Acceptance and commitment therapy for long-term conditions; and, Pain acceptance clustering in a population with persistent pain

Abstract

BACKGROUND AND AIMS; Acceptance and Commitment Therapy (ACT) is increasingly used in the man-agement of long-term conditions and is thought to reduce psychological distress and improve quality of life. The first systematic review of ACT in long term conditions was published in 2016. Given the rapid evolution of ACT in long-term conditions, we aimed to update this review and systematically review the evidence base in the past seven years (Chapter 1). Specifically, we aimed to comment on the effectiveness of ACT in reducing psychological distress and improving quality of life in these con-texts and assess the methodological quality of the studies. In Chapter 2 we consider persistent pain, which is a distressing and disabling condition. Pain Management programmes reduce distress and dis-ability associated with persistent pain, but treatment response is uneven among completers. Group composition may affect outcomes, but grouping people based on pain condition or demographic var-iables has shown limited utility. Research has suggested that grouping people based on their scores on the Chronic Pain Acceptance Questionnaire (CPAQ-8) may be clinically useful. Previous research indicated four clusters with different profiles based on the Activity Engagement and Pain Willingness subscales. We sought to explore CPAQ-clustering in an English-speaking sample and identify whether different clusters have different profiles of functioning and distress, which may indicate differing treat-ment needs.

METHODS; In Chapter 1, we systematically review the evidence base for ACT in long-term conditions. Relevant databases were systematically searched for ACT intervention studies from 2015 to the present, and applications in mental health and conditions that have already been reviewed were ex-cluded. In Chapter 2, we describe the results of an online survey exploring CPAQ clustering in a population with persistent pain. This study recruited 213 people with persistent pain through social media and specialist pain clinics, who responded to questionnaires on pain and functioning. They were divided into four clusters based on CPAQ-8 cut-off scores.

RESULTS;: Our systematic search (Chapter 1) identified 12 relevant studies, two of which were random-ised controlled trials (RCTs), two were case studies/series, and eight used a pre-post design. Their methodological quality was appraised, and half were rated by a second reviewer. ACT has been ap-plied in a wide range of conditions since 2015 (e.g. cystic fibrosis, myocardial infarction, systemic lu-pus), many of which have not been subject of much psychological research previously. ACT showed some effect in reducing distress. Evidence was lacking for quality of life, psychological flexibility and health indices. In Chapter 2, MANOVAs revealed cluster differences on measures of functioning (pain interference, self-efficacy, and valued living) and distress (anxiety and depression).

DISCUSSION;: Chapter 1 results indicate that ACT may improve distress across long-term conditions. Small sample sizes and lack of RCTs limit the methodological quality of the evidence base, and we offer suggestions for how future ACT intervention studies may be improved. The findings in Chapter 2 indi-cate that people who present to specialist pain clinics may be meaningfully grouped based on their CPAQ-8 profile. The differences between these clusters are discussed and suggestions offered for how this may inform triage and intervention in specialist pain clinics. Future research will indicate whether this in turn may improve treatment response.