, posttraumatic stress disorder symptoms (PTSD)-only, and pain plus PTSD (pain+PTSD) comparison groups. Negative binomial models were used to compare adjusted rates of primary care, mental health, and specialty pain service use, as well as opioids, benzodiazepines, nonopioid analgesics, and antidepressant prescriptions. Rates of clinic visits were calculated by days per year, and rates of medication use were calculated by prescription months per year. Participants were followed for a mean duration of 47 months. RESULTS: Participants were 94.7% men and had a mean age of 58.9 years. Nearly all used primary care (99.2%), 37.1% used pain-related specialty care, and 33.8% used mental health services. Nonopioid and opioid analgesics were the most commonly used medications (63.7% and 53.8%, respectively). Except for mental health visits, which did not differ between PTSD-only and pain+PTSD groups, the pain+PTSD group used significantly more of all categories of health care services than the pain-only and PTSD-only groups. For example, the pain+PTSD group had 7% more primary care visits (rate ratio [RR]=1.07; 95% confidence interval [CI]: 1.05, 1.09) than the pain-only group and 46% more primary care visits than the PTSD-only group (RR=1.46; 95% CI: 1.40, 1.52). Adjusted rates of opioid, benzodiazepine, nonopioid analgesic, and antidepressant prescriptions were higher for the pain+PTSD group than either of the comparison groups. CONCLUSIONS: Our findings support our expectation that veterans with both pain and PTSD symptoms use more health care services than those with pain or PTSD symptoms alone. Research is needed to assess the health care costs associated with increases in health care utilization among these veterans.
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Dolor Crónico/complicaciones , Aceptación de la Atención de Salud/estadística & datos numéricos , Trastornos por Estrés Postraumático/complicaciones , Atención Ambulatoria/estadística & datos numéricos , Analgésicos/uso terapéutico , Dolor Crónico/tratamiento farmacológico , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Trastornos por Estrés Postraumático/tratamiento farmacológico , Estados Unidos , United States Department of Veterans Affairs , VeteranosRESUMEN
Interest has arisen in the role stressors play in the development and outcome of schizophrenia. This article examines one such stressor - trauma experienced prior to the onset of illness. We discuss research on the incidence, types and correlates of trauma in schizophrenia, and review work suggesting trauma may increase risk for schizophrenia. Studies are further detailed that have examined links between trauma and heightened levels of positive symptoms and anxiety, and poorer social, vocational and treatment outcomes. Here, literature on approaches to addressing trauma among persons with schizophrenia is presented, along with a commentary that points to the need for research on how trauma might increase the risk for the development of schizophrenia and worsen the symptoms and treatment outcome of individuals in recovery from this illness.