Psychological treatments are designed to treat pain, distress and disability, and
are in common practice. This review updates and extends the 2009 version of this systematic
review.
To evaluate the effectiveness of psychological therapies for chronic pain (excluding
headache) in adults, compared with treatment as usual, waiting list control, or placebo
control, for pain, disability, mood and catastrophic thinking.
We identified randomised controlled trials (RCTs) of psychological therapy by searching
CENTRAL, MEDLINE, EMBASE and Psychlit from the beginning of each abstracting service
until September 2011. We identified additional studies from the reference lists of
retrieved papers and from discussion with investigators.
Full publications of RCTs of psychological treatments compared with an active treatment,
waiting list or treatment as usual. We excluded studies if the pain was primarily
headache, or was associated with a malignant disease. We also excluded studies if
the number of patients in any treatment arm was less than 20.
Forty-two studies met our criteria and 35 (4788 participants) provided data. Two authors
rated all studies. We coded risk of bias as well as both the quality of the treatments
and the methods using a scale designed for the purpose. We compared two main classes
of treatment (cognitive behavioural therapy(CBT) and behaviour therapy) with two control
conditions (treatment as usual; active control) at two assessment points (immediately
following treatment and six months or more following treatment), giving eight comparisons.
For each comparison, we assessed treatment effectiveness on four outcomes: pain, disability,
mood and catastrophic thinking, giving a total of 32 possible analyses, of which there
were data for 25.
Overall there is an absence of evidence for behaviour therapy, except a small improvement
in mood immediately following treatment when compared with an active control. CBT
has small positive effects on disability and catastrophising, but not on pain or mood,
when compared with active controls. CBT has small to moderate effects on pain, disability,
mood and catastrophising immediately post-treatment when compared with treatment as
usual/waiting list, but all except a small effect on mood had disappeared at follow-up.
At present there are insufficient data on the quality or content of treatment to investigate
their influence on outcome. The quality of the trial design has improved over time
but the quality of treatments has not.
Benefits of CBT emerged almost entirely from comparisons with treatment as usual/waiting
list, not with active controls. CBT but not behaviour therapy has weak effects in
improving pain, but only immediately post-treatment and when compared with treatment
as usual/waiting list. CBT but not behaviour therapy has small effects on disability
associated with chronic pain, with some maintenance at six months. CBT is effective
in altering mood and catastrophising outcomes, when compared with treatment as usual/waiting
list, with some evidence that this is maintained at six months. Behaviour therapy
has no effects on mood, but showed an effect on catastrophising immediately post-treatment.
CBT is a useful approach to the management of chronic pain. There is no need for more
general RCTs reporting group means: rather, different types of studies and analyses
are needed to identify which components of CBT work for which type of patient on which
outcome/s, and to try to understand why.