Optimizing Psychotherapy for Older Veterans with Chronic Pain

优化患有慢性疼痛的老年退伍军人的心理治疗

• 批准号: 10291796
• 负责人: Brandon C Yarns
• 金额: --
• 依托单位: VA GREATER LOS ANGELES HEALTHCARE SYSTEM
• 依托单位国家: 美国
• 财政年份: 2019
• 资助国家: 美国
• 起止时间: 2019-04-01 至 2024-03-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10291796
• 关键词: Affect; Aftercare; Age; Anxiety; Awareness; Behavioral; Brain region; Centers for Disease Control and Prevention (U.S.); Client satisfaction; Clinical Trials; Cognitive; Cognitive Therapy; Conflict (Psychology); Coping Skills; Data; Development; Educational process of instructing; Emotional; Emotions; Enrollment; Environment; Epidemic; Fatigue; Female; Functional disorder; Goals; Healthcare; Healthcare Systems; Infrastructure; Intervention; Lead; Learning; Life Stress; Light; Literature; Los Angeles; Measures; Mediating; Mediation; Mediator of activation protein; Medical; Medical center; Mental Depression; Mentors; Moods; Opioid Analgesics; Pain; Pain interference; Pain management; Patient-Focused Outcomes; Patients; Pharmaceutical Preparations; Post-Traumatic Stress Disorders; Proxy; Psychotherapy; Publishing; Randomized Clinical Trials; Recommendation; Research; Risk; Severities; Sleep; Sleep disturbances; Symptoms; Testing; Trauma; Veterans; Work; anxiety symptoms; base; career development; chronic musculoskeletal pain; chronic pain; chronic pain patient; cognitive benefits; cognitive enhancement; comorbidity; coping; depressive symptoms; emotion regulation; emotional distress; follow-up; improved; innovation; male; multi-ethnic; multi-racial; novel; opioid epidemic; pain catastrophizing; primary outcome; psychiatric symptom; psychologic; psychosocial; response; secondary outcome; showing emotion; skills; standard care

The overarching goal of the proposed research is to learn how to optimize psychotherapy for those Veterans most in need and most likely to benefit from psychotherapy, older Veterans with chronic musculoskeletal pain. Chronic pain is a critical healthcare challenge, as the condition affects 50% of all Veterans and affects older Veterans most commonly, severely, and persistently. For years, chronic pain treatment has been notoriously difficult at VA and elsewhere, especially in light of the recent “opioid crisis,” in which opioid analgesics, previously a mainstay of chronic pain treatment, have come under increased scrutiny. In response, CDC, VA/DoD, and some experts have called for enhancing and expanding psychosocial treatment options for chronic pain, such as psychotherapy, which are low risk for older Veterans who frequently have multiple medical comorbidities and are taking multiple medications. Yet standard VA psychotherapy approaches, such as Cognitive Behavior Therapy (CBT), have shown modest benefits for Veterans on pain and other related patient-centered outcomes (PCO), such as mood, anxiety, and sleep. In contrast, a novel psychotherapy approach, Emotional Awareness and Expression Therapy (EAET), has shown medium to large benefits for some chronic pain patients. Whereas CBT improves pain and negative emotion by teaching patients cognitive and behavioral coping skills, affecting brain regions that enhance “cognitive control” of pain, EAET operates primarily through emotion regulation, which is thought to influence brain regions and circuits that modulate both physical pain and emotion—a mechanism absent from existing approaches. The literature and our pilot data indicate that patients who express a significant amount of emotional distress at baseline, such as high anxiety and depressive symptoms, may be particularly likely to benefit from EAET’s emotion regulation approach, whereas patients who express less emotional distress may derive more benefit from an approach like CBT, which does not require ready access to emotions. The proposed randomized clinical trial tests the hypothesis that EAET is superior to CBT on reduction in mean pain severity and other PCO (derived from IMMPACT recommendations). To examine which patients are most likely to benefit, this research also tests whether greater baseline emotional distress (using measures of anxiety and depression) predicts stronger benefits from EAET and whether lower baseline emotional distress predicts stronger benefits from CBT. Finally, this research explores whether the benefits of EAET are mediated by improved emotion regulation (using measures of ambivalence over emotional expression and emotional approach coping), the benefits of CBT are mediated by improved cognitive and behavioral coping (using measures of pain catastrophizing and adaptive coping), and whether the benefits of both are mediated by a stronger working alliance. We plan to enroll 160 multi-ethnic/multi- racial older Veterans (age 60-95 years) with chronic musculoskeletal pain at the West Los Angeles VA Medical Center, an ideal environment as the largest VA Medical Center on the West Coast. This research can introduce an additional, potentially more effective format of psychotherapy at VA so that more Veterans with chronic pain can respond. In addition, this research can lead to better treatment targeting and enhance our understanding of how psychotherapy treatments work. Finally, this research can facilitate the development of critical skills for the PI in psychotherapy research and pain management and enhance his ability to effect positive change for older Veterans.

拟议研究的总体目标是学习如何优化这些退伍军人的心理治疗 最需要和最有可能受益于心理治疗，老年退伍军人与慢性肌肉骨骼疼痛。 慢性疼痛是一个关键的医疗保健挑战，因为这种疾病影响了50%的退伍军人和老年人。 最常见的，严重的，持久的。多年来，慢性疼痛治疗一直是臭名昭著的 在VA和其他地方很难，特别是考虑到最近的“阿片类药物危机”，其中阿片类镇痛药， 以前是慢性疼痛治疗的支柱，已经受到越来越多的审查。作为回应，CDC， VA/DoD，一些专家呼吁加强和扩大心理社会治疗的选择， 慢性疼痛，如心理治疗，这是低风险的老年退伍军人谁经常有多个 合并症，正在服用多种药物。 然而，标准的VA心理治疗方法，如认知行为疗法（CBT）， 退伍军人在疼痛和其他相关的以患者为中心的结果（PCO）方面的益处，如情绪，焦虑， 睡吧相反，一种新的心理治疗方法，情绪意识和表达疗法（EAET）， 对一些慢性疼痛患者显示出中等至大的益处。CBT可以改善疼痛， 通过教授患者认知和行为应对技能，影响大脑区域， EAET增强了对疼痛的“认知控制”，它主要通过情绪调节来运作， 被认为会影响调节身体疼痛和情绪的大脑区域和回路， 现有方法中缺乏的机制。文献和我们的试验数据表明， 在基线时表达大量情绪困扰的人，如高度焦虑， 抑郁症状，可能特别有可能受益于EAET的情绪调节方法， 而情绪困扰较少的患者可能会从以下方法中获得更多益处， CBT，不需要随时接触情绪。 拟议的随机临床试验检验了EAET在平均减少方面上级CBT的假设 疼痛严重程度和其他PCO（源自IMMPACT建议）。检查哪些病人最 这项研究还测试了更大的基线情绪困扰（使用 焦虑和抑郁）预测EAET更强的益处， 痛苦预示着CBT的更大益处。最后，本研究探讨了 EAET是通过改善情绪调节（使用情绪上的矛盾情绪的措施）来介导的。 表达和情绪方法应对），CBT的好处是通过改善认知能力来介导的。 和行为应对（使用疼痛灾难化和适应性应对措施），以及是否 双方的利益都通过更强大的工作联盟来实现。我们计划招收160名多种族/多民族- 西洛杉矶VA医疗中心患有慢性肌肉骨骼疼痛的种族老年退伍军人（年龄60-95岁） 中心，作为西海岸最大的VA医疗中心的理想环境。 这项研究可以在VA引入一种额外的，潜在的更有效的心理治疗形式， 更多患有慢性疼痛的退伍军人可以做出反应。此外，这项研究可以更好地 治疗靶向和增强我们对心理治疗如何工作的理解。最后， 这项研究可以促进PI在心理治疗研究中的关键技能的发展， 疼痛管理和提高他的能力，影响积极的变化，为老年退伍军人。