Telephone-Based versus In-Person Delivery of Cognitive Behavioral Treatment for Veterans with Chronic Multisymptom Illness: A Controlled, Randomized Trial

Background:The goal of this randomized clinical trial was to examine the efficacy of a cognitive behavioral stress reduction treatment for reducing disability among veterans with chronic multisymptom illness (CMI).Method: Veterans (N=128) who endorsed symptoms of CMI were randomized to: usual care (n=43), in-person (n=42) or telephone-delivered cognitive behavioral stress management (n=43). Assessments were conducted at baseline, three months, and twelve months. The primary outcome was limitation in roles at work and home (i.e., ‘role physical’). Reductions in catastrophizing cognitions were evaluated as a mechanism of action. Results: Intent-to-treat analyses showed no statistically significant main effect (F(2, 164)=.58, p=.56) or interaction effect (F(4,164)=.94, p=.45) for role physical. Over time, veterans improved in their physical function (F(2,170)=5.34, p2partial=.06), PTSD symptoms (F(2,170)=9.39, p2partial=.10), depressive symptoms (F(2,170)=10.81, p2partial=.11), and physical symptoms (F(2, 172)=12.65, p2partial=.13), but these improvements did not differ across study arms over time. Completer analyses yielded similar results. There were no differences in catastrophizing between arms. Conclusion: Findings suggest stress reduction may not be the right target for improving disability among veterans with CMI. Veterans with CMI may need intervention that directly impacts medical self-management to improve disability

Concordance of Illness Representations: The Key to Improving Care of Medically Unexplained Symptoms

How can effective patient-provider relationships be developed when the underlying cause of the health condition is not well understood and becomes a point of controversy between patient and provider? This problem underlies the difficulty in treating medically unexplained symptoms and syndromes (MUS; e.g., fibromyalgia, chronic fatigue syndrome), which primary care providers consider to be among the most difficult conditions to treat.1 This difficulty extends to the patient-provider relationship which is characterized by discord over MUS.1 In this article, we argue that the key to improving the patient provider relationship is for the patient and provider to develop congruent illness perceptions about MUS

Doctor recommendations are related to patient interest and use of behavioral treatment for chronic pain and addiction

The opioid crisis has highlighted the importance of improving patients’ access to behavioral treatments for chronic pain and addiction. What is not known is if patients are interested in receiving these treatments. In this cross-sectional study, over 1000 participants with chronic pain were surveyed using an anonymous online questionnaire on Amazon Mechanical Turk (Mturk) to investigate participants’ use of and interest in pharmacological and behavioral treatments for chronic pain and addiction. Participants also indicated whether their doctor had recommended these treatments. The majority of participants reported using medication for their pain (83.19%) and that their doctor recommended medication (85.05%), whereas fewer participants reported using (67.45%) and being recommended to (62.82%) behavioral treatments. We found 63.67% of participants screened positive for possible opioid misuse; those who screened positive were more interested in receiving behavioral treatments than those who did not screen positive. Participants who received treatment recommendations were more likely to be interested in receiving those treatments as compared to participants who did not. The results suggest that recommendations for behavioral treatments and interest in those treatments are related. Results also suggest that patients endorsing behaviors consistent with opioid misuse are interested in behavioral treatments

A Retrospective Cohort Study of U.S. Service Members Returning from Afghanistan and Iraq: Is Physical Health Worsening Over time?

Background: High rates of mental health disorders have been reported in veterans returning from deployment to Afghanistan (Operation Enduring Freedom: OEF) and Iraq (Operation Iraqi Freedom: OIF); however, less is known about physical health functioning and its temporal course post-deployment. Therefore, our goal is to study physical health functioning in OEF/OIF veterans after deployment. Methods: We analyzed self-reported physical health functioning as physical component summary (PCS) scores on the Veterans version of the Short Form 36 health survey in 679 OEF/OIF veterans clinically evaluated at a post-deployment health clinic. Veterans were stratified into four groups based on time post-deployment: (1Yr) 0 – 365 days; (2Yr) 366 – 730 days; (3Yr) 731 – 1095 days; and (4Yr+) > 1095 days. To assess the possibility that our effect was specific to a treatment-seeking sample, we also analyzed PCS scores from a separate military community sample of 768 OEF/OIF veterans evaluated pre-deployment and up to one-year post-deployment. Results: In veterans evaluated at our clinic, we observed significantly lower PCS scores as time post-deployment increased (p = 0.018) after adjusting for probable post-traumatic stress disorder (PTSD). We similarly observed in our community sample that PCS scores were lower both immediately after and one year after return from deployment (p < 0.001) relative to pre-deployment PCS. Further, PCS scores obtained 1-year post-deployment were significantly lower than scores obtained immediately post-deployment (p = 0.02). Conclusion: In our clinical sample, the longer the duration between return from deployment and their visit to our clinic, the worse the Veteran’s physical health even after adjusting for PTSD. Additionally, a decline is also present in a military community sample of OEF/OIF veterans. These data suggest that, as time since deployment length increases, physical health may deteriorate for some veterans

Longitudinal relationship between onset of physical symptoms and functional impairment

Patients with chronic physical symptoms (e.g., chronic pain) often have significant functional impairment (i.e., disability). The fear avoidance model is the dominant theoretical model of how the relationship between chronic physical symptoms and functional impairment develops and proposes a cyclical/bidirectional relationship. There has never been a definitive test of the proposed bi-directional relationship. The current study followed 767 Operation Enduring Freedom/Operation Iraqi Freedom soldiers from pre-deployment, when they were relatively healthy, to one year after deployment, when it was anticipated that symptoms would increase or develop. Over the four assessment time points, physical symptom severity consistently predicted worse functional impairment at the subsequent time point. Functional impairment did not show a consistent relationship with worsening of physical symptom severity. These findings suggest that changes to functional impairment do not have a short-term impact on physical symptom severit

Iraq and Afghanistan Veterans report symptoms consistent with chronic multisymptom illness one year after deployment

Many Veterans returning from service in Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) experience chronic pain. What is not known is whether for some OIF/OEF Veterans this pain is part of a larger condition of diffuse multisystem symptoms consistent with chronic multisymptom illness (CMI). We use data from a prospective longitudinal study of OIF/OEF Veterans to determine the frequency of CMI. We found that 1 yr after deployment, 49.5% of OIF/OEF Veterans met criteria for mild to moderate CMI and 10.8% met criteria for severe CMI. Over 90% of Veterans with chronic pain met criteria for CMI. CMI was not completely accounted for either by posttraumatic stress disorder or by predeployment levels of physical symptoms. Veterans with symptoms consistent with CMI reported significantly worse physical health function than Veterans who did not report symptoms consistent with CMI. This study suggests that the presence of CMI should be considered in the evaluation of OIF/OEF Veterans. Further, it suggests that the pain management for these Veterans may need to be tailored to take CMI into consideration

The Common Sense of Counseling Psychology: Introducing

The goal of therapy is typically to improve clients’ self-management of their problems, not only during the course of therapy but also after therapy ends. Although it seems obvious that therapists are interested in improving client’s self-management, the psychotherapy literature has little to say on the topic. This article introduces Leventhal’s Common-Sense Model of Self-Regulation, a theoretical model of the self-management of health, and applies the model to the therapeutic process. The Common-Sense Model proposes that people develop illness representations of health threats and these illness representations guide self-management. The model has primarily been used to understand how people self-manage physical health problems, we propose it may also be useful to understand self-management of mental health problems. The Common-Sense Model’s strengths-based perspective is a natural fit for the work of counseling psychologists. In particular, the model has important practical implicationsfor addressing how clients understand mental health problems over the course of treatment and self-manage these problems during and after treatment

Less Engagement in Pleasure Activities is associated with poorer quality of life for Veterans with Comorbid Post-Deployment Conditions

Objective: The presence of multiple comorbid conditions is common after combat deployment and complicates treatment. A potential treatment approach is to target shared mechanisms across conditions that maintain poorer health-related quality of life (HRQOL). One such mechanism may be decrements in pleasurable activities. Impairment in pleasurable activities frequently occurs after deployment and may be associated with poorer HRQOL. Method: In this brief report, we surveyed 126 Veterans who had previously sought an assessment at a Veterans Affairs post-deployment health clinic and assessed pleasurable activities, HRQOL, and post-deployment health symptoms. Results: Forty-three percent of Veterans met our criteria for all three post-deployment conditions (PTSD, depression and chronic wide-spread physical symptoms). Greater engagement in pleasurable activities was associated with better HRQOL for all Veterans regardless of type or level of post-deployment health symptoms. Conclusion: Future research should study if interventions that encourage Veterans with post-deployment health conditions to engage in pleasurable activities are effective rehabilitation strategies

High Healthcare Utilization at the Onset of Medically Unexplained Symptoms

Objective: Patients with medically unexplained syndromes (MUS) often do not receive appropriate healthcare. A critical time for effective healthcare is the inception of MUS. The current study examined data from a prospective longitudinal study of Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans to understand the relationship of increasing physical symptom burden to healthcare utilization. Methods: Data was examined from a prospective study of OEF/OIF veterans assessed before and one year after deployment (n=335). Physical symptom burden was measured with the Patient Health Questionnaire (PHQ-15). Analyses were conducted with polynomial regression and response surface analysis (RSA). Results: Increases in physical symptom burden predicted greater healthcare utilization one year after deployment: primary care practitioner (slope = -0.26, F=4.07, p=0.04), specialist (slope = -.43, t=8.67, p=0.003), allied health therapy (e.g., physical therapy) (slope = -.41, t=5.71, p=0.02) and mental health (slope = -.32, F=4.04, p=0.05). There were no significant difference in utilization between those with consistently high levels and those with increases in physical symptom burden. Conclusion: This is the first prospective study to examine, and show, a relationship between onset of clinically significant physical symptoms and greater healthcare utilization. Our data suggest that patients with increasing physical symptom burden have the same level of healthcare as patients with chronic physical symptom burden. Needed next steps are to better understand the quality of care at inception and determine how to intervene so that recommended approaches to care are provided from the onset