Yarns BC, Jackson NJ, Alas A, et al. Emotional Awareness and Expression Therapy vs Cognitive Behavioral Therapy for Chronic Pain in Older Veterans: A Randomized Clinical Trial. JAMA Netw Open. 2024 Jun 3;7(6):e2415842. doi: 10.1001/jamanetworkopen.2024.15842. (Original study)

IMPORTANCE: Chronic pain is common and disabling in older adults, and psychological interventions are indicated. However, the gold standard approach, cognitive-behavioral therapy (CBT), produces only modest benefits, and more powerful options are needed.

OBJECTIVES: To evaluate whether emotional awareness and expression therapy (EAET) is superior to CBT for treatment of chronic pain among predominantly male older veterans and whether higher baseline depression, anxiety, or posttraumatic stress disorder (PTSD) symptoms-key targets of EAET-moderate treatment response.

DESIGN, SETTING, AND PARTICIPANTS: This 2-arm randomized clinical trial was conducted from May 16, 2019, to September 14, 2023, in the US Department of Veterans Affairs Greater Los Angeles Healthcare System. The trial included a racially and ethnically diverse group of veterans aged 60 to 95 years with at least 3 months of musculoskeletal pain.

INTERVENTIONS: Emotional awareness and expression therapy or CBT, conducted concurrently, each presented as one 90-minute individual session followed by eight 90-minute group sessions.

MAIN OUTCOMES AND MEASURES: The primary outcome was Brief Pain Inventory pain severity (range, 0 to 10) from baseline to posttreatment (week 10, primary end point) and 6-month follow-up. Secondary outcomes included Patient Reported Outcomes Institute Measurement System Anxiety, Depression, Fatigue, General Life Satisfaction (NIH Toolbox), Pain Interference, and Sleep Disturbance Short Forms, Patient Global Impression of Change (PGIC), and Satisfaction with Therapy and Therapist Scale-Revised. A subset of participants completed the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition). All analyses were for the intention-to-treat population and included all randomized participants.

RESULTS: Among 126 randomized participants (66 in the EAET group and 60 in the CBT group; mean [SD] age, 71.9 [5.9] years; 116 [92%] male), 111 (88%) completed posttreatment, and 104 (82%) completed the 6-month follow-up. The EAET was superior to CBT for the primary outcome of reduction in pain severity at posttreatment (estimate, -1.59 [95% CI, -2.35 to -0.83]; P < .001) and follow-up (estimate, -1.01 [95% CI, -1.78 to -0.24]; P = .01). A greater percentage of participants in EAET vs CBT had clinically significant (at least 30%) pain reduction (63% vs 17%; odds ratio, 21.54 [95% CI, 4.66-99.56]; P < .001) at posttreatment. In addition, EAET was superior to CBT on 50% pain reduction (35% vs 7%; odds ratio, 11.77 [95% CI, 2.38-58.25]; P = .002), anxiety (estimate, -2.49 [95% CI, -4.30 to -0.68]; P = .006), depression (estimate, -3.06 [95% CI, -5.88 to -0.25]; P = .03), general life satisfaction (estimate, 1.23 [95% CI, 0.36-2.10]; P = .005), PTSD symptoms (estimate, -4.39 [95% CI, -8.44 to -0.34]; P = .03), PGIC score (estimate, 1.46 [95% CI, 0.77-2.15]; P < .001), and global treatment satisfaction (estimate, 0.28 [95% CI, 0.12-0.45]; P < .001) at posttreatment. Higher baseline depression (estimate, -1.55 [95% CI, -0.37 to 2.73]; P < .001), anxiety (estimate, -1.53 [95% CI, -2.19 to -0.88]; P < .001), and PTSD symptoms (estimate, -1.69 [95% CI, -2.96 to -0.42]; P = .009) moderated greater reduction in pain severity after EAET but not CBT.

CONCLUSIONS AND RELEVANCE: The results of this randomized clinical trial suggest that EAET may be a preferred intervention for medically and psychiatrically complex patients with pain. The societal burden of chronic pain could be improved by further incorporating the principles of EAET into mainstream clinical pain medicine.

TRIAL REGISTRATION: Identifier: NCT03918642.

Discipline Area Score
Psychologist 6 / 7
Physician 5 / 7
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Comments from MORE raters

Physician rater

Important new findings that should be confirmed with research in other pain populations. Practitioners (like me) who are not familiar with Emotional Awareness and Expressive Therapy would be well advised to consider becoming so, particularly if they practice in the area of chronic pain and trauma.

Physician rater

This is a good RCT but no real blinding of the participants with a main self-reported outcome. The authors don't state that the primary outcome (pain) didn't reach a clinically significant difference at 6 months, so neither CBT or EAET are meaningful interventions for most of the participants six months after the interventions.

Psychologist rater

This is an interesting study comparing two models of care for people with poorly-controlled pain management The main concern with this study is its size and lack of power. Emotional Awareness and Expression Therapy (EAET) is a form of therapy that is rather new, and so only a handful of clinical trials have been published testing it. Many case reports suggest that EAET can be quite powerful, even leading to the remission of pain in some people (University of Michigan pain guide website 2023). I am aware to 47 articles to date.
Comments from PAIN+ CPN subscribers

Dr. Hélène Bertrand (7/6/2024 4:39 AM)

Most nonspecific low-back pain comes from displaced joints. A simple test people can do at home allows them to know the direction the pelvic bones are displaced on the sacrum. Once that is known, a two-minute corrective exercise immediately removes the pain experienced by 90% of those who do the exercise. Check it out at Bertrand H, Reeves KD, Mattu R, Garcia R, Mohammed M, Wiebe E, Cheng AL. Self-Treatment of Chronic Low Back Pain Based on a Rapid and Objective Sacroiliac Asymmetry Test: A Pilot Study. Cureus. 2021 Nov 11;13(11):e19483. doi: 10.7759/cureus.19483. PMID: 34912624; PMCID: PMC8665897.