INDIANAPOLIS - Pain is the most common physical symptom for which adults seek medical attention in the United States, while anxiety and depression are the most common mental health symptoms for which adults visit a doctor. Drugs, especially opioids, may not be the only or best therapy.

Highlighting another potential treatment option, a new study led by Regenstrief Institute research scientist Kurt Kroenke, M.D., a pioneer in the treatment of patient symptoms, has found that both online symptom self-management and online symptom self-management plus clinician telecare can be effective for individuals with all three symptoms, which frequently co-occur in this difficult to treat patient population.

"Pain, anxiety and depression can produce a vicious cycle in which the presence of one symptom, if untreated, may negatively affect the response to treatment of the other two symptoms," said Dr. Kroenke. "So treating not just pain but pain and mood symptoms simultaneously is quite important as is doing it how, when and where the patient is most receptive."

In a new paper published in the Journal of General Internal Medicine, Dr. Kroenke and colleagues report that online symptom self-management works to decrease pain, anxiety and depression symptoms. They also found that online symptom self-management works even better when coupled with clinician telecare. In previous studies, Dr. Kroenke and colleagues have found a benefit to adding telecare to usual care in the doctor's office. The researchers have now shown that the intermediate (and less costly) mechanism of online pain and mood self-management is effective and, for some, even more effective when coupled with live phone follow-up with a nurse.

"The magnitude of effect on pain, anxiety and depression we report is comparable to the effect of online and telecare interventions for chronic disorders like hypertension, diabetes and heart disease," said Dr. Kroenke. "The moderate improvement in symptoms we saw at a group level indicates that some individuals had great symptom improvement while others had little improvement. Our results strongly suggest that web-based self-management might be enough for some patients while others may require a combination of online self-management and phone consultations with a nurse manager in order to experience symptom reduction."

To test whether pain, anxiety and depression symptoms could be simultaneously addressed by patients in their homes or other location of their choice, Dr. Kroenke and colleagues conducted the CAMMPS (short for Comprehensive vs. Assisted Management of Mood and Pain Symptoms) trial. This randomized comparative effectiveness study builds upon Dr. Kroenke's previous work including the design of widely used depression and anxiety screening tools and the conduct of several studies demonstrating the effectiveness of telecare.

A total of 294 individuals with arm, leg, back, neck or widespread pain which persisted (for 10 or more years in more than half of CAMMPS participants) despite medication, who also had at least moderately severe depression and anxiety, were divided into two groups.

One group received a web-based self-management program comprised of nine modules (coping with pain; pain medications; communicating with providers; depression; anxiety; sleep; anger management; cognitive strategies; and problem-solving). The other group was given this program plus telecare by a nurse who made scheduled telephone calls as well as contacts prompted by patient responses to the online self-management program or e-mail requests.

A supplementary paper, published in the journal Telemedicine and Telecare, reports that CAMMPS participants in both arms of the study found it helpful and were satisfied -- with higher satisfaction in the group that received both online self-management and telecare. While those in the online self-management group indicated they wanted more human contact, participants in the group that received telecare from a nurse were divided - some wanted more contact, others desired less contact. This led the paper's authors, including first author Regenstrief Institute affiliated scientist Michael A. Bushey, M.D., of the IU School of Medicine and senior author Dr. Kroenke, to conclude that customizable solutions would best suit a range of patients.

"Automated Self-Management (ASM) vs. ASM-Enhanced Collaborative Care for Chronic Pain and Mood Symptoms: The CAMMPS Randomized Clinical Trial" Journal of General Internal Medicine Authors in addition to Dr. Kroenke are Fitsum Baye, M.S., and Spencer G. Lourens, PhD, of IU School of Medicine; Erica Evans; Sharon Weitlauf, R.N., Stephanie McCalley and Brian Porter, B.S., of VA Health Services Research and Development Center for Health Information and Communication, Roudebush VA Medical Center; and Regenstrief Institute and VA investigators Marianne S. Matthias, PhD, and Matthew J. Bair, M.D. Dr. Matthias is also on the faculty of the School of Liberal Arts at IUPUI and Dr. Bair is on the faculty of IU School of Medicine.

"Telecare management of pain and mood symptoms: Adherence, utility, and patient satisfaction" Telemedicine and Telecare Authors, in addition to Dr. Bushey and Dr. Kroenke, are Julia Weiner, a former Regenstrief Institute summer scholar, Brian Porter, Erica Evans and Sharon Weitlauf of the VA Medical Center; and Fitsum Baye and Spencer Lourens of the IU Richard M. Fairbanks School of Public Health at IUPUI.

The CAMMPS trial was supported by a Department of Veterans Affairs Health Services Research and Development Merit Review award to Dr. Kroenke (IIR 12-095).

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