Background & Aims
There is a marked co-occurrence between chronic pain and mental health problems (1, 2), and a need for a more integrated conceptualization and treatment model for these patients’ health problems (3, 4). The aim of this project was to implement and explore the effectiveness of a transdiagnostic emotion-focused treatment for patients with chronic pain and comorbid emotional problems in clinical care. The primary objective was to evaluate effects on pain, pain coping, catastrophizing, depressive symptoms, and anxiety. The secondary objective was to evaluate the feasibility aspects: reach, patient recruitment, treatment adherence and satisfaction.
The hybrid treatment, previously evaluated in an efficacy trial (5, 6), addresses comorbid anxiety- and depressive and pain problems and targets core emotion regulation processes hypothesized to maintain and exacerbate these problems.
Methods
This study had a sequential single-case experimental AB design with randomized baseline lengths (4, 5, or 6 weeks), with repeated weekly measures for 20 weeks (pain, pain coping, catastrophizing, depressive symptoms, and anxiety) and standardized pre-post and 12-months follow-up measurements. Eligible participants were screened and a total of 41 participants with anxiety or depressive symptoms and chronic pain with functional impairment were recruited from primary and secondary care, final sample with sufficient data for analyses n=31. The transdiagnostic emotion-focused treatment was provided by a psychologist in 10-15 sessions. Data were analyzed with descriptive and inferential statistics. For effectiveness, analyses were performed on the individual level and study level using non-overlap of all pairs (NAP) (7) and multilevel modeling (MultiSCED) (8). NAP interpretation was: 0-.65 weak, .65-.92 moderate, .93-1 large effects (7).
Results
Among the 31 participants, mean age was 39 years (SD 13), 22 (71%) were women, 6 (19%) had a university degree and 20 (65%) had Swedish nationality. A majority (61%) reported sick leave >180 days during the past year. On the individual level, 11 participants were found to have a moderate treatment effect across the primary outcomes. On the study level, significant improvement was found in pain interference only; average standardized treatment effect (delta): 0.34; p-value: 0.032. Treatment responders (n=11) had higher adherence to the treatment protocol (e.g., exposure 82% vs 50%) compared to non-responders (n=20), even though session adherence were similar (M=10.7 sessions vs M=10.4 sessions). Analysis of 12-month follow-up of secondary outcomes is ongoing.
Conclusions
The hybrid treatment could be implemented in primary and secondary care with moderately positive, clinically relevant, effects. One third of the sample could be classified as responders but two thirds could not. Treatment response seemed to be related to the actual treatment content that was delivered specifically content targeting avoidance through exposure
References
1.Tsang A, Von Korff M, Lee S, Alonso J, Karam E, Angermeyer MC, et al. Common chronic pain conditions in developed and developing countries: gender and age differences and comorbidity with depression-anxiety disorders. J Pain. 2008 Oct;9(10):883-91.
2.Reme SE, Tangen T, Moe T, Eriksen HR. Prevalence of psychiatric disorders in sick listed chronic low back pain patients. Eur J Pain. 2011 Nov;15(10):1075-80.
3.Sharp TJ, Harvey AG. Chronic pain and posttraumatic stress disorder: mutual maintenance? Clin Psychol Rev. 2001 Aug;21(6):857-77.
4.Linton SJ. A Transdiagnostic Approach to Pain and Emotion. J Appl Biobehav Res. 2013 Jun;18(2):82-103.
5.Boersma K, Södermark M, Hesser H, Flink IK, Gerdle B, Linton SJ. Efficacy of a transdiagnostic emotion-focused exposure treatment for chronic pain patients with comorbid anxiety and depression: a randomized controlled trial. Pain. 2019 Aug;160(8):1708-1718.
6.Södermark M, Linton SJ, Hesser H, Flink I, Gerdle B, Boersma K. What Works? Processes of Change in a Transdiagnostic Exposure Treatment for Patients With Chronic Pain and Emotional Problems. Clin J Pain. 2020 Sep;36(9):648-657.
7.Parker R, Vannest K. An Improved Effect Size for Single-Case Research: Nonoverlap of All Pairs. Behavior Therapy. 2009; 40 (4): 357-67.
8.Declercq, L., Cools, W., Beretvas, S. N., Moeyaert, M., Ferron, J. M., & Van den Noortgate, W. MultiSCED: A tool for (meta-)analyzing single-case experimental data with multilevel modeling. Behavior Research Methods. 2020;52: 1-16.
9.Braden JB, Zhang L, Zimmerman FJ, Sullivan MD. Employment Outcomes of Persons With a Mental Disorder and Comorbid Chronic Pain. Psychiatr Serv. 2008;59(8):878–85.
10.Gerdle B, Åkerblom S, Brodda Jansen G, Enthoven P, Ernberg M, Dong HJ, et al. Who benefits from multimodal rehabilitation; an exploration of pain, psychological distress, and life impacts in over 35,000 chronic pain patients identified in the Swedish Quality Registry for Pain Rehabilitation. J Pain Res. 2019;12:891–908.
Presenting Author
Hedvig Zetterberg
Poster Authors
Hedvig Zetterberg
PhD
School of Behavioral, Social and Legal Sciences, Örebro University
Lead Author
Xiang Zhao
PhD
School of Behavioral, Social and Legal Sciences, Örebro University
Lead Author
Sofia Bergbom
PhD
School of Behavioral, Social and Legal Sciences, Örebro University
Lead Author
Rebecca Lennartsson
MSc.
School of Behavioral, Social and Legal Sciences, Örebro University
Lead Author
Steven Linton
PhD
School of Behavioral, Social and Legal Sciences, Örebro University
Lead Author
Ida Flink
Karlstad University
Lead Author
Katja Boersma
PhD
School of Behavioral, Social and Legal Sciences, Örebro University
Lead Author
Topics
- Treatment/Management: Pharmacology: Psychological and Rehabilitative Therapies