An Ecological Momentary Assessment Study Examining the Efficacy of Third-Wave Cognitive-Behavioral Therapies on Different Indices of Pain-Related Outcomes.

IntroductionThe IMPACT study focuses on chronic low back pain (CLBP) and depression symptoms, a prevalent and complex problem that represents a challenge for health professionals. Acceptance and Commitment Therapy (ACT)...

Efficacy of Videoconference Group Acceptance and Commitment Therapy (ACT) and Behavioral Activation Therapy for Depression (BATD) for Chronic Low Back Pain (CLBP) Plus Comorbid Depressive Symptoms: A Randomized Controlled Trial (IMPACT Study)

This study analyzed the efficacy of acceptance and commitment therapy (ACT) in six individuals with chronic low back pain plus depressive symptoms using an idiographic approach within a randomized controlled trial. Daily ecological momentary assessments (EMA) and full assessments at baseline, posttreatment, and follow-up were collected. Outcomes included pain interference, pain intensity, and depressed mood, and the process variable was psychological inflexibility. Analyses involved visual inspection, non-overlap of all pairs, Tau, Tau-U, and idiographic network analysis. Moderate improvements were observed in pain interference (5/6), depressed mood (5/6), and psychological inflexibility (3/6), with limited change in pain intensity (1/6). Most participants (4/6) reported an overall relevant improvement. Idiographic networks showed considerable variability across participants, with psychological inflexibility and depressed mood playing a central role. Findings suggest ACT may help reduce pain interference and depressed mood, highlighting the need for personalized approaches and the continued use of single-case methods combined with EMA.

Secular Mindfulness-Based Interventions: Efficacy and Neurobiology.

Pain is prevalent among adults with neurofibromatoses (NF) and hinders quality of life. Pain management for NF is predominantly pharmacological and often ineffective. Psychosocial treatments improve pain outcomes in other chronic illness populations but have not been developed and tested in fully powered efficacy trials among adults with NF. Using data from a fully powered randomized clinical trial of an 8-week mind-body program (Relaxation Response Resiliency Program for NF [3RP-NF]) versus a health education control (HEP-NF), we examined (1) improvements in pain intensity and pain interference, and (2) mechanisms underlying improvements. Participants (N = 210, M age = 42.6, 73.4% female) were randomized to 3RP-NF versus HEP-NF. They completed measures of pain intensity, pain interference, and putative mechanisms (eg, mindfulness, coping, and social support) at baseline, post-intervention, 6-month, and 12-month follow-ups. There was a statistically significant change in pain interference over time F(3, 537.06) = 7.21, P < .001, but not pain intensity. Neither group (3RP-NF vs. HEP-NF) nor the group-by-time interaction predicted change in pain interference. While the group-by-time interaction was not statistically significant across all time points, planned post-hoc analyses probing the interaction at specific time points revealed a statistically significant decrease in pain interference from baseline to post-intervention (P < .001), which was sustained (ie, no subsequent change) from post-intervention through 6-month (P = 1.00) and 12-month follow-ups (P = 1.00) in the 3RP-NF group. The HEP-NF group had no significant changes in pain intensity or interference over time. The association between group (3RP-NF) and decreased pain interference from baseline to post-intervention was fully mediated by change in coping over the same period. Participation in the 3RP-NF is associated with sustained improvement in pain interference. Improvement occurred through increased coping. ClinicalTrials.gov Identifier: NCT03406208. https://clinicaltrials.gov/study/NCT03406208.

School attendance problems (SAPs) are associated with negative short- and long-term outcomes. Despite high prevalence of SAPs, there is a shortage of evidence-based interventions. Existing approaches often target either school refusal or truancy, leaving a gap in effective interventions addressing both types of SAPs. This randomized controlled trial (RCT) assessed the effectiveness of Back2School (B2S), a modular transdiagnostic cognitive behavioral therapy (CBT) for SAPs, compared to treatment as usual (TAU). Outcomes included youths’ school attendance and mental health. A group (B2S, TAU) × time (Pre, Post, 3-Month Follow-Up) design involving 152 youths (B2S; n = 74, TAU; n = 78) with SAPs (i.e., ≥ 10% absence in the past three months), aged 6–16 years (M = 12.2, SD = 2.2, males = 60%) were used. B2S comprised three months of CBT with youths, parents, and school involvement, while TAU comprised public and/or private intervention services. On average, youths in B2S received 15.0, (SD = 3.9) hours of intervention, while those in TAU received 13.4, (SD = 21.6). Intervention effects were investigated using mixed linear models. Both B2S and TAU exhibited significant within-group improvements in school attendance, with no significant differences between them. However, the B2S group significantly outperformed TAU in reducing youths’ emotional problems, conduct problems, problems with peers, the overall impact of problems, and increasing youths self-efficacy for attending school and parent self-efficacy for dealing with a SAP. This RCT represents the first evaluation of a modular transdiagnostic CBT for youths displaying SAPs, showing significant mental health and self-efficacy benefits. (Clinical trial registration: ClinicalTrials.gov: NCT03459677).

Background: Literature suggests that non-pharmacological treatments like non-invasive brain stimulation and cognitive behavioural therapy (CBT) may be used as augments in the management of Tension-Type Headache (TTH). Aims and Objectives: To assess the efficacy of Transcranial Direct Current Stimulation (tDCS) and Cognitive Behavioral Therapy (CBT) compared to treatment as usual (TAU) on headache-related disability and the psychological impact of headache on life of patients suffering from TTH. Materials and Methods: Thirty right-handed TTH patients HDI (headache disability index) &gt; 30 were randomly allocated to group A (tDCS + TAU), group B (CBT + TAU), and group C (TAU). While the primary outcome measure was headache related disability (Headache Disability Index(HDI)), somatic symptoms (Somatic Symptom Severity (SSS-8)), anxiety &amp; depression (Hospital Anxiety and Depression Scale (HADS)) and sleep quality (Pittsburgh Sleep Quality Index (PSQI). Assessments were done at baseline, end of the third and sixth month. Results: We found a statistically significant reduction in HDI (F=12.419, p &lt;0.001), SSS-8 (F=4.587, p=0.010), and HADS-anxiety (F=4.810, p=0.002). tDCS showed better efficacy than CBT, while these two were significantly better than TAU on HDI and SSS-8. On HADS-A also both tDCS and CBT were better than TAU, but showed no significant difference between them. Conclusion: Supplementing non-pharmacological techniques like tDCS and CBT will be effective in reducing headache-related disability and associated psychological symptoms.

Objective To examine change in pain interference and depression over a 10-year time period in individuals with long-term traumatic spinal cord injury (SCI) and to identify the extent to which changes in pain interference over time predicts change in depressive symptoms. Design Longitudinal analyses of self-report assessment data. Setting Specialty and university hospitals in the Southeastern and Midwestern United States. Participants Adults with a history of traumatic SCI (n = 504) who responded to the three most recent data collection periods of the SCI Longitudinal Aging Study (2008 [Time 1], 2013 [Time 2], and 2018 [Time 3]). The participants averaged 59 years of age and 32 years since injury onset at Time 3. Interventions Not applicable. Main Outcome Measures Patient Health Questionnaire (PHQ-9) assessed depressive symptom severity. The 7-item Pain Interference scale from the Brief Pain Inventory assessed pain interference. Results Over the three study timepoints, the sample averaged moderate levels of pain interference and mild depressive symptom severity. Unconditional linear growth models, reflecting changes in central tendency, indicated that pain interference significantly decreased and depressive symptom severity significantly increased over time. Multiple independent variables random coefficient modeling based on correlations suggested that change in pain interference was positively associated with change in depressive symptom severity over the 10-year study follow-up. Conclusion Average depressive symptom severity worsened over time. Change in pain interference was positively associated with change in depressive symptom severity. These results point to the complexity of aging related changes in depressive symptoms and pain interference. They further support the need for continued assessment of mood and pain experiences, particularly among individuals reaching aging milestones with SCI.

(121) Pain, Sleep Disturbances, Fatigue, Mood Changes, and Underlying Inflammation: A Study of Patients with Chronic Low Back Pain (CLBP)

COVID-19 social distancing mandates increased social isolation, resulting in changes in pain severity and interference among individuals with chronic pain. Differences in personality (e.g., introversion/extraversion) may modulate responses to social isolation. We examined the influence of introversion on reported social distancing-related increases in pain interference and assessed for mediators of this relationship. Individuals with chronic pain (n = 150) completed validated questionnaires 4–8 weeks after implementation of social distancing mandates. Introversion/extraversion was measured using a subscale of the Myers-Briggs Type Indicator and changes in pain and psychosocial variables were calculated by comparing participants’ recalled and current scores. Association between introversion/extraversion and other variables were assessed using linear regression. A parallel mediation was used to examine mediators of the association between introversion and change in pain interference. Higher introversion was associated with a decrease in pain interference after social distancing (Rho = − .194, p = .017). Parallel mediation analysis revealed that the relationship between introversion/extraversion and change in pain interference was mediated by changes in sleep disturbance and depression, such that higher introversion was associated with less isolation-induced sleep disruption and depression, and thereby less worsening of pain interference. These findings suggest that personality factors such as introversion/extraversion should be considered when personalizing treatment of chronic pain.

Although significant research has explored the digital phenotype in mood disorders, the time-lagged and bidirectional relationship between mood and global positioning system (GPS) mobility remains relatively unexplored. Leveraging the widespread use of smartphones, we examined correlations between mood and behavioral changes, which could inform future scalable interventions and personalized mental health monitoring. This study aims to investigate the bidirectional time lag relationships between passive GPS data and active ecological momentary assessment (EMA) data collected via smartphone app technology. Between March 2020 and May 2022, we recruited 45 participants (mean age 42.3 years, SD 12.1 years) who were followed up for 6 months: 35 individuals diagnosed with mood disorders referred by psychiatrists and 10 healthy control participants. This resulted in a total of 5248 person-days of data. Over 6 months, we collected 2 types of smartphone data: passive data on movement patterns with nearly 100,000 GPS data points per individual and active data through EMA capturing daily mood levels, including fatigue, irritability, depressed, and manic mood. Our study is limited to Android users due to operating system constraints. Our findings revealed a significant negative correlation between normalized entropy (r=-0.353; P=.04) and weekly depressed mood as well as between location variance (r=-0.364; P=.03) and depressed mood. In participants with mood disorders, we observed bidirectional time-lagged associations. Specifically, changes in homestay were positively associated with fatigue (β=0.256; P=.03), depressed mood (β=0.235; P=.01), and irritability (β=0.149; P=.03). A decrease in location variance was significantly associated with higher depressed mood the following day (β=-0.015; P=.009). Conversely, an increase in depressed mood was significantly associated with reduced location variance the next day (β=-0.869; P<.001). These findings suggest a dynamic interplay between mood symptoms and mobility patterns. This study demonstrates the potential of utilizing active EMA data to assess mood levels and passive GPS data to analyze mobility behaviors, with implications for managing disease progression in patients. Monitoring location variance and homestay can provide valuable insights into this process. The daily use of smartphones has proven to be a convenient method for monitoring patients' conditions. Interventions should prioritize promoting physical movement while discouraging prolonged periods of staying at home.

ABSTRACTBackgroundChronic low back pain (cLBP) is a prevalent and debilitating condition. Gaining insight into the daily experiences of those with cLBP is crucial for developing effective management. Pain and activity are typically assessed at a single time point and often rely on retrospective self‐reports, which can be prone to recall bias and may not reflect the day‐to‐day variability of these experiences. As a part of the University of Pittsburgh LB3P Mechanistic Research Center, this study used ecological momentary assessment (EMA) and wearable devices to collect real‐time data in a large cohort of adults with cLBP. The primary aims were to collect and characterize pain and activity profiles of individuals with cLBP.MethodsThis study enrolled 1007 adults with cLBP who met the National Institutes of Health defined criteria. Over 7 days, participants were assessed in their own environment. EMA was gathered in real‐time via a custom mobile app, prompting participants three times daily to provide their perceptions of current pain intensity (0–10), pain interference (0–10), and activity level (very light to vigorous). Time of falling asleep and waking was also reported. Participants wore ActiGraph GT9X devices on their wrist and waist. A custom back sensor was also adhered to the skin over the lumbar (L5) segment. Activity counts, wear time, and step counts were calculated, utilizing algorithms provided by ActiGraph. Sensor data were filtered to include at least 4 days of 10 or more hours each. Activity counts were categorized into sedentary, light, and moderate‐to‐very‐vigorous based on Freedson Adult cutpoints.ResultsOut of 1007 participants, 989 submitted EMA data (58.8 ± 16.5 years old; 40% male and 60% female; mean pain intensity at enrollment of 5.4 (SD 2.1) and a median of 5 (interquartile range [IQR] 3) on a 0–10 scale; mean PROMIS Pain Interference T‐score at enrollment of 60.5 (SD 7.5) and a median of 61.2 (IQR 9.6)). The median reported pain intensity level from the EMA was 1 (IQR = 3), while pain interference was 3 (IQR = 3). More than half of the participants reported a median pain intensity of either 0 or 1 (54.0%) and a median pain interference between 0 and 3 (57.4%). Most participants self‐reported their activity levels as moderate (36%) or light (33%). Based on pain ratings during each day, most participants had their pain intensity (30%) and pain interference (40%) peaking in the evening. ActiGraph data from 884 wrist‐worn and 785 waist‐worn devices were analyzed. Wrist data showed a median of 1 765 325 (IQR 796 995) activity counts/day and 9575 (IQR 4228) steps/day. Waist data showed 358 390 (IQR 223 758) activity counts/day and 4114 (IQR 3146) steps/day. The percentage of daily sedentary activity was 47.3% for wrist and 72.8% for waist. The back sensor data from 586 participants showed a median of 340 345 (IQR = 223 399) activity counts/day and a median of 3695 (IQR = 2743) steps/day. The percentage of time spent in daily sedentary activity was 82.6%. Both ActiGraph devices and the back sensor indicated that the majority of the time was spent in sedentary activity level, which is lower than the activity level reported in the EMA.ConclusionsDespite having cLBP with self‐reported moderate pain levels, participants generally reported periods of relatively low levels of pain intensity and interference in their EMA. In addition, their EMA‐reported activity levels differed from the sensor data. Participants self‐reported higher levels of activity compared to the activity levels calculated by the wearable sensors. This suggests that participants overestimated their activity levels on EMA, or that the activity level cut‐points may need to be re‐evaluated for the cLBP population. Additionally, sensors placed on different body locations showed varying activity and step counts. The activity counts calculated from the waist ActiGraph and the back sensor from this cohort were lower than the average activity counts in the US adult population. Further research is needed to better quantify these differences for people with cLBP to develop a more comprehensive understanding of the pain experience.

BackgroundEcological momentary assessment is a method of investigating individuals’ real-time experiences, behaviors, and moods in their natural environment over time. Despite its general usability and clinical value for evaluating daily depressive mood, there are several methodological challenges when applying ecological momentary assessment to older adults.ObjectiveThe aims of this integrative literature review were to examine possible uses of the ecological momentary assessment methodology with older adults and to suggest strategies to increase the feasibility of its application in geriatric depression research and practice.MethodsWe searched 4 electronic databases (MEDLINE, CINAHL, PsycINFO, and EMBASE) and gray literature; we also hand searched the retrieved articles’ references. We limited all database searches to articles published in peer-reviewed journals from 2009 to 2019. Search terms were “ecological momentary assessment,” “smartphone assessment,” “real time assessment,” “electronic daily diary,” “mHealth momentary assessment,” “mobile-based app,” and “experience sampling method,” combined with the relevant terms of depression. We included any studies that enrolled older adults even as a subgroup and that reported depressive mood at least once a day for more than 2 days.ResultsOf the 38 studies that met the inclusion criteria, only 1 study enrolled adults aged 65 years or older as the entire sample; the remainder of the reviewed studies used mixed samples of both younger and older adults. Most of the analyzed studies (18/38, 47%) were quantitative, exploratory (descriptive, correlational, and predictive), and cohort in design. Ecological momentary assessment was used to describe the fluctuating pattern of participants’ depressive moods primarily and to examine the correlation between mood patterns and other health outcomes as a concurrent symptom. We found 3 key methodological issues: (1) heterogeneity in study design and protocol, (2) issues with definitions of dropout and adherence, and (3) variation in how depressive symptoms were measured with ecological momentary assessment. Some studies (8/38, 21%) examined the age difference of participants with respect to dropout or poor compliance rate. Detailed participant burden was reported, such as technical problems, aging-related health problems, or discomfort while using the device.ConclusionsEcological momentary assessment has been used for comprehensive assessment of multiple mental health indicators in relation to depressive mood. Our findings provide methodological considerations for further studies that may be implemented using ecological momentary assessment to assess daily depressive mood in older adults. Conducting more feasibility studies focusing on older adults with standardized data collection protocols and mixed-methods research is required to reflect users’ experiences. Further telepsychiatric evaluation and diagnosis based on ecological momentary assessment data should involve standardized and sophisticated strategies to maximize the potential of ecological momentary assessment for older adults with depression in the community setting.

Chronic low back pain (CLBP), the most prevalent chronic pain condition, imparts substantial disability and discomfort. Cognitive behavioral therapy (CBT) reduces the effect of CLBP, but access is limited.To determine whether a single class in evidence-based pain management skills (empowered relief) is noninferior to 8-session CBT and superior to health education at 3 months after treatment for improving pain catastrophizing, pain intensity, pain interference, and other secondary outcomes.This 3-arm randomized clinical trial collected data from May 24, 2017, to March 3, 2020. Participants included individuals in the community with self-reported CLBP for 6 months or more and an average pain intensity of at least 4 (range, 0-10, with 10 indicating worst pain imaginable). Data were analyzed using intention-to-treat and per-protocol approaches.Participants were randomized to (1) empowered relief, (2) health education (matched to empowered relief for duration and format), or (3) 8-session CBT. Self-reported data were collected at baseline, before treatment, and at posttreatment months 1, 2, and 3.Group differences in Pain Catastrophizing Scale scores and secondary outcomes at month 3 after treatment. Pain intensity and pain interference were priority secondary outcomes.A total of 263 participants were included in the analysis (131 women [49.8%], 130 men [49.4%], and 2 other [0.8%]; mean [SD] age, 47.9 [13.8] years) and were randomized into 3 groups: empowered relief (n = 87), CBT (n = 88), and health education (n = 88). Empowered relief was noninferior to CBT for pain catastrophizing scores at 3 months (difference from CBT, 1.39 [97.5% CI, -∞ to 4.24]). Empowered relief and CBT were superior to health education for pain catastrophizing scores (empowered relief difference from health education, -5.90 [95% CI, -8.78 to -3.01; P < .001]; CBT difference from health education, -7.29 [95% CI, -10.20 to -4.38; P < .001]). Pain catastrophizing score reductions for empowered relief and CBT at 3 months after treatment were clinically meaningful (empowered relief, -9.12 [95% CI, -11.6 to -6.67; P < .001]; CBT, -10.94 [95% CI, -13.6 to -8.32; P < .001]; health education, -4.60 [95% CI, -7.18 to -2.01; P = .001]). Between-group comparisons for pain catastrophizing at months 1 to 3 were adjusted for baseline pain catastrophizing scores and used intention-to-treat analysis. Empowered relief was noninferior to CBT for pain intensity and pain interference (priority secondary outcomes), sleep disturbance, pain bothersomeness, pain behavior, depression, and anxiety. Empowered relief was inferior to CBT for physical function.Among adults with CLBP, a single-session pain management class resulted in clinically significant improvements in pain catastrophizing, pain intensity, pain interference, and other secondary outcomes that were noninferior to 8-session CBT at 3 months.ClinicalTrials.gov Identifier: NCT03167086.

Objective This study explored the extent to which within-patient changes in processes targeted in Acceptance and Commitment Therapy (ACT) and Behavioral Activation Therapy for Depression (BATD) are associated with changes within-patient in pain intensity and depressed mood and evaluated the extent that process-outcome relationships differed between patients. Methods An idiographic analysis embedded within a randomized controlled trial comparing ACT, BATD, and treatment-as-usual (TAU) was conducted to examine the strength of the relationship between outcomes and process variables in patients with chronic low back pain (CLBP) plus depressive symptoms. Based on data from ecological momentary assessment in patients (n = 82), the level of heterogeneity and the pooled effects of these relationships during the intervention period (70 days) were explored. Results Overall, a high level of heterogeneity was identified in the relationship between pain intensity or depressed mood and psychological inflexibility or behavioral activation. Individual differences in the relationships between outcomes and process variables were identified in individual people during the intervention period. These individual differences appear independent of the group (ACT, BATD, and TAU) and other definable differences (responders/non-responders, completers/non-completers, and clinical depression/non-clinical depression). Conclusions These findings suggest the potential utility of personalizing psychological interventions according to the therapeutic needs of these patients.