Automated Self-management (ASM) vs. ASM-Enhanced Collaborative Care for Chronic Pain and Mood Symptoms: the CAMMPS Randomized Clinical Trial

Abstract

Background: Chronic musculoskeletal pain is often accompanied by depression or anxiety wherein co-occurring pain and mood symptoms can be more difficult to treat than either alone. However, few clinical trials have examined interventions that simultaneously target both pain and mood conditions.

Objective: To determine the comparative effectiveness of automated self-management (ASM) vs. ASM-enhanced collaborative care.

Design: Randomized clinical trial conducted in six primary care clinics in a VA medical center.

Participants: Two hundred ninety-four patients with chronic musculoskeletal pain of at least moderate intensity and clinically significant depressive and/or anxiety symptoms.

Intervention: ASM consisted of automated monitoring and 9 web-based self-management modules. Comprehensive symptom management (CSM) combined ASM with collaborative care management by a nurse-physician team. Both interventions were delivered for 12 months.

Main measures: Primary outcome was a composite pain-anxiety-depression (PAD) z-score consisting of the mean of the BPI, PHQ-9, and GAD-7 z-scores: 0.2, 0.5, and 0.8 represent potentially small, moderate, and large clinical differences. Secondary outcomes included global improvement, health-related quality of life, treatment satisfaction, and health services use.

Key results: Both CSM and ASM groups had moderate PAD score improvement at 12 months (z = - 0.65 and - 0.52, respectively). Compared to the ASM group, the CSM group had a - 0.23 (95% CI, - 0.38 to - 0.08; overall P = .003) greater decline in composite PAD z-score over 12 months. CSM patients were also more likely to report global improvement and less likely to report worsening at 6 (P = .004) and 12 months (P = .013).

Conclusions: Two intervention models relying heavily on telecare delivery but differing in resource intensity both produced moderate improvements in pain and mood symptoms. However, the model combining collaborative care led by a nurse-physician team with web-based self-management was superior to self-management alone.

Trial registration: ClinicalTrials.gov : NCT0175730.

Keywords: anxiety; clinical trial; collaborative care; depression; pain; telemedicine.

Fig. 1

Flowchart of participants in the CAMMPS trial. Fourteen patients (7 in each group) had no follow-up assessments after baseline and were therefore not included in the primary MMRM analysis since at least one follow-up data point is required for MMRM. (A) Other reasons included living out of state (n = 43), life expectancy less than 12 months (n = 31), no VA primary care physician (n = 29), deceased (n = 23), cognitive impairment (n = 20), severe visual or hearing impairment (n = 12), pain less than 3 months (n = 9), no analgesics tried (n = 6), and other (n = 8). (B) Indeterminate eligibility included 245 individuals who refused to do an eligibility interview and 128 who could not be contacted.

Fig. 2

Patient-reported global change in pain and mood. Patients rated their pain and mood separately as improved, unchanged, or worse at each follow-up assessment. They were classified as much improved if both pain and mood were improved; as partially improved if one of the symptoms (pain or mood) was improved, and the other symptom was unchanged; as unchanged if either both symptoms were unchanged, or one symptom was improved and the other symptom was worse; and worse if one symptom was worse, and the other symptom was worse or unchanged. The number of patients in the comprehensive symptom management (CSM) and assisted symptom management (ASM) arms who provided global change data was 129 and 130 at 3 months, 126 and 129 at 6 months, and 124 and 123 at 12 months. Between-group differences were not significant by chi-square analysis at 3 months (P = .17), but were significant at 6 months (P = .004) and 12 months (P = .013). At 12 months, CSM patients were more likely than ASM patients to report being much improved (39.5% vs. 26.8%) and less likely to report worsening (19.4% vs. 35.8%)