Behavioral Medicine Interventions Research Articles

Behavioral medicine for migraine and medication overuse headache

Primary headaches, including migraine and medication overuse headache (MOH), can be conceptualized as biobehavioral disorders based on the interaction of biological, psychological, and environmental factors. This article reviews empirically supported and efficacious behavioral approaches to the treatment and management of headaches in general, with an emphasis on migraine and MOH from a biopsychosocial perspective. Evidence-based behavioral medicine treatments for migraine and MOH are reviewed, including patient education, cognitive behavioral therapy, and biobehavioral training (biofeedback, relaxation training, and stress management). Information regarding psychological comorbidities and risk factors for progression of migraine and the development of MOH is also reviewed. Strategies are provided for enhancing adherence and motivation, as well as facilitating medical communication.

Preventing Progression to Chronicity in First Onset, Subacute Low Back Pain: An Exploratory Study

Slater MA, Weickgenant AL, Greenberg MA, Wahlgren DR, Williams RA, Carter C, Patterson TL, Grant I, Garfin SR, Webster JS, Atkinson JH. Preventing progression to chronicity in first onset, subacute low back pain: an exploratory study. Objectives To evaluate the effects of a behavioral medicine intervention, relative to an attention control, in preventing chronic pain and disability in patients with first-onset, subacute low back pain (LBP) with limitations in work-role function. Design A 2-group, experimental design with randomization to behavioral medicine or attention control groups. Setting Orthopedic clinic at a Naval Medical Center. Participants Sixty-seven participants with first-onset LBP of 6 to 10 weeks of duration and impairment in work function, of whom 50 completed all 4 therapy sessions and follow-up 6 months after pain onset. Intervention Four 1-hour individual treatment sessions of either behavioral medicine, focused on back function and pain education, self-management training, graded activity increases, fear reduction, and pain belief change; or attention control condition, focused on empathy, support, and reassurance. Main Outcome Measures The primary outcome was proportion of participants classified as recovered, according to pre-established clinical cutoffs on standardized measures, signifying absence of chronic pain and disability at 6 months after pain onset. Secondary analyses were conducted on pain, disability, health status, and functional work category. Intervention credibility and pain belief manipulation checks were also evaluated. Results Chi square analyses comparing proportions recovered at 6 months after pain onset for behavioral medicine and attention control participants found relative rates of 52% versus 31% in the modified intent-to-treat sample ( P=.09) and 54% versus 23% for those completing all 4 sessions and 6-month follow-up ( P=.02). At 12 months, 79% of recovered and 68% of chronic pain participants still met criteria for their respective groups ( P<.0001). Recovered participants also had higher rates of functional work status recovery at 12 months (recovered: 96% full duty and 4% light duty; chronic pain: 61% full duty, 18% light duty, and 21% medical discharge, respectively; P=.03). Conclusions Early intervention using a behavioral medicine rehabilitation approach may enhance recovery and reduce chronic pain and disability in patients with first-onset, subacute LBP. Effects are stronger for participants attending all 4 sessions and the follow-up assessment.

Experience from a behavioural medicine intervention among poorly controlled adult type 1 diabetes patients

Aim To describe experience from a behavioural medicine intervention among poorly controlled adult type 1 diabetes patients, in terms of feasibility, predictors and associations of improved glycaemic control. Methods Data were collected on 94 poorly controlled adult type 1 diabetes patients who were randomised to a study evaluating the effects of a behavioural medicine intervention. Statistics covered descriptive and comparison analysis. Backward stepwise regression models were used for predictive and agreement analyses involving socio-demographic and medical factors, as well as measures of diabetes self-efficacy (DES), diabetes locus of control (DLOC), self-care activities (SDSCA), diabetes-related distress (Swe-PAID-20), fear of hypoglycaemia (HFS), well-being (WBQ), depression (HAD) and perceived stress (PSS). Results The participation rate in the study was 41% and attrition was 24%. Of those patients actually participating in the behavioural medicine intervention, 13% withdrew. From the regression models no predictors or associations of improvement in HbA 1c were found. Conclusions The programme proved to be feasible in terms of design and methods. However, no clear pattern was found regarding predictors or associations of improved metabolic control as the response to the intervention. Further research in this area is called for.

Relaxation Training and Written Emotional Disclosure for Tension or Migraine Headaches: A Randomized, Controlled Trial

Behavioral medicine interventions that directly reduce arousal and negative emotions, such as relaxation training (RT), are conceptually different from interventions that temporarily increase negative emotions, such as written emotional disclosure (WED), but no studies have directly compared their efficacy. We compared the effects of RT and WED on people with tension or migraine headaches. College students with either tension (n = 51) or migraine (n = 90) headaches were randomized to one of three groups: RT, WED, or a neutral writing control condition; four sessions were held over 2 weeks. Mood was measured before and after each session, and outcomes (headache frequency, severity, disability, and general physical symptoms) were assessed at baseline and at 1-month and 3-month follow-ups. As expected, RT led to an immediate increase in calmness, whereas WED led to an immediate increase in negative mood, for both headache samples. Intent-to-treat analyses showed that, for the tension headache sample, RT led to improved headache frequency and disability compared to both WED and the control group, but WED had no effect. For migraine headaches, RT improved pain severity relative to the control group, but WED again had no effect. A brief RT protocol was effective for tension headaches, but WED had no effect on health status for either tension or migraine headaches. Modifications to WED, such as targeting people with unresolved stress, providing guidance to enhance the potency of the writing, or including additional at-home writing and exposure exercises, may improve its efficacy for people with headaches and other health problems.

Exploring Refinements in Targeted Behavioral Medicine Intervention to Advance Public Health

Similar to other fields, a targeted behavioral medicine perspective can aid decision-making related to participant-intervention matching. To present one potentially useful definition of intervention targeting activity; describe potential targeting domains of particular relevance to behavioral medicine; discuss different statistical approaches to aid the targeted intervention development process; and discuss the challenges and opportunities accompanying the incorporation of targeted intervention development methods into behavioral randomized clinical trial (RCT) research. Drawing from recent conceptual work by the MacArthur group and other scientists in the field, methods and approaches to undertaking moderator analysis are discussed. Examples of moderator analyses are provided which reflect the different statistical methods and variable domains that may serve as moderators of intervention success. The recommended exploratory work can help to make the most efficient use of RCTs to identify the best paths for subsequent RCT development in a resource-constrained era.

Developing a database of behavioural medicine interventions1

To describe the development of the Cochrane Behavioral Medicine Field database of interventions and its contribution to the knowledge base of this field. A list of behavioural medicine interventions was solicited from content experts. The resulting list of index terms was used to generate a comprehensive search strategy to retrieve relevant records, and a thesaurus of terms with which to index them. The records are included in a register. A subset of records have been coded for study design, health condition, intervention, study participants, setting and provider and made available in a public online database. The Cochrane Behavioral Medicine Field database consists of over 3500 records of systematic reviews, meta-analyses and randomized controlled trials for public educational use. The register provides a comprehensive listing of studies relating to behavioural medicine interventions. The public online database enables easy access to the evidence base and provides enhanced details of the studies included on it. These databases are a valuable resource for the behavioural medicine community. Other fields are encouraged to duplicate these methods in the design of content-specific databases.

Idiographic outcome analyses of the clinical significance of two interventions for patients with musculoskeletal pain

This study adopted a perspective of the individual to define domains of everyday life for the analysis of clinically meaningful change. The purpose was to compare the clinical significance of two interventions for patients with musculoskeletal pain, applying an idiographic outcome measure, The Patient Goal Priority Questionnaire, in combination with the Jacobson and Truax methodology [(1991). Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 67 (3), 300–307] for determination of clinical significance. The concurrent validity of the outcome variables behavioral performance, satisfaction with behavioral performance, and fulfilled pre-treatment expectations was also studied. Eighty-two patients, randomized to either individually tailored behavioral medicine treatment (experimental group) or physical exercise therapy (control group) were evaluated at baseline and 3 months post-treatment regarding behavioral treatment goals. The experimental intervention had high impact on participants’ performance of their highest ranked everyday life activities, and resulted in larger proportions of clinically significant outcomes compared with controls. The concurrent validity of the outcomes was high for those reporting clinically significant changes, but more generally, there was a moderate agreement across outcome categories. The individual should be the unit for analyses of clinical significance to enhance the ecological validity of the construct. Further development of idiographic outcome measures is necessary, as is the inclusion in pain intervention research.

Individually Tailored Treatment Targeting Activity, Motor Behavior, and Cognition Reduces Pain–Related Disability: A Randomized Controlled Trial in Patients With Musculoskeletal Pain

This study compares the outcomes of an individually tailored behavioral medicine intervention (experimental) with physical exercise therapy (control). The experimental intervention was systematically individualized according to each participant’s behavioral treatment goals and functional behavioral analyses. One hundred twenty-two patients seeking care at 3 primary health care clinics because of musculoskeletal pain were randomized. Ninety-seven completed the trial. Data were collected at baseline, immediately after treatment, and at a 3-month follow-up. Analyses of data from completers, as well as intention-to-treat analyses, showed that the experimental group experienced lower levels of disability ( P = .01), lower maximum pain intensity ( P = .02), higher levels of pain control ( P = .001), and lower fear of movement ( P = .022) as a result of treatment condition. Self-efficacy ( P = .0001) and physical performance ( P = .0001) increased over time for both groups. Participants in the experimental group generally reported more positive effects after treatment. Treatment fidelity was maintained during the course of the study. Activity can be resumed and pain might be managed by the patients themselves if treatment incorporates the biopsychosocial explanatory model of pain and strategies are tailored according to individual’s priorities of everyday life activities and empirically derived determinants of pain-related disability. Perspective This study shows that the biomedical and the psychosocial perspectives of the experiences and consequences of pain complement rather than contradict each other. Primary health care patients with persistent musculoskeletal pain benefit more from a systematic tailoring of treatments according to biopsychosocial factors than from a physically based exercise intervention.

The Rate and Variation of Referrals to Behavioral Medicine Services for Patients Reporting Poor Mental Health in the National Spine Network

Descriptive analysis of cross-sectional data collected prospectively in 20 National Spine Network (NSN) centers. First, to summarize clinical and demographic characteristics of patients likely to need servicesfor psychosocial concerns. Second, to determine the rate and variability of referrals for behavioral medicine interventions (BMED) across the NSN. The prevalence of mental distress resulting from or coexisting with spinal pain is unclear. There is evidence that psychological treatments, particularly BMED, can aid the recovery of patients with symptoms of mental distress. From 1998 to 2001, 28,349 patients presenting to NSN centers completed the SF-36 General Health Survey. Patients were dichotomized by the mental component summary (MCS) score into two groups: 1) those scoring <or=35 on the MCS scale (patients self-reporting significant signs of mental distress) and 2) those scoring >35. Clinicians recorded a "treatment plan" comprised of a standard array of treatment options. For patients scoring <or=35 on the MCS, the rate and variation of referrals to BMED was assessed. Baseline health status scores were lower across all SF-36 scales for the patients scoring an MCS <or= 35. For mentally distressed patients, the overall average referral rate for any BMED service for patients scoring MCS <or= 35 was 11.8%. The rate varied across NSN sites from 0 to 41%. With only 11.8% of mentally distressed NSN patients receiving a referral for any form of BMED, it appears that a large proportion of eligible patients are not receiving a potentially beneficial treatment. Wide variation across centers may indicate an inability to adequately assess mental distress via the usual clinical interview and examination for spinal conditions or a lack of consensus regarding BMED's availability and utility.

Negative mood endures after completion of high-altitude military training

Associations between physical and emotional stress and negative mood states have been documented in a variety of populations. In military personnel, more physical symptoms and decrements in ability to perform critical tasks have been shown to accompany such stress-induced negative mood. Most research in this area has focused on immediate effects of stress on mood. We wondered what immediate mood effects strenuous training would have on Marines, what mood effects would endure 30 and 90 days after completion of training, and how mood scores would compare with normative data. Sixty male Marines (M age = 19 years, range = 18-28) completed the Profile of Mood States (POMS) at multiple time points before and after participating in a 30-day, cold weather, high-altitude field training exercise. Anthropometric measurements were taken at the same time points. The Marines reported significant increases in POMS scores from baseline to completion of training, most of which endured up to 90 days. The anger and fatigue scores reported by the Marines were comparable to adult male psychiatric outpatient norms. Rigorous training in challenging environments may result in enduring negative moods that approach levels of clinical significance and may have implications for readiness for duty and performance of critical tasks. Behavioral medicine interventions may be helpful in military populations to reduce the impact of negative mood.

A primer on current evidence-based review systems and their implications for behavioral medicine

Multiple review systems have been established within medicine and psychology to evaluate and disseminate research findings to clinical practice. Within this article, five evidence-based review systems are reviewed to inform the development or the use of an evidence review system for the behavioral medicine field. Each review system is described on several dimensions: history of the review system, the review process, and details about translation/sustainability efforts. Various factors from each system have been identified that would benefit a behavioral medicine evidence review system, such as a discussion of clinical features that influence the generalizability of review findings (i.e., the American Psychiatric Association) and the use of pre-review protocols (i.e., the Cochrane Collaboration). Although each review system has limitations, it is important for behavioral medicine to join one system because (a) systematic reviews are the only feasible means to evaluate and judge the usefulness of our interventions, and (b) reviews can inform policy, and, with effort, influence patient well-being. This group of behavioral medicine experts recommends that the Cochrane Collaboration review behavioral medicine interventions.

Secondary prevention in acute coronary syndrome patients

Objective: To compare study quality and clinically meaningful effect sizes in behavioural medicine interventions and medication interventions for post-acute coronary syndrome (ACS) patients.

Psychosocial determinants of relapse in ulcerative colitis: a longitudinal study

Objectives To determine the association between psychosocial characteristics and time to relapse in patients with inactive ulcerative colitis. Methods Sixty patients with clinically and endoscopically inactive ulcerative colitis were followed for 1 yr, or less if they relapsed. Demographic, psychosocial, and clinical data were obtained. Stressful life events (Psychiatric Epidemiology Research Interview Life Events Scale), psychological distress (Symptom Checklist-90R), and perceived stress (Perceived Stress Scale) were recorded monthly by self-report. Multivariate time-dependent Cox regression was used to identify the independent determinants of earlier time to clinical relapse. Results The patients' mean age was 39 yr (SD = 9.4), 37 (62%) were female, and 22 (37%) relapsed during the 1-yr follow-up. Univariate Cox regression indicated a weak association between number of stressful events in the preceding month and time to relapse ( p = 0.09). This association strengthened in multivariate analysis ( p = 0.02, hazard ratio = 1.26 per event, 95% CI = 1.04–1.53) after adjustment for significant covariates. Conclusions After controlling for demographic and clinical variables, more recent stressful events were associated with earlier time to relapse. These findings, which support a biopsychosocial model of disease, might help clinicians identify patients who might benefit from more intensive maintenance medical therapy and behavioral medicine interventions to reduce stress and improve coping.

Behavioral medicine in the prevention and treatment of cardiovascular disease.

Cardiac behavioral medicine is the application of behavioral and psychosocial principles to the prevention and treatment of heart disease. Most biomedical cardiovascular risk factors (e.g., high blood lipids, high blood pressure, diabetes) require behavioral and medical interventions. Other risks, including obesity, high-fat eating pattern, smoking, and inactivity, clearly require lifestyle change. Behavioral medicine screening and intervention have been applied to psychosocial risk factors such as depression, hostility, and social isolation. Appropriate assessment of risk factors is essential because research has demonstrated successful prevention of heart disease and reduction of morbidity and mortality in patients with existing disease. Behavioral interventions have been beneficial in improving cardiac outcomes by enhancing compliance with medication taking and dietary/exercise recommendations. Future needs include the study of psychosocial factors in women and ethnic minorities with heart disease and the integration of behavioral medicine with newer medical technologies designed to detect subclinical biomarkers of heart disease.

Extended, Strategic Therapy for Recalcitrant Mind/Body Healing: An Integrative Model

The development of the power therapies, behavioral medicine, and short term interventions have reported such success even with trauma cases that it is relevant to question the justification for lengthy psychotherapy. Yet some patients with complex mind/body conditions impervious to medical treatment/hypnosis may require extended, multi-modal, integrative therapy. This paper details a single complex case of paruresis as a prototype for illustrating a holographic treatment model for recalcitrant conditions: Component features of the proposed model presented include: 1) the sequential utilization of hypnobehavioral and analytic approaches; 2) uncovering work providing access to the somatic ego state associated with the illness condition; 3) the extended treatment time frame required for deep psycho-physiological change; and 4) the stages of counter-transference expectably evoked by such patients (e.g. urgency, exuberant optimism, frustration, discouragement), and the transformation of such reactions to achieve maximum therapeutic efficacy.

Evaluating the Feasibility and Efficacy of a Self-Administered Manual-Based Stress Management Intervention for Individuals With Asthma: Results From a Controlled Study

Several behavioral medicine interventions (eg, relaxation training and written emotional expression) have been proposed as effective supplemental treatments for individuals with chronic illnesses such as asthma. Whether these treatments are feasible or effective in a manual-based, self-administered format is unclear, and few studies have examined the effectiveness of such treatments presented in a complementary format. We examined the feasibility and effectiveness of a 4 week stress management treatment compared with a matched placebo intervention in young adults with asthma. Both groups considered the workbooks credible treatment interventions and completed them conscientiously. The treatment group showed significant improvement in measures of lung function compared with the placebo group, but analysis revealed no differences in measures of perceived stress. These findings provide initial support for the feasibility of self-administered manual-based interventions and some evidence that they can produce health benefits in individuals with asthma and, perhaps other chronic conditions.

Anxiety Is a Good Indicator for Somatic Symptom Reduction through Behavioral Medicine Intervention in a Mind/Body Medicine Clinic

Background: This study examined the effect of anxiety on symptom reduction through a behavioral medicine intervention in a Mind/Body Medicine Clinic. Method: Participants were 1,312 outpatients attending a 10-week behavioral medicine intervention which included training in the relaxation response, cognitive restructuring, exercise and nutrition. All of the patients had physical symptoms and were referred to the clinic by their physician. The Medical Symptom Checklist (12 major symptoms), Symptom Checklist 90 Revised (SCL-90R), Stress Perception Scale and the Health-Promoting Lifestyle Profile were administered before and after the program. Results: Of the sample, 1,012 patients completed the program, and 911 completed the posttreatment assessment. Self-reported frequency of medical symptoms, degree of discomfort and interference with daily activities were significantly reduced as a result of the program. Anxiety and other psychological distress as measured by the SCL-90R and stress perception scales also showed significant reductions. Furthermore, health-promoting lifestyle functioning significantly improved. High levels of pretreatment anxiety predicted a decrease in the total number of medical symptoms endorsed. Conclusions: Behavioral medicine interventions are effective in reducing medical symptoms coinciding with improvement in anxiety. High anxiety at program entry may predict better outcome.

Somatization and Symptom Reduction Through a Behavioral Medicine Intervention in a Mind/Body Medicine Clinic

The authors assessed data from 1,148 outpatients in a 10-week medical symptom reduction program to determine the effectiveness of a behavioral medicine intervention among somatizing patients. The program included instruction in the relaxation response, cognitive restructuring, nutrition, and exercise. Before and after the intervention, the patients were evaluated on the Symptom Checklist-90 Revised (SCL-90R), the Medical Symptom Checklist, and the Stress Perception Scale. They were divided into high- and low-somatizing groups on the basis of the pretreatment SCL-90R somatization scale. At the end of the program, physical and psychological symptoms on the Medical Symptom Checklist and the SCL-90R were significantly reduced in both groups, with the reductions greater in the high-somatizing group. Improvements in stress perception were about the same in both groups, but the absence of an untreated control group precluded estimates of how much the improvements resulted from the behavioral medicine intervention and how much from natural healing over time.

Depression and Education as Predicting Factors for Completion of a Behavioral Medicine Intervention in a Mind/Body Medicine Clinic

The authors compared characteristics of 1,012 outpatients completing a 10-week behavioral medicine intervention with 300 outpatients who dropped out. They administered the Symptom Checklist-90 Revised (SCL-90R) before and after the program. Patients who completed the treatment, compared with dropouts, tended to be more highly educated, married, and gainfully employed. Their pretreatment scores on the SCL-90R were significantly lower than those of the dropouts on somatization, depression, and obsessive-compulsive scales and on the global severity index. Multiple logistic regression analysis indicated that lower depression and higher education marked the group who completed the intervention in contrast to the dropouts. After the intervention, all of the SCL-90R scores were significantly lower among patients who completed the treatment. Pre- to postintervention score changes were not significantly associated with the number of sessions attended. The findings suggest that the intervention had salutary effects in patients with mind/body distress and that its effectiveness was not diminished by a few absences. Depressed or less educated patients might benefit from preparatory interventions or from a modified approach to their treatment.

The COPE Program: Treatment Efficacy and Medical Utilization Outcome of a Chronic Pain Management Program at a Major Military Hospital

This study presents a treatment efficacy and medical utilization evaluation of a cognitive-behavioral, outpatient, chronic pain management program in a military hospital setting. A total of 61 nonmalignant chronic pain patients with heterogeneous pain syndromes who participated in sequential group programs were included in the study. Comprehensive and multi-dimensional outcome criteria were used, including pain ratings, relaxation skills, quality of life, satisfaction ratings, and medical utilization. The findings demonstrated improvements on all general indices. Military status had no effect on any of the outcome measures. Most significant was an 87% reduction in outpatient clinic visits in the first 3 months after treatment. This reduction amounts to a projected net annual saving of $78,960 in the first year after behavioral medicine intervention. In light of the increasing cost of health care for chronic pain patients, psychological approaches as an adjunct to traditional medical care seem to present a sound solution for cost savings. This study also supports the notion that a strategic biopsychosocial pain program, which targets the multiple dimensions of persistent pain, provides effective treatment and increases patient satisfaction.