Kathryn Nicholson Perry

The Pain Course: A randomised controlled trial of a clinician-guided Internet-delivered cognitive behaviour therapy program for managing chronic pain and emotional well-being

&NA; Examination of a clinician‐guided Internet‐delivered cognitive behaviour therapy program for chronic pain found significant improvements in disability, anxiety, depression, and average pain ratings. &NA; The present study evaluated the efficacy of a clinician‐guided Internet‐delivered cognitive behaviour therapy (iCBT) program, the Pain Course, to reduce disability, anxiety, and depression associated with chronic pain. Sixty‐three adults with chronic pain were randomised to either a Treatment Group or waitlist Control Group. Treatment consisted of 5 iCBT‐based lessons, homework tasks, additional resources, weekly e‐mail or telephone contact from a Clinical Psychologist, and automated e‐mails. Twenty‐nine of 31 Treatment Group participants completed the 5 lessons during the 8‐week program, and posttreatment and 3‐month follow‐up data were collected from 30/31 and 29/31 participants, respectively. Treatment Group participants obtained significantly greater improvements than Control Group participants in levels of disability, anxiety, depression, and average pain levels at posttreatment. These improvements corresponded to small to large between‐groups effect sizes (Cohen’s d) at posttreatment for disability (d = .88), anxiety (d = .38), depression (d = .66), and average pain (d = .64), respectively. These outcomes were sustained at follow‐up and participants rated the program as highly acceptable. Overall, the clinician spent a total mean time of 81.54 minutes (SD 30.91 minutes) contacting participants during the program. The results appear better than those reported in iCBT studies to date and provide support for the potential of clinician‐guided iCBT in the treatment of disability, anxiety, and depression for people with chronic pain.

Is there a potential role for attention bias modification in pain patients? Results of 2 randomised, controlled trials

Summary Attention bias modification resulted in positive outcomes compared to placebo in 2 randomised, controlled trials in patients with acute and chronic pain. Abstract Potential applications of attention bias modification (ABM) for acute and chronic pain patients are investigated. In study 1, 54 acute back pain patients (46 of whom completed the study) were recruited at their initial physiotherapy session and randomised to receive 1 session of ABM or placebo. Patients were followed up 3 months later. Participants who were randomised to receive ABM reported less average (P = 0.001) and current pain (P = 0.008) and experienced pain for fewer days (P = 0.01) than those who received placebo. In study 2, 34 chronic pain patients were recruited and randomly assigned to receive either 4 sessions of ABM (n = 22) or placebo (n = 12), followed by 8 sessions of cognitive behavioural treatment (CBT). After ABM, there was a significant group‐by‐time effect for disability. By 6‐month follow‐up, differences had emerged between the 2 training groups, such that the ABM group had shown greater reductions in anxiety sensitivity and disability than the placebo group. Although the results of these studies show that there is potential in the application of ABM to pain conditions, the mechanisms of treatment could not be established. Neither group showed an initial bias towards the word stimuli or a training effect, and only in the acute pain group were changes in biases related to outcome. Nonetheless, the fact that 2 independent samples showed a positive effect of ABM on clinical outcomes suggests that ABM is worthy of future study as an intervention for pain patients.

Spinal cord injury-related pain in rehabilitation : a cross-sectional study of relationships with cognitions, mood and physical function

Although psychological aspects of SCI‐related pain have been investigated in those with chronic pain, little data is available regarding these factors in those early in the course of the injury. Using a sample admitted for SCI rehabilitation, this paper describes the relationships between usual pain intensity, mood, disability and both pain and SCI‐related psychological factors. The sample were largely similar to other samples of individuals with SCI‐related chronic pain in terms of mood, but were noted to be less catastrophic in their thinking about pain than a comparative pain clinic sample. They also reported SCI self‐efficacy and acceptance scores consistent with other SCI samples. Compared with other SCI populations there were mixed findings in relation to physical disability. Consistent with previous findings in chronic pain SCI samples, usual pain intensity was found to have a strong relationship with symptoms of anxiety and depression, and pain‐related life interference. SCI acceptance was significantly negatively associated with depression scores, pain catastrophizing was significantly positively associated with both anxiety and depression scores, and SCI self‐efficacy was significantly negatively associated with both anxiety and depression scores. SCI self‐efficacy was also significantly positively associated with physical function scores. These findings suggest that pain‐related psychological factors may have importance even early in the clinical course following SCI, but that it is important, however, to consider more general SCI‐related psychological factors alongside them. In addition, these findings suggest the possibility that early interventions based upon the cognitive behavioural treatment of pain may be integrated into SCI rehabilitation programmes.

Comparison of a pain management program with usual care in a pain management center for people with spinal cord injury-related chronic pain.

ObjectiveTo evaluate the effectiveness of a specifically modified group-based, multidisciplinary cognitive-behavioral pain management program (PMP) in comparison to usual care in a clinical sample of people with spinal cord injury (SCI)-related chronic pain. MethodChanges over time on a range of measures, including usual pain intensity, pain catastrophizing and self-efficacy, mood, SCI acceptance and self-efficacy, and interference due to pain were examined in 2 groups with SCI-related chronic pain after a multidisciplinary pain assessment. One group (n=19) attended the PMP, and the other (n=17) received standard care on an individualized basis in a pain management center. ResultsThe groups were significantly different at baseline, with the PMP group scoring more negatively on a number of the measures, including usual pain intensity. The PMP group showed an overall improvement in mood and life interference due to pain at the end of the PMP when compared with the usual care group. Within the PMP group, there was a significant improvement over time in anxiety and pain catastrophizing. No changes in SCI-related psychologic variables (acceptance and self-efficacy) were observed in either group. DiscussionThis study demonstrates that a PMP may offer benefits to clinical populations with SCI-related chronic pain in a pain management center. The reported improvements were of a magnitude to be clinically significant. However, some of the initial benefits reported were not maintained at the nine month follow-up. The interventions may need to be augmented to address the effects of SCI-related psychologic variables that may impact upon the individuals ability to benefit from a PMP.

The Pain Course: a randomised controlled trial examining an internet-delivered pain management program when provided with different levels of clinician support

Abstract The present study evaluated an internet-delivered pain management program, the Pain Course, when provided with different levels of clinician support. Participants (n = 490) were randomised to 1 of 4 groups: (1) Regular Contact (n = 143), (2) Optional Contact (n = 141), (3) No Contact (n = 131), and (4) a treatment-as-usual Waitlist Control Group (n = 75). The treatment program was based on the principles of cognitive behaviour therapy and comprised 5 internet-delivered lessons provided over 8 weeks. The 3 Treatment Groups reported significant improvements (between-group Cohens d; avg. reduction) in disability (ds ≥ 0.50; avg. reduction ≥ 18%), anxiety (ds ≥ 0.44; avg. reduction ≥ 32%), depression (ds ≥ 0.73; avg. reduction ≥ 36%), and average pain (ds ≥ 0.30; avg. reduction ≥ 12%) immediately posttreatment, which were sustained at or further improved to 3-month follow-up. High treatment completion rates and levels of satisfaction were reported, and no marked or consistent differences were observed between the Treatment Groups. The mean clinician time per participant was 67.69 minutes (SD = 33.50), 12.85 minutes (SD = 24.61), and 5.44 minutes (SD = 12.38) for those receiving regular contact, the option of contact, and no clinical contact, respectively. These results highlight the very significant public health potential of carefully designed and administered internet-delivered pain management programs and indicate that these programs can be successfully administered with several levels of clinical support.

Prospective Study of the Occurrence of Psychological Disorders and Comorbidities After Spinal Cord Injury

OBJECTIVE To conduct a prospective study of the occurrence of psychological disorders and comorbidities after spinal cord injury (SCI), determine psychotropic medication usage, and establish predictors of psychological disorders after transition to the community. DESIGN Longitudinal design with multiple measures. SETTING Assessment occurred in SCI units and the community. PARTICIPANTS Adults with SCI (N=88) admitted over a period of 32 months into 3 SCI units. INTERVENTIONS Participants completed inpatient rehabilitation for an acute SCI. Longitudinal assessment occurred up to 6 months postdischarge. MAIN OUTCOME MEASURES Measures were chosen that had a theoretical and clinical foundation for contributing to recovery after SCI. The Mini International Neuropsychiatric Interview, a structured diagnostic psychiatric interview, was conducted to determine the presence of psychological disorders. Medical measures included severity of secondary conditions or complications. Psychological measures included measures of anxiety and depressive mood, resilience, pain catastrophization, self-efficacy, and cognitive capacity. RESULTS Rates of psychological disorders of 17% to 25% were substantially higher than rates found in the Australian community. The occurrence of psychological disorder comorbidities was also very high. Anxiety was significantly elevated in those with a psychological disorder. Psychotropic medications were prescribed to more than 36% of the sample, with most being antidepressants. Factors predictive of psychological disorders included years of education, premorbid psychiatric/psychological treatment, cognitive impairment, secondary complications, resilience, and anxiety. CONCLUSIONS SCI can have a substantial negative impact on mental health that does not change up to 6 months postdischarge. Findings suggest a substantial minority experience increased psychosocial distress after the injury and after transitioning into the community. Additional resources should be invested in improving the mental health of adults with SCI.

Adjustment following chronic spinal cord injury: Determining factors that contribute to social participation

OBJECTIVES Spinal cord injury (SCI) is a catastrophic event that may result in diminished physical, social, and mental health. The main objective of this research was to establish inpatient factors that contribute to social participation following discharge into the community. DESIGN Prospective longitudinal design with measures taken three times, soon after admission to rehabilitation (N = 88), at discharge from the inpatient phase (N = 81) and 6 months following discharge (N = 71). METHODS Participants included adults with SCI admitted into three SCI units over a 33-month period. Assessment included demographic, injury, and psychosocial health measures. Adjustment was defined by the extent of social re-integration or participation post-discharge after 6 months in the community. Social participation was measured by the Impact on Participation and Autonomy Questionnaire (IPAQ). Logistic regression models were used to establish inpatient factors that significantly predicted social participation 6 months post-discharge. RESULTS Six months after discharge, around 55% of the sample had difficulties with social participation. The odds against being employed for an adult with poor social participation was found to be 8.4 to 1. Factors that predicted social participation included a younger age, having less severe secondary medical complications like bladder and bowel dysfunction, having a higher cognitive capacity, perceiving one has control (self-efficacy) over ones life and environment, and having greater perceived social support. CONCLUSIONS These results provide direction for enhancing existing psychosocial health strategies within SCI rehabilitation, affording an opportunity for every person who sustains a permanent SCI to have optimal capacity for social participation. Statement of contribution What is already known on this subject? Spinal cord injury (SCI) is associated with significant challenges to wellbeing, including a high risk of secondary chronic illnesses, risk of co-morbid mental health problems, financial insecurity and social isolation. Research has shown poor social participation can lead to problems in re-integration into society following discharge from inpatient rehabilitation. Research to date has examined various factors related to poor social participation, but the majority of this research has been survey based with convenience samples. What does this study add? This study adds results of prospective longitudinal research on adjustment following SCI, where adjustment was defined by the rate of social participation when living in the community. About one-third of SCI participants were found to have very poor social participation, and only one-third had found some form of employment 6 months after discharge. Multiple factors were found to predict and contribute to poor social participation, including older age when injured, more severe medical complications, cognitive deficits, poor perceptions of control or self-efficacy, and poor social support.

Towards a new model of attentional biases in the development, maintenance, and management of pain.

Abstract Individuals with chronic pain demonstrate attentional biases (ABs) towards pain-related stimuli. However, the clinical importance of these biases is yet to be determined and a sound theoretical model for explaining the role of ABs in the development and maintenance of pain is lacking. Within this article, we (1) systematically review prospective and experimental research exploring ABs and pain outcomes in light of current theoretical models and (2) propose a theoretical framework for understanding AB in pain. Across prospective research, an attentional pattern of vigilance–avoidance was observed. Interventions targeting ABs were less consistent; however, there were promising findings among studies that found attentional training effects, particularly for laboratory research. The proposed Threat Interpretation Model suggests a relationship between threat, interpretation, and stimuli in determining attentional processes, which while tentative generates important testable predictions regarding the role of attention in pain and builds on previous theoretical and empirical work in this area.

Psychosocial predictors of depression and anxiety in patients with epilepsy: A systematic review

BACKGROUND People with epilepsy (PWE) have a high chance of experiencing depression and anxiety disorders over their lifetime. However, those most at risk are unknown. Psychosocial variables have been suggested as potentially important risk factors. A systematic review was conducted in order to critically assess available evidence regarding the psychosocial predictors of depression and anxiety in adults with epilepsy. METHODS Electronic databases searched were MEDLINE, PsycINFO and Web of Science. Studies were included if they assessed depressive or anxiety symptoms using a validated questionnaire, and controlled for the role of potentially important epilepsy factors. Eleven studies were identified and assessed for research standards using the Quality Index Scale (QIS). RESULTS Ten of the eleven studies found at least one significant predictor of depression and all six studies that assessed anxiety found one or more significant predictors. LIMITATIONS Overall QIS score was only 7.5 out of 15, indicating significant design limitations of many included studies. There was also large variability between studies in measures used to assess psychosocial variables. CONCLUSION Studies did not support the importance of attributional theory and stigma in the development of depression in epilepsy. There was inconsistent support for the role of illness representations but likely support for the role of stress and self-efficacy. Consistent support was found for the role of coping strategies and perceived social support. Given that psychosocial factors are potentially modifiable, a better understanding of their role in the development of depression in people with epilepsy is urgently needed to guide effective treatments.

Gender-Related Victimization, Perceived Social Support, and Predictors of Depression Among Transgender Australians

ABSTRACT. This study examined mental health outcomes, gender-related victimization, perceived social support, and predictors of depression among 243 transgender Australians (n = 83 assigned female at birth, n = 160 assigned male at birth). Overall, 69% reported at least 1 instance of victimization, 59% endorsed depressive symptoms, and 44% reported a previous suicide attempt. Social support emerged as the most significant predictor of depressive symptoms (p >.05), whereby persons endorsing higher levels of overall perceived social support tended to endorse lower levels of depressive symptoms. Second to social support, persons who endorsed having had some form of gender affirmative surgery were significantly more likely to present with lower symptoms of depression. Contrary to expectations, victimization did not reach significance as an independent risk factor of depression (p =.053). The pervasiveness of victimization, depression, and attempted suicide represents a major health concern and highlights the need to facilitate culturally sensitive health care provision.