Addressing chronic pain with Focused Acceptance and Commitment Therapy in integrated primary care: findings from a mixed methods pilot randomized controlled trial

BACKGROUND

Over 100 million Americans have chronic pain and most obtain their treatment in primary care clinics. However, evidence-based behavioral treatments targeting pain-related disability are not typically provided in these settings. Therefore, this study sought to: 1) evaluate implementation of a brief evidence-based treatment, Focused Acceptance and Commitment Therapy (FACT-CP), delivered by an integrated behavioral health consultant (BHC) in primary care; and 2) preliminarily explore primary (self-reported physical disability) and secondary treatment outcomes (chronic pain acceptance and engagement in valued activities).

METHODS

This mixed-methods pilot randomized controlled trial included twenty-six participants with non-cancer chronic pain being treated in primary care (54% women; 46% Hispanic/Latino). Active participants completed a 30-min individual FACT-CP visit followed by 3 weekly 60-min group visits and a booster visit 2 months later. An enhanced treatment as usual (ETAU) control group received 4 handouts about pain management based in cognitive-behavioral science. Follow-up research visits occurred during and after treatment, at 12 weeks (booster visit), and at 6 months. Semi-structured interviews were conducted to collect qualitative data after the last research visit. General linear mixed regression models with repeated measures explored primary and secondary outcomes.

RESULTS

The study design and FACT-CP intervention were feasible and acceptable. Quantitative analyses indicate at 6-month follow-up, self-reported physical disability significantly improved pre-post within the FACT-CP arm (d = 0.64); engagement in valued activities significantly improved within both the FACT-CP (d = 0.70) and ETAU arms (d = 0.51); and chronic pain acceptance was the only outcome significantly different between arms (d = 1.04), increased in the FACT-CP arm and decreased in the ETAU arm. Qualitative data analyses reflected that FACT-CP participants reported acquiring skills for learning to live with pain, consistent with increased chronic pain acceptance.

CONCLUSION

Findings support that FACT-CP was acceptable for patients with chronic pain and feasible for delivery in a primary care setting by a BHC. Results provide preliminary evidence for improved physical functioning after FACT-CP treatment. A larger pragmatic trial is warranted, with a design based on data gathered in this pilot.

TRIAL REGISTRATION

clinicaltrials.gov, NCT04978961 (27/07/2021).

The Impact of Brief Interventions on Functioning Among those Demonstrating Anxiety, Depressive, and Adjustment Disorder Symptoms in Primary Care: The Effectiveness of the Primary Care Behavioral Health (PCBH) Model

Limited scalability combined with limited opportunities for patients to receive evidence-based interventions in traditional behavioral health treatment models for anxiety and depression creates a gap in access to adequate care. Primary Care Behavioral Health (PCBH) is one model of treatment in which behavioral health consultants (BHC) work directly within primary care settings, but there is limited evidence regarding the effectiveness of this model of care. The functional outcomes and appointment characteristics of Beneficiaries (N = 5402) within the military healthcare system were assessed. The study sample was predominately Caucasian, female, military dependents seen for 2 to 4 appointments. A reliable change index revealed that 17.2% showed reliable improvement and 2.4% showed reliable deterioration (p < .05). Of individuals with a severe Behavioral Health Measure-20 score at baseline, 81.5% showed some improvement at their final appointment, with 33% demonstrating reliable improvement. A mixed model analysis was used to determine the predictive value of appointment characteristics. All relations were significant (p < .001), except the between-subjects effect of appointment duration. Appointment duration revealed individuals reported worse functioning at the start of atypically long appointments. Individuals with generally longer intervals between appointments reported worse functioning, but an atypically long interval predicted better functioning at the following appointment. As it relates to number of appointments, individuals with more total appointments reported worse functioning outcomes, with generally better functioning across appointments. Overall, these data support the effectiveness of time-limited care provided through the PCBH model.

The Behavioral Health Consultant: Roles and Responsibilities

With the scarcity of mental health services, integration of behavioral health into pediatric primary care increases the accessibility and availability to mental health services to a broad range of patients and their families while bridging the gap of physical and mental health. Encouraging whole-person care, the role of the behavioral health consultant serves as a proactive and preventative means fostering early intervention and detection, as 50% of all lifetime mental health disorders begin by the age of 14 years.

Evaluation of clinical outcomes in an interdisciplinary abdominal pain clinic: A retrospective, exploratory review

BACKGROUND

Pediatric functional gastrointestinal disorders (FGIDs) are common and well-accepted to be etiologically complex in terms of the contribution of biological, psychological, and social factors to symptom presentations. Nonetheless, despite its documented benefits, interdisciplinary treatment, designed to address all of these factors, for pediatric FGIDs remains rare. The current study hypothesized that the majority of pediatric patients seen in an interdisciplinary abdominal pain clinic (APC) would demonstrate clinical resolution of symptoms during the study period and that specific psychosocial variables would be significantly predictive of GI symptom improvement.

AIM

To evaluate outcomes with interdisciplinary treatment in pediatric patients with pain-related FGIDs and identify patient characteristics that predicted clinical outcomes.

METHODS

Participants were 392 children, ages 8-18 [M = 13.8; standard deviation (SD) = 2.7], seen between August 1, 2013 and June 15, 2016 in an interdisciplinary APC housed within the Division of Gastroenterology in a medium-sized Midwestern children's hospital. To be eligible, patients had to be 8 years of age or older and have had abdominal pain for ≥ 8 wk at the time of initial evaluation. Medical and psychosocial data collected as part of standard of care were retrospectively reviewed and analyzed in the context of the observational study. Logistic regression was used to model odds of reporting vs never reporting improvement, as well as to differentiate rapid from slower improvers.

RESULTS

Nearly 70% of patients followed during the study period achieved resolution on at least one of the employed outcome indices. Among those who achieved resolution during follow up, 43% to 49% did so by the first follow up (i.e., within roughly 2 mo after initial evaluation and initiation of interdisciplinary treatment). Patient age, sleep, ease of relaxation, and depression all significantly predicted the likelihood of resolution. More specifically, the odds of clinical resolution were 14% to 16% lower per additional year of patient age (P < 0.001 to P = 0.016). The odds of resolution were 28% to 42% lower per 1-standard deviation (SD) increase on a pediatric sleep measure (P = 0.006 to P < 0.040). Additionally, odds of clinical resolution were 58% lower per 1-SD increase on parent-reported measure of depression (P = 0.006), and doubled in cases where parents agreed that their children found it easy to relax (P = 0.045). Furthermore, sleep predicted the rapidity of clinical resolution; that is, the odds of achieving resolution by the first follow up visit were 47% to 60% lower per 1-SD increase on the pediatric sleep measure (P = 0.002).

CONCLUSION

Outcomes for youth with FGIDs may be significantly improved by paying specific attention to sleep, ensuring adequate skills for relaxation, and screening of and referral for treatment of comorbid depression.

The Primary Care Behavioral Health (PCBH) Model: An Overview and Operational Definition

The Primary Care Behavioral Health (PCBH) model is a prominent approach to the integration of behavioral health services into primary care settings. Implementation of the PCBH model has grown over the past two decades, yet research and training efforts have been slowed by inconsistent terminology and lack of a concise, operationalized definition of the model and its key components. This article provides the first concise operationalized definition of the PCBH model, developed from examination of multiple published resources and consultation with nationally recognized PCBH model experts. The definition frames the model as a team-based approach to managing biopsychosocial issues that present in primary care, with the over-arching goal of improving primary care in general. The article provides a description of the key components and strategies used in the model, the rationale for those strategies, a brief comparison of this model to other integration approaches, a focused summary of PCBH model outcomes, and an overview of common challenges to implementing the model.