A Controlled Trial of Methods for Managing Pain in Primary Care Patients With or Without Co-Occurring Psychosocial Problems

Chronic pain frequently occurs in the context of inter-connected social, emotional, and cultural factors. The literature is rich in studies examining the association of specific mental disorders with different pain conditions. However, patients with chronic pain who also have multiple psychosocial problems which are not necessarily classifiable in the form of discrete psychiatric disorders. It is for this reason that, for most patients with chronic pain, efective forms of psychological interventions that address not only the pains but also social and psychological conditions in which the pain occurs is often indicated. The report by Ables and colleagues describes the results of a targeted form of problem- solving approach delivered by nurse-educators by telephone in the context of on-going follow-up by primary care physicians. They showed that this form of intervention was not only effective in regard to improvement in pain and of the psychosocial problems, but that the gains were sustained over a 12-month period. Even though the authors did not address the issue of cost-effectiveness directly, the approach seems to offer substantial gain at relatively modest cost. The methodology of the study was robust and the findings are convincing.

The attraction of psychological intervention for patients with chronic pains is that its effectiveness does not seem to rely solely on the presence of a psychiatric disorder. Foe example, as shown in a recent study by Creed and colleagues, the effectiveness of psychodynamic interpersonal therapy among patients with irritable bowel syndrome shows that the improvement in symptom severity correlated with, but was not fully explained by reduction in psychological symptoms. The importance of such findings is that many patients with chronic pain may not in fact have a full range of psychological symptoms to receive a formal psychiatric diagnosis but may nevertheless have multiple social and psychological problems that are nevertheless distressing and that have a bearing on the impact their pains have on day-to-day functioning. When treatment modalities address the social and psychosocial problems that patients with chronic pain often have, an overall improvement in their condition is likely.

As noted by Ables and colleagues, the challenge of utilizing the results of their study is how to incorporate the type of interventions they describe into the day-to-day clinical practice of primary care teams.

Creed, F., E. Guthrie, et al. (2005). "Does psychological treatment help only those patients with severe irritable bowel syndrome who also have a concurrent psychiatric disorder?" Australian and New Zealand Journal of Psychiatry 39: 807 - 815.

Competing interests:   None declared

The following question was posed about the design of the study: "I wonder why the group with pain but no self-reported problems was not randomized to the telephone-based CBT?"

In the spirit of a stepped-care model, we were hoping to match the level of intervention to the need of the patients. We reasoned that patients who had pain, but no self-reported psychosocial problems would benefit from the Infofeed intervention alone, i.e., tailored information that was shared with both the patient and their physician. However, the reader raises an important point. A certain percentage of patients who were in the no psychosocial problem group may have actually had problems that they were unwilling to report on an initial questionnaire. However, these problems may have been revealed and dealt with if the Nurse Educator had made a phone assessment. Clearly, additional research is needed to refine the intervention(s) in order to optimize outcomes.

Competing interests:   None declared