The report is a product of the VA/HSR Evidence Synthesis Program.

Systematic Review: Implementation of Psychotherapies and Mindfulness-based Stress Reduction for Chronic Pain and Chronic Mental Health Conditions

Chronic pain conditions are common causes of disability in the United States and contribute to other serious problems such as opioid use disorder. Chronic pain is associated with high levels of psychological distress. Individuals with chronic pain have a higher prevalence of mental health conditions, including PTSD, depression, and insomnia; they are also at greater risk for other chronic health conditions. Veterans have a higher prevalence of chronic pain conditions compared to civilians, resulting in significant healthcare costs for VA. Current guidelines for chronic pain recommend non-pharmacologic and non-invasive therapies with demonstrated benefits. First-line treatment options include evidence-based psychotherapies (EBPs), exercise and movement therapies, physical therapy, and non-opioid medications. EBPs with demonstrated efficacy for improving chronic pain outcomes include cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), and mindfulness-based stress reduction (MBSR).

To help identify areas of research critical for improving the uptake of EBPs for chronic pain, HSR&D’s Pain/Opioid COnsortia for REsearch (CORE) requested an evidence review on barriers, facilitators, and implementation strategies for EBPs. Because implementation research focusing on EBPs for chronic pain may be limited, the scope of this review also included other EBPs commonly used in VA. This systematic review presents evidence on implementation of EBPs for chronic pain and chronic mental health conditions, including 1) barriers and facilitators at the patient, provider, and system levels, and 2) results of implementation strategies aimed at promoting uptake of and engagement with EBPs. The review focuses on CBT, ACT, and MBSR because these have demonstrated efficacy for improving chronic pain outcomes. The review also addresses other EBPs commonly used to treat mental health conditions in VA (e.g., trauma-focused psychotherapies, depression). Investigators from VA’s Evidence Synthesis Program (ESP) Center in Minneapolis, MN searched the literature, including MEDLINE, Embase, PsycINFO, and CINAHL, from inception through March 2021. From 7,295 unique citations, investigators identified 67 eligible articles; most studies were conducted in the US, and the majority (n=47) in VA settings. Most articles were of high or moderate quality (n=53).

Summary of Findings

• A common barrier to the uptake of CBT, MBSR, and ACT for chronic pain was a mismatch between patients’ pain-related beliefs and perceptions of core therapy concepts. Other barriers to CBT included cultural, communication, and logistical factors. Barriers to MBSR and ACT included physical discomfort and logistical challenges.
• Shared facilitators of CBT, MBSR, and ACT for chronic pain included positive patient-therapist or patient-group dynamics. Other facilitators of CBT included patient readiness for change and telehealth availability.
• Patient demographics did not consistently predict pain psychotherapy attendance.
• Shared barriers across psychotherapies for chronic mental health conditions included: workload and scheduling challenges for providers, lack of educational resources and training for referring providers, transportation needs and competing responsibilities for patients, and variable patient buy-in to therapy rationale.
• Shared facilitators included leadership engagement, training and treatment delivery resources, communications and networks for continuing provider education, and positive patient-provider relationships.
• Evaluations of VA national initiatives to implement psychotherapies have not, for the most part, focused on patient factors affecting implementation and uptake or heterogeneity in treatment effects.

Implications for VA

VA national training programs for EBPs have greatly increased the number of mental health providers who are prepared to deliver EBPs. Development and dissemination of tailored patient educational materials are likely necessary to increase awareness, acceptability, and uptake. At the provider- and system-level, VA facilities may benefit from strategies to streamline EBP referral processes, as well as guidance for conducting local needs assessment on implementation readiness and matching of strategies and resources. Moreover, it may be important for VA initiatives to provide additional support and information for facilities regarding how to organize and integrate mental health services.

Research Gaps/Future Research

Studies of barriers and facilitators to EBPs for chronic pain focused largely on patient-level findings, with little provider- or system-level information. Future work is needed to explore heterogeneity of treatment effects within EBPs for chronic pain, as well as provider- and system-level barriers and facilitators for EBPs for chronic pain. Specific recommendations for future research include the following.

• Examine provider- and system-level barriers and facilitators for CBT, MBSR, and ACT for chronic pain using comprehensive frameworks and in clinical practice settings.
• Identify patient-level factors contributing to heterogeneity of both treatment effects and treatment uptake for EBPs for chronic pain, to identify targets for future effectiveness and implementation work.
• Assess patient-level sociocultural and demographic factors, including sex, gender, race, and ethnicity, accurately and with clear analytic purpose.
• Evaluate the added value of external facilitation, when used with education/training and audit/feedback, in implementation of EBPs.
• Describe reach – uptake by target patient populations and use by relevant clinical staff, proportion or representativeness of settings and staff – for implementation of EBPs, including VA national training programs for EBPs.
• Use implementation frameworks to guide future evaluations of barriers and facilitators, processes of change, and key implementation outcomes.

Goldsmith E, Koffel E, Ackland P, Hill J, Landsteiner A, Miller W, Stroebel B, Ullman K, Wilt T, and Duan-Porter W. Implementation of Psychotherapies and Mindfulness-based Stress Reduction for Chronic Pain and Chronic Mental Health Conditions. Washington, DC: Evidence Synthesis Program, Health Services Research and Development Service, Office of Research and Development, Department of Veterans Affairs. VA ESP Project #09-009; 2021.

To view the full report, go to vaww.hsrd.research.va.gov/publications/esp/Psychotherapies-Pain.cfm (Intranet only)

ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.

This Management e-Brief is provided to inform you about recent HSR&D findings that may be of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. If you have any questions or comments about this Brief, please email CIDER. The Center for Information Dissemination and Education Resources (CIDER) is a VA HSR&D Resource Center charged with disseminating important HSR&D findings and information to policy makers, managers, clinicians, and researchers working to improve the health and care of Veterans.

This report is a product of VA/HSR&D's Evidence Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers –; and to disseminate these reports throughout VA.

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