Relief: A Behavioral Intervention for Depression and Chronic Pain for Primary Care Practices

Kiosses, Dimitris

Abstract

RELIEF ABSTRACT This developmental project combines the expertise of our Cornell transdisciplinary team and of our partner, the Institute for Family Health (IFH). We propose to test the reach, feasibility, acceptability, and preliminary effectiveness of Relief, a 9-session behavioral intervention for older and middle-aged primary care patients with chronic pain and depression. Relief was jointly developed with IFH and is designed to be administered by licensed social workers (LCSWs) and/or nurse practitioners (NP) of IFH primary care practices. Our conceptual model assumes that chronic pain and depression are characterized by an attentional bias assigning greater salience to interoceptive stimuli and to negative emotions, along with a difficulty in shifting attention to goal-oriented/reward-driven state, leading to inadequate engagement of the reward networks. Accordingly, Relief aims to shift patient attention away from pain and negative feelings and to increase their focus and engagement in meaningful and pleasurable activities. Relief also assesses patient views on pain treatment (which may be adversely affected by depression, corrects unrealistic expectations, and helps to enhance communication between patients and primary care physicians. To improve its delivery and enhance behavioral assessment, Relief uses easy-to operate smartphone apps. We will recruit 60 adults (50+ years old), from four randomly assigned, large IFH primary care practices that screen all patients for depression with the PHQ-9. Two practices will offer Relief (N=40) and two will offer referrals (based on clinical indication) for mental health care (RMH) (N=20), provided at the practice site. Participants will have clinically significant depression (PHQ-9 ?10) and suffer from pain (during most days for ? 3 months). To facilitate future implementation studies, LCSWs and NPs of the IFH will be trained and administer Relief. Assessments will be conducted at entry, and at 6, 9, & 12 weeks.
Specific aims i nclude: Months 1-4: 1) To finalize the Relief manual and train and credential IFH therapists in Relief; 2) Develop an operations manual for procedures implementation; Months 5-24: 3) Assess Relief's reach, feasibility, and acceptability; 4) Evaluate preliminary effectiveness; 5) Assess preliminary evidence of target engagement; and 6) Perform exploratory analyses on sex differences, quality of life, pain medication use, suicidal ideation, cost and savings. We will use the results of this project to support an R01 application to rigorously test the feasibility, acceptability, effectiveness, non-billable costs and savings, and barriers to implementation of Relief in a randomized effectiveness trial in a wide range of large practices beyond New York.

Public Health Relevance

Chronic pain and depression frequently co-exist in late and mid-life and increase disability and health care cost. Our research team and The Institute for Family Health developed Relief, a behavioral intervention, built on a neurobiological model, and designed to be administered by non-medical clinicians of primary care practices eligible to provide billable services. If Relief is acceptable by patients and therapists and improves depression and disability, we will conduct a larger study with the goal to develop a sustainable mental health model for the large group of depressed-pain patients who have few viable treatment options.