Improving the Assessment and Treatment of Chronic Pain in Veterans with Serious Mental Illness

对退伍军人医疗保健的预期影响：慢性疼痛是康复的关键障碍， 患有严重精神疾病的退伍军人（SMI;精神分裂症谱系和双相情感障碍）的康复。的 退伍军人健康管理局（VHA）已经制定了治疗慢性疼痛，特别是非药物治疗， 作为一个高度优先事项，在全国范围内传播了慢性病认知行为疗法， 疼痛（CBT-CP）-一种循证心理治疗-整个VHA系统。然而，CBT-CP并没有被 在SMI人群中进行了科学测试，并且在很大程度上不提供给患有慢性疼痛和并发症的退伍军人 SMI，一组慢性疼痛和相关的负面功能结果的发生率最高。这 研究将：1）测试CBT-CP改善疼痛相关功能结局的可行性和可接受性， 退伍军人与SMI; 2）研究生态瞬时评估（EMA）的可行性，以捕捉现实世界 疼痛、心理健康症状的经历及其关系; 3）评估退伍军人的经历 与CBT-CP，告知CBT-CP是否需要定制，以优化其与SMI退伍军人的使用， 发生慢性肌肉骨骼疼痛。 项目背景：慢性疼痛是个体中最常见的身体健康诊断之一 1 -3患有SMI和慢性疼痛的个体报告的精神和身体健康功能较差， 有其他精神或身体健康状况的人。4-8尽管知道慢性疼痛的高发病率 在患有SMI的个体中，很少有研究进一步了解这种复杂的关系。 疼痛和精神症状之间的联系，并考虑目前治疗的有效性或适当性 接近。已知的是有问题的;退伍军人与SMI在很大程度上没有提供选择， 非药物性疼痛管理策略，包括CBT-CP，更有可能是处方疼痛 对这一人群构成独特风险的药物。9-13 项目目标：拟议的CDA-2研究将通过更好地评估 慢性疼痛、精神症状和相关功能障碍之间的关系;并测试可行性 和CBT-CP在SMI退伍军人中的可接受性。这项研究的第一步将集中在完成一个小的 CBT-CP的随机对照试验，以检查可行性和可接受性，并探索功能的变化 45名退伍军人随机接受CBT-CP（n=30），相对于健康和健康干预（n=15）。 我们将评估招募率、初始干预参与率和会议出席率（可行性）;评估 退伍军人对CBT-CP的满意度（可接受性）;并初步探索对CBT-CP的反应。第二步 将使用EMA收集关于退伍军人疼痛、SMI症状及其 使用自动电话调查对功能的影响。数据将用于更好地了解复杂的 这些变量之间的关系。这项研究的最后一步将涉及进行过程评估 考虑如何优化CBT-CP用于未来的临床试验，以改善退伍军人的功能恢复， SMI和慢性疼痛。本评价将综合以下信息：1）CBT-CP干预者记录; 2）EMA 数据;和3）与CBT-CP条件下的退伍军人子集（n=15）进行定性访谈，以了解他们的 CBT-CP的经验，包括治疗参与的障碍和促进因素。 项目方法：本项目将包括：1）完成一项随机对照试验（RCT），纳入45名退伍军人， 参与者，监测保真度，可行性和可接受性; 2）开发和实施基于电话的EMA 评估慢性疼痛、精神健康症状和相关功能之间的时间关系;以及3） 透过质性访谈研究退伍军人的CBT-CP经验。我们将测量功能结果 在EMA期间和RCT基线、治疗后和3个月随访时通过自我报告问卷进行。

Anticipated Impacts on Veteran’s Healthcare: Chronic pain is a critical obstacle to the rehabilitation and recovery of Veterans with serious mental illness (SMI; schizophrenia spectrum and bipolar disorders). The Veteran Health Administration (VHA) has made treatment of chronic pain, especially nonpharmacological approaches, a high priority and initiated a nationwide dissemination of Cognitive Behavioral Therapy for Chronic Pain (CBT-CP) – an evidence-based psychotherapy – across the VHA system. However, CBT-CP has not been scientifically tested in SMI populations and is largely not provided to Veterans with chronic pain and co-occurring SMI, a group with some of the highest rates of chronic pain and associated negative functional outcomes. This study will: 1) test the feasibility and acceptability of CBT-CP for improving pain-related functional outcomes in Veterans with SMI; 2) examine the feasibility of ecological momentary assessment (EMA) to capture real-world experiences of and relationships among pain, mental health symptoms; and 3) evaluate Veteran experiences with CBT-CP to inform whether CBT-CP requires tailoring to optimize its use with Veterans with SMI and co- occurring chronic musculoskeletal pain. Project Background: Chronic pain is one of the most common physical health diagnoses among individuals with SMI.1-3 Individuals with SMI and chronic pain report worse mental and physical health functioning relative to people with other mental or physical health conditions. 4-8 Despite knowing about high rates of chronic pain among individuals with SMI; little research has been conducted to further understand the complex relation between pain and psychiatric symptoms and consider the usefulness or appropriateness of current treatment approaches. What is known is problematic; Veterans with SMI are largely not provided options for nonpharmacological pain management strategies, including CBT-CP, and are more likely to be prescribed pain medications that pose unique risks to this population. 9-13 Project Objectives: The proposed CDA-2 research will address research and clinical gaps by better assessing relations among chronic pain, psychiatric symptoms, and related functional impairment; and testing the feasibility and acceptability of CBT-CP in Veterans with SMI. The first step of this research will focus on completing a small randomized controlled trial of CBT-CP to examine feasibility and acceptability and explore changes to functioning and quality life in 45 Veterans randomized to CBT-CP (n=30) relative to a Health & Wellness intervention (n=15). We will assess rates of recruitment, initial intervention engagement, and session attendance (feasibility); assess Veteran satisfaction with CBT-CP (acceptability); and preliminarily explore response to CBT-CP. The second step will use EMA to collect real-time data (three times daily for one week) on Veterans’ pain, SMI symptoms, and their impact on functioning using an automated telephone survey. Data will be used to better understand the complex relationships between these variables. The final step of this research will involve conducting a process evaluation to consider ways to optimize CBT-CP for future clinical trials to improve functional recovery for Veterans with SMI and chronic pain. This evaluation will synthesize information from: 1) CBT-CP interventionist notes; 2) EMA data; and 3) qualitative interviews with a subset of Veterans in the CBT- CP condition (n=15) to learn about their experiences with CBT-CP, including barriers and facilitators to treatment engagement. Project Methods: This project will include: 1) completing a randomized control trial (RCT) with 45 Veteran participants, monitoring fidelity, feasibility, and acceptability; 2) developing and implementing phone-based EMA to assess temporal relationships among chronic pain, mental health symptoms, and related functioning; and 3) studying Veterans’ experiences of CBT-CP through qualitative interviews. We will measure functional outcomes during the EMA and at RCT baseline, post-treatment and 3-month follow-up through self-report questionnaires.