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

对退伍军人医疗的预期影响：慢性疼痛是康复和康复的关键障碍 患有严重精神疾病(精神分裂症、精神分裂症和躁郁症)的退伍军人的康复。这个 退伍军人健康管理局(VHA)已经对慢性疼痛进行了治疗，特别是非药物治疗 方法，高度优先，并在全国范围内推广慢性病认知行为疗法 疼痛(CBT-CP)--一种循证心理疗法--贯穿VHA系统。然而，CBT-CP尚未得到 在SMI人群中进行了科学测试，基本上不提供给患有慢性疼痛和共病的退伍军人 SMI，这是一个慢性疼痛和相关负面功能结果发生率最高的组。这 研究将：1)测试CBT-CP改善疼痛相关功能结果的可行性和可接受性 患有SMI的退伍军人；2)检查生态瞬时评估(EMA)的可行性，以捕捉真实世界 疼痛体验与心理健康症状的关系；3)退伍军人体验评估 通过CBT-CP告知CBT-CP是否需要量身定做，以优化其与具有SMI和联合 发生慢性肌肉骨骼疼痛。 项目背景：慢性疼痛是个人最常见的身体健康诊断之一 对于SMI.1-3患有SMI和慢性疼痛的患者报告的心理和身体健康功能比 有其他精神或身体健康问题的人。4-8岁，尽管知道慢性疼痛的比率很高 在患有SMI的个体中，很少有人进行研究来进一步了解这种复杂的关系 疼痛和精神症状之间的关系，并考虑当前治疗的有效性或适当性 接近了。已知的是有问题的；患有SMI的退伍军人基本上没有选择 非药物止痛策略，包括CBT-CP，更有可能是处方止痛 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研究将通过更好的评估来解决研究和临床差距 慢性疼痛、精神症状和相关功能损害之间的关系；并检验其可行性 退伍军人SMI患者CBT-CP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，以检查其可行性和可接受性，并探索其对功能的改变 45名退伍军人随机分为CBT-CP组(n=30)和健康福利干预组(n=15)。 我们将评估招聘、初始干预参与率和课程出席率(可行性)；评估 退伍军人对CBT-CP的满意度(可接受性)；初步探讨对CBT-CP的反应。第二步 将使用EMA收集关于退伍军人的疼痛、SMI症状和他们的实时数据(每天三次，为期一周) 使用自动电话调查对功能的影响。数据将被用于更好地理解复杂的 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 考虑如何在未来的临床试验中优化CBT-CP，以改善退伍军人的功能恢复 SMI和慢性疼痛。这项评估将综合以下信息：1)CBT-CP干预者笔记；2)EMA 数据；3)对CBT-CP条件下的退伍军人(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者。 项目方法：该项目将包括：1)完成45名退伍军人的随机对照试验 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、心理健康症状和相关功能之间的时间关系；以及3) 通过定性访谈研究退伍军人CBT-CP经验。我们将测量功能结果 在EMA期间和RCT基线时，通过自我报告问卷进行治疗后和3个月的随访。

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.