What is best – cognitive therapy, mindfulness-based stress reduction, or behavioral therapy?

Patients with chronic pain, including those with migraines, have been shown to benefit from psychological interventions. There is a wide variety of such treatments – biofeedback, meditation, acceptance-commitment, dialectical behavioral, and other types of therapy. These treatments improve the frequency and the severity of migraine attacks, as well as other types of pain which in turn leads to improved mood, sleep, and physical function. What we don’t know is which treatment is the most effective.

In a study just published in Pain, the journal of the International Association for the Study of Pain, researchers compared cognitive therapy (CT), mindfulness-based stress reduction, and behavioral therapy (BT) with treatment as usual (TAU).

This was a randomized controlled study of 521 patients with chronic low back pain. Each person underwent eight weekly individual treatment sessions. The primary outcome measure was pain interference, which assessed interference with general functioning due to pain. Secondary outcome measures were pain intensity, depressive symptoms, physical function, and sleep disturbance.

All three interventions produced similar improvement on all five outcome measures. And on all five measures, all three interventions produced better results than TAU. The difference with TAU was noted after the 6th treatment session and this improvement was still present six months later.

These findings are not surprising. The authors mentioned that three recent comparative outcome studies with fairly large samples also found similar efficacy of different psychosocial approaches. One study compared cognitive-behavioral therapy (CBT) with MBSR with usual care. Another compared CBT with pain education with usual care, And the third one compared CBT with emotional awareness and expression therapy with pain education.

The authors discussed the possibility that all psychological interventions produce similar results. However, it is more likely that the individual psychosocial characteristics of each patient is what determines the response. So it is possible that different patients may respond to different treatments and some will not respond to any. The researchers are planning to look at various patient characteristics that they’ve collected to see if any were predictive of a positive response to various treatments.