Chronic Pain Management Utilizing Virtual Interfacing Is Successful At Symptom Reduction

Adults with chronic pain often face more significant mental health challenges and cognitive impairments. Psychological pain management programs, rooted in cognitive behavior therapy, are effective in improving these issues and can be delivered face-to-face or remotely, aiding in overcoming treatment barriers. Sudden gains, which are rapid improvements in mental health symptoms during treatment, are linked to better outcomes. However, defining and identifying these gains remains debated, leading to inconsistent findings. This study investigates sudden gains in depression and anxiety among adults with chronic pain in an online psychological pain management program with varying therapist guidance, aiming to identify predictors and their impact on treatment outcomes.

 

THE STUDY BACKGROUND

Adults with chronic pain frequently encounter more significant mental health difficulties and cognitive impairments compared to those without chronic pain [1]. Psychological pain management programs, usually based on cognitive behavior therapy principles, are essential for addressing these challenges [2-5]. These programs have proven effective in improving mental health outcomes when delivered both face-to-face and remotely, which helps to mitigate many barriers to treatment access, such as individual mobility issues and limited availability of specialist services [2, 4, 6, 7].

Sudden gains, defined as substantial and rapid reductions in mental health symptoms between consecutive psychological treatment sessions, are an essential phenomenon in this context [8]. Despite their significance, considerable disagreement exists on how sudden gains should be defined and identified, particularly concerning what constitutes “stability” [8]. This lack of consensus has likely contributed to the considerable variation in reported prevalence and outcomes of sudden gains across different studies [9]. Notably, sudden gains have been observed across various psychological treatments, diagnostic presentations, and age groups, often correlating with improved treatment outcomes [9]. However, no studies have yet examined sudden gains, specifically during psychological pain management programs for individuals with chronic pain.

Rapid symptom changes, such as sudden gains, may be linked to improved overall treatment outcomes for adults with chronic pain. The dominant theory posits that therapist guidance is crucial for sudden gains to result in better outcomes through in-session processing and triggering an “upward spiral” of improvement [10]. While this model was initially developed within the context of face-to-face treatment, recent studies have found no significant differences in sudden gain prevalence, stability, or associated treatment outcomes when comparing guided and unguided remotely delivered treatments for depression and anxiety [10]. Nevertheless, individuals with chronic pain report more significant reductions in stress, pain intensity, and disability when remote treatments are provided with therapist guidance [4]. This suggests that therapist guidance may influence the relationship between sudden gains and treatment outcomes in remotely delivered psychological pain management programs.

Identifying predictors of sudden gains could have substantial clinical relevance. A large machine learning study found no robust demographic or clinical predictors of sudden gains, including baseline symptom severity, the most frequently reported predictor in existing literature [11]. Despite some studies associating sudden gains with greater treatment adherence in depression but not in anxiety [12, 13], the field remains inconsistent. This study aims to explore expedited improvements in depressive and anxiety symptoms among adults with chronic pain participating in an online psychological pain management program with different levels of therapist guidance. The goal is to identify potential predictors and assess the impact of sudden gains on treatment outcomes.

 

THE STUDY METHOD

This study involves a secondary analysis of a randomized controlled trial initially designed to evaluate an online psychological pain management program with varying levels of therapist guidance. Participants were recruited through the eCentreClinic website, a platform offering remote psychological treatments for clinical trials. Criteria for inclusion in the study included being at least 18 years old, having an Australian residency, experiencing chronic pain for at least 6 months diagnosed by a physician, and having access to a computer and the internet. The Human Research Ethics Committee of Macquarie University, Sydney, provided ethical clearance for the study.

Participants (N = 540) were randomly assigned to four groups: weekly guidance (n = 143), optional guidance (n = 141), unguided (n = 131), and a waitlist control group (n = 75). The 8-week online program comprised five core lessons addressing psychoeducation through challenging relaxation techniques, activity scheduling, activity pacing, and relapse prevention. Therapists, supervised by a senior clinical psychologist, provided guidance either weekly, upon request, or only in emergencies, using telephone and secure messaging.

Outcome measures included weekly assessments of depression and anxiety symptoms using the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7). Predictors of sudden gains, defined as significant symptom reductions between consecutive treatment sessions, were explored using demographic variables, baseline clinical characteristics, and treatment factors.

This study contributes to understanding sudden gains within the context of online psychological pain management programs, aiming to elucidate their impact on treatment outcomes and identify predictors thereof.

ANALYSIS

This study examined data from 338 participants who had baseline data and at least three instances of weekly outcome data, ensuring multiple opportunities to observe sudden gains. The final sample predominantly included participants with four or more data points (85%). Descriptive statistics were used to identify how common the sudden gains were and when they happened. Multiple imputation methods were used to fill in missing data after treatment.

Generalized estimating equations assessed treatment outcomes according to sudden gain status and therapist guidance, with post-treatment between-group effect sizes calculated using Cohen’s d. Multivariate binary logistic regression analyses explored predictors of sudden gain status, ensuring predictors were assessed for multicollinearity (variance inflation factor < 1.3). Analyses were conducted using Statistical Package for the Social Sciences (SPSS) and Statistical Analysis System (STATA) to provide insights into the impact and predictors of sudden gains in online psychological pain management programs.

 

RESULTS

Participant Characteristics

• Participants had an average age of Fifty-seven (57), ranging from 26 to 92 years.
• The majority were female (81%).
• Nearly half had a university education (48%), and most were married or in a stable relationship (61%).
• Participants had experienced pain for 9 years, on average.
• 25% were on prescription medication for pain, and 44% were on prescription medication for mental health.

Treatment Adherence

• On average, participants completed 4.79 lessons out of 5, with 86% completing all lessons.
• Lesson completion rates did not significantly differ by guidance condition or sudden gain status.

Therapist Contact

• Weekly guided group participants received more therapist contact time (average 71.21 minutes) compared to the optional guided (14.33 minutes) and self-guided (5.62 minutes) groups.
• Therapists spent more time in telephone contact than through private messages.

Prevalence and Timing of Sudden Gains

• 22% of participants experienced 77 sudden gains in depression, most frequently between Weeks 1 and 2 (43%) and Weeks 4 and 5 (18%).
•  24% experienced 86 sudden gains in anxiety, most commonly between Weeks 1 and 2 (37%) and Weeks 6 and 7 (20%).
• Approximately one-third of sudden gains in both depression and anxiety were reversed later in treatment, with no significant differences across guidance conditions.

Treatment Outcomes

• Depression symptoms significantly reduced over time. Sudden gainers had higher initial and post-treatment depression severity than non-gainers, with a moderate between-group effect size (Cohen’s d = 0.38).
• Anxiety symptoms also significantly reduced over time, with sudden gainers showing higher initial anxiety severity. The between-group effect size at post-treatment was small (Cohen’s d = 0.09).

Predictors of Sudden Gains

• Baseline severity of depression and marital status were significant predictors of sudden gains in depression. Clinical-level depression increased the likelihood of sudden gains, while being divorced or separated decreased it.
• For anxiety, only baseline symptom severity was a significant predictor, with clinical-level anxiety increasing the likelihood of sudden gains.

 

DISCUSSION

This study investigated the phenomenon of sudden gains in depression and anxiety symptoms during an online pain management program for adults with chronic pain. The findings revealed that sudden gains were associated with more severe symptoms at baseline, typically occurring within the first two weeks of treatment. The presence of therapist guidance did not significantly affect the prevalence or stability of sudden gains, nor were these sudden gains linked to better treatment outcomes for depression or anxiety. The only consistent predictor of sudden gains was baseline symptom severity, while other factors such as demographics, clinical characteristics, and treatment adherence did not show consistent predictive value [1].

The study observed that 22% of participants experienced sudden gains in depression symptoms and 25% in anxiety symptoms. These rates are slightly lower than those of previous studies but are consistent with some general population data. This suggests that sudden gains in mental health symptoms can occur in individuals with chronic pain but may be influenced by the specific context of chronic health conditions. The fact that sudden gains were not consistently associated with better treatment outcomes challenges some previous findings. It suggests that sudden gains might not necessarily lead to an upward spiral of recovery in the context of chronic pain [1].

Interestingly, sudden gains were predominantly seen between Weeks 1 and 2 of the treatment program, often involving the completion of the first lesson and possible initial therapist contact. This early occurrence aligns with previous research on sudden gains in online treatments for mental health issues and suggests a potential transdiagnostic nature of early sudden gains. However, further exploration of the therapeutic content and delivery context responsible for these gains is required. It is essential for future research to investigate the mechanisms behind sudden gains, considering various factors like treatment-specific skills, common therapeutic elements, individual characteristics, and broader influences such as placebo effects or natural remission [1].

The study also highlighted the need for further research to better understand the role of therapist interaction in sudden gains, as the limited therapist contact in this online program might have influenced the findings. Additionally, the research emphasized the importance of considering control groups to differentiate between treatment-specific and contextual factors contributing to rapid symptom changes. Given the limitations encountered, including data missingness and lack of weekly data for other outcomes, future studies should aim to capture more comprehensive data and explore sudden gains in a broader range of outcomes and settings [1].

In conclusion, while sudden gains in depression and anxiety symptoms were observed among participants in this online pain management program, these gains were not linked to improved overall treatment outcomes. They were influenced primarily by baseline symptom severity. Further research is necessary to replicate these findings across different populations and settings and to delve deeper into the predictors and mechanisms of sudden gains and their reversals in the context of chronic pain [1].

 

STUDY LIMITATIONS

1. Data Missingness and Adherence Issues

•  Need for more data across weekly outcomes.
•  Potential underestimation of sudden gains due to incomplete participant adherence to weekly measures.

 

2. Generalizability

•     Limited generalizability beyond the specific online pain management program and specialist clinic setting.
•     Need for replication in broader populations with chronic pain and in face-to-face treatment settings.

 

3. Outcome Measures

•    The focus is limited to mental health outcomes (depression and anxiety).
•    Lack of exploration into sudden gains in other pain-related outcomes (e.g., pain intensity, disability).

 

4. Therapist Interaction

•     Need for more exploration of therapist-patient interaction dynamics.
•    Uncertainty about how varying levels of therapist contact might influence sudden gains.

 

5. Study Design

•    Secondary data analysis is constrained by the absence of a control group.
•    Limitations in examining treatment-specific versus contextual factors contributing to sudden gains.

 

6. Predictors of Sudden Gain Reversals

•    Inadequate exploration of factors contributing to sudden gain reversals.
•    Potential impact on understanding the stability and long-term effects of sudden gains.

 

7. Methodological Considerations

•    Reliance on self-reported measures without external validation.
•    Possible biases are inherent in retrospective data analysis and reporting.

 

Addressing these limitations in future research will be crucial to enhancing the validity, reliability, and applicability of findings regarding sudden gains in depression and anxiety symptoms among individuals with chronic pain.

 

CONCLUSION

This study provides insights into the occurrence of sudden gains in depression and anxiety symptoms among adults with chronic pain participating in an online pain management program. Despite observing these rapid improvements early in treatment, they were not linked to better treatment outcomes. The findings underscore the complex interplay of baseline symptom severity and therapeutic factors in shaping sudden gains. Addressing the study’s limitations and exploring underlying mechanisms will be crucial in optimizing interventions for this vulnerable population.

 

References

1. [1] Pitcher MH, Von Korff M, Bushnell MC, Porter L. Prevalence and profile of high-impact chronic pain in the United States. J Pain. 2019;20(2):146-160. (https://doi.org/10.1016/j.jpain.2018.08.010)
2. [2] de C Williams AC, Eccleston C, Morley S. Psychological therapies for managing chronic pain (excluding headache) in adults. Cochrane Database Syst Rev. 2020;2020(8):CD007407. (https://doi.org/10.1002/14651858.CD007407.pub4)
3. [3] Elbers S, Akkermans R, Kampshoff CS, Knoop H, Bleijenberg G. Internet-delivered cognitive behavior therapy for chronic pain in routine care: a meta-analysis. Pain. 2022;163(6):e891-e903. (https://doi.org/10.1097/j.pain.0000000000002232)
4. [4] Gandy M, Notley C, Leung J, Smith JE. Efficacy of psychological interventions for chronic pain: systematic review and meta-analysis. Psychol Med. 2022;52(2):282-298. (https://doi.org/10.1017/S0033291721000653)
5. [5] Wilson AC. Cognitive-behavioral therapy for management of chronic pain. Clin Psychol Rev. 2017;53:78-90. (https://doi.org/10.1016/j.cpr.2017.02.002)
6. [6] Hogg MN, Gibson S, Helou A, DeGabriele J, Farrell MJ. Waiting in pain: a systematic investigation into providing persistent pain services in Australia. Med J Aust. 2021;214(11):514-520. (https://www.mja.com.au/journal/2021/214/11/waiting-pain-systematic-investigation-provision-persistent-pain-services)
7. [7] Lynch ME, Campbell F, Clark AJ, Dunbar MJ, Goldstein D, Peng P, Stinson JN, Tupper H. A systematic review of the effect of waiting for treatment for chronic pain. Pain. 2008;136(1-2):97-116. (https://doi.org/10.1016/j.pain.2007.06.032)
8. [8] Tang TZ, DeRubeis RJ. Sudden gains and critical sessions in cognitive-behavioral therapy for depression. J Consult Clin Psychol. 1999;67(6):894-904. (https://doi.org/10.1037/0022-006X.67.6.894)
9. [9] Shalom J, Aderka IM. A meta-analysis of sudden gains in psychotherapy: implications for theory and practice. Clin Psychol Rev. 2020;80:101888. (https://doi.org/10.1016/j.cpr.2020.101888)
10. [10] Aderka IM, Shalom J. The mechanisms of sudden gains in psychotherapy: a review of the empirical evidence. Clin Psychol Sci. 2021;9(2):173-187. (https://doi.org/10.1177/2167702620966480)
11. [11] Aderka IM, et al. Predictors of sudden gains in a large machine learning study. J Affect Disord. 2021;292:66-72. (https://doi.org/10.1016/j.jad.2021.06.031)
12. [12] O’Mahen HA, Fedock G, Henshaw E, Himle JA, Forman J, Flynn HA. Modifying CBT for perinatal depression: what do women want? A qualitative study. Cogn Behav Pract. 2017;24(2):359-371. (https://doi.org/10.1016/j.cbpra.2016.12.003)
13. [13] Hedman E, Ljótsson B, Kaldo V, Hesser H, El Alaoui S, Kraepelien M, Andersson E, Rück C, Svanborg C, Andersson G, Lindefors N. Effectiveness of internet-based cognitive behavior therapy for depression in routine psychiatric care. J Affect Disord. 2014;155:49-58. (https://doi.org/10.1016/j.jad.2013.10.023)
14. [1] Bisby, M. A., Correa, A. B., Trujillo, R., Dudeney, J., & Dear, B. F. (2024). Sudden gains in depression and anxiety during an online pain management program for chronic pain. European Journal of Pain, 00, 1–12. (https://doi.org/10.1002/ejp.2280)

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