Pain is the most common presenting somatic symptom in medical outpatients, and depression and anxiety are the two most common mental disorders. All three conditions are often inadequately treated and result in substantial disability, reduced health-related quality of life, and increased health care costs and utilization. Additionally, pain, anxiety, and depression (PAD) are frequently comorbid with one another and have reciprocal negative effects on treatment response and additive effects on adverse health outcomes. The PAD triad is especially burdensome in Veterans, with their high prevalence of chronic pain, depression, PTSD, and other anxiety disorders.
The Comprehensive vs. Assisted Management of Mood and Physical Symptoms (CAMMPS) study was a randomized comparative effectiveness trial designed to test the relative effectiveness of a lower-resource vs. a higher-resource enhancement of usual primary care in the management of veterans suffering from pain plus comorbid anxiety and/or depression.
This was a single-site study enrolling Veterans. Patients followed in primary care clinics at the Roudebush VAMC were eligible if they had clinically significant levels of pain plus comorbid anxiety and/or depression. A total of 294 eligible patients who provided informed consent were randomized to one of two treatment arms. One group (n=147) received assisted symptom management (ASM) consisting of automated symptom monitoring by interactive voice recording or Internet and prompted pain self-management guided by symptom levels. The second group (n=147) received comprehensive symptom management (CSM) which combined ASM with optimized medication management delivered by a nurse-physician specialist team and facilitated mental health care. This team partnered with both VA primary care physicians/PACTs and psychologists embedded in primary care to monitor and adjust treatments using evidence-based analgesic and antidepressant algorithms, reinforced self-management, and care coordination. We postulated that although both interventions are likely to be beneficial, CSM will be superior to ASM.
In short, this trial compared: 1) usual care plus assisted symptom management (ASM) vs. 2) usual care plus ASM plus optimized medication and facilitated mental health care (CSM). Outcomes were assessed at baseline, 1, 3, 6, and 12 months.
The primary outcome was a composite pain-anxiety-depression severity score. Secondary outcomes included individual pain, anxiety, and depression scores; functional status and health-related quality of life; treatment satisfaction; and perceived barriers and facilitators of the CSM and ASM interventions. The rationale for ASM was preliminary evidence of its effectiveness and its lower use of resources. The rationale for CSM was that the addition of optimized medication management, facilitated mental health care, and coordination with both primary care physicians/PACTs and psychologists for the PAD symptoms should substantially enhance the benefits of ASM.
Both CSM and ASM groups had moderate PAD score improvement at 12 months (0.65 and 0.52, respectively). Compared to the ASM group, patients in the CSM group had a 0.23 (95% CI, -0.38 to -0.08, p = .003) greater decline in their composite PAD z-score over 12 months. CSM patients were more likely to report being "much improved" (40% vs. 27%) by 12 months and less likely to being "worse (19% vs. 36%). Opioids were successfully discontinued in 19 (30%) of the 63 patients on opioids at the beginning of the trial, and initiated in only 6 (2.6%) of the 231 patients not on opioids. Functional status and quality of life outcomes showed small improvements in both groups, with several favoring the CSM group. Treatment satisfaction was good, and health care use was similar among both groups.
CAMMPS provided an integrated approach to PAD symptom comorbidity rather than fragmented care of single symptoms; coordinated symptom management in partnership with both primary care clinicians and psychologists embedded in primary care; the efficient use of health information technology; attention to physical and psychological symptom comorbidity; and the coupling of self-management with optimized medication management and facilitated mental health care.
Anticipated future directions for extending the impact of this research on health care within VHA include: (1) expanding telecare pain management to specialty clinics such as oncology, rheumatology, and neurology, where pain is a substantial problem; (2) providing coverage for more than one VA facility, including multiple clinics within a region (e.g., a VISN); and (3) disseminating the medication algorithms, self-management modules, training manuals, and care manager resources to other VA Medical Center facilities.
External Links for this Project
Grant Number: I01HX000905-01A1
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Mental, Cognitive and Behavioral Disorders
Treatment - Comparative Effectiveness