A controlled study of couple therapy in chronic low back pain patients. No improvement of disability

Family-based Interventions Benefit Individuals With Musculoskeletal Pain in the Short-term but not in the Long-Term: A Systematic Review and Meta-Analysis

INTRODUCTION

The benefits of family-based interventions for patients with musculoskeletal pain have been previously shown in individual randomized controlled trials (RCTs), but no systematic review has summarized their effects.

MATERIALS AND METHODS

A systematic review was conducted to assess the effectiveness of family-based interventions on clinical and biopsychosocial outcomes in people with musculoskeletal pain (PROSPERO CRD42018118442). Meta-analyses were performed for the outcomes of pain intensity, disability, mood, self-efficacy, and marital adjustment.

RESULTS

Of 1223 records identified, 18 reports representing 15 RCTs were included in the qualitative review and 10 in the meta-analyses. Family-based interventions were more effective to reduce pain (mean difference [MD], -3.55/100; 95% confidence intreval [CI], -4.03 to -3.06) and disability (MD, -1.51/100; 95% CI, -1.98 to -1.05) than individual-focused interventions at short-term, but not at mid term or long term. There were no effects on other outcomes. Family-based interventions were more effective to reduce pain (MD, -6.05/100; 95% CI, -6.78 to -5.33) compared with usual care only at short-term. No effects were found on disability and other outcomes.

DISCUSSION

There is moderate-quality evidence that family-based interventions result in small, significantly better pain and disability outcomes in the short-term compared with individual-focused interventions in patients with musculoskeletal pain. Based on low-quality evidence, family-based interventions result in small improvements on pain in the short-term compared with usual care. Future studies should review the content and optimize the mechanisms underpinning family-based interventions in musculoskeletal pain so that the approach could be further tested in adequately powered RCTs.

Couple Interventions for Chronic Pain: A Systematic Review

OBJECTIVE

Couple interventions for chronic pain have been shown to more effectively reduce pain intensity for individuals with chronic pain (ICPs) than individual behavioral interventions or usual care. This systematic review identified randomized controlled trials of couple interventions to highlight strategies that could be incorporated into psychotherapy with ICPs and their romantic partners.

METHODS

The authors identified articles reporting randomized controlled trials of couple interventions for chronic pain. Three databases were searched (ie, PubMed, Embase, and PsycInfo), resulting in 18 studies and 22 articles.

RESULTS

Couple interventions resulted in statistically significant improvements in pain intensity compared with other conditions in 8% to 40% of the studies depending on the comparator group (i.e., control, individual intervention, another couple intervention), and in statistically significant improvements on a pain-related outcome compared with other conditions in 31% to 50% of the studies depending on the comparator group (ie, control, individual intervention, another couple intervention). Educating couples about pain was the most common strategy (83%). Jointly administered relaxation or meditation skills were included in nearly half of the interventions (48%). Many interventions taught cognitive-behavioral skills jointly to couples (39%) or to the ICP with partner encouragement (30%). Teaching couples how to request and provide assistance (30%), and encouraging partners to avoid reinforcing pain behaviors (39%), occurred frequently. ICPs and their partners were often asked to set goals (30%).

DISCUSSION

This review outlined strategies included in couple interventions for chronic pain that are derived from the cognitive-behavioral therapy, acceptance and commitment therapy, and operant behavioral traditions, but delivered relationally. Therapists working with ICPs and their partners may integrate these strategies into their practice to help couples who are managing chronic pain.

The efficacy of systemic therapy with adult patients: a meta-content analysis of 38 randomized controlled trials

Systemic therapy is a widely used psychotherapy approach. Yet there exist few systematic reviews on its efficacy. A meta-content analysis was performed to analyze the efficacy of systemic therapy for the treatment of mental disorders in adulthood. All randomized (or matched) controlled trials (RCT) evaluating systemic/systems oriented therapy in various settings (family, couple, individual, group, multifamily group therapy) with adult index patients suffering from mental disorders were identified by database searches and cross-references in other reviews. Inclusion criteria were: index patient diagnosed with a DSM or ICD listed mental disorder, trial published in any language up to the end of 2008. The RCTs were content analyzed according to their research methodology, interventions applied, and results. Thirty-eight trials published in English, German, Spanish, and Chinese were identified, 34 of them showing systemic therapy to be efficacious for the treatment of mood disorders, eating disorders, substance use disorders, mental and social factors related to medical conditions and physical disorders, and schizophrenia. Systemic therapy may also be efficacious for anxiety disorders. Results were stable across follow-up periods of up to 5 years. There is a sound evidence-base for the efficacy of systemic therapy for adult index patients with mental disorders in at least five diagnostic groups.

On-site mental health workers delivering psychological therapy and psychosocial interventions to patients in primary care: effects on the professional practice of primary care providers

BACKGROUND

Mental health problems are common in primary care and mental health workers (MHWs) are increasingly working in this setting delivering psychological therapy and psychosocial interventions to patients. In addition to treating patients directly, the introduction of on-site MHWs represents an organisational change that may lead to changes in the clinical behaviour of primary care providers (PCPs).

OBJECTIVES

To assess the effects of on-site MHWs delivering psychological therapy and psychosocial interventions in primary care on the clinical behaviour of primary care providers (PCPs).

SEARCH STRATEGY

The following sources were searched in 1998: the Cochrane Effective Practice and Organisation of Care Group Specialised Register, the Cochrane Controlled Trials Register, MEDLINE, EMBASE, PsycINFO, CounselLit, NPCRDC skill-mix in primary care bibliography, and reference lists of articles. Additional searches were conducted in February 2007 using the following sources: MEDLINE, EMBASE, PsycINFO, CINAHL, and Cochrane Central Register of Clinical Trials (CENTRAL) (The Cochrane Library).

SELECTION CRITERIA

Randomised trials, controlled before and after studies, and interrupted time series analyses of MHWs working alongside PCPs in primary care settings. The outcomes included objective measures of PCP behaviours such as consultation rates, prescribing, and referral.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed study quality.

MAIN RESULTS

Forty-two studies were included in the review. There was evidence that MHWs caused significant reductions in PCP consultations (standardised mean difference -0.17, 95% CI -0.30 to -0.05), psychotropic prescribing (relative risk 0.67, 95% CI 0.56 to 0.79), prescribing costs (standardised mean difference -0.22, 95% CI -0.38 to -0.07), and rates of mental health referral (relative risk 0.13, 95% CI 0.09 to 0.20) for the patients they were seeing. In controlled before and after studies, the addition of MHWs to a practice did not affect prescribing behaviour towards the wider practice population and there was no consistent pattern to the impact on referrals in the wider patient population.

AUTHORS' CONCLUSIONS

This review provides some evidence that MHWs working in primary care to deliver psychological therapy and psychosocial interventions cause a significant reduction in PCP behaviours such as consultations, prescribing, and referrals to specialist care. However, the changes are modest in magnitude, inconsistent, do not generalise to the wider patient population, and their clinical or economic significance is unclear.

Chronic pain and the family: theory-driven treatment approaches

The chronic pain experience is the product of a complex interaction of many factors including biological, social, psychological, environmental, and familial. The presence of chronic pain can impact the family system with significant, negative consequences; the family may also be responsible, in part, for maintaining and perpetuating pain problems. The need to examine the family dimension of the chronic pain experience and offer family/couple therapy, should it be indicated, is vital to comprehensive pain management. Operant behavioral, cognitive-behavioral, and structural family therapy approaches are advocated for such families, along with a clear need for controlled evaluations of these approaches.

Chronic pain in a couples context: a review and integration of theoretical models and empirical evidence

Researchers have become increasingly interested in the social context of chronic pain conditions. The purpose of this article is to provide an integrated review of the evidence linking marital functioning with chronic pain outcomes including pain severity, physical disability, pain behaviors, and psychological distress. We first present an overview of existing models that identify an association between marital functioning and pain variables. We then review the empirical evidence for a relationship between pain variables and several marital functioning variables including marital satisfaction, spousal support, spouse responses to pain, and marital interaction. On the basis of the evidence, we present a working model of marital and pain variables, identify gaps in the literature, and offer recommendations for research and clinical work.

PERSPECTIVE

The authors provide a comprehensive review of the relationships between marital functioning and chronic pain variables to advance future research and help treatment providers understand marital processes in chronic pain.

Integrative behavioral couple therapy for chronic pain: Promoting behavior change and emotional acceptance

Couple therapy has been used with success in treating marital distress, psychological distress, and other problems. Researchers in the pain field have also shown that the inclusion of the spouse in pain treatment may be beneficial to the patient. In this article, we present integrative behavioral couple therapy (IBCT) as one option for therapists treating patients who have pain and marital distress. IBCT improves on traditional behavior therapy because it promotes processes that have been shown to be lacking in pain patients' relationships: emotional acceptance and empathy. After reviewing the use of behavior change and emotional acceptance strategies in couples, we describe a couple for whom IBCT improved functioning.

What are the marital problems of patients with chronic pain?

Throughout the past two decades, researchers have studied the close relationships of patients to understand the role that these relationships play in the maintenance and alleviation of pain and the role that pain plays in affecting relationships. In this article, a brief review of the evidence is provided, showing a link between marital functioning and pain, and the marital problems reported by patients with chronic pain in our studies also are described. We provide information about several promising couples pain management and couples therapy approaches that appear to help couples manage pain together. Recommendations for clinical and research directions also are offered.

Is it beneficial to involve a family member? A meta-analysis of psychosocial interventions for chronic illness

Links between chronic illness and family relationships have led to psychosocial interventions targeted at the patient's closest family member or both patient and family member. The authors conducted a meta-analytic review of randomized studies comparing these interventions with usual medical care (k=70), focusing on patient outcomes (depression, anxiety, relationship satisfaction, disability, and mortality) and family member outcomes (depression, anxiety, relationship satisfaction, and caregiving burden). Among patients, interventions had positive effects on depression when the spouse was included and, in some cases, on mortality. Among family members, positive effects were found for caregiving burden, depression, and anxiety; these effects were strongest for nondementing illnesses and for interventions that targeted only the family member and that addressed relationship issues. Although statistically significant aggregate effects were found, they were generally small in magnitude. These findings provide guidance in developing future interventions in this area.

Marriage and health: his and hers

This review focuses on the pathway leading from the marital relationship to physical health. Evidence from 64 articles published in the past decade, particularly marital interaction studies, suggests that marital functioning is consequential for health; negative dimensions of marital functioning have indirect influences on health outcomes through depression and health habits, and direct influences on cardiovascular, endocrine, immune, neurosensory, and other physiological mechanisms. Moreover, individual difference variables such as trait hostility augment the impact of marital processes on biological systems. Emerging themes in the past decade include the importance of differentiating positive and negative dimensions of marital functioning, the explanatory power of behavioral data, and gender differences in the pathways from the marital relationship to physiological functioning. Contemporary models of gender that emphasize self-processes, traits, and roles furnish alternative perspectives on the differential costs and benefits of marriage for men's and women's health.

On-site mental health workers in primary care: effects on professional practice

BACKGROUND

Mental health problems are common in primary care and mental health workers (MHWs) are increasingly working in this setting. In addition to treating patients, the introduction of on-site MHWs may lead to changes in the clinical behaviour of primary care providers (PCPs).

OBJECTIVES

To assess the effects of on-site MHWs in primary care on the clinical behaviour of primary care providers (PCPs).

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Group specialised register (18-22 June 1998), the Cochrane Controlled Trials Register (18-22 June 1998), MEDLINE (1966 to 1998), EMBASE (1980 to 1998), PsychInfo (1984 to 1998), CounselLit (18-22 June 1998), NPCRDC skill-mix in primary care bibliography, and reference lists of articles.

SELECTION CRITERIA

Randomised trials, controlled before and after studies and interrupted time series analyses of MHWs either replacing PCPs as providers of mental health care ('replacement' models) or providing collaborative care/support to PCPs in managing patients' mental health problems ('consultation-liaison' models). The participants were primary care providers. The outcomes included objective PCP behaviours such as diagnosis, prescribing and referral.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed study quality.

MAIN RESULTS

Thirty-eight studies were included involving more than 460 PCPs and more than 3880 patients. There was some evidence that 'replacement' model MHWs achieved significant short-term reductions in PCP psychotropic prescribing and mental health referral, but the effects were not reliable. Consultation rates were also reduced, but with even less evidence of a consistent effect. There were no indirect effects in prescribing behaviour on the wider population and no consistent pattern to the impact on referrals. 'Indirect' effects on PCP consultation rates were not assessed. There was some evidence that 'consultation-liaison' model MHWs had a direct effect on PCP prescribing behaviour when used as part of complex, multifaceted interventions. Few studies examined the 'indirect' effects of such interventions, and those that did failed to provide evidence that 'direct' effects were generalisable to the wider population or endured once the 'consultation-liaison' intervention was removed.

REVIEWER'S CONCLUSIONS

This review does not support the hypothesis that adding MHWs to primary care provider organisations in 'replacement' models causes a significant or enduring change in PCP behaviour. 'Consultation-liaison' interventions may cause changes in psychotropic prescribing, but these seem short-term and limited to patients under the direct care of the MHW. Longer-term studies are needed to assess the degree to which demonstrated effects endure over time.

Couple therapy improves mental well-being in chronic low back pain patients. A controlled, five year follow-up study

Fifty-six chronic low back pain (CLBP) patients participated in a controlled, prospective 5-yr follow-up study evaluating the long-term effects of five-session couple therapy. Twenty-eight patients were included both in the treatment group and in the control group. Outcome measures were self-reported psychological distress, marital satisfaction, health locus of control, pain and disability as well as clinical examinations. The reliability of the outcome measures was statistically analysed and found acceptable. At the 5-yr follow-up assessments, psychological distress was found to be decreased in the treatment group and increased in controls. The difference between the groups was significant. No difference was found in the other self-reported or clinical outcome measures. We conclude that couple therapy has a prolonged beneficial effect on the mental well-being of CLBP patients.