Self-Directed vs Clinician-Delivered Cognitive Behavioral Therapy for Chronic Pain: A Randomized Clinical Trial

Area of Science:

• Health Services Research
• Behavioral Medicine
• Pain Management

Background:

• Cognitive behavioral therapy for chronic pain (CBT-CP) is a key non-pharmacological treatment.
• Low patient uptake of CBT-CP is attributed to various access barriers.

Purpose of the Study:

• To compare the effectiveness of self-directed CBT-CP with asynchronous, personalized feedback against clinician-delivered CBT-CP.
• To evaluate if a scalable, convenient self-directed CBT model can improve patient outcomes and treatment adherence.

Main Methods:

• A randomized, open-label, pragmatic superiority trial involving 764 patients with chronic musculoskeletal pain across 9 US Veterans Health Administration (VHA) systems.
• Participants were assigned to either self-directed CBT-CP (11 weeks with weekly personalized feedback) or clinician-delivered CBT-CP (4-11 sessions).
• The primary outcome was pain interference (Brief Pain Inventory-Interference scale) at 4 months, with secondary outcomes assessed at 4, 6, and 12 months.

Main Results:

• Self-directed CBT-CP demonstrated superiority in reducing pain interference at 4 months (mean difference, -0.98; P < .001), with sustained effects at 12 months.
• Significant improvements were observed for all secondary outcomes, including pain intensity, catastrophizing, and self-efficacy, favoring the self-directed group.
• The self-directed CBT-CP group also showed higher treatment session completion rates compared to the clinician-delivered group.

Conclusions:

• Self-directed CBT-CP offers a scalable and convenient alternative to traditional clinician-delivered therapy.
• This approach is associated with sustained improvements in pain interference and secondary outcomes, potentially increasing CBT-CP uptake.
• Findings suggest that self-directed CBT-CP can effectively manage chronic pain and overcome access barriers prevalent in usual care settings.