Feature Article: Psychological Treatments for Pain and Depression After Spinal Cord Injury: Rationale and Challenges to Implementation
Phil Ullrich, PhD; Marylou Guihan, PhD; and Frances M. Weaver, PhD
Abstract
Pain and depression are common conditions among persons with SCI so it is surprising that very little is known regarding best practices for treating these conditions in this population. Various psychological treatment modalities have been shown to be efficacious for treating pain and depression among other populations and are currently the focus of ongoing controlled clinical trials among persons with SCI. Of equal concern to clinicians and researchers should be how to effectively implement evidence-based treatments in real-world settings. Strategies for overcoming implementation barriers are discussed.
Introduction
Pain and depression are common conditions after spinal cord injury (SCI) with considerable negative impacts on functioning and quality of life. Prevalence estimates range from 18% to 94% for chronic pain (Ehde, et al. 2003) and from 22% to over 30% for depression (Elliott & Frank, 1996). Depression has been associated with adverse outcomes among persons with SCI including lower functioning, reduced activity levels, and increased secondary medical complications (Elliott & Frank, 1996). Similarly, chronic pain is consistently implicated in reduced quality of life and functional impairments among persons with SCI (for reviews, see Ehde, et al., 2003; Richards, 2005). Unfortunately, pain conditions tend to be stable among persons with SCI (Rintala, Hart, & Priebe, 2004) and are associated with greater levels of depression (Rintala, Loubser, Castro, & Hart, 1998). Cairns and colleagues (1996) found that during inpatient rehabilitation, between 22% and 35% of persons with SCI were identified as having both elevated depression and pain, with the co-occurrence of these conditions more common that either alone. Numerous reports have documented that pain and depression are commonly linked in other populations (Bair, Robinson, Katon, & Kroenke, 2003; Banks & Kerns, 1996). This is of particular concern because pain and depression levels tend to be more severe when co-occurring (Campbell, Clauw, & Keefe, 2003), and the presence of one condition adversely effects the detection and treatment of the other (Banks & Kerns, 1996). Consequentially, calls for improvements in the understanding, detection and treatment of comorbid pain and depressive conditions in SCI (Cairns, Adkins, & Scott, 1996) and other medical populations (Banks & Kerns, 1996; Romano & Turner, 1985) have been made for some time.
Little empirical knowledge is available regarding effective treatments for pain and depression as either co-occurring or separate syndromes among people with SCI. In a recent review, Elliott and Kennedy (2004) noted that there were no randomized clinical trials of treatments for depression in persons with SCI. A few studies utilizing non-randomized designs have found positive effects on depression for psychological treatments (Craig, Hancock, Dickson, & Chang, 1997; King & Kennedy, 1999). Since that time, Kemp and colleagues (2004) reported on an observational study comparing a group of patients with SCI and depression who accepted combined treatment with psychotherapy and an antidepressant to those who refused such treatment. Patients who accepted treatment showed a 57% decrease in depressive symptoms over the six months of the study, as compared to a 12% decrease among those who refused treatment. In a follow-up report (Kahan, Mitchell, Kemp, & Dakins, 2006), the investigators reported that patients with SCI benefited from the combined treatment as much as did participants with other disabilities.
Studies of pharmacological pain treatments among people with SCI are only modestly better represented than treatments for depression (Richards, 2005; Warms, Turner, Marshall, & Cardenas, 2002). No randomized clinical trials of psychological treatments for pain in persons with SCI have been published. Encouraging reports, however, have come from pain treatment pilot projects emphasizing cognitive-behavioral principles (Ehde & Jensen, 2004; Gironda, 2004; Norrbrink-Budh, Kowalski, & Lundeberg, 2006), and a case series of hypnotic analgesia treatments for pain in SCI (Jensen, et al. 2005). Other trials of psychological treatments for pain in persons with SCI are underway (cf., Haythornthwaite, et al., 2003; Richards, 2005).
Outside of the SCI population, evidence abounds for the efficacy of both pharmacological and psychological treatments for pain (for review, see Morley, Eccleston, & Williams, 1999) and depression (for review, see Hollon, Thase, & Markowitz, 2002) as separate syndromes. Much less empirical knowledge exists regarding best treatments for comorbid depression and pain in any population, though the topic has prompted frequent review and theoretical discourse (e.g., Fleischman, 2004; Rost, 2003; Williams, 2005). Campbell and colleagues (2003) recently noted the lack of clinical trials for treatment of comorbid pain and depression, and since that time, one clinical trial has been published addressing the pharmacological treatment of comorbid depression and chronic pain (Arnold et al., 2005).
It may be that targeting either depression or pain for treatment can have positive effects on both conditions. Psychological treatments for pain typically yield improvements in mood and other depressive symptoms concomitant with pain reduction (Morley, et al., 1999). Similarly, antidepressant treatments have been shown to alleviate pain complaints in depressed patients (Mallinckrodt, Prakash, Andorn, Watkin, & Wohlreich, 2006). It has also been shown, however, that pain conditions blunt the effectiveness of antidepressant treatment, and conversely, that depressive symptoms may blunt the effectiveness of pain treatments (Bair, et al., 2003). These demonstrations of the link between pain and depression have provoked calls for an elaboration of existing treatment models and increased clinical trials to properly determine best practices in the care of comorbid depression and pain (Rost, 2003; Williams, 2005).
Challenges to Implementation of Empirically-Supported Psychological Treatments for Pain and Depression.
Reviews of empirical research have suggested that for some conditions, psychological treatments may be equivalent to pharmacological treatments (Hollon et al. 2002), or that best outcomes are associated with treatments combining pharmacological and psychological treatments (for review, see Haythornthwaite, 2005). Psychological treatments may even have an advantage over other approaches, such as medications, because the effects may be more likely to endure far beyond cessation of active treatment (Hollon, Stewart, & Shrunk, 2006). But evidence-based psychological treatments can also be more difficult to implement in real world settings (Addis, 2002; Stirman, Crits-Christoph, & DeRubeis, 2004). Implementation challenges arising at the level of the patient, the practice team and system will be discussed in turn.
Challenges to the implementation of psychological treatments are often found at the patient level. For example, physical impairments, transportation difficulties, and lack of time have been cited as patient-level challenges to the use of psychological treatments (Hollon et al., 2002), challenges that are commonly associated with persons with SCI. Additionally, it is possible that implementation fails in real-world settings due to patients’ perceptions and beliefs about psychosocial issues and psychological treatments. As an example, depressed persons believe that others will degrade or discriminate against them because of their illness, and they may hold stigmatizing views about persons with mental illness, including themselves (Corrigan & Watson, 2002). Furthermore, depressed patients may have negative attitudes about mental health care (Cooper et al., 2003).
Both perceived stigma and negative attitudes towards mental health treatments have been associated with poorer participation in mental health care (Sirey et al., 2001; Wells, Robins, Bushnell, Jarosz, Oakley-Browne, 1994). Patient attitudes towards psychological treatments for pain are mixed, with studies suggesting that patients view psychological treatments as having effects on pain problems that are weaker (Warms, Turner, Marshall, Cardenas, 2002; Widerstrom-Noga & Turk, 2003) or stronger (Chapman, Jamison, Sanders, Lyman, & Lynch, 2000) relative to other treatments. Furthermore, medical patients (The ENRICHD Investigators, 2001) including those with SCI (Elliott & Shewchuck, 2002; Elliott & Kennedy, 2004) may be disinterested in psychological problems or interventions, possibly due to personality features of persons who sustain SCI.
Challenges to implementation of psychological treatments also exist at the level of individual practitioners and their practice teams. Moreover, implementation challenges among practitioners and their teams can be manifested at multiple time points beginning with the screening for pain and depression conditions, to appropriate referral, and finally to the delivery of treatment, ultimately resulting in the underutilization of psychological services among medical patients (Charlson & Peterson, 2002). Some of this underutilization may be attributed to the lack of standardized screening methods (Pignone et al., 2002), and infrequent referral to mental health professionals that conduct longer term or focused psychological treatment (Desai, Rosenheck, & Craig, 2006). Paradoxically, patients with medical comorbidities such as SCI, while being more likely to screen positive for depression in primary care settings, are less likely to be screened or referred for follow-up (Desai). In the general population of patients that are referred for psychological treatment, less than half will begin treatment (Blumenthal & Endicott, 1996). Unfortunately, the majority of those who begin treatment receive fewer than five sessions of psychological treatment, with most attending only one session (Garfield, 1994; Wierzbicki & Pekarik, 1993; Young, Klap, Sherbourne, & Wells, 2001).
Clearly, it is challenging to identify individuals who could benefit from psychological treatments, make appropriate referral, and otherwise arrange for the implementation of psychological treatments of appropriate duration. Even if those initial implementation steps are completed successfully, however, challenges remain in the form of variability in practitioner characteristics. Practitioners’ skill or competence in delivering treatment (Shaw et al., 1999), adherence to treatment protocols (Luborsky, McLellan, Woody, O’Brien, & Auerbach, 1985), and ability to form a working alliance with patients (Horvath & Luborsky, 1993) have all been related to degree of success in psychological treatments in studies outside of the SCI population.
The use of manuals has been suggested as one way to improve the delivery of psychological treatments in clinical practice (Wade, Treat, & Stuart, 1998; Wilson, 1998). Psychological treatment manuals provide greater technical detail than typical psychotherapy texts about how to carry out a treatment, thereby enhancing training and delivery of treatment (Dobson & Shaw, 1988; Rounsaville, O’Malley, Foley, & Weissman, 1988). This idea, however, has not been widely embraced by providers of psychological treatment. Only a minority of psychologists utilize manualized psychological therapies (Addis & Krasnow, 2000), perhaps because most training sites do not require students to be competent in manualized empirically supported treatments (Crits-Christoph, Frank, Chambless, Brody, & Karp, 1995). In fact, psychiatry residency programs are more likely to require training and supervision in evidence-based psychotherapies than other professional training programs (Weissman et al., 2006). Among programs that train psychologists and social workers, 56% (PhD), 33% (PsyD), and 38% (MSW) require both a didactic and clinical supervision in evidence-based psychological treatments (Weissman, 2006). Overall, across professional disciplines, training in non-evidence-based psychological treatments is more likely to be required than training in evidence-based treatments (Weissman, 2006).
Reluctance to embrace manualized treatments in clinical practice may relate to a lack of understanding regarding the nature of treatment manuals (Addis & Krasnow, 2000). In addition, treatment manuals may be viewed as inappropriate for clinical settings for various reasons (Addis, Wade, & Hatgis, 1999). Even if a clinician is favorable toward the use of manualized treatments, it is likely to be impractical to pursue competence in more than a few of over 100 different manualized treatments that exist for adult patients (Chambless & Ollenbeck, 2001). Other logistical challenges are important to consider. The degree to which manualized interventions are complex, time-consuming, and costly may have important bearing on whether or not practitioners are capable of delivering psychological treatments effectively (Backer, Liberman, & Kuehnel, 1986). Finally, psychological treatment manuals specifically targeted for SCI populations have not been published. An important question is whether manuals developed for the general population are applicable in the SCI population. Treatment manuals targeting medical patients have been developed for both CBT (Antoni, 2003; ENRICHD, 2001; Penedo, et al., 2006) and IPT (Weissman, Markowitz, & Klerman, 2000), suggesting the need for similar efforts in SCI.
Strategies for Successfully Implementing Psychological Treatments for Pain and Depression After SCI
Innovative delivery
Successful implementation of psychological interventions for pain and depression in the SCI population may require the development of more innovative methods of delivery. Possible innovations may involve novel utilizations of technology, or modifications to treatment delivery aimed at increasing the efficiency or reach of treatments.
Broadly speaking, telecommunications and information technology have shown promise towards effecting improvements in general health care among persons with chronic illnesses (for review, see Glueckauf & Ketterson, 2004). As an example, emerging evidence supports the use of telephone-administered psychological treatments and has been of particular interest to those in the rehabilitation professions (Wade & Wolfe, 2005). Especially intriguing is the apparent effectiveness of telephone-administered treatments across theoretical modalities, populations, and practitioners of varying professional backgrounds. Simon and colleagues (2004) have demonstrated the efficacy of telephone-administered cognitive behavioral therapy (CBT) for primary care patients conducted by therapists with master’s degrees. Telephone-administered CBT (Mohr, et al., 2000) and emotion-focused therapy (Mohr, et al., 2005) have both demonstrated efficacy among patients with multiple sclerosis and depression. Interpersonal psychotherapy (IPT) for depression is being tested as a telephone-administered treatment (Frasure-Smith et al., 2006).
There is much recent interest in applying computer-based technologies such as the internet for psychological assessment and treatment (for reviews, see Emmelkamp, 2005; Ritterband et al., 2003). Internet-based and computerized self-help programs emphasizing cognitive-behavioral principles have shown promise for treating diverse conditions including stress (Zetterqvist, Maanmies, Strom, & Andersson, 2003), anxiety disorders (Richards, Klein, & Carlbring, 2003; Litz, Williams, Wang, Bryant, & Engel, 2004), complicated grief (Wagner, Knaevelsrud, Maercker, 2006), tinnitus (Andersson, Stromgren, Strom, & Lyttkens, 2002) and depression (Andersson, et al., 2005; Proudfoot, 2004). For pain conditions, internet-based self-help programs have been used to treat headache (Strom, Petterson, & Andersson, 2000) and backache (Buhrman, Faltenhag, Strom, & Anderrson, 2004). Virtual-reality technology has recently been developed by Patterson and colleagues (2006) to deliver a hypnotic intervention for pain; this has had some success in terms of reduced pain ratings and pain medication usage among burn patients.
Psychological treatments have been the traditional domain of professional therapists, and yet there is growing evidence suggesting that treatments delivered by trained paraprofessionals can be effective. For example, nurses have been trained to deliver effective behavioral or cognitive behavioral treatments to improve health behaviors (Moore, et al., 2006) or to augment antidepressant medication management (Hunkeler, et al., 2006). Some research has suggested that psychological treatments delivered by paraprofessionals have effects comparable to treatments delivered by psychologists or psychiatrists (Seligman, 1995). Other results, however, suggest that therapists with doctoral-level training produce superior results (Bright, Naker, & Neimeyer, 1999). Reviews are similarly equivocal, suggesting that professional background may (Smith, Glass, & Miller, 1980) or may not (Christensen & Jacobson, 1994; den Boer, Wiersma, Russo, & van den Bosch, 2006) relate to outcome in psychological treatments. In the absence of evidence that doctoral or other advanced professional training is required to administer effective psychological treatments, paraprofessionals should be considered a viable option for improving the reach and cost-effectiveness of psychological interventions.
One potentially fruitful area for innovation in psychological treatments may be in preventive care. Prevention of depression relapse has garnered the most attention, with ample research suggesting that psychological interventions can help maintain treatment gains (Hollon, Thase, & Markowitz, 2002). Less is known about primary prevention of conditions such as depression and chronic pain. Craig and colleagues (1997, 1998) have developed a group-based CBT treatment for the prevention of depression and anxiety after SCI, demonstrating encouraging findings from quasi-experimental designs. In primary care settings, Wells and colleagues (2005) have shown that a CBT-based intervention may effectively prevent the manifestation of major depression among persons who present with subthreshold depressive symptoms. Studies of psychological interventions for pain prevention are lacking, but a funded trial of CBT for pain prevention is underway at the University of Washington (Dawn Ehde, personal communication). As noted earlier, pain or depression symptoms may make it more difficult to treat the coexisting disorder (Bair, et al., 2003), implying that pain and depression treatments should include a focus on sub-threshold syndromes rather than merely target a primary disorder such as major depressive disorder.
Create informed, activated patients
Helping persons with SCI to become informed and activated managers of their pain and depression conditions may be an important aspect of effective care according to a leading model of chronic illness management (Bodenheimer, Wagner, & Grumbach, 2002). Major modalities of psychological treatments such as CBT and IPT explicitly involve informing and activating patients at the beginning of treatment. For example, in IPT, the initial sessions emphasize educating patients about depression and providing them with a treatment framework that includes defining depression as a medical disorder and giving the patient the sick role, and in so doing, providing exemptions from some social responsibilities while adopting a commitment to getting well through active participation in treatment. Modifications of IPT have been proposed to make the treatment more suitable for persons with depression and comorbid medical illnesses. Specifically, it is suggested that psychoeducation be expanded beyond depression and its treatments to include the medical disorder and its treatments as well (Weissman, Markowitz, & Klerman, 2000). Depression is explicitly compared to, and discussed within the context of, the medical illness in order to illustrate the interpersonal model and the importance of taking on the sick role. Patients’ engagement in treatment is further enhanced by focusing on psychosocial stressors common to medical patients, for example, social and lifestyle changes, loss of favored activities, and dealing with medical care providers.
CBT for depression (Beck, Rush, Shaw, & Emery, 1979) and pain (Turk, 2003) is also designed to promote disease self-management by enhancing patients’ knowledge and sense of self-efficacy early in treatment Adaptations of CBT for medical populations (Antoni, 2003; ENRICHD, 2001; Penedo, Dahn, Molton, Gonzalez, Kinsinger, et al., 2004) include education regarding the medical disorders and strategies for coping with common stressors related to the disorders. In CBT for pain, the psychological treatment provider is expected to work with the medical team to provide more comprehensive rehabilitation aiming to improve psychosocial functioning (Turk). CBT for depression may be presented as a personalized strategy for dealing with the psychosocial aspects of major medical problems (ENRICHD, 2001). In most examples of manualized IPT and CBT reviewed here, treatments typically remain flexible in terms of delivery so as to keep patients engaged and activated in their care. Because medical patients are often challenged in terms of mobility and medical events, treatment sessions may be shortened, or may occur by telephone, during inpatient stays, or in patients’ homes. In summary, across treatment modalities and populations, manualized psychological treatments for pain and depression are designed to create informed, activated patients by: 1) providing education about the co-occurring conditions; 2) providing a rationale and framework for treating pain or depression that relates to their medical disorder and personal circumstances; and 3) remaining flexible in the timing, setting, and nature of treatment delivery.
Develop smoothly functioning, effective clinical practice
The recognition that many persons in need of mental health services never reach care providers has drawn the attention of policy makers, researchers, and clinicians to the organization of care for depression. This has lead to the development of quality improvement (QI) interventions that aim to improve overall quality of care by implementing treatment that is consistent with clinical practice guidelines. For example, the Partners in Care study (Wells, et al., 2000) sought to improve access to either psychotherapy or antidepressant medications according to the preferences of primary care patients. While both medication and psychotherapy interventions were successful in improving quality of care and mental health outcomes (Wells, et al., 2000), the psychotherapy quality improvement intervention had better long-term (2-year) outcomes than the medication management group (Sherbourne, et al., 2001). Dozens of comparable QI studies of depression care have been conducted, with overall positive results in the detection and care of persons with depression (see reviews: Badamgarav, WeinGarten, Henning, Knight, Hasselblad, et al., 2003; Gilbody, Whitty, Grimshaw, & Thomas, 2003). Examination of the elements of the Partners in Care study illustrates the importance of developing smoothly functioning clinical practice. In this intervention, factors at the organizational, clinician, and patient level were targeted so as to increase the probability that enhanced care would be delivered. The study was carried out in primary care clinics operated within managed care organizations throughout the United States. The focus of the intervention was the use of practice teams consisting of a primary care physician, an RN depression care manager, and a psychologist. As part of the intervention, physicians and nurses received training in the detection, assessment, and treatment of depression. Psychologists received formal training in manualized CBT. The operations of the practice team were structured to include standardized screening, referral, and team meetings for case review. Results of Partners in Care and other depression care QI projects would suggest that practices would benefit from developing improvements in terms of structured screening for depression, coordinated team-based care, and practitioner training.
Conclusion
Pain and depression are common conditions among persons with SCI and yet the evidence base for best treatment practices is just beginning to develop. A number of psychological treatment modalities that are currently the focus of controlled clinical trials may represent the practitioner’s best chance to assist persons with SCI who suffer from pain. While the evidence base for pain and depression treatments among persons with SCI grows, parallel work should be conducted to facilitate the implementation of evidence-based treatments into real-world settings. Multiple professional bodies have suggested that the effective dissemination of evidence-based practices must involve partnerships between clinicians and researchers (American Psychological Association 2005 Presidential Task Force on Evidence-Based Practice, 2005; Spring, et al., 2005).
In that spirit, the Veterans Administration Quality Enhancement Research Initiative (QUERI) was launched in 1998, with a mission to translate research discoveries and innovations into better patient care and systems improvement (McQueen, Mittman, & Demakis, 2004). SCI was one of ten conditions selected to be part of the QUERI effort. SCI QUERI has recently focused on examining patterns of care for depression and pain among veterans with SCI with the intent to enhance the delivery of psychological care for depression and pain in this population. SCI QUERI represents a vehicle for collaborative work between SCI clinicians and researchers. An invitation is extended to parties interested in collaborating with QUERI towards the improvement of care for pain and depression conditions among persons with SCI.
Acknowledgements
Research Support: This work was supported by a grant from the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service, Spinal Cord Injury Quality Enhancement Research Initiative (SCI QUERI, SCT 01-169).
Disclaimer: This paper presents the views of the authors; it does not necessarily represent the views or policies of the Department of Veterans Affairs or the Health Services Research and Development Service.
The authors also thank Dr. Dawn Ehde for constructive comments on the manuscript.
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Phil Ullrich, PhD, is with the Department of Veterans Affairs Spinal Cord Injury Quality Enhancement Initiative and the Department of Rehabilitation Medicine, University of Washington, Seattle, WA.
Marylou Guihan, PhD, is with the VA Spinal Cord Injury Quality Enhancement Initiative, the Midwest Center for Health Services & Policy Research at Hines VA Hospital, and the Institute for Health Services and Policy Research, Northwestern University, Chicago, IL.
Frances M. Weaver, PhD, is with the VA Spinal Cord Injury Quality Enhancement Initiative, the Midwest Center for Health Services & Policy Research at Hines VA Hospital, and the Department of Neurology and Institute for Health Services and Policy Research, Northwestern University, Chicago, IL.