Mental-health Services Embedded in Pain-management Clinics Appears to Have Value

By Will Boggs MD

December 26, 2019

NEW YORK (Reuters Health) - Embedding mental-health services in pain-management clinics may have value for patients, but the picture appears mixed, according to a new retrospective study.

As many as 60% of patients with chronic pain also have depression or anxiety. The National Academy of Medicine (formerly the Institute of Medicine) recommends that multidisciplinary pain-management programs include behavioral-medicine services, but few studies have examined the comparative effectiveness of embedded behavioral medicine in pain-management clinics.

Dr. Ajay D. Wasan from UPMC Pain Medicine, in Pittsburgh, Pennsylvania, and colleagues used data from the Collaborative Health Outcomes Information Registry (CHOIR) and electronic medical records to examine the comparative effectiveness of behavioral medicine embedded in a pain-management clinic, compared with standard care, for improving pain, mental health, and physical health.

The study included 453 patients in the behavioral-medicine group and 8,383 patients receiving standard multimodal treatment without behavioral-medicine treatment.

At baseline, standard-care patients had a less-severe pain syndrome than did behavioral-medicine patients, with significantly less pain, anxiety, depression, sleep, and functional symptoms.

Average pain intensity decreased in the standard-care group at all time points compared with baseline levels, whereas pain improvement in the behavioral medicine group was not statistically significant at any time points versus baseline.

Across all time points, however, the degree of pain improvement did not differ significantly between the standard care and behavioral medicine groups, the researchers report in Pain Medicine.

Both groups showed significant improvement in pain-interference score and pain-behavior score, with no significant difference between the groups.

Behavioral-medicine patients showed significantly greater improvements in overall impression of change, compared with standard care patients, whereas standard-care patients showed greater improvements in anxiety and neuropathic pain scores.

At 12 months, behavioral medicine patients had significantly more body regions affected by pain and had significantly worse global mental-health scores, compared with standard care patients.

"Despite this mixed picture in patient outcomes between groups, the results of the present study show that embedded behavioral medicine provides a valuable benefit to pain management," the authors conclude. "These improvements occurred in a population who without behavioral medicine would otherwise likely have had a downward pain syndrome trajectory of failure to improve despite multimodal therapy."

Dr. Christian Eckhoff of University Hospital North Norway, in Tromsoe, who has researched the association between musculoskeletal pain in adolescence and later mental health disorders, told Reuters Health by email, "This type of treatment works for a troubled patient group that is difficult to treat. This type of pain treatment, with cognitive-behavioral therapy (CBT) and acceptance and commitment therapy (ACT), must be embedded in the pain clinic, given as a holistic approach to the patient's problem. Fragmented services for these types of patients do not give the same positive results."

"Chronic pain and mental-health problems are the most costly patient groups to society, in terms of disability-adjusted life-years (DALYs)," he said. "The important point is that without this type of treatment, these patients usually have a downward trajectory with an increase in symptoms and opioid and drug use, with the further need of healthcare services and social support. Therefore, there is a high probability that the cost of this clinical treatment is less costly for society as a whole, in addition to the valuable help for the individual patient."

SOURCE: Pain Medicine, online November 16, 2019.