Preliminary Outcomes of an Older Peer and Clinician Co-Facilitated Pain Rehabilitation Intervention Among Adults Aged 50 Years and Older with Comorbid Chronic Pain and Mental Health Conditions

Abstract

The present study aimed to examine the acceptability, feasibility, and preliminary effectiveness of an older peer and clinician co-facilitated Behavioral Activation for Pain Rehabilitation (BA-PR) intervention among adults aged 50 years and older with comorbid chronic pain and mental health conditions. This was a mixed-methods research design with eight participants aged 55 to 62 years old with mental health conditions including schizophrenia spectrum disorder, bipolar disorder, major depressive disorder, personality disorder, and adjustment disorder. The quantitative data were assessed from observational methods, a pain rating scale and related measures. We used semi-structured interviews for qualitative feedback on experiences with the BA-PR intervention after participation. Overall, the participants had positive experiences following receipt of the BA-PR intervention. The recruitment and adherence rates for participants were 72.7% and 100%, respectively. Approximately 75% of the participants remained enrolled in the study. Findings from a paired t-test showed the BA-PR intervention was linked to significantly reduced prescription opioid misuse risk, t(7) = 2.42, p < 0.05. There were also non-significant reductions in pain intensity and depression severity, in addition to improvements in active and passive pain coping strategies and behavioral activation. The BA-PR intervention is the first pain rehabilitation intervention specifically designed for middle-aged and older adults with comorbid chronic pain and mental health conditions. Our findings indicate promise for the BA-PR intervention to potentially reduce prescription opioid misuse risk, pain, and depressive symptoms. However, a quasi-experimental study is needed before rigorous effectiveness testing.

The increased opioid overdose rates linked to pain relievers have reached the state of a national emergency in the U.S. (1). There have been calls for the development of innovative non-pharmacological pain interventions to prevent prescription opioid misuse for all affected (2). More than half of community-dwelling adults aged 50 years or older with various mental health conditions report disabling, costly, and life-shortening chronic pain (3). There are effective intervention options for several medical and mental health comorbidities in middle-aged and older adults with mental health conditions of varying severity (4, 5), but little is known about how to manage chronic pain in this group and tailored interventions are needed now to address their complex needs.

Because of the recent developments in self-management interventions delivered by older peers to middle-aged and older adults with various mental health conditions (6), there are precedents for using such types of psychosocial interventions. Older peers are persons with mental health conditions who are aged 50 years and older and are trained to support middle-aged and older adults with similar life experiences. Implementing a psychosocial intervention enhanced with older peer support might then also help with pain rehabilitation in middle-aged and older adults with varying mental health conditions. Behavioral Activation (BA) is a simple psychotherapy approach that focuses on reconnecting with pleasant activities and is highly effective for depression (7). However, there are pain-specific coping activities, such as pain communication skills training and reducing the use of or avoiding prescription opioids to control pain, that might also need to be intervention targets for adults 50 years and older with comorbid chronic pain and mental health conditions.

Despite the emerging concerns about chronic pain in middle-aged and older adults with various mental health conditions, there is a lack of research on the feasibility and appropriateness of pain rehabilitation interventions in this population and the role of older peer support in such programs. Using a mixed-methods design, the study’s main objective was to assess the acceptability and feasibility of an older peer and clinician co-facilitated BA for Pain Rehabilitation (BA-PR) intervention in eight adults aged 50 years and older with mental health conditions. An exploratory aim was to evaluate the preliminary effectiveness of BA-PR in decreasing pain intensity, depression severity, and prescription opioid misuse risk.

Methods

Study Design

This study used a mixed-methods research design to collect and analyze qualitative and quantitative data from eight peer and client participants aged 50+ years old with self-reported, doctor-diagnosed mental health conditions. Quantitative data were collected from a survey before and within one month following two 6-week intervention trials. Qualitative data were derived from semi-structured interviews with six out of eight participants agreeing to participate in one month following the 6-week trials. IRB approval was obtained from Dartmouth College.

Study Participants

Peer and client participants were recruited from one community-based aging center and one community-based mental health site in the New England region. The following criteria were met for participant study eligibility: (1) self-reported history of any doctor-diagnosed mental health disorder; (2) chronic pain (self-reported pain >3 months); (3) self-reported depressive symptoms; (4) ability to speak and read English; and (5) 50 years of age and older. The cutoff of 50 years was used as a designation for “middle-aged and older adults,” given that aging among persons with mental health conditions of varying degrees of severity has been described to begin as early as age 50 to account for the premature aging-related functional impairment (8). Participants were excluded based on: (1) residence in a skilled nursing facility; (2) a terminal illness with death expected to occur in one year; and (3) designation of a legal guardian. IRB approval was obtained from Dartmouth College.

BA-PR Intervention

By adapting and extending the theory and methods of BA, our research team developed BA-PR (See Table 1). BA-PR is the first pain rehabilitation intervention for middle-aged and older adults with varying types of mental health conditions. BA-PR is a 6-week, 2-hour, group-based, weekly, older peer and clinician co-facilitated intervention for pain rehabilitation. This brief, structured, psychosocial intervention uses in-session activities and homework focusing on: (1) brief psychoeducation on pain, depression, and prescription opioid use risk management; (2) values and priorities identification; (3) pain and depression coping activity selection, scheduling, and monitoring; (4) graded task completion, problem-solving, and pain communication skills training; and (5) social support contracts. The clinician was a PhD-level trained psychotherapist. At study enrollment, two participants reported coping well despite chronic pain and depressive symptoms and each person was subsequently asked to be an active peer supporter in one trial. With ongoing support from the psychotherapist, the peers offered success stories and positive coping strategy examples. During the study, both peer and client participants informed us about their pain communication difficulties with healthcare providers. To address these concerns, we developed and completed a pain communication skills training activity based on assertive communication practices.

Table 1.

Overview of a Six-Week, Group-Based Behavioral Activation for Pain Rehabilitation (BA-PR) Intervention

Session (2hr/week)	Intervention Topics	Weekly Activities and Goals
Week 1	Introduction, Treatment Rationale, & Brief Psychoeducation	• Engage participants in treatment through introductions. • Provide brief psychoeducation on chronic pain, depression, and prescription opioid misuse risk management. • Share treatment rationale and the clear, concise explanation of the need for pain rehabilitation in aging adults with comorbid chronic pain and mental health disorders. • Assign homework of activity monitoring for one week.
Week 2	Values identification; pain and depression coping activity selection and ranking; activity scheduling; & accommodations determination	• Assist participants with reviewing activity monitoring homework. • Identify life values and priorities of the participants. • Help participants understand the key pain coping activities such as activity pacing; graded physical activity; pain communication skills training; and reducing the use of or avoiding prescription opioids, alcohol or drugs to control pain; in addition to pleasant and rewarding activities for depression management. • Select a balance of 10–15 pain and depression coping activities aligned with values and appropriate for aging adults with serious mental health conditions. • Schedule the least difficult pain and depression coping activities to practice for one week. • Determine if additional education, support services, and accommodations are needed to reach these goals.
Week 3	Graded tasks, & social support contracts	• Assist participants with monitoring activity scheduling homework. • Schedule activities for the upcoming week and determine if scheduled activities include realistic, focused, and graded tasks. • Help participants with choosing a potential friend, family member, peer, or healthcare provider to enlist in providing social support relevant to pain and depression management.
Week 4	Problem-solving, & pain communication skills training	• Assist participants with monitoring activity scheduling homework. Engage in troubleshooting to better understand problems that limit access to pain and depression coping activities and other barriers to homework. • Help participants with learning, preparing, and rehearsing pain communication skills for interactions with prescribers about the initiation and use of non-opioid pain medications and for interactions with other healthcare providers, family, friends, and peers.
Week 5	Homework review & reevaluate needs and progress	• Assist participants with monitoring activity scheduling homework. • Help participants with reviewing previous in-session activity forms and assignments. Reevaluate the accuracy of completed activity forms and whether additional education, support services, and accommodations are needed. • Refine and update activity scheduling plans for the upcoming week.
Week 6	Activity scheduling maintenance, & termination of treatment	• Assist participants with monitoring activity scheduling plans. Develop a maintenance plan for activity scheduling. • Bring treatment to closure. Determine if education, support services, and accommodations are needed for activity scheduling maintenance plans. • Facilitate transition to only treatment as usual with other clinicians.

Measures

Sociodemographic and clinical variables.

The sociodemographic and clinical variables included age, gender, race/ethnicity, and self-reported, doctor-diagnosed mental health condition.

Qualitative evaluation.

To evaluate acceptability of the BA-PR intervention, we developed an interview guide based on our group’s past work. We asked the following interview questions: (1) “What did you find were the benefits of this program? and What did you personally find to be valuable?”; (2) “What were the challenges of this program?”; (3) “If you could change anything about the program, what would you change?”; and (4) “What other recommendations do you have to improve the program?”. We also developed and used prompts as needed.

Quantitative evaluation.

Enrollment, attrition and adherence rates were recorded by the clinician facilitator. The 0–10 Numerical Rating Scale (9) was used to measure average pain intensity during the past week. Depression severity was assessed by the Patient Health Questionnaire (PHQ-9) (10). We evaluated prescription opioid misuse risk using the Current Opioid Misuse Measure (11). The abbreviated Chronic Pain Coping Inventory was used to measure cognitive and behavioral coping strategies (active, passive) for pain management (12). The activation subscale from the Behavioral Activation for Depression Scale was used to assess activation behavior in spite of depressive symptoms (13).

Data Analysis

The PI and one other investigator read qualitative data, wrote memos, and developed operational definitions for transcript coding, a validated approach that allows for multiple perspectives (14, 15). A codebook was developed and consisted of a priori researcher-driven codes and codes that emerged inductively during data analysis. Codes were assigned to smaller units of text and then grouped into several themes. External auditors were used to assess the reliability and validity of qualitative results.

Quantitative data analyses were conducted using the Statistical Package for the Social Science Version 25. Descriptive statistics were conducted to identify sociodemographic and clinical characteristics, in addition to analyze preliminary feasibility using fidelity, recruitment, and retention data. Finally, we evaluated potential effectiveness using paired t-tests and descriptive statistics from pre- and post-intervention measure data. Given that data were missing from two participants at post-intervention, mean imputation was used to replace missing data. Although we were under-powered for both qualitative and quantitative analyses based on our past research (8), this project’s goal was to pilot test BA-PR in anticipation of a fully-powered trial (16) It is, therefore, appropriate to only assess general themes and data trends in potential effectiveness.

Results

Sociodemographic and Clinical Characteristics

A total of 11 participants were recruited and screened from referrals, with three (27.3%) participants disenrolling before starting BA-PR due to increased symptoms of pain-related conditions. At baseline, eight participants with mental health conditions (n=1 with schizophrenia, n=1 with bipolar disorder, n=4 with major depressive disorder, n=1 with personality disorder, n=1 with adjustment disorder) were 55 to 62 years old (M=57.1, SD=2.12). Seven participants were White, with one person identifying as Hispanic. Most were men (62.5%), but the sample included one gender non-conforming individual (12.5%) and two women (25%).

Quantitative Findings

Two (25%) participants were lost to attrition. The adherence rate for the retained participants was 100%, with all six participants either attending the group-based sessions or requesting a 1:1 session if experiencing severe pain on the day of the intervention session. A summary of the results for the paired samples t-tests comparing scores on primary and secondary outcomes from baseline to post-intervention is shown in Table 2. Findings show that at the end of the 6-week intervention, participants indicated reductions in prescription opioid misuse risk, t(7) = 2.42, p < 0.05. Although other changes in outcomes were not statistically significant, the results demonstrated mean trends in the expected directions.

Table 2.

Mean Scores on Primary and Secondary Outcomes at Pre- and Post-Intervention (n = 8)

Outcome	Baseline		Post-intervention
	M	SD	M	SD	t-test	p-value*
Primary outcomes
Pain intensity	7.00	1.60	6.67	1.02	.558	.594
Depression severity	14.75	8.83	10.17	5.62	1.99	.087
Prescription opioid misuse risk	11.75	9.31	5.13	6.83	2.42	.046*
Secondary outcomes
Active pain coping strategies	3.44	1.46	3.83	1.75	−.905	.396
Passive pain coping strategies	4.88	1.77	3.92	1.29	1.38	.210
Behavioral activation in spite of depressive symptoms	26.00	17.04	31.17	8.15	−.863	.417

Note.

^*The significance level is at 0.05.

Qualitative Findings

Six out of eight participants agreed to complete the semi-structured interviews following the intervention period. As shown in the summary of findings in Table 3, there were six major themes: (1) Peer and professional support, (2) In-session activities, (3) Homework, (4) Treatment length, (5) Treatment satisfaction, and (5) Recommended changes. Overall, participants reported enjoying the face-to-face support from the peer and clinician co-facilitators during and in between intervention sessions. Several participants stated they liked in-session activities, including learning how to communicate with health care providers and others when experiencing severe pain. Other participants stated that they enjoyed completing the homework, especially activity scheduling and monitoring because of difficulties with managing pain while remaining engaged in coping activities. However, a few participants noted motivational issues or ongoing mental health symptoms, as well as recommendations on how to address such difficulties. All participants reported high levels of intervention satisfaction, with one participant suggesting longer group session periods. One participant indicated that future intervention programs should better address management strategies when suffering from the most severe pain. Other recommendations included that future groups meet outside or at different venues (e.g., museum, mall). No concerns about not being physically capable of the recommended graded activities.

Table 3.

Participants’ Feedback on the Acceptability of the Treatment

Themes	Sample Quotes
Peer and Professional Support	“Getting together and having a discussion was very good, excellent!” Participant #2 “Talking to others in the group was great. You want more people to bounce things off of.” Participant #1 “I liked the comradery—from others in group and professional. I think there should be more than 6 in the groups.” Participant #5 “I liked having others around who knew what it’s like.” Participant #6
In-Session Activities	“I liked learning how to speak up when in pain.” Participant #7 “Learning the different ways of coping was helpful.” Participant #6
Homework	“Process for scheduling it (homework activities)… It feels good when you look back at it later.” Participant #2 “Homework is hard because I am a procrastinator.” Participant #6 “Those activities (homework)-- it is helpful with managing pain because housework is the hardest and with more pain it can be frustrating.” Participant #2 “I wish I could’ve finished the homework.” Participant #1 “Better address motivation for homework.” Participant #5 “I liked the activity work—just a little.” Participant #6
Treatment Length	“Length of the session—hour and half. It is okay with that breaking in the middle.” Participant #4 “The length of the session was 2 ½ hours. I think you could even go longer because at the end everybody stayed and chatted.” Participant #1
Treatment Satisfaction	“I can’t think of anything I’d change (about the group). I loved it.” Participant #4 “I liked coming to the group. It was good to get out the house.” Participant #6 “Overall, a 10”. Participant #6
Recommended Changes	“I think you should have at least one session out of the building without a lot walking. Outside or a museum.” Participant #1 “A treatment manual or book would’ve helped (with completing homework).” Participant #7 “You could add more mental health resources. It helps with pain.” Participant #7 “Better address extreme pain—when in or outside.” Participant #5

Discussion

The primary purpose of the current study was to test the acceptability, feasibility, and preliminary effectiveness of BA-PR in eight middle-aged and older adults with comorbid chronic pain and various mental health conditions. The findings showed that BA-PR is feasible and acceptable for use among this small sample of participants. The recruitment (72.7%) and adherence rates (100%) for participants were high. Attrition was relatively low, with 25% of participants dropping out of the study. Study participants also reported high levels of satisfaction with the BA-PR intervention, learning activities, and support from peers and the clinician. Given there is a dearth of research on pain rehabilitation interventions for people with varying mental health conditions, BA-PR could potentially be implemented as a novel psychosocial approach among middle-aged and older adults with comorbid chronic pain and mental health conditions.

Our findings indicated that BA-PR was associated with significant reductions in prescription opioid misuse risk among middle-aged and older adults with mental health conditions. BA-PR might be effective in reducing opioid risk because of the inclusion of older peer support. There is evidence that sharing lived experiences can be effective in peer-based health interventions among persons with serious mental health conditions (17). Another important intervention strategy might be the activation target of pain-specific coping activities, but future research will need to formally test potential underlying mechanisms behind its effectiveness. Although there is a lack of previous research examining the relationship between BA and prescription opioid misuse risk, studies have established that mindfulness and other cognitive-behavioral therapy approaches—which have overlapping behavioral strategies with BA—are effective in reducing both pain and opioid misuse (18, 19).

Our findings revealed trends for improvements in pain intensity, pain coping strategies, and depressive symptoms. Previous research has indicated BA may be a successful intervention for reducing depressive symptoms and pain in older adults (20, 21). Brooks et al. (22) found perceived pain-related activity interference mediates the relationship between pain intensity and depressive symptoms in older adults with severe mental health conditions, which implies that the BA techniques of targeting pain-specific coping strategies might help with managing pain and depressive symptoms in middle-aged and older adults with severe mental health conditions. However, research has not yet demonstrated rigorous evidence that BA is a successful intervention in reducing depression and pain symptoms in middle-aged and older adults with varying mental health conditions.

Although there were several strengths of our study such as the initial pilot testing of a pain rehabilitation intervention specifically designed for adults aged 50 years and older with comorbid chronic pain and various mental health conditions, there are a few limitations to consider. The limitations include the small sample size, which affects the statistical power and generalizability of the results to a larger, diverse middle-aged and older adult populations with comorbid chronic pain and mental health conditions. However, the small number of participants is consistent with the main objective of pilot studies, which is to first explore the feasibility and potential benefits of a new intervention. We were unable to maintain the enrollment of all referred participants due to more acute episodes of illness and limitations associated with chronic pain. Future studies should recruit larger sample sizes and implement a quasi-experimental study to evaluate the effectiveness of BA-PR in reducing pain and related outcomes for middle-aged and older adults with varying mental health conditions.

Biography

Dr. Brooks is a Postdoctoral Researcher at Columbia University School of Nursing and a licensed psychologist with a PhD in Rehabilitation Psychology. Rehabilitation psychology is a psychology subspecialty that focuses on maximizing health, functioning, and participation across the lifespan of people with disabilities and chronic health conditions. For over a decade, Dr. Brooks has been involved in clinical care and behavioral health and vocational rehabilitation research for adults and older adults with serious mental illnesses. Dr. Brooks has also taught clinical mental health and rehabilitation counseling students and has served as full-time or adjunct faculty at multiple universities. She has been PI on a mixed-methods project funded by the Hogg Foundation for Mental Health on vocational rehabilitation and recovery perspectives among employed peer specialists with a lived experience of a serious mental illness. Dr. Brooks also completed an NIMH-funded T32 fellowship in geriatric mental health services research at Dartmouth College and an NIMHD-funded traineeship in geriatric minority health services research at Columbia University. During her work at Dartmouth, she addressed psychological, physical, and social health-related functional impairment among older adults with serious mental illnesses through her initiative and collaborative work on clinical trials, including interventions facilitated by peer specialists with a lived experience of a serious mental illness. Her primary research interests are in behavioral outcomes, behavioral interventions, vocational rehabilitation outcomes, and mental health care workforce outcomes. Her research has resulted in over 60 manuscripts in rehabilitation, mental health, and public health journals, with a recent first-author publication attracting attention in Reuters Health, the Daily Mail, and other international news media outlets. Dr. Brooks serves as an Associate Member of the Editorial Board for the American Journal of Geriatric Psychiatry.

Dr. Umucu, Ph.D., is an assistant professor at the University of Texas at El Paso. His research focuses predominantly on psychosocial adaptation to chronic illnesses and disabilities. He is also interested in developing culturally-sensitive positive psychology interventions to improve well-being among individuals with chronic health conditions. He has published several scientific articles and book chapters on psychosocial adjustment, employment, quality of life, well-being, and mental health among individuals with chronic illnesses.

Marianne Storm, Ph.D., is professor at the department of Public Health at the University of Stavanger, Norway. She was a 2017–2018 Norwegian Harkness Fellow in Health Care Policy and Practice at Dartmouth College, New Hampshire, United States. She has been the principal and co-investigator for several research projects receiving grants from the Norwegian Research Council. Currently she is member of the steering board of the Norwegian Health Services Research network with the aim to promote high quality health services research in Norway. Her research interests include patient- and user involvement, organizational culture, care coordination and integration of services, telecare and digital health.

Chungyi Chiu, Ph.D., is an associate professor in the Department of Kinesiology and Community Health at the University of Illinois at Urbana-Champaign. Dr. Chiu received her PhD in rehabilitation psychology from the University of Wisconsin-Madison and her master’s degree in occupational therapy from the National Taiwan University. She is the founder and director of the Health Promotion and Rehabilitation Laboratory. Her research interests are in the areas of health promotion for people with chronic illness and disability, psychosocial adjustment, and social participation.

Jia-Rung Wu, Ph.D., is an assistant professor in the Department of Counselor Education, College of Education in Northeastern Illinois University. She is a certified rehabilitation counselor, a licensed professional counselor and licensed occupational therapist. Dr. Wu has 10 years of clinical rehabilitation experience and published 15 refereed journal articles and three book chapters. Her research interest areas include psychiatric rehabilitation, vocational rehabilitation, health promotion, the International Classification of Functionality, Disability and Health (ICF) model, demand-side employment, evidence-based practice, testing and assessment, and research methodologies.

Dr. Fortuna holds a doctorate in Social Welfare and a master’s degree in Social Work. Dr. Fortuna is an Assistant Professor of Psychiatry in the Geisel School of Medicine at Dartmouth College. Her primary research interest is service delivery strategies for older adults with serious mental illnesses and chronic health conditions. Dr. Fortuna is using community-engaged research methods to develop and implement peer-supported mobile health (mHealth) intervention. Dr. Fortuna was awarded an NIMH K01 award (K01MH117496), a NARSAD Young Investigator Grants from the Brain and Behavior Foundation and the Alvin R. Tarlov & John E. Ware Jr. Award in Patient Reported Outcomes for her work, and the Gerontological Society of America’s AGESW Faculty Achievement Award. Dr. Fortuna served on the International Standards Advisory Committee to develop the first-ever international accreditation standards for behavioral health care for older adults. Dr. Fortuna’s work can be seen in numerous book chapters on digital peer support, in Nature, Psychiatric Services, and Forbes Magazine. She currently serves as editor of the Journal of Participatory Medicine. She is a board member of the International Association of Peer Supporters. She currently serves on the International Editorial Board for the British Journal of Social Work. She was invited to serve as a member of the American Psychiatric Association’s Smartphone App Expert Advisory Panel.