Five-year observational study of Internet-delivered cognitive behavioural pain management when offered as routine care by an online therapy clinic

Internet-Delivered Psychological Pain Management: A Prospective Cohort Study Examining Routine Care Delivery by a Specialist Regional Multidisciplinary Pain Service

Several clinical trials have demonstrated the effectiveness of internet-delivered psychological-based pain management programs (PMPs). However, to date, no large studies have reported the outcomes of PMPs when delivered by specialist multidisciplinary pain services in routine care. The present study reports (n = 653) the outcomes of an internet-delivered PMP provided as routine care by a specialist Australian regional pain service over a 6-year period. High levels of treatment commencement (85%) and completion (72%) were observed, with more than 80% of patients reporting they were satisfied with the intervention. Clinical improvements were observed from pretreatment to post-treatment (% change, 95% confidence intervals (CI)) in pain-related disability (8.8%; 4.5, 12.8), depression (28.4%; 23.0, 33.4), anxiety (21.9%; 14.6, 28.5), and pain intensity (7%; 3.5, 10.5), which were maintained to 3-month follow-up. At 3-month follow-up, 27% (23, 31), 46% (41, 51), 44% (39, 49), and 22% (19, 26) reported clinically meaningful (defined as ≥ 30%) improvements in pain-related disability, depression, anxiety, and pain intensity, respectively. These results were obtained with relatively little therapist time per patient (M = 30.0, (standard deviation) SD = 18.8) to deliver the intervention. The current findings highlight the potential of internet-delivered PMPs as part of the services provided by specialist pain services, particularly those servicing large geographical regions and for patients unable to travel to clinics for face-to-face care. PERSPECTIVE: This study reports the outcomes of the routine delivery of an internet-delivered psychological PMP by a specialist pain service. The findings highlight the potential of this model of care when provided by specialist pain services, particularly for patients not unable to attend and not requiring intensive face-to-face care.

Sudden gains in depression and anxiety during an online pain management programme for chronic pain

BACKGROUND

Chronic pain is associated with depression and anxiety symptoms. Pain management programms, delivered face-to-face or via the internet, can effectively help adults manage the impacts of chronic pain. Sudden gains are defined as substantial, rapid, and lasting symptom reductions that occur between consecutive treatment sessions and have been associated with better treatment outcomes in non-pain samples. This study examined whether adults with chronic pain report sudden gains in depression or anxiety symptoms during an 8-week online pain management programme, and whether sudden gains were associated with better treatment outcomes for depression or anxiety. Dominant theories of sudden gains argue that therapists are required for sudden gains to be maintained and improve treatment outcomes.

METHODS

Using data from a published randomized controlled trial (n = 338), sudden gains and treatment outcomes were compared across three levels of therapist guidance provided alongside the programme: weekly, optional, and self-guided.

RESULTS

Similar rates of sudden gains were observed in depression (22%) and anxiety (24%) across the treatment period, and most sudden gains occurred between Weeks 1 and 2 of treatment. Therapist guidance was not associated with sudden gains; higher baseline symptom severity emerged as the only consistent predictor of sudden gain status. No significant differences in treatment outcomes for depression or anxiety symptoms between sudden gainers and non-gainers were observed across therapist guidance conditions.

CONCLUSIONS

These results do not support an association between sudden gains in depression or anxiety symptoms and better post-treatment outcomes, at least for adults with chronic pain.

SIGNIFICANCE STATEMENT

Sudden gains in depression and anxiety symptoms were not associated with improved treatment outcomes for adults with chronic pain who participated in an online pain management programme, regardless of the level of therapist guidance provided. These findings suggest possible differences in symptom change in chronic pain samples compared to general population samples.

Acceptability and effectiveness study of therapist-assisted internet-delivered cognitive behaviour therapy for agriculture producers

Agriculture producers are less likely to seek or to receive mental health services compared to the general population. Additional research is needed to identify effective and accessible mental health interventions for this underserved population. This study used a mixed-methods approach and open trial design to examine the acceptability and effectiveness of therapist-assisted internet-delivered cognitive behaviour therapy (ICBT) supplemented with an additional agricultural resource for clients from agricultural backgrounds receiving ICBT in routine care. Clients (n = 34) participated in an online, five-lesson course that provided psychoeducation and strategies for dealing with symptoms of anxiety and depression, with weekly therapist assistance. Clients also received a tailored resource (developed with input from those with an agricultural background) providing culturally specific information and case stories pertinent to agricultural communities. Intent-to-treat analyses showed that the ICBT program was effective in reducing anxiety and depression symptoms among the agricultural population. Large within-group pre-to-post-treatment Cohen's effect sizes of d = 1.14, 95 % CI [0.41, 1.86] and d = 1.15, 95 % CI [0.42, 1.87] were found for depression and anxiety, respectively and comparable to the same program offered to the general population. Clients also experienced reductions in perceived stress and significant improvements in resiliency from pre- to post-treatment. Semi-structured interviews conducted at post-treatment with the agricultural clients (n = 31) on their experiences with ICBT identified four main themes: perceived strengths of ICBT and the tailored resource, suggestions to improve service delivery for agriculture producers, clients experienced internal and external challenges to participating in ICBT, and the positive impact of the course reached beyond the client. Very high satisfaction rates were found. These results provide support for the acceptability and effectiveness of ICBT with a tailored resource offered in routine care among agriculture producers.

Evaluation of a therapist-guided virtual psychological pain management program when provided as routine care: a prospective pragmatic cohort study

INTRODUCTION

Numerous randomized controlled trials have evaluated the outcomes of internet-delivered psychological pain management programs (PMPs) as a way of increasing access to care for people with chronic pain. However, there are few reports of the effectiveness of these PMPs when provided as part of routine care.

METHODS

The present study sought to report the clinical and demographic characteristics of users (n = 1367) and examine the effectiveness of an established internet-delivered psychological PMP program in improving several pain-related outcomes, when offered at a national digital mental health service over a 5-year period. It also sought to comprehensively explore predictors of treatment commencement, treatment completion, and clinical improvement.

RESULTS

Evidence of clinical improvements (% improvement; Hedges g) were found for all outcomes, including pain interference (18.9%; 0.55), depression (26.1%; 0.50), anxiety (23.9%; 0.39), pain intensity (12.8%; 0.41), pain self-efficacy (-23.8%; -0.46) and pain-catastrophizing (26.3%; 0.56). A small proportion of users enrolled but did not commence treatment (13%), however high levels of treatment completion (whole treatment = 63%; majority of the treatment = 75%) and satisfaction (very satisfied = 45%; satisfied = 37%) were observed among those who commenced treatment. There were a number of demographic and clinical factors associated with commencement, completion and improvement, but no decisive or dominant predictors were observed.

DISCUSSION

These findings highlight the effectiveness and acceptability of internet-delivered psychological PMPs in routine care and point to the need to consider how best to integrate these interventions into the pathways of care for people with chronic pain.

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.