Feasibility randomized-controlled trial of online Acceptance and Commitment Therapy for patients with complex chronic pain in the United Kingdom

Acceptance and commitment therapy for patients with chronic pain: A systematic review and meta-analysis on psychological outcomes and quality of life

OBJECTIVES

To assess the efficacy of acceptance and commitment therapy (ACT) for patients with chronic pain.

MATERIALS AND METHODS

The research conducted a systematic search of the Cochrane Library, Web of Science, PubMed, EMBASE, PsycINFO, and Cumulative Index of Nursing and Allied Health Literature (CINAHL) databases following the PRISMA guidelines. The retrieval time limit was from the establishment of the database to October 2023. A meta-analysis was carried out for the randomized controlled trials (RCTs) that meet the inclusion and exclusion criteria by using RevMan 5.3.

RESULTS

Twenty-one RCTs were included. At post-treatment, a significant medium effect size (ES) was found in measuring pain interference, functional impairment, pain acceptance, psychological inflexibility, and depression; Pain intensity, anxiety, and quality of life (QOL) had a small ES. At three months post-treatment, a large ES was found in measuring functional impairment, and a medium ES was found in the other indicators.

CONCLUSION

The researchers provided evidence for the effectiveness of ACT as an intervention for patients with chronic pain, which can be applied by clinicians or nurses in practice. Future research should explore the applicability of ACT to different pain conditions and modalities.

IMPLICATIONS FOR NURSING

Post-treatment data highlight the efficacy of ACT in moderating pain-related outcomes. Clinical nurses are encouraged to incorporate ACT into routine patient education and interventions, including promoting pain acceptance, promoting mindfulness practices, and using cognitive stress reduction techniques. Standardized follow-up after an ACT intervention for patients with chronic pain is critical, including regular assessment, feedback, and realignment of treatment strategies. Overall, ACT became an important tool for nurses to improve the lives of patients with chronic pain.

The efficacy, acceptability and safety of acceptance and commitment therapy for fibromyalgia - a systematic review and meta-analysis

Background

Fibromyalgia (FM) is a chronic pain disorder characterised by widespread pain, fatigue and cognitive symptoms. Acceptance and commitment therapy (ACT) aims to improve psychological flexibility and has been found to be beneficial in treating chronic pain; however, there are few studies evaluating its efficacy in treating FM.

Aim

This systematic review and meta-analysis evaluated the efficacy of acceptance and commitment therapy in patients with fibromyalgia.

Methods

PubMed, Embase and PsychInfo databases were searched. Randomised Controlled Trials (RCTs) were eligible for inclusion if participants had FM, and the intervention was based on the ACT framework/model, and not combined with any other active therapy; any non-ACT control was accepted. A meta-analysis was performed, with the primary outcomes pain acceptance (chronic pain acceptance questionnaire, CPAQ), health-related quality of life (fibromyalgia impact questionnaire, FIQ), attrition rate and frequency of adverse events, and the secondary outcomes pain intensity, disability, depression, anxiety, and fatigue.

Results

Six RCTs, with a total of 384, mostly-female, participants were included, with ACT being delivered online, in a group setting, or one-to-one. ACT was superior to controls in improving FIQ score at post-intervention (SMD -1.05, 95% CI -2.02, -0.09) and follow-up (SMD -1.43, 95% CI -2.17, -0.69) and CPAQ post-intervention (SMD 1.05, 95% CI 0.61, 1.49) and at follow-up (SMD 0.95, 95% CI 0.40, 1.49). Attrition was below 20% in 4/6 studies and no adverse events were reported as attributable to ACT. All secondary outcomes showed large-to-moderate pooled effect estimates post-intervention, indicating improvement in anxiety, depression, pain and disability. Fatigue also improved, with a large negative effect.

Conclusions

The results suggest ACT improved outcomes in patients with FM: there was an overall improvement in all outcomes post-intervention, with most maintained at follow-up. This review was, however, limited by the small body of evidence and differing methodologies of included studies.

Acceptance and Commitment Therapy for Chronic Pain: An Overview of Systematic Reviews with Meta-Analysis of Randomized Clinical Trials

This overview of reviews aimed to summarize the evidence from systematic reviews and meta-analyses of randomized clinical trials of the efficacy of acceptance and commitment therapy (ACT) for adults with chronic pain in relation to pain intensity, pain-related functioning, quality of life, and psychological factors. The Cumulative Index of Nursing and Allied Health Literature (CINAHL), Embase, PsycINFO, PubMed, and the Cochrane Library databases were searched from inception to July 2, 2023. AMSTAR 2 was used to assess the methodological quality of systematic reviews. The overlap among reviews was calculated. Nine reviews comprising 84 meta-analyses of interest were included. At post-treatment, some meta-analyses mainly showed that ACT can reduce depression symptoms, anxiety symptoms, psychological inflexibility, and pain catastrophizing; and can improve mindfulness, pain acceptance, and psychological flexibility. At three-month follow-up, ACT can reduce depression symptoms and psychological inflexibility, as well as improve pain-related functioning and psychological flexibility. At six-month follow-up, ACT can improve mindfulness, pain-related functioning, pain acceptance, psychological flexibility, and quality of life. At six-twelve-month follow-up, ACT can reduce pain catastrophizing and can improve pain-related functioning. Some methodological and clinical issues are identified in the reviews, such as a very high overlap between systematic reviews, the fact that the certainty of the evidence is often not rated and specific details needed to replicate the interventions reviewed are often not reported. Overall, however, randomized clinical trials and systematic reviews show that ACT can improve outcomes related to chronic pain (eg, pain-related functioning). Future systematic reviews should address the methodological and clinical concerns identified here to produce higher-quality findings. PERSPECTIVE: Despite certain methodological and clinical issues, randomized clinical trials and systematic reviews of ACT appear to show that it can improve outcomes related to chronic pain (eg, psychological factors).

Guided internet-based acceptance and commitment therapy for provoked vestibulodynia: A randomized controlled trial

BACKGROUND

Provoked vestibulodynia (PVD) causes suffering in many women's lives due to its impact on relationships, sexual functioning and functioning in other key domains.

OBJECTIVE

Here, we report a randomized controlled trial conducted to examine whether Acceptance and Commitment Therapy (ACT) with a focus on values-based exposure, delivered online, benefits women with PVD.

METHODS

Participants (n = 88) were randomized to either guided online ACT for 10 weeks or a wait-list control group. Outcomes were assessed at baseline, post treatment and 1 year later. Analyses were based on intention to treat using linear mixed models.

RESULTS

There were significant group differences on the primary outcomes, Female Sexual Index and Female Sexual Distress Scale, in favour of online ACT with moderate effect sizes. Differences were also found on several secondary outcomes and therapeutic process measures, all in favour of ACT. No differences were found at post-treatment for depression or anxiety. At the 1-year follow-up, results were maintained and a difference between baseline and follow-up was also found for depression.

CONCLUSION/SIGNIFICANCE

In summary, a relatively brief, guided, online version of ACT appears to produce benefits for women with PVD and related impacts on daily functioning. 50% to 60% of the women who participated in the treatment reliably improved in sexual functioning and distress.

MITIG.RA: study protocol of a tailored psychological intervention for managing fatigue in rheumatoid arthritis randomized controlled trial

BACKGROUND

Despite remarkable medical advances in the treatment of rheumatoid arthritis (RA), a subset of patients fails to achieve complete clinical remission, as the Patient Global Assessment (PGA) of disease activity remains above 1, even after the inflammatory process is brought under control. This so-called state of 'PGA-near-remission' negatively impacts individuals' functioning and potentiates inadequate care. Fatigue is a distressing and disabling symptom frequently reported by patients in PGA-near-remission, and its management remains challenging. While classic cognitive-behavioural interventions show some benefits in managing fatigue, there is potential for improvement. Recently, contextual-cognitive behavioural therapies (CCBT), like mindfulness, acceptance, and compassion-based interventions, have shown promising results in fatigue-associated disorders and their determinants. This study primarily aims to examine the efficacy of the Compassion and Mindfulness Intervention for RA (MITIG.RA), a novel intervention combining different components of CCBT, compared to treatment-as-usual (TAU) in the management of RA-associated fatigue. Secondary aims involve exploring whether MITIG.RA produces changes in the perceived impact of disease, satisfaction with disease status, levels of depression, and emotion-regulation skills.

METHODS

This is a single center, two-arm parallel randomized controlled trial. Patients will be screened for eligibility and willingness to participate and will be assessed and randomized to the experimental (MITIG.RA + TAU) or control condition (TAU) using computer randomization. MITIG.RA will be delivered by a certified psychologist and comprises eight sessions of 2 h, followed by two booster sessions. Outcomes will be assessed through validated self-report measures, including fatigue (primary outcome), perceived impact of disease, depressive symptoms, mindfulness, self-compassion, safety, and satisfaction (secondary outcomes). Assessment will take place at baseline, post-intervention, before the first and second booster sessions (weeks 12 and 20, respectively), and at 32 and 44 weeks after the interventions' beginning.

DISCUSSION

We expect MITIG.RA to be effective in reducing levels of RA-associated fatigue. Secondarily, we hypothesize that the experimental group will show improvements in the overall perceived impact of disease, emotional distress, and emotion regulation skills. Our findings will contribute to determine the benefits of combining CCBT approaches for managing fatigue and associated distress in RA.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05389189. Registered on May 25, 2022.

An Observational Study of Outcomes Associated With Virtual Pain Management Programs Based on Acceptance and Commitment Therapy Implemented During the COVID-19 Pandemic

OBJECTIVE

In response to COVID-19, virtual, group-based interdisciplinary pain management programs (PMPs) were rapidly implemented. This included implementing different intensities and formats of virtual PMPs to address a range of patient needs and complexity. This observational study investigated outcomes associated with virtual high and low-intensity and pre-neuromodulation PMPs based on acceptance and commitment therapy as part of routine care during the pandemic.

METHODS

Depending on patients' needs, participants completed a virtual high-intensity or low-intensity PMP, or a virtual PMP in preparation for neuromodulation, from June 2020 to June 2022. Participants completed standardized measures of pain intensity and interference, work and social adjustment, depression, and pain acceptance before and after treatment. Data from 2018 to 2019 for in-person residential ( n= 561), outpatient ( n =123), and pre-neuromodulation ( n =207) PMPs were also examined to provide a historical benchmark of performance.

RESULTS

The virtual high-intensity PMP ( n =294) showed significant improvements in all variables, with small effects. There were significant improvements with small effects for pain interference, depression, and acceptance for the virtual pre-neuromodulation PMP ( n =129). No statistically significant improvements were observed for the virtual low-intensity PMP ( n =90). The improvements associated with prepandemic in-person PMPs were generally larger relative to the virtual PMPs of comparable intensity delivered during the pandemic.

DISCUSSION

These data provide preliminary support for the potential benefits of high, but not low, intensity virtual acceptance and commitment therapy-based PMPs, including in the context of neuromodulation. Research is needed to maximize the impact of virtual PMPs and match patients with the most appropriate delivery format.

Psychological therapies delivered remotely for the management of chronic pain (excluding headache) in adults

BACKGROUND

Chronic pain (pain lasting three months or more) is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Common types (excluding headache) include back pain, fibromyalgia, and neuropathic pain. Access to traditional face-to-face therapies can be restricted by healthcare resources, geography, and cost. Remote technology-based delivery of psychological therapies has the potential to overcome treatment barriers. However, their therapeutic effectiveness compared to traditional delivery methods requires further investigation.

OBJECTIVES

To determine the benefits and harms of remotely-delivered psychological therapies compared to active control, waiting list, or treatment as usual for the management of chronic pain in adults.

SEARCH METHODS

We searched for randomised controlled trials (RCTs) in CENTRAL, MEDLINE, Embase, and PsycINFO to 29 June 2022. We also searched clinical trials registers and reference lists. We conducted a citation search of included trials to identify any further eligible trials.

SELECTION CRITERIA

We included RCTs in adults (≥ 18 years old) with chronic pain. Interventions included psychological therapies with recognisable psychotherapeutic content or based on psychological theory. Trials had to have delivered therapy remote from the therapist (e.g. Internet, smartphone application) and involve no more than 30% contact time with a clinician. Comparators included treatment as usual (including waiting-list controls) and active controls (e.g. education).

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures.

MAIN RESULTS

We included 32 trials (4924 participants) in the analyses. Twenty-five studies delivered cognitive behavioural therapy (CBT) to participants, and seven delivered acceptance and commitment therapy (ACT). Participants had back pain, musculoskeletal pain, opioid-treated chronic pain, mixed chronic pain, hip or knee osteoarthritis, spinal cord injury, fibromyalgia, provoked vestibulodynia, or rheumatoid arthritis. We assessed 25 studies as having an unclear or high risk of bias for selective reporting. However, across studies overall, risk of bias was generally low. We downgraded evidence certainty for primary outcomes for inconsistency, imprecision, and study limitations. Certainty of evidence ranged from moderate to very low. Adverse events were inadequately reported or recorded across studies. We report results only for studies in CBT here. Cognitive behavioural therapy (CBT) versus treatment as usual (TAU) Pain intensity Immediately after treatment, CBT likely demonstrates a small beneficial effect compared to TAU (standardised mean difference (SMD) -0.28, 95% confidence interval (CI) -0.39 to -0.16; 20 studies, 3206 participants; moderate-certainty evidence). Participants receiving CBT are probably more likely to achieve a 30% improvement in pain intensity compared to TAU (23% versus 11%; risk ratio (RR) 2.15, 95% CI 1.62 to 2.85; 5 studies, 1347 participants; moderate-certainty evidence). They may also be more likely to achieve a 50% improvement in pain intensity (6% versus 2%; RR 2.31, 95% CI 1.14 to 4.66; 4 studies, 1229 participants), but the evidence is of low certainty. At follow-up, there is likely little to no difference in pain intensity between CBT and TAU (SMD -0.04, 95% CI -0.17 to 0.09; 8 studies, 959 participants; moderate-certainty evidence). The evidence comparing CBT to TAU on achieving a 30% improvement in pain is very uncertain (40% versus 24%; RR 1.70, 95% CI 0.82 to 3.53; 1 study, 69 participants). No evidence was available regarding a 50% improvement in pain. Functional disability Immediately after treatment, CBT may demonstrate a small beneficial improvement compared to TAU (SMD -0.38, 95% CI -0.53 to -0.22; 14 studies, 2672 participants; low-certainty evidence). At follow-up, there is likely little to no difference between treatments (SMD -0.05, 95% CI -0.23 to 0.14; 3 studies, 461 participants; moderate-certainty evidence). Quality of life Immediately after treatment, CBT may not have resulted in a beneficial effect on quality of life compared to TAU, but the evidence is very uncertain (SMD -0.16, 95% CI -0.43 to 0.11; 7 studies, 1423 participants). There is likely little to no difference between CBT and TAU on quality of life at follow-up (SMD -0.16, 95% CI -0.37 to 0.05; 3 studies, 352 participants; moderate-certainty evidence). Adverse events Immediately after treatment, evidence about the number of people experiencing adverse events is very uncertain (34% in TAU versus 6% in CBT; RR 6.00, 95% CI 2.2 to 16.40; 1 study, 140 participants). No evidence was available at follow-up. Cognitive behavioural therapy (CBT) versus active control Pain intensity Immediately after treatment, CBT likely demonstrates a small beneficial effect compared to active control (SMD -0.28, 95% CI -0.52 to -0.04; 3 studies, 261 participants; moderate-certainty evidence). The evidence at follow-up is very uncertain (mean difference (MD) 0.50, 95% CI -0.30 to 1.30; 1 study, 127 participants). No evidence was available for a 30% or 50% pain intensity improvement. Functional disability Immediately after treatment, there may be little to no difference between CBT and active control on functional disability (SMD -0.26, 95% CI -0.55 to 0.02; 2 studies, 189 participants; low-certainty evidence). The evidence at follow-up is very uncertain (MD 3.40, 95% CI -1.15 to 7.95; 1 study, 127 participants). Quality of life Immediately after treatment, there is likely little to no difference in CBT and active control (SMD -0.22, 95% CI -1.11 to 0.66; 3 studies, 261 participants; moderate-certainty evidence). The evidence at follow-up is very uncertain (MD 0.00, 95% CI -0.06 to 0.06; 1 study, 127 participants). Adverse events Immediately after treatment, the evidence comparing CBT to active control is very uncertain (2% versus 0%; RR 3.23, 95% CI 0.13 to 77.84; 1 study, 135 participants). No evidence was available at follow-up.

AUTHORS' CONCLUSIONS

Currently, evidence about remotely-delivered psychological therapies is largely limited to Internet-based delivery of CBT. We found evidence that remotely-delivered CBT has small benefits for pain intensity (moderate certainty) and functional disability (moderate to low certainty) in adults experiencing chronic pain. Benefits were not maintained at follow-up. Our appraisal of quality of life and adverse events outcomes post-treatment were limited by study numbers, evidence certainty, or both. We found limited research (mostly low to very low certainty) exploring other psychological therapies (i.e. ACT). More high-quality studies are needed to assess the broad translatability of psychological therapies to remote delivery, the different delivery technologies, treatment longevity, comparison with active control, and adverse events.

A feasibility trial of online Acceptance and Commitment Therapy for women with provoked vestibulodynia

OBJECTIVES

Acceptance and Commitment Therapy (ACT) is an established treatment for chronic pain. However, it is a form of treatment that have not yet been applied much in the treatment of persistent vulvar pain disorders. This study examines the feasibility and preliminary effects of online ACT for patients with provoked vestibulodynia.

METHODS

Women diagnosed with provoked vestibulodynia were assigned randomly either to online ACT or to a waitlist control group. Feasibility was assessed in terms of recruitment potential, treatment credibility, completions rates, retention in trial, and data quality. Participants completed measures of pain with sexual activity, sexual functioning, emotional and relational adjustment, and potential treatment processes before and after treatment.

RESULTS

Of the 111 women who were invited to participate in the study, 44 were included (39.6 % recruitment rate). Thirty seven participants (84.1 %) completed the pre-treatment assessment. Participants who received online ACT rated treatment credibility positively, and completed on average 4.31 (SD=1.60) of the six treatment modules. Of participants, 34 provided post treatment data, giving a trial retention rate of 77 %. Effects of online ACT, as compared to waitlist, were large for pain acceptance and quality of life, medium for anxiety and pain catastrophizing, and small for sexual satisfaction, pain with sexual activity, and relationship adjustment.

CONCLUSIONS

With some adjustments to recruitment procedures, a full scale randomized controlled trial of online ACT for provoked vestibulodynia appears feasible.

An updated audit of the patient selection process for pain management programmes in a speciality care service before and during the COVID-19 pandemic

BACKGROUND

The provision of pain management programmes (PMPs) changed substantially in response to the COVID-19 pandemic with virtual delivery implemented in many services. Little is known about patient selection processes for virtual PMPs and how this might differ from in-person programmes. The aim of this audit was to document the patient selection process for PMPs at a speciality pain service prior to and during the pandemic.

METHODS

This retrospective audit used data from consecutive patients attending a multidisciplinary assessment to determine the suitability of a PMP. Anonymized data were extracted from assessment letters and hospital records in the months prior to the pandemic (n =168) and during the start of the pandemic once the service began delivering virtual PMPs (n =171).

RESULTS

For the standard pain management pathway, most patients were offered a PMP option within the service before and during the pandemic, although a greater proportion of patients were offered treatment during the pandemic. For the neuromodulation pathway, most patients were offered a pre-neuromodulation PMP option, and this was similar before and during the pandemic. Psychosocial complexities and unwillingness to engage in a pain management approach that does not principally focus on pain reduction were the most common reasons that patients were not offered a programme.

DISCUSSION

This audit points to a pattern of more inclusive assessment outcomes within our service over time and particularly during the pandemic. Offering a range of in-person and virtual PMPs can meet a wider range of patient need. Research is needed to understand how to best assess and match patients with the breadth of treatment delivery formats now available.

The efficacy of acceptance and commitment therapy for chronic pain: A three-level meta-analysis and a trial sequential analysis of randomized controlled trials

The current study included randomized controlled trials (RCTs) to assess the benefits of Acceptance and commitment therapy (ACT) for chronic pain. Searches were conducted in Web of Science, PsycINFO, PubMed, Scopus, Cochrane Library, and Embase from inception until September 30, 2022. Thirty-three RCTs, including 2293 participants, were included. Small to medium effect sizes for pain intensity/physical function favoring ACT were found both at post-treatment (pain intensity: g = 0.44; physical function: g = 0.59) and follow-up (pain intensity: g = 0.34; physical function: g = 0.56). The effect sizes on psychological outcomes were significant at post-treatment (depression: g = 0.43; anxiety: g = 0.43; quality of life: g = 0.45) and follow-up (depression: g = 0.43; anxiety: g = 0.35; quality of life: g = 0.43). The results of the trial sequential analyses indicated that pooled estimates were unlikely to be incidental findings, as effects of multiple testing were controlled and power was adequate. Face-to-face ACT yielded significantly larger effects on physical outcomes than internet-delivered ACT. Participants with chronic headache and fibromyalgia showed greater benefit from ACT compared to those with non-specific pain or mixed pain. In addition, the longer the follow-up duration, the smaller the effect sizes for pain intensity/physical function at follow-up. The present meta-analysis suggests sufficient evidence for the significant benefits of ACT for people with chronic pain.

The Efficacy of Acceptance and Commitment Therapy for Chronic Pain: A Systematic Review and Meta-analysis

OBJECTIVES

Previous meta-analyses of a small number of trials showed that acceptance and commitment therapy (ACT) might improve chronic pain. Many new trials have been published afterward, and the factors that may impact the efficacy of ACT are less understood. We, therefore, conducted an updated systematic review with meta-analysis to investigate the efficacy of ACT for people with chronic pain.

METHODS

Randomized controlled trials that investigated the efficacy of ACT in clinical or community setting for adult populations with chronic pain were included. The methodological quality of trials was assessed with the Cochrane Risk of Bias tool. Standardized mean differences between ACT and comparison groups in their effects on 6 outcomes (ie, pain acceptance, quality of life, pain-related functioning, pain intensity, anxiety, and depression) were pooled across studies.

RESULTS

Of the 3171 records identified, 21 trials with 1962 participants were included for analysis. The comparison groups included active treatment and waitlist control/usual care. The standardized mean difference was 0.67 (95% CI: 0.48, 0.87) for pain acceptance, 0.43 (95% CI: 0.29, 0.57) for quality of life, -0.88 (95% CI: -1.14, -0.63) for pain-related functioning, -0.45 (95% CI: -0.62, -0.27) for pain intensity, -0.35 (95% CI: -0.54, -0.15) for anxiety, and -0.74 (95% CI, -0.98, -0.50) for depression, all favoring ACT. Subgroup analyses showed that the effects were statistically significant across almost all subgroups and for some outcomes were greater in the trials conducted in people with a specific diagnosis (as compared with those conducted in people with general chronic pain), the trials with waitlist or usual care control, the trials with a greater number of sessions of ACT, and the trials with a longer ACT intervention.

DISCUSSION

ACT is effective and comparable to, if not better than, some other available active treatments for chronic pain.

Efficacy of Internet-Based Acceptance and Commitment Therapy for Depressive Symptoms, Anxiety, Stress, Psychological Distress, and Quality of Life: Systematic Review and Meta-analysis

BACKGROUND

Acceptance and commitment therapy (ACT) is an empirically supported transdiagnostic approach that involves mindfulness processes and behavior change processes for valued living.

OBJECTIVE

This systematic review and meta-analysis of randomized controlled trials (RCTs) aimed to assess the efficacy of internet-based ACT (iACT) for depressive symptoms, anxiety, stress, psychological distress, and quality of life (QoL).

METHODS

PubMed, CINAHL, PsycINFO, and SCOPUS databases were searched to identify relevant RCTs published up to June 5, 2021. The included RCTs were assessed using the Cochrane Collaboration risk-of-bias tool. The use of either a random effects model or fixed effects model was determined using I2 statistic values for heterogeneity. Subgroup analyses were conducted according to the type of control group, the use of therapist guidance, delivery modes, and the use of targeted participants, when applicable.

RESULTS

A total of 39 RCTs met the inclusion criteria. Meta-analyses found small effects of iACT on depressive symptoms, anxiety, stress, psychological distress, and QoL at the immediate posttest and follow-up. There was no significant effect of iACT on stress at follow-up. Subgroup analyses showed small to medium effects of iACT on all the outcomes at the immediate posttest and follow-up compared with the passive control groups. In contrast, subgroup analyses that compared iACT with active control groups found no differences between groups on stress, psychological distress, and QoL at the immediate posttest or on depressive symptoms, anxiety, and stress at follow-up. In addition, subgroup analyses conducted according to the use of therapist guidance, delivery modes, and the use of targeted participants found no statistically significant subgroup differences among studies in all the outcomes, except for the subgroup difference among studies according to the use of targeted participants for depressive symptoms at the immediate posttest (ie, a statistically significant, larger effect of iACT when studies targeted people with depressive symptoms). The overall risk of bias across the studies was unclear.

CONCLUSIONS

The findings of this study contribute to the body of evidence regarding the effects of iACT on depressive symptoms, anxiety, stress, psychological distress, and QoL and may be applicable in any population, as ACT is a transdiagnostic approach. Few studies have compared iACT with active control conditions, especially for stress and psychological distress at the immediate posttest and follow-up. In addition, the active control conditions varied among the included studies. Further high-quality studies are needed to better understand whether iACT is comparable or superior to other evidence-based interventions, such as cognitive behavioral therapy, in decreasing depressive symptoms, anxiety, stress, and psychological distress and improving QoL.

Guided internet-based cognitive-behavioral therapy for patients with chronic pain: A meta-analytic review

BACKGROUND

Chronic pain has a large individual and societal burden. Previous reviews have shown that internet-based cognitive-behavioral therapy (iCBT) can support patients' pain coping. However, factors related to participant experience of iCBT and effective and safe iCBT delivery for chronic pain have not recently been summarized.

OBJECTIVE

The aim of this review was to give an overview of the efficacy of guided iCBT for chronic pain on psychological, physical, and impact on daily life outcomes, including factors that inform optimal delivery.

METHODS

Cochrane, Emcare, Web of Science, PubMed, PsycINFO, and Embase were systematically searched from inception to 11 February 2022. Randomized controlled trials on guided iCBTs for adults with chronic pain were included with a broad range of outcomes.

RESULTS

The search yielded 7406 studies of which 33 studies were included totaling 5133 participants. ICBT was more effective than passive control conditions for psychological (ES = 0.34-0.47), physical (ES = 0.26-0.29), and impact outcomes (ES = 0.38-0.41). ICBT was more effective than active control conditions for distress (ES = 0.40), pain acceptance (ES = 0.15), and pain interference after outlier removal (ES = 0.30). Longer treatments were associated with larger effects for anxiety and quality of life than shorter treatments. Mode of therapist contact (synchronous, asynchronous or a mix of both) was not related to differences in effect sizes in most outcomes. However, studies with mixed and synchronous contact modes had higher effects on pain self-efficacy than studies with asynchronous contact modes. Treatment satisfaction was high and adverse events were minor. Dropout was related to time, health, technical issues, and lack of computer skills.

CONCLUSIONS

Guided iCBT is an effective and potentially safe treatment for chronic pain. Future research should more consistently report on iCBT safety and detail the effectiveness of individual treatment components to optimize iCBT in clinical practice.

Psychosocial Predictors of Chronic Musculoskeletal Pain Outcomes and their Contextual Determinants Among Black Individuals: A Narrative Review

Black communities are disproportionally affected by Chronic Musculoskeletal Pain (CMP), but little is known about the psychological predictors of CMP outcomes and their contextual determinants among Black individuals. To address this gap, we conducted a narrative review of extant literature to (1) report the major conceptual models mentioned in prior work explaining the link between contextual determinants and psychological responses to pain among Black individuals with CMP; and (2) describe psychological factors related to CMP outcomes in this population that are highlighted in the literature. We searched 4 databases (APA PsycNet, PubMed/MEDLINE, Scopus, and Google Scholar) using the following search terms: musculoskeletal pain, chronic pain, mental health, psychological, coping, health disparities, contextual factors, conceptual models, psychosocial, Black, African American, pain, disability, and outcomes. We illustrate 3 relevant conceptual models - socioecological, cumulative stress, and biopsychosocial - related to contextual determinants and several psychological factors that influence CMP outcomes among Black individuals: (1) disproportionate burden of mental health and psychiatric diagnoses, (2) distinct coping strategies, (3) pain-related perceived injustice and perceived racial/ethnic discrimination, and (4) preferences and expectations related to seeking and receiving pain care. The detailed clinical and research implications could serve as a blueprint for the providers and clinical researchers to address health disparities and improve care for Black individuals with CMP. PERSPECTIVE: This narrative review illustrates conceptual models explaining the link between contextual determinants and psychological responses to pain among Black individuals with chronic musculoskeletal pain. We discuss 3 relevant conceptual models - socioecological, cumulative stress, biopsychosocial -, and 4 psychological factors: disproportionate burden of mental health, distinct coping strategies, perceived injustice/discrimination, preferences/expectations.

Effects of internet-based acceptance and commitment therapy on process measures: A systematic review and meta-analysis (Preprint)

Background

Acceptance and commitment therapy (ACT) is based on a psychological flexibility model that encompasses 6 processes: acceptance, cognitive defusion, self-as-context, being present, values, and committed action.

Objective

This systematic review and meta-analysis of randomized controlled trials (RCTs) aimed to examine the effects of internet-based ACT (iACT) on process measures.

Methods

A comprehensive search was conducted using 4 databases. The quality of the included RCTs was assessed using the Cochrane Collaboration Risk of Bias Tool. A random-effects or fixed-effects model was used. Subgroup analyses for each outcome were conducted according to the type of control group, use of therapist guidance, delivery modes, and use of targeted participants, when applicable.

Results

A total of 34 RCTs met the inclusion criteria. This meta-analysis found that iACT had a medium effect on psychological flexibility and small effects on mindfulness, valued living, and cognitive defusion at the immediate posttest. In addition, iACT had a small effect on psychological flexibility at follow-up. The overall risk of bias across studies was unclear.

Conclusions

Relatively few studies have compared the effects of iACT with active control groups and measured the effects on mindfulness, valued living, and cognitive defusion. These findings support the processes of change in iACT, which mental health practitioners can use to support the use of iACT.

Evidence-based digital support during 1 year after an Interdisciplinary Pain Rehabilitation Programme for persons with chronic musculoskeletal pain to facilitate a sustainable return to work: a study protocol for a registry-based multicentre randomised controlled trial

INTRODUCTION

Chronic musculoskeletal pain (CMSP) severely affects the individual's quality of life, functioning and ability to work, and comes with significant societal costs for sick leave and productivity loss. After rehabilitation, patients with CMSP often experience lack of support when responsibility for the return-to-work process is taken over by the employer. Therefore, we aim to evaluate the effectiveness of a digital support (Sustainable WorkEr digital support for Persons with chronic Pain and their Employers (SWEPPE)) for promoting a sustainable return-to-work for persons with CMSP and to facilitate the employers' supportive role and responsibilities in the process.

METHODS AND ANALYSIS

In this registry-based multicentre randomised controlled trial, 360 patients with CMSP will be randomised to either receive the smartphone application SWEPPE (n=180) or to a control group (n=180). The intervention group will use SWEPPE for 1 year and the control group will not receive any intervention for return to work (RTW). Participants will be recruited from approximately 10 specialist and primary care level units connected to the Swedish National Quality Registry for Pain Rehabilitation providing Interdisciplinary Pain Rehabilitation Programmes (IPRP) for CMSP. Eligibility criteria are age 18-65 years and a need for support in RTW or continued support at work for creating a sustainable work situation. Baseline data will be collected when the participants have completed the IPRP. Final assessment will be performed after 12 months. The primary outcome will be a number of days with sickness cash benefit. Secondary outcomes and explanatory variables including important domains affected by CMSP such as health-related quality of life, functioning and work ability will be collected.

ETHICS AND DISSEMINATION

The Swedish Ethics Review Board approved the study (Dnr 2020-01593, Dnr 2021-01854). The study findings will be disseminated through publication, national and international conferences, and meetings to be available for patients, healthcare providers or stakeholders.

TRIAL REGISTRATION NUMBER

NCT05058547.

Implementation of Online Behavior Modification Techniques in the Management of Chronic Musculoskeletal Pain: A Systematic Review and Meta-Analysis

Purpose: The main aim of this systematic review and meta-analysis (MA) was to assess the effectiveness of online behavior modification techniques (e-BMT) in the management of chronic musculoskeletal pain. Methods: We conducted a search of Medline (PubMed), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, APA PsychInfo, and Psychological and Behavioral Collections, from inception to the 30 August 2021. The main outcome measures were pain intensity, pain interference, kinesiophobia, pain catastrophizing and self-efficacy. The statistical analysis was conducted using RStudio software. To compare the outcomes reported by the studies, we calculated the standardized mean difference (SMD) over time and the corresponding 95% confidence interval (CI) for the continuous variables. Results: Regarding pain intensity (vs. usual care/waiting list), we found a statistically significant trivial effect size in favor of e-BMT (n = 5337; SMD = −0.17; 95% CI −0.26, −0.09). With regard to pain intensity (vs. in-person BMT) we found a statistically significant small effect size in favor of in-person BMT (n = 486; SMD = 0.21; 95%CI 0.15, 0.27). With respect to pain interference (vs. usual care/waiting list) a statistically significant small effect size of e-BMT was found (n = 1642; SMD = −0.24; 95%CI −0.44, −0.05). Finally, the same results were found in kinesiophobia, catastrophizing, and self-efficacy (vs. usual care/waiting list) where we found a statistically significant small effect size in favor of e-BMT. Conclusions: e-BMT seems to be an effective option for the management of patients with musculoskeletal conditions although it does not appear superior to in-person BMT in terms of improving pain intensity.

Development of a Digital Support Application With Evidence-Based Content for Sustainable Return to Work for Persons With Chronic Pain and Their Employers: User-Centered Agile Design Approach

BACKGROUND

Persons with chronic pain experience a lack of support after completing rehabilitation and the responsibility for the return-to-work (RTW) process is taken over by the employer. In addition, employers describe not knowing how to support their employees. Smartphone apps have been increasingly used for self-management, but there is a lack of available eHealth apps with evidence-based content providing digital support for persons with chronic pain and their employers when they return to work.

OBJECTIVE

This study aims to describe the development of a digital support application with evidence-based content that includes a biopsychosocial perspective on chronic pain for sustainable RTW for persons with chronic pain and their employers (SWEPPE [Sustainable Worker Digital Support for Persons With Chronic Pain and Their Employers]).

METHODS

A user-centered agile design approach was applied. The multidisciplinary project team consisted of health care researchers, a user representative, and a software team. A total of 2 reference groups of 7 persons with chronic pain and 4 employers participated in the development process and usability testing. Mixed methods were used for data collection. The design was revised using feedback from the reference groups. The content of SWEPPE was developed based on existing evidence and input from the reference groups.

RESULTS

The reference groups identified the following as important characteristics to include in SWEPPE: keeping users motivated, tracking health status and work situation, and following progress. SWEPPE was developed as a smartphone app for the persons with chronic pain and as a web application for their employers. SWEPPE consists of six modules: the action plan, daily self-rating, self-monitoring graphs, the coach, the library, and shared information with the employer. The employers found the following functions in SWEPPE to be the most useful: employees' goals related to RTW, barriers to RTW, support wanted from the employer, and the ability to follow employees' progress. The persons with chronic pain found the following functions in SWEPPE to be the most useful: setting a goal related to RTW, identifying barriers and strategies, and self-monitoring. Usability testing revealed that SWEPPE was safe, useful (ie, provided relevant information), logical, and easy to use with an appealing interface.

CONCLUSIONS

This study reports the development of a digital support application for persons with chronic pain and their employers. SWEPPE fulfilled the need of support after an interdisciplinary pain rehabilitation program with useful functions such as setting a goal related to RTW, identification of barriers and strategies for RTW, self-monitoring, and sharing information between the employee and the employer. The user-centered agile design approach contributed to creating SWEPPE as a relevant and easy-to-use eHealth intervention. Further studies are needed to examine the effectiveness of SWEPPE in a clinical setting.

Effectiveness of Telematic Behavioral Techniques to Manage Anxiety, Stress and Depressive Symptoms in Patients with Chronic Musculoskeletal Pain: A Systematic Review and Meta-Analysis

Anxiety, depressive symptoms and stress have a significant influence on chronic musculoskeletal pain. Behavioral modification techniques have proven to be effective to manage these variables; however, the COVID-19 pandemic has highlighted the need for an alternative to face-to-face treatment. We conducted a search of PubMed, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, APA PsychInfo, and Psychological and Behavioural Collections. The aim was to assess the effectiveness of telematic behavioral modification techniques (e-BMT) on psychological variables in patients with chronic musculoskeletal pain through a systematic review with meta-analysis. We used a conventional pairwise meta-analysis and a random-effects model. We calculated the standardized mean difference (SMD) with the corresponding 95% confidence interval (CI). Forty-one randomized controlled trials were included, with a total of 5018 participants. We found a statistically significant small effect size in favor of e-BMT in depressive symptoms (n = 3531; SMD = -0.35; 95% CI -0.46, -0.24) and anxiety (n = 2578; SMD = -0.32; 95% CI -0.42, -0.21) with low to moderate strength of evidence. However, there was no statistically significant effect on stress symptoms with moderate strength of evidence. In conclusion, e-BMT is an effective option for the management of anxiety and depressive symptoms in patients with chronic musculoskeletal pain. However, it does not seem effective to improve stress symptoms.

New generation psychological treatments in chronic pain

Chronic pain conditions are common and have a considerable impact on health and wellbeing. This impact can be reduced by cognitive behavioral therapy (CBT), the most commonly applied psychological approach to chronic pain. At the same time, CBT continues to develop, and now includes what is sometimes called "third wave" CBT. In this review, we examine the evidence for application of acceptance and commitment therapy (ACT), a principal example of this new wave or latest generation of treatment approaches, in people with chronic pain. We identified 25 randomized controlled trials of ACT for adults with chronic pain. Across the included trials, small to large effect sizes favoring ACT were reported for key outcomes including pain interference, disability, depression, and quality of life. Evidence from three studies provided some support for the cost effectiveness of ACT for chronic pain. Evidence also supported the mediating role of theoretically consistent processes of change (psychological flexibility) in relation to treatment outcomes. Investigation of moderators and predictors of outcomes was limited and inconsistent. In future, a greater focus on process based treatments is recommended. This should include continued identification of evidence based processes of change, and research methods more suited to understanding the experience and needs of individual people.

Digital Mental Health Intervention Plus Usual Care Compared to Usual Care Only and Usual Care Plus In-Person Psychological Counseling for Orthopedic Patients with Symptoms of Depression and/or Anxiety: Cohort Study (Preprint)

Background

Depression and anxiety frequently coexist with chronic musculoskeletal pain and can negatively impact patients’ responses to standard orthopedic treatments. Nevertheless, mental health is not routinely addressed in the orthopedic care setting. If effective, a digital mental health intervention may be a feasible and scalable method of addressing mental health in an orthopedic setting.

Objective

We aimed to compare 2-month changes in mental and physical health between orthopedic patients who received a digital mental health intervention in addition to usual orthopedic care, those who received usual orthopedic care only (without a specific mental health intervention), and those who received in-person care with a psychologist as part of their orthopedic treatment plan.

Methods

In this single-center retrospective cohort study involving ancillary analysis of a pilot feasibility study, 2-month self-reported health changes were compared between a cohort of orthopedic patients who received access to a digital mental health intervention (Wysa) and 2 convenience sample comparison cohorts (patients who received usual orthopedic care without a specific mental health intervention and patients who received in-person care with a psychologist as part of their orthopedic treatment plan). All patients were 18 years or older and reported elevated symptoms of depression or anxiety at an orthopedic clinic visit (Patient-Reported Outcomes Measurement Information System [PROMIS] Depression or Anxiety score ≥55). The digital intervention was a multi-component mobile app that used chatbot technology and text-based access to human counselors to provide cognitive behavioral therapy, mindfulness training, and sleep tools, among other features, with an emphasis on behavioral activation and pain acceptance. Outcomes of interest were between-cohort differences in the 2-month longitudinal changes in PROMIS Depression and Anxiety scores (primary outcomes) and PROMIS Pain Interference and Physical Function scores (secondary outcomes).

Results

Among 153 patients (mean age 55, SD 15 years; 128 [83.7%] female; 51 patients per cohort), patients who received the digital mental health intervention showed clinically meaningful improvements at the 2-month follow-up for all PROMIS measures (mean longitudinal improvement 2.8-3.7 points; P≤.02). After controlling for age and BMI, the improvements in PROMIS Depression, Pain Interference, and Physical Function were meaningfully greater than longitudinal changes shown by patients who received usual orthopedic care (mean between-group difference 2.6-4.8 points; P≤.04). Improvements in PROMIS Physical Function were also meaningfully greater than longitudinal changes shown by patients who received in-person psychological counseling (mean between-group difference 2.4 points; P=.04).

Conclusions

Patients who received a digital mental health intervention as part of orthopedic care reported greater 2-month mean improvements in depression, pain interference, and physical function than patients who received usual orthopedic care. They also reported a greater mean improvement in physical function and comparable improvements in depression, anxiety, and pain interference compared with orthopedic patients who received in-person psychological counseling.

Internet-delivered cognitive and behavioural based interventions for adults with chronic pain: a systematic review and meta-analysis of randomized controlled trials

ABSTRACT

This study examined the efficacy of Internet-delivered cognitive and behavioural interventions for adults with chronic pain, and explored the role of clinical and study characteristics as moderators of treatment effects. PubMed, Embase, PsycINFO, and CENTRAL and CINAHL were searched to identify randomised controlled trials published up to October 2021. A meta-analysis of 36 studies (5778 participants) was conducted, which found small effect sizes for interference/disability (Hedges' g = 0.28; 95% CI 0.21, 0.35), depression (g = 0.43; 95% CI 0.33, 0.54), anxiety (g = 0.32; 95% CI 0.24, 0.40), pain intensity (g = 0.27; 95% CI 0.21, 0.33), self-efficacy (g = 0.39; 95% CI 0.27, 0.52) and pain catastrophizing (g = 0.31; 95% CI 0.22, 0.39). Moderator analyses found interventions which involved clinician guidance had significantly greater effect sizes for interference/disability (g = 0.38), anxiety (g = 0.39), and pain intensity (g = 0.33) compared to those without (g = 0.16, g = 0.18; g = 0.20, respectively). Studies using an inactive control had greater effects for depression (g = 0.46) compared to active control trials (g = 0.22). No differences were found between treatments based on traditional Cognitive Behaviour Therapy versus Acceptance and Commitment Therapy. Sample size, study year, and overall risk of bias (Cochrane rating) did not consistently moderate treatment effects. Overall, the results support the use of internet-delivered cognitive and behavioural interventions as efficacious and suggest guided interventions are associated with greater clinical gains for several key pain management outcomes.Prospectively registered on OSF Registries (citation: osf.io/cvq3j/).

Technology-supported Acceptance and Commitment Therapy for chronic health conditions: A systematic review and meta-analysis

Chronic health conditions (CHCs) are common and associated with functional limitations. Acceptance and commitment therapy (ACT) shows promise in improving functioning, quality of life, and distress across several CHCs. The purpose of this study was to conduct a systematic review of technology-supported ACT for CHCs and perform a meta-analysis on functioning and ACT process outcomes. Multiple databases were systematically searched for randomized controlled trials. A total of 20 unique studies with 2,430 randomized participants were included. CHCs addressed in these studies were chronic pain (k = 9), obesity/overweight (k = 4), cancer (k = 3), hearing loss (k = 1), HIV (k = 1), multiple sclerosis (k = 1), and tinnitus (k = 1). Internet and telephone were the most used technology platforms. All studies included therapist contact with considerable heterogeneity between studies. Random effects meta-analyses found medium effect sizes showing technology-supported ACT outperformed comparator groups on measures of function at post-treatment (Hedges' g = -0.49; p = 0.002) and follow-up (Hedges' g = -0.52; p = 0.02), as well as ACT process outcomes at post-treatment (Hedges' g = 0.48; p < 0.001) and follow-up (Hedges' g = 0.44; p < 0.001). Technology-supported ACT shows promise for improving function and ACT process outcomes across a range of CHCs. Recommendations are provided to optimize technology-supported ACT for CHCs. PROSPERO registration number: CRD42020200230.

Online Acceptance and Commitment Therapy (ACT) interventions for chronic pain: A systematic literature review

BACKGROUND

We systematically reviewed all literature concerning online Acceptance and Commitment Therapy (ACT) interventions for chronic pain to evaluate their (1) ACT content, (2) design characteristics, (3) design rationales, and (4) adherence.

MATERIAL AND METHODS

A systematic search was performed on July 9th, 2020 in; PubMed, PsycINFO, CINAHL, and Web of Science. Search terms related to: Acceptance and Commitment Therapy, chronic pain, and eHealth. Extracted data concerned ACT content, design characteristics, adherence, and design rationales.

RESULTS

20 articles, in which 14 interventions were described, met all inclusion criteria. Adherence and design rationales were described to a limited extent in the included studies. In total, the majority provided an overview of the included ACT processes. In 10 articles it was described that the intervention was delivered via a dedicated website (n = 10), which was sometimes combined with an app (n = 3). Guidance was included in most studies (n = 19). Studies including RCT's (n = 8) reported online ACT interventions to be effective.

CONCLUSION

Online ACT interventions for chronic pain have been shown to be effective and have generally been constructed in line with ACT theory. However, the majority of studies does not provide information about the choices to optimize the fit between task, technology, and user. Considerations behind the choices for intervention features as well as design rationales could help to optimize future online ACT interventions. Additionally, consistent attention should be paid to measurement and operationalization of adherence, since this is a crucial link between content, design and effectiveness.

The Psychological Functioning in the COVID-19 Pandemic and Its Association With Psychological Flexibility and Broader Functioning in People With Chronic Pain

AIMS

People with chronic pain may be particularly vulnerable to the impact of the pandemic COVID-19, and psychological flexibility may protect them. This study investigates psychological functioning in the context of COVID-19, including fear and avoidance in the context of COVID-19, specifically its association with daily functioning, and the role of psychological flexibility, among people with chronic pain.

METHODS

Responses from 555 adults with chronic pain were collected through a cross-sectional online survey and analyzed.

RESULTS

Eight out of 10 participants reported significant depression and nearly 9 out of 10 reported significant functional impairment. COVID-19-related fear and avoidance significantly correlated with pain, pain-related disability, depression, and work and social adjustment (r = 18-.32), as well as psychological flexibility processes, including pain acceptance, self-as-context, and committed action, |r|=.13-.30. COVID-19-related fear and avoidance and COVID-19-related interference were significant predictors of some measures of daily functioning beyond demographics and pain, β = .09-.14. However, these associations weakened when psychological flexibility processes were factored into the models, with fear of COVID-19 no longer being a significant predictor of pain-related disability or depression, and COVID-19 avoidance no longer a significant predictor of depression.

CONCLUSIONS

The psychological functioning in the context of COVID-19 appears to be negatively associated with daily functioning in people with chronic pain, and is statistically significant in this regard. Psychological flexibility may have a role in these associations for people with chronic pain in the pandemic.

PERSPECTIVE

This article demonstrates the psychological implication of COVID-19 and its association with broader emotional and daily functioning in people with chronic pain. It also demonstrates that Psychological flexibility may have a role in these associations for people with chronic pain in the pandemic.

New Evidence in the Booming Field of Online Mindfulness: An Updated Meta-analysis of Randomized Controlled Trials

BACKGROUND

There is a need to regularly update the evidence base on the effectiveness of online mindfulness-based interventions (MBIs), especially considering how fast this field is growing and developing.

OBJECTIVE

This study presents an updated meta-analysis of randomized controlled trials assessing the effects of online MBIs on mental health and the potential moderators of these effects.

METHODS

We conducted a systematic literature search in PsycINFO, PubMed, and Web of Science up to December 4, 2020, and included 97 trials, totaling 125 comparisons. Pre-to-post and pre-to-follow-up between-group effect sizes (Hedges g) were calculated for depression, anxiety, stress, well-being, and mindfulness using a random effects model.

RESULTS

The findings revealed statistically significant moderate pre-to-post effects on depression (g=0.34, 95% CI 0.18-0.50; P<.001), stress (g=0.44, 95% CI 0.32-0.55; P<.001), and mindfulness (g=0.40, 95% CI 0.30-0.50; P<.001) and small effects on anxiety (g=0.26, 95% CI 0.18-0.33; P<.001). For well-being, a significant small effect was found only when omitting outliers (g=0.22, 95% CI 0.15-0.29; P<.001) or low-quality studies (g=0.26, 95% CI 0.12-0.41; P<.001). Significant but small follow-up effects were found for depression (g=0.25, 95% CI 0.12-0.38) and anxiety (g=0.23, 95% CI 0.13-0.32). Subgroup analyses revealed that online MBIs resulted in higher effect sizes for stress when offered with guidance. In terms of stress and mindfulness, studies that used inactive control conditions yielded larger effects. For anxiety, populations with psychological symptoms had higher effect sizes. Adherence rates for the interventions ranged from 35% to 92%, but most studies lacked clear definitions or cut-offs.

CONCLUSIONS

Our findings not only demonstrate that online MBIs are booming but also corroborate previous findings that online MBIs are beneficial for improving mental health outcomes in a broad range of populations. To advance the field of online MBIs, future trials should pay specific attention to methodological quality, adherence, and long-term follow-up measurements.

Efficacy of Online-Based Acceptance and Commitment Therapy for Chronic Pain: A Systematic Review and Meta-Analysis

Acceptance and Commitment Therapy (ACT) has been widely tested for chronic pain, with demonstrated efficacy. Nevertheless, although there is meta-analytical evidence on the efficacy of face-to-face ACT, no reviews have been performed on online ACT in this population. The aim of this meta-analysis is to determine the efficacy of online ACT for adults with chronic pain, when compared with controls. PubMed, PsycINFO, CENTRAL, and Web of Knowledge were searched for randomized controlled trials (RCTs) of online-delivered ACT for chronic pain. Effects were analyzed at post-treatment and follow-up, by calculating standardized mean differences. Online-delivered ACT was generally favored over controls (5 RCTs, N = 746). At post-treatment, medium effects for pain interference and pain acceptance, and small effects for depression, mindfulness, and psychological flexibility were found. A medium effect for pain interference and acceptance, and small effects for pain intensity, depression, anxiety, mindfulness, and psychological flexibility were found at follow-up. ACT-related effects for pain interference, pain intensity, mindfulness, and anxiety increased from post-treatment to follow-up. Nevertheless, the current findings also highlight the need for more methodologically robust RCTs. Future trials should compare online ACT with active treatments, and use measurement methods with low bias. PERSPECTIVE: This is the first meta-analytical review on the efficacy of online ACT for people with chronic pain. It comprises 5 RCTs that compared online ACT with active and/or inactive controls. Online ACT was more efficacious than controls regarding pain interference, pain intensity, depression, anxiety, mindfulness, and psychological flexibility.

Feasibility randomized-controlled trial of online acceptance and commitment therapy for painful peripheral neuropathy in people living with HIV: The OPEN study

BACKGROUND

Neuropathic pain negatively affects quality of life among people living with HIV (PLWH). This study examined the feasibility of conducting a full-scale randomized-controlled trial of online acceptance and commitment therapy ("ACT OPEN") for neuropathic pain in PLWH.

METHODS

Using a parallel-groups design, thirty-eight participants were randomized to ACT OPEN or a waitlist control (2:1). Participants completed standard self-report outcome measures at baseline, and two- and five-months post-randomization. Participants were aware of their allocation, but assessment was blinded.

RESULTS

Twenty-five participants were randomized to ACT OPEN and 13 to the control (of 133 referrals). ACT OPEN completion was 69% and two-month trial retention was 82%. Treatment credibility and satisfaction scores for ACT OPEN were comparable to scores reported in previous trials of cognitive-behavioural treatments for pain. Four adverse events were reported during the study, including one serious adverse event; all of these were unrelated to the research procedures. Small to moderate effects and 95% confidence intervals suggest that the true effect may favour ACT OPEN for improvements in pain intensity/interference and depression.

CONCLUSIONS

A full-scale RCT of online ACT for pain management in PLWH may be feasible with refinements to trial design to facilitate recruitment.

SIGNIFICANCE

Research on pain management in people living with HIV has primarily focused on pharmacological treatments with limited success. This is the first study to show the potential feasibility of a psychological treatment based on acceptance and commitment therapy delivered online and tailored for pain management in people with HIV ("ACT OPEN"). ACT OPEN may be a promising treatment in this population and further evaluation in a full-scale randomized-controlled trial appears warranted.

TRIAL REGISTRATION

The trial was registered (clinicaltrials.gov; NCT03584412).

Efficacy of an ACT and Compassion-Based eHealth Program for Self-Management of Chronic Pain (iACTwithPain): Study Protocol for a Randomized Controlled Trial

BACKGROUND

Chronic pain (CP) has serious medical and social consequences and leads to economic burden that threatens the sustainability of healthcare services. Thus, optimized management of pain tools to support CP patients in adjusting to their condition and improving their quality of life is timely. Although acceptance and commitment therapy (ACT) is considered an evidence-based psychological approach for CP, evidence for the efficacy of online-delivered ACT for CP is still scarce. At the same time, studies suggest that self-compassion mediates the change in disability and psychopathological symptoms in ACT interventions for CP, although self-compassion is not a specific target in ACT. Thus, an explicit focus on self-compassion might increase the efficacy of ACT interventions for CP, although this hypothesis has not been tested. This study aims to develop an eHealth ACT and compassion-based self-management intervention for CP, the iACTwithPain, and to compare its efficacy in improving health outcomes to a similar ACT-only intervention and a medical TAU group.

METHODS

The eHealth platform that will host the interventions will be developed using a flat design identity and will be interactive. The iACTwithPain intervention will comprise eight weekly self-management sessions and will be developed taking into consideration the psychological flexibility model applied to CP, with the addition of explicit compassion-based components. To analyze whether the iACTwithPain intervention will present superiority in improving CP's impact and related health markers over the two other conditions, this study will follow an RCT design with three arms. CP patients will be recruited through direct contact with patient associations and healthcare services and a national press release in Portugal. Outcome measurement will be conducted at baseline, post-intervention and at 3- and 6-month follow-ups. The interventions' acceptability will also be assessed.

DISCUSSION

The iACTwithPain intervention is expected to improve CP patients' psychosocial functioning, quality of life, and empowerment, by promoting adaptive disease management and regulation of pain-related internal experiences. Results will contribute to a better understanding on the pertinence of adding compassion elements to ACT for CP and to reach an optimized intervention for CP.

CLINICAL TRIAL REGISTRATION

This trial has been registered at ClinicalTrials.Gov (NCT04200183; 16 December 2019; https://clinicaltrials.gov/ct2/show/NCT04200183). The current manuscript comprises the first version of this clinical trial's protocol.

Internet-Based Acceptance and Commitment Therapy: A Transdiagnostic Systematic Review and Meta-Analysis for Mental Health Outcomes

Internet-based acceptance and commitment therapy (iACT) primarily targets the process of psychological flexibility. Its accessibility and low-intensity delivery are applicable across different treatment and prevention scenarios. This transdiagnostic meta-analysis reviews the effectiveness of iACT on anxiety, depression, quality of life, and psychological flexibility across individuals with different psychological and somatic conditions/complaints, or undiagnosed complaints. Seven databases were searched for randomized controlled trials that reported on anxiety, depression, quality of life, and psychological flexibility outcomes from iACT in any adult population. Engagement with iACT was summarized and methodological and population-related variables were investigated as potential moderators of effectiveness. Across 25 studies, small pooled effects were found for all outcomes at post-assessment and maintained at follow-up time-points. Interventions with therapist guidance demonstrated greater effectiveness in improving depression and psychological flexibility outcomes compared to nonguided iACT, and populations defined by a psychological condition or symptoms (e.g., depressed samples) demonstrated greater improvements in anxiety compared to nonclinical or somatic populations (e.g., chronic pain samples or students). Participants completed on average 75.77% of iACT treatments. While we found iACT to be effective in improving and maintaining mental health outcomes across diverse populations, there was limited evidence of reliable, clinically significant effects. PROSPERO registration number: CRD42020140086.

ACTsmart: Guided Smartphone-Delivered Acceptance and Commitment Therapy for Chronic Pain-A Pilot Trial

BACKGROUND

Acceptance and commitment therapy (ACT) is a behavioral health intervention with strong empirical support for chronic pain but, to date, widespread dissemination is limited. Digital solutions improve access to care and can be integrated into patients' everyday lives.

OBJECTIVE

ACTsmart, a guided smartphone-delivered ACT intervention, was developed to improve the accessibility of an evidence-based behavioral treatment for chronic pain. In the present study, we evaluated the preliminary efficacy of ACTsmart in adults with chronic pain.

METHODS

The study was an open-label pilot trial. The treatment lasted for 8 weeks, and participants completed all outcome measures at pretreatment and posttreatment and at 3-, 6-, and 12-month follow-ups, with weekly assessments of selected measures during treatment. The primary outcome was pain interference. The secondary outcomes were psychological flexibility, values, insomnia, anxiety, depressive symptoms, health-related quality of life, and pain intensity. All outcomes were analyzed using linear mixed-effects models.

RESULTS

The sample consisted of 34 adults (88% women) with long-standing chronic pain (M=20.4 years, SD=11.7). Compliance to treatment was high, and at the end of treatment, we observed a significant improvement in the primary outcome of pain interference (d = -1.01). All secondary outcomes significantly improved from pretreatment to posttreatment with small to large effect sizes. Improvements were maintained throughout 12 months of follow-up.

CONCLUSION

The results of this pilot study provide preliminary support for ACTsmart as an accessible and effective behavioral health treatment for adults with chronic pain and warrant a randomized controlled trial to further evaluate the efficacy of the intervention.

Acceptability of psychologically-based pain management and online delivery for people living with HIV and chronic neuropathic pain: a qualitative study

OBJECTIVES

Chronic neuropathic pain is common in people living with HIV. Psychological treatments can improve quality of life for people with chronic pain in general, and online delivery can increase access to these treatments. However, the acceptability of psychological treatment and online delivery have not been investigated in-depth in people living with HIV and chronic neuropathic pain. Therefore, a qualitative study was undertaken to explore views about a psychological treatment for pain management in this population and to investigate the acceptability of online treatment delivery.

METHODS

Qualitative interviews were conducted and analysed using inductive thematic analysis, adopting a critical realist perspective. Twenty-six people living with HIV and chronic neuropathic pain completed semi-structured interviews. Their views about a psychological treatment for pain management and online delivery were explored in-depth.

RESULTS

Three themes and 12 subthemes were identified. Theme one represents a desire for a broader approach to pain management, including not wanting to take more pills and having multidimensional goals that were not just focussed on pain relief. Theme two includes barriers to online psychologically-based pain management, including concerns about using the Internet and confidentiality. Theme three describes treatment facilitators, including accessibility, therapist support, social connection, and experiencing success.

CONCLUSIONS

A psychological treatment for chronic neuropathic pain management appears acceptable for people living with HIV. Therapist-supported online delivery of cognitive-behavioural pain management may be acceptable for people living with HIV given appropriate development of the treatment to address identified barriers to engagement. These data can inform developments to enhance engagement in online psychologically-informed pain management in people living with HIV and more broadly in remote delivery of psychological treatments.

Internet-delivered acceptance and commitment therapy as microlearning for chronic pain: A randomized controlled trial with 1-year follow-up

BACKGROUND

Studies of Internet-delivered acceptance and commitment therapy (ACT) for chronic pain have shown small to moderate positive effects for pain interference and pain acceptance. Effects on pain intensity, depression, anxiety and quality of life (QoL) have been less favourable, and improvements for values and sleep are lacking. In this randomized controlled trial iACT - a novel format of Internet-ACT using daily microlearning exercises - was examined for efficacy compared to a waitlist condition.

METHODS

Adult participants (mean age 49.5 years, pain duration 18.1 years) with diverse chronic pain conditions were recruited via self-referral, and randomized to iACT (n = 57) or waitlist (n = 56). The primary outcome was pain interference. The secondary outcomes were QoL, depression, anxiety, insomnia and pain intensity. The process variables included psychological inflexibility and values. Post-assessments were completed by 88% (n = 100) of participants. Twelve-month follow-up assessments were completed by 65% (iACT only, n = 37). Treatment efficacy was analysed using linear mixed models and an intention-to-treat-approach.

RESULTS

Significant improvements in favour of iACT were seen for pain interference, depression, anxiety, pain intensity and insomnia, as well as process variables psychological inflexibility and values. Between-group effect sizes were large for pain interference (d = 0.99) and pain intensity (d = 1.2), moderate for anxiety and depressive symptoms and small for QoL and insomnia. For the process variables, the between-group effect size was large for psychological inflexibility (d = 1.0) and moderate for values. All improvements were maintained at 1-year follow-up.

CONCLUSIONS

Internet-ACT as microlearning may improve a broad range of outcomes in chronic pain.

SIGNIFICANCE

The study evaluates a novel behavioral treatment with positive results on pain interference, mood as well as pain intensity for longtime chronic pain sufferers. The innovative format of a digital ACT intervention delivered in short and experiential daily learnings may be a promising way forward.

An enhanced psychological mindset intervention to promote adolescent wellbeing within educational settings: A feasibility randomized controlled trial

OBJECTIVE

This randomized controlled trial feasibility study aimed to investigate a single-session mindset intervention, incorporating third-wave constructs, within educational settings as a universal tool to promote emotional wellbeing.

METHOD

Eighty adolescents (age M = 16.63) were randomized to the 30-min computer intervention or a usual curriculum waitlist. Outcome measures were administered at baseline, posttreatment, 4-week, and 8-week follow-ups.

RESULTS

Student feedback about the intervention and trial procedure was mainly positive. Participants engaged with the intervention content and data were suggestive of possible small-large intervention effects for targeted mechanisms of personality mindset and psychological flexibility. Between-group differences over time across wellbeing outcomes of self-compassion, self-esteem, low mood, and anxiety also yielded some promising results, though assessments of reliable change were less clear. No harm was reported.

CONCLUSIONS

The intervention and study design were deemed feasible, though areas for improvement were noted. A full-scale trial to determine effectiveness is warranted.

Online Acceptance and Commitment Therapy for People with Painful Diabetic Neuropathy in the United Kingdom: A Single-Arm Feasibility Trial

OBJECTIVE

This study aimed to assess the feasibility of online Acceptance and Commitment Therapy for painful diabetic neuropathy in the United Kingdom and to determine if a larger randomized controlled trial testing treatment efficacy is justified.

METHODS

Participants with painful diabetic neuropathy were recruited online and from hospital services. This was a single-arm study in which all participants received online Acceptance and Commitment Therapy. Participants completed questionnaires at baseline and three months post-treatment. Primary feasibility outcomes were recruitment, retention, and treatment completion rates. Secondary outcomes were pre- to post-treatment effects on pain outcomes and psychological flexibility.

RESULTS

Of 225 potentially eligible participants, 30 took part in this study. Regarding primary feasibility outcomes, the treatment completion and follow-up questionnaire completion rates were 40% and 100%, respectively. Generally, at baseline those who completed the treatment, compared with those who did not, had better daily functioning and higher psychological flexibility. With respect to secondary outcomes, results from the completers group showed clinically meaningful effects at post-treatment for 100% of participants for pain intensity and pain distress, 66.7% for depressive symptoms, 58.3% for functional impairment, 41.7% for cognitive fusion, 66.7% for committed action, 58.3% for self-as-context, and 41.7% for pain acceptance.

CONCLUSIONS

This preliminary trial suggests feasibility of recruitment and follow-up questionnaire completion rates, supporting planning for a larger randomized controlled trial. However, treatment completion rates did not achieve the prespecified feasibility target. Changes to the treatment content and delivery may enhance the feasibility of online Acceptance and Commitment Therapy for people with painful diabetic neuropathy on a larger scale.

The Effectiveness of Acceptance and Commitment Therapy on Pain Acceptance and Pain Perception in Patients with Painful Diabetic Neuropathy: A Randomized Controlled Trial

INTRODUCTION

Neuropathic pain is a complex phenomenon in patients with diabetes. These patients have many problems, such as psychological problems, high-level pain perception, and pain acceptance. This study aimed to evaluate the effectiveness of acceptance and commitment therapy on pain acceptance and pain perception in patients with painful diabetic neuropathy.

METHODS

This study was performed according to the clinical trial method. The sample size was 50 participants. In this study, participants were divided into interventional and control groups. According to the diagnosis of neurologists, all participants received conventional medications to manage neuropathic pain. The intervention group received acceptance and commitment therapy for eight sessions. The results in the three phases of pre-test, post-test, and follow-up were evaluated. After completing the study, to comply with ethical standards, the control group received psycho-education. The tools used were the McGill Pain Questionnaire (MPQ) and the Chronic Pain Acceptance Questionnaire (CPAQ). Statistical analysis includes mean, standard deviation, and repeated-measures (ANOVA) conducted by SPSS software version 22.

RESULTS

The results demonstrated that in the post-test and follow-up phases, acceptance and commitment therapy could improve pain acceptance and reduce pain perception in the intervention group compared to the control group (P < 0.01).

CONCLUSION

The results indicated that acceptance and commitment therapy could be used as a psychological intervention besides pharmacotherapy to improve pain acceptance and reduce pain perception in patients with painful diabetic neuropathy.

CLINICAL TRAIL REGISTRATION

This study was registered at the Iranian Registry of Clinical Trials (IRCT20180205038630N4).

Internet-delivered acceptance and commitment therapy (iACT) for chronic pain-feasibility and preliminary effects in clinical and self-referred patients

BACKGROUND

Acceptance and commitment therapy (ACT) is an evidence-based treatment to improve functioning and quality of life (QoL) for chronic pain patients, but outreach of this treatment is unsatisfactory. Internet-delivery has been shown to increase treatment access but there is limited evidence regarding feasibility and effectiveness of web-based ACT for chronic pain. The aim of the study was to evaluate and iterate a novel internet-delivered ACT program, iACT, in a clinical and a self-referred sample of chronic pain patients. The intervention was developed in close collaboration with patients. To enhance learning, content was organized in short episodes to promote daily engagement in treatment. In both the clinical and self-referred samples, three critical domains were evaluated: (I) feasibility (acceptability, practicality and usage); (II) preliminary efficacy on pain interference, psychological inflexibility, value orientation, QoL, pain intensity, anxiety, insomnia and depressive symptoms; and (III) potential treatment mechanisms.

METHODS

This was an open pilot study with two samples: 15 patients from a tertiary pain clinic and 24 self-referred chronic pain participants, recruited from October 2015 until January 2017. Data were collected via an online platform in free text and self-report measures, as well as through individual oral feedback. Group differences were analyzed with Chi square-, Mann-Whitney U- or t-test. Preliminary efficacy and treatment mechanism data were collected via self-report and analyzed with multilevel linear modeling for repeated measures.

RESULTS

Feasibility: patient feedback guided modifications to refine the intervention and indicated that iACT was acceptable in both samples. User insights provided input for both immediate and future actions to improve feasibility. Comprehensiveness, workability and treatment credibility were adequate in both samples. Psychologists spent on average 13.5 minutes per week per clinical patient, and 8 minutes per self-referred patient (P=0.004). Recruitment rate was 24 times faster in the self-referred sample (24 patients in 1 month, compared to 15 patients in 15 months, P<0.001) and the median distance to the clinic was 40 km in the clinical sample, and 426 km in the self-referred sample (P<0.001). Preliminary effects: post-assessments were completed by 26 participants (67%). Significant effects of time were seen from pre- to post-treatment across all outcome variables. Within group effect sizes (Cohen's d) at post-treatment ranged from small to large: pain interference (d=0.64, P<0.001), psychological inflexibility (d=1.43, P<0.001), value progress (d=0.72, P<0.001), value obstruction (d=0.42, P<0.001), physical QoL (d=0.41, P=0.005), mental QoL (d=0.67, P=0.005), insomnia (d=0.31, P<0.001), depressive symptoms (d=0.47, P<0.001), pain intensity (d=0.78, P=0.001) and anxiety (d=0.46, P<0.001). Improvements were sustained at 1-year follow-up. Psychological inflexibility and value progress were found to be potential treatment mechanisms.

CONCLUSIONS

The results from the present study suggests that iACT was feasible in both the clinical and the self-referred sample. Together with the positive preliminary results on all outcomes, the findings from this feasibility study pave the way for a subsequent large randomized efficacy trial.

The Phenomenon of Treatment Dropout, Reasons and Moderators in Acceptance and Commitment Therapy and Other Active Treatments: A Meta-Analytic Review

Treatment dropout is one of the most crucial issues that a therapist has to face on a daily basis. The negative effects of premature termination impact the client who is usually found to demonstrate poorer treatment outcomes. This meta-analysis reviewed and systematically examined dropout effects of Acceptance and Commitment Therapy (ACT) as compared to other active treatments. The goals of this study were to compare treatment dropout rates and dropout reasons, examine the influence of demographic variables and identify possible therapy moderators associated with dropout.

The current meta-analysis reviewed 76 studies of ACT reporting dropout rates for various psychological and health-related conditions.

Across reviewed studies (N = 76), the overall weighted mean dropout rate was 17.95% (ACT = 17.35% vs. comparison conditions = 18.62%). Type of disorder, recruitment setting and therapists’ experience level were significant moderators of dropout. The most frequently reported reasons for dropout from ACT were lost contact, personal and transportation difficulties, whereas for comparative treatments they were lost contact, therapy factors and time demands.

Given that most moderators of influence are not amenable to direct changes by clinicians, mediation variables should also be explored. Overall, results suggest that ACT appears to present some benefits in dropout rates for specific disorders, settings and therapists.

There was no difference in dropout rate between ACT and control conditions (17.35% vs.18.62%). Significant moderators were client disorder, therapists’ experience level and recruitment and setting.

Comparison condition frequently reported therapy related dropout factors, suggesting that ACT may be a more acceptable option.

Acceptance and commitment therapy for chronic pain: protocol of a systematic review and individual participant data meta-analysis

BACKGROUND

Acceptance and commitment therapy (ACT) can be effective in treating chronic pain. Despite evidence supporting the effectiveness of ACT, uncertainties remain regarding which subgroups in the chronic pain population are likely to benefit most and least. This protocol describes the application for two meta-analytic approaches, one at the level of individual participant data and the other at the level of aggregated data, from randomized controlled trials of ACT for chronic pain (ACT-CP-MA).

METHODS

We will systematically conduct literature searches in CENTRAL, MEDLINE, EMBASE, PsycINFO, and trial registers. Two reviewers will independently select studies for inclusion and data extraction. ACT-CP-MA will include randomized controlled trials with ACT for chronic pain compared to control conditions for adults (≥ 18 years) with chronic pain (> 3 months). We will invite the authors of all eligible trials to share individual participant data. Outcomes will include standardized measures of pain interference, pain intensity, depression, anxiety, health-related quality of life, participants' rating of overall improvement, and ACT-related process variables. Using the Cochrane Collaboration's tool and GRADE, reviewers will independently check for risk of bias, quality of evidence, and strength of recommendations. In the individual participant data meta-analysis, we will use a one-step approach where participants are clustered with studies and data from all studies are modeled simultaneously. For analyses, we will use mixed-effects models. Additionally, we will employ a meta-analysis with aggregate data and compare the results of both meta-analyses.

DISCUSSION

This collaborative meta-analysis of individual participant data from randomized controlled trials of ACT for chronic pain versus control conditions will demonstrate how the known benefits of ACT for chronic pain vary across different subtypes of the chronic pain population. The results of the meta-analyses will be based on a comprehensive search of multiple databases and will help to inform future clinical trials and decision-making on the use of ACT in chronic pain and improve the quality, design, and reporting of future trials in this field.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019120901.

Third Wave Treatments for Functional Somatic Syndromes and Health Anxiety Across the Age Span: A Narrative Review

Functional disorders (FD) are present across the age span and are commonly encountered in somatic health care. Psychological therapies have proven effective, but mostly the effects are slight to moderate. The advent of third wave cognitive behavioural therapies launched an opportunity to potentially improve treatments for FD.

A narrative review of the literature on the application of mindfulness-based therapies (MBT) and Acceptance &amp; Commitment Therapy (ACT) in children and adult populations with FD.

There were very few and mainly preliminary feasibility studies in children and adolescents. For adults there were relatively few trials of moderate to high methodological quality. Ten MBT randomised trials and 15 ACT randomised trials of which 8 were internet-delivered were identified for more detailed descriptive analysis. There was no evidence to suggest higher effects of third wave treatments as compared to CBT. For MBT, there seemed to be minor effects comparable to active control conditions. A few interventions combining second and third wave techniques found larger effects, but differences in outcomes, formats and dosage hamper comparability.

Third wave treatments are getting established in treatment delivery and may contribute to existing treatments for FD. Future developments could further integrate second and third wave treatments across the age span. Elements unambiguously targeting specific illness beliefs and exposure should be included. The benefit of actively engaging close relatives in the treatment not only among younger age groups but also in adults, as well as the effect of more multimodal treatment programmes including active rehabilitation, needs to be further explored.

The methodological quality of third wave interventions for FD should be improved, especially in younger age groups.

The effect of ACT interventions may be comparable to CBT in adults with FD.

The evidence for third wave interventions in young people with FD is still very limited.

Newer studies combining second and third wave treatments show some promise.

Agreement on, and for child populations further development of, core outcomes, could help determine effect across studies.

The role of psychological flexibility in relation to suicidal thinking in chronic pain

BACKGROUND

Suicidal thinking (ST) is common in people with chronic pain. It is relevant as it can be associated with suicidal attempts, and typically reflects significant suffering. While little is known about the psychological processes that contribute to ST, current psychological models, such as the Psychological Flexibility (PF) model, could help guide further investigation. This study investigates relations between ST and components of PF in chronic pain.

METHODS

Participants were 424 adults attending treatment for chronic pain in the UK. Included in measures administered before treatment were standardized measures of depression, pain, pain-related interference, and measures of PF, including acceptance, cognitive defusion, committed action, and self-as-context. An item from the measure of depression was used to reflect ST.

RESULTS

A large proportion of the sample reported ST, 45.7%. ST was uncorrelated with participant background characteristic, medications taken, or pain intensity. However, it was correlated with the presence of widespread pain, pain-related interference, and depression. Each component of PF was found to be significantly negatively associated with ST, as predicted. General acceptance correlated with ST at a level equal to that achieved by the depression score. In adjusted multivariate logistic regression general acceptance and committed action remained significantly uniquely associated with it.

CONCLUSION

This preliminary study suggests for the first time that components of PF are associated with part of a pattern of suicidal behaviour in people with chronic pain. They may be relevant for reducing avoidance in general and providing more positive behavioural options.

SIGNIFICANCE

This study provides evidence that components of psychological flexibility are associated with a reduced frequency of suicidal thinking in people with chronic pain. Treatments targeting psychological flexibility may help mitigate the impact of chronic pain on suicidal thinking.