Psychological interventions do not reduce pain, despite claims of proponents

A provocative review finds a “lack of strong supporting empirical evidence for the effectiveness of psychological treatments for pain management.”

The open access paper

Georgios Markozannes, Eleni Aretouli, Evangelia Rintou, Elena Dragioti, Dimitrios Damigos, Evangelia Ntzani, Evangelos Evangelou and Konstantinos K. Tsilidis. An umbrella review of the literature on the effectiveness of psychological interventions for pain reduction, BMC Psychology

This article received open or public peer review . The three versions, reviewers’ comments, and author responses are available here 

Why this review was needed

According to the review:

Psychological interventions were introduced over 40 years ago and are now well established in clinical practice [5]

…the effect sizes across all meta-analyses are modest, only rising above a medium-size effect (i.e., standardised mean difference larger than 0.5) in lower quality studies [4].

… Because of the wide implementation of psychological interventions in pain management and the elevated likelihood for biases in this field as shown in prior relevant empirical research [19, 20], we used an umbrella review approach [21, 22] that systematically appraises the evidence on an entire field across many meta-analyses. In the present study we aimed to broaden the scope of a typical umbrella review by further evaluating the strength of the evidence and the extent of potential biases [23, 24, 25, 26, 27] on this body of literature.

What is an umbrella review?

 A key source defines an umbrella review:

Ioannidis JP. Integration of evidence from multiple meta-analyses: a primer on umbrella reviews, treatment networks and multiple treatments meta-analyses. CMAJ. 2009;181(8):488–93.

Umbrella reviews (Figure 1) are systematic reviews that consider many treatment comparisons for the management of the same disease or condition. Each comparison is considered separately, and meta-analyses are performed as deemed appropriate. Umbrella reviews are clusters that encompass many reviews. For example, an umbrella review presented data from 6 reviews that were considered to be of sufficiently high quality about nonpharmacological and nonsurgical interventions for hip osteoarthritis. 9 Ideally, both benefits and harms should be juxtaposed to determine trade-offs between the risks and benefits. 10

ioannidis umbrella review

Ioannidis provides the following caveat about umbrella reviews and data syntheses more generally:

Integrating data from multiple meta-analyses may provide a wide view of the evidence landscape. Transition from a single patient to a study of many patients is a leap of faith in generalizability. A further leap is needed for the transition from a single study to meta-analysis and from a traditional meta-analysis to a treatment network and multiple treatments meta-analysis, let alone wider domains. With this caveat, zooming out toward larger scales of evidence may help us to understand the strengths and limitations of the data guiding the medical care of individual patients.

Discrepancy of this review with past evaluations

Our results come in discordance with the generally strong belief in the literature that psychological therapies are universally effective on a variety of pain conditions [76, 77, 78]. However, this belief is mainly established based on a limited number of small primary studies, and future larger studies are warranted. Notably, the median number of individuals in the intervention and control groups in each individual study included in our systematic evaluation was only 33 and 28 respectively, whereas the median number of studies included in each meta-analysis was only three. Our evaluation revealed that the reported effectiveness is usually overstated in the existing studies. The nominally statistically significant associations between psychological interventions and pain were confirmed in less than half of the examined meta-analyses. In addition, the random effects estimates were statistically significant in only 20% of the meta-analyses, when a P-value threshold of 0.001 was applied. Furthermore, in only nine meta-analyses the prediction interval excluded the null value, thus suggesting that only 6% of future studies are expected to demonstrate substantial “positive” (i.e. not null) associations between psychological interventions and pain treatment.

The punchline and the remedy

In conclusion, the present findings support that the effectiveness of psychological treatments for pain management is overstated and the supporting empirical evidence is weak. The present findings combined with the fact that psychological intervention trials are still at an early research stage and fall short compared to drug trials [87] underline the necessity for larger and better-conducted RCTs [85] Future research should further focus on building networks involving all stakeholder groups to achieve consensus and develop guidance on best practices for assessing and reporting pain outcomes [88, 89]. The use of standardized definitions and protocols for exposures, outcomes, and statistical analyses may diminish the threat of biases and improve the reliability of this important literature.

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