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

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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.