Tailored internet-based cognitive behavioral therapy for individuals with chronic pain and comorbid psychological distress: a randomized controlled trial

Effectiveness of psychological interventions to decrease cognitive fusion in patients with chronic pain: A systematic review and meta-analysis

OBJECTIVE

While there is sufficient evidence of Acceptance and Commitment Therapy's effectiveness in allowing patients to deal with chronic pain, the effectiveness in cognitive fusion, one of the six core components of the Psychology Flexibility Model, has yet to be established. The aim of this article is to assess whether psychological interventions decrease cognitive fusion.

METHODS

The Web of Science, SCOPUS, Medline, and PsycINFO databases were searched for primary studies up to June 2024. Studies with a cognitive fusion measure in which chronic pain patients received a psychological intervention were included. A methodological quality scale was applied to the selected studies and the average effect sizes (Hedges g) were calculated.

RESULTS

This review included 18 articles with 24 studies (19 pre-post/follow-up studies and five randomized control trials). Cognitive fusion decreased significantly after the intervention. The effect sizes were small/medium at post-test, g = -0.39, p < .001, 95% CI [-0.52, -0.26]; and medium at long-term follow-up, g = -0.55, p < .001, 95% CI [-0.74, -0.36]. A similar tendency was found for studies with RCTs at post-test, g = -0.61, p = .006, 95% CI [-1.05, -0.17], short-term follow-up, g = -0.79, p < .001, 95% CI [-1.18, -0.40] and long-term follow-up, g = -0.58, p = .003, 95% CI [-0.95, -0.20]). Moderator variables such as unemployment, gender, pain intensity, level of depression before the intervention, and duration and intervention modality were identified.

CONCLUSION

Psychological interventions tended to decrease cognitive fusion in chronic pain patients. Nonetheless, more clinical trials are needed to establish the role of cognitive fusion in psychological flexibility.

Older Adults Experience with a Layperson-Supported Digital Mental Health Intervention for Depression: Qualitative Insights on Engagement

OBJECTIVES

This qualitative study examines the experiences of older adults with Empower@Home, an older adult-centered, layperson-supported internet-based cognitive behavioral therapy (iCBT) program for depression, with a focus on engagement-related factors.

METHODS

Adults aged 50 or older with at least mild depressive symptoms were recruited from multiple resources. A random subset of participants was invited for a semi-structured qualitative interview during a post-intervention assessment conducted over the phone (N = 148). Interviews were recorded and transcribed verbatim. Transcripts were coded in a multi-phase, team-based approach utilizing inductive coding techniques, followed by thematic analysis to identify key themes.

RESULTS

Six key themes regarding engagement emerged: the importance of a structured, skills-based, and self-paced approach; the essential role of weekly coaching for accountability, web interface's ease of use and accessibility; narrative engagement dynamics; enhanced learning through multimodal instruction; and tailoring challenges in iCBT.

CONCLUSIONS

Older adult-centered, layperson-supported, and multimodal iCBT can effectively engage older adults in managing their mental health.

CLINICAL IMPLICATIONS

iCBT programs can be integrated into various community aging settings. By leveraging each setting's strengths and involving a range of professionals, these programs can play an important role in enhancing older adults' mental health.

The latest developments with internet-based psychological treatments for depression

INTRODUCTION

Internet-based psychological treatments for depression have been around for more than 20 years. There has been a continuous line of research with new research questions being asked and studies conducted.

AREAS COVERED

In this paper, the author reviews studies with a focus on papers published from 2020 and onwards based on a Medline and Scopus search. Internet-based cognitive behavior therapy (ICBT) programs have been developed and tested for adolescents, older adults, immigrant groups and to handle a societal crisis (e.g. COVID-19). ICBT works in regular clinical settings and long-term effects can be obtained. Studies on different treatment orientations and approaches such as acceptance commitment therapy, unified protocol, and tailored treatments have been conducted. Effects on quality-of-life measures, knowledge acquisition and ecological momentary assessment as a research tool have been reported. Factorial design trials and individual patient data meta-analysis are increasingly used in association with internet intervention research. Finally, prediction studies and recent advances in artificial intelligence are mentioned.

EXPERT OPINION

Internet-delivered treatments are effective, in particular if therapist guidance is provided. More target groups have been covered but there are many remaining challenges including how new tools like artificial intelligence will be used when treating depression.

Hurdles and potentials when implementing internet-delivered Acceptance and commitment therapy for chronic pain: a retrospective appraisal using the Quality implementation framework

OBJECTIVES

Internet-delivered psychological interventions can be regarded as evidence-based practices and have been implemented in psychiatric and somatic care at primary and specialist levels. However, challenges as low adherence and poor routinization, have arisen during attempts to implement internet-delivered interventions in chronic pain settings. Internet-delivered Acceptance and Commitment Therapy (IACT) has been found to be helpful for chronic pain patients and might aid in developing pain rehabilitation services. However, the integration of IACT into standard health care has not yet been described from an implementation science perspective. The aim of this hybrid 1 effectiveness-implementation study was to evaluate the process of implementing IACT in a pain rehabilitation setting, to guide future implementation initiatives.

METHODS

In this retrospective study we described actions taken during an implementation initiative, in which IACT was delivered as part of an interdisciplinary pain rehabilitation program (IPRP) at a specialist level clinic. All documents relevant to the study were reviewed and coded using the Quality Improvement Framework (QIF), focusing on adoption, appropriateness and sustainability.

RESULTS

The QIF-analysis of implementation actions resulted in two categories: facilitators and challenges for implementation. Sustainability may be facilitated by sensitivity to the changing needs of a clinical setting and challenged by unfitting capacity building. Appropriateness might be challenged by an insufficient needs assessment and facilitated by aligning routines for communication with the clinic's existing infrastructure. Adoption may be facilitated by staff key champions and an ability to adapt to occurring hurdles. Possible influential factors, hypotheses and key process challenges are presented in a logic model to guide future initiatives.

CONCLUSIONS

Sustainable implementation may depend on both the continuity of facilitating implementation actions and flexibility to the changing needs and interests of patients, caregivers and organization. We conclude that the use of theories, models and frameworks (TMF) as well as a logic model may ease design, planning and evaluation of an implementation process. Lastly, we suggest that IACT may be appropriate for IPRP when given before or after IPRP, focusing on psychiatric comorbidities.

A systematic review of cognitive behavioral therapy-based interventions for comorbid chronic pain and clinically relevant psychological distress

Objective

Chronic pain frequently co-occurs with clinically relevant psychological distress. A systematic review was conducted to identify the efficacy of cognitive behavioral therapy-based interventions for patients with these comorbid conditions.

Methods

The systematic search was carried out in Medline, PsycINFO, Web of Science, and Scopus up to March 18th, 2023. Four reviewers independently conducted screenings, extraction, and quality assessment.

Results

Twelve randomized controlled trials and one non-randomized controlled trial involving 1,661 participants that examined the efficacy of Cognitive Behavioral Therapy (nine studies), Mindfulness-based Interventions (three studies), Acceptance and Commitment Therapy (one study), and Behavioral Activation Therapy for Depression (one study) were included. Compared to treatment as usual, six out of eight studies of traditional Cognitive Behavioral Therapy reported significant differences in the reduction of depressive symptoms at post-treatment (d from 1.31 to 0.18) and four out of six at follow-up (d from 0.75 to 0.26); similarly, five out of six reported significant differences in the reduction of anxiety symptoms at post-treatment (d from 1.08 to 0.19) and three out of four at follow-up (d from 1.07 to 0.27). Overall, no significant differences between traditional Cognitive Behavioral Therapy and treatment as usual were reported at post-treatment and follow-up in the studies exploring pain intensity and pain catastrophizing.

Conclusion

The available evidence suggests that traditional Cognitive Behavioral Therapy may produce significant benefits for the improvement of depression, anxiety, and quality of life, but not for pain intensity and pain catastrophizing. More evidence is needed to determine the effects of MBI, ACT, and BATD.

Systematic review registration

PROSPERO, CRD42021219921.

Personalized pain management: Is it time for process-based therapy for particular people with chronic pain?

BACKGROUND AND OBJECTIVE

Psychological treatments for chronic pain have helped many people around the world. They are among the most researched and best evidenced treatments a person can receive when they have persistent, disabling and distressing pain. At the same time, improvements in the effectiveness of these treatments appear to be at a standstill. This may be due to an inherent lack of generalizability from aggregated group data to the individual, limited utility of our current schemes for categorizing people with pain conditions, faced with their inherent heterogeneity, our relatively coarse categories of treatment types and focus on treatment packages rather than individual methods, and our current failures to find adequate predictors of outcome, or to assign people their best-suited treatment methods, based on group data. In this review, it is argued that the development and examination of truly personalized treatment is a next logical step to create progress and improve the results people achieve.

METHODS

Key research studies pertaining to psychological treatments, treatment outcome, heterogeneity in chronic pain, prediction of treatment outcome, subtyping and treatment tailoring are reviewed.

RESULTS AND CONCLUSION

It is suggested that development of future treatments for chronic pain ought to incorporate an idiographic, process-based approach, focused on evidence-based mechanisms of change, individually and dynamically addressed, based on contextually sensitive ongoing assessment. Knowledge and practical solutions needed to make process-based therapy for chronic pain happen are discussed.

SIGNIFICANCE

Psychological approaches to chronic pain have been highly successful in the past but improvement in the effectiveness of these over time is slow to nonexistent. It is argued here that this has happened due to a failure to adequately consider the individual. Future psychological treatments for chronic pain ought to incorporate an idiographic, process-based approach, focused on evidence-based mechanisms of change, individually and dynamically addressed, grounded in ongoing contextually sensitive assessment.

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.

Internet-based and mobile-based cognitive behavioral therapy for chronic diseases: a systematic review and meta-analysis

Positive adjustment to chronic diseases reduces psychiatric comorbidity and enhances quality of life. Very little is known about the benefit of internet-based and mobile-based Cognitive Behavioral Therapy (IM-CBT) on physical outcomes and its reciprocal interactions with psychiatric outcomes, the active therapeutic elements, and effect moderators among people with major chronic medical conditions. In this systematic review and meta-analysis (PROSPERO: CRD42022265738), CINAHL of Systematic Reviews, MEDLINE, PsycINFO, PubMed, Web of Science are systematically searched up to 1 June 2022, for randomized controlled trials (RCTs) comparing IM-CBT against non-CBT control condition(s) among people with chronic disease(s). Primary outcomes include improvements in psychiatric symptoms (depressive, anxiety, PTSD symptoms, general psychological distress) from baseline to post-intervention and follow-ups. Secondary outcomes include improvements in physical distress (physical symptoms, functional impairment, self-rated ill health, objective physiological dysfunction). Among 44 RCTs (5077 patients with seven different chronic diseases), IM-CBT improves depressive symptoms, anxiety symptoms, and general psychological distress at post-intervention and across follow-ups, and improves physical distress and functional impairment at post-intervention. Preliminary evidence suggests that behavioral modification and problem-solving could be necessary components to reduce psychiatric symptoms in IM-CBT, whereas cognitive restructuring, psychoeducation, and mindfulness elements relate to reduced physical distress. IM-CBT shows stronger benefits in chronic pain, cancer, arthritis, and cardiovascular disease, relative to other conditions. Changes in psychiatric symptoms and physical distress prospectively predict each other over time. IM-CBT is an effective intervention for comprehensive symptom management among people with chronic diseases.