Cognitive Behavioral Therapy for Depression and Anxiety in an Interdisciplinary Rehabilitation Program for Chronic Pain: a Randomized Controlled Trial with a 3-Year Follow-up



Cognitive behavioral therapy (CBT) is known to be effective for treating depression and anxiety in patients with chronic pain, but there is limited research studying the long-term benefits of CBT in this population. The present study evaluated the effects of CBT provided in the context of an interdisciplinary pain management program with a 3-year follow-up.


One hundred fifteen patients with chronic musculoskeletal pain participated in an interdisciplinary pain management program. Eighty of these patients meeting criteria for CBT treatment were randomized to receive or not receive CBT for depression and anxiety in addition to rehabilitation pain management. The remaining 35 patients constituted a second comparison group. Follow-up data were collected 1 and 3 years post-treatment with 19% of the patients dropping out after 1 year and 34% after 3 years. Attrition analysis did not indicate that there was significant attrition bias in the data.


All three groups evidenced improved depression following treatment (p < 0.001). The pre- to post-treatment effect sizes (Cohen’s d) for depression in the CBT treatment group was large (ES = 1.36). The CBT treatment group maintained improvements on all measures at a 3-year follow-up, while the comparison groups did not. This was especially evident with respect to depression (pre-treatment to 3 years follow-up ES = 1.35 and between-group ES = 0.57). Before treatment, 36% of all the patients reported that they were able to work. At 3 years post-treatment, 59%, 58%, and 44% of the patients were working who were in the CBT treatment group, the Comparison group, and the Non-CBT group, respectively.


The results indicate that providing CBT for depression and anxiety as part of a rehabilitation pain management program may enhance the long-term benefits of treatment. This finding, if replicated in additional studies, has important clinical and economic implications.

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Fig. 1


  1. 1.

    Linton SJ, Bergbom S. Understanding the link between depression and pain. Scand J Pain. 2011;2:47–54.

  2. 2.

    Banks SM, Kerns RD. Explaining high rates of depression in chronic pain: a diathesis-stress framework. Psychol Bull. 1996;119(1):95–110.

  3. 3.

    Tunks ER, Crook J, Weir R. Epidemiology of chronic pain with psychological comorbidity: prevalence, risk, course, and prognosis. Can J Psychiatr. 2008;53(4):224–34.

  4. 4.

    Wilson KG, Eriksson MY, D'Eon JL, Mikail SF, Emery TC. Major depression and insomnia in chronic pain. Clin J Pain. 2002;18(2):77–83.

  5. 5.

    Ericsson M, Poston WSC, Linder J, Taylor JE, Haddock CK, Foreyt JP. Depression predicts disability in long-term chronic pain patients. Disabil Rehabil. 2002;24(6):334–40.

  6. 6.

    Haythornthwaite JA, Sieber WJ, Kerns RD. Depression and the chronic pain experience. Pain. 1991;46(2):177–84.

  7. 7.

    Romano JM, Turner JA. Chronic pain and depression: does the evidence support a relationship? Psychol Bull. 1985;97(1):18–34.

  8. 8.

    Chou R, Shekelle P. Will this patient develop persistent disabling low back pain? JAMA. 2010;303(13):1295–302.

  9. 9.

    Mallen CD, Peat G, Thomas E, Dunn KM, Croft PR. Prognostic factors for musculoskeletal pain in primary care: a systematic review. Br J Gen Pract. 2007;57(541):655–61.

  10. 10.

    McWilliams LA, Cox BJ, Enns MW. Mood and anxiety disorders associated with chronic pain: an examination in a nationally representative sample. Pain. 2003;106:127–33.

  11. 11.

    Gerrits MMJG, van Oppen P, van Marwijk HWJ, Penninx BWJH, van der Horst HE. Pain and the onset of depressive and anxiety disorders. Pain. 2014;155:53–9.

  12. 12.

    Ehde DM, Dillworth TM, Turner JA. Cognitive-behavioral therapy for individuals with chronic pain: efficacy, innovations, and directions for research. Am Psychol. 2014;69(2):153.

  13. 13.

    Morley S, Williams A, Eccleston C. Examining the evidence about psychological treatments for chronic pain: time for a paradigm shift? Pain. 2013;154:1929–31.

  14. 14.

    Hauksson P, Ingibergsdóttir S, Gunnarsdóttir T, Jónsdóttir IH. Effectiveness of cognitive behaviour therapy for treatment-resistant depression with psychiatric comorbidity: comparison of individual versus group CBT in an interdisciplinary rehabilitation setting. Nord J Psychiatry. 2017;71:465–72.

  15. 15.

    Butler AC, Chapman JE, Forman EM, Beck AT. The empirical status of cognitive-behavioral therapy: a review of meta-analyses. Clin Psychol Rev. 2006;26(1):17–31.

  16. 16.

    Tolin DFI. Cognitive-behavioral therapy more effective than other therapies? A meta-analytic review. Clin Psychol Rev. 2010;30(6):710–20.

  17. 17.

    Hampel P, Graef T, Krohn-Grimberghe B, Tlach L. Effects of gender and cognitive-behavioral management of depressive symptoms on rehabilitation outcome among inpatient orthopedic patients with chronic low back pain: a 1 year longitudinal study. Eur Spine J. 2009;18(12):1867.

  18. 18.

    Tlach L, Hampel P. Long-term effects of a cognitive-behavioral training program for the management of depressive symptoms among patients in orthopedic inpatient rehabilitation of chronic low back pain: a 2-year follow-up. Eur Spine J. 2011;20(12):2143–51.

  19. 19.

    Hampel P, Tlach L. Cognitive-behavioral management training of depressive symptoms among inpatient orthopedic patients with chronic low back pain and depressive symptoms: a 2-year longitudinal study. J Back Musculoskelet Rehabil. 2015;28(1):49–60.

  20. 20.

    Turk DC, Wilson HD, Cahana A. Treatment of chronic non-cancer pain. Lancet. 2011;377(9784):2226–35.

  21. 21.

    Angst F, Verra ML, Lehmann S, Brioschi R, Aeschlimann A. Clinical effectiveness of an interdisciplinary pain management programme compared with standard inpatient rehabilitation in chronic pain: a naturalistic, prospective controlled cohort study. J Rehabil Med. 2009;41(7):569–75.

  22. 22.

    Gatchel RJ, Okifuji A. Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic nonmalignant pain. J Pain. 2006;7(11):779–93.

  23. 23.

    Hoffman BM, Papas RK, Chatkoff DK, Kerns RD. Meta-analysis of psychological interventions for chronic low back pain. Health Psychol. 2007;26(1):1–9.

  24. 24.

    Nicholas MK, Asghari A, Blyth FM, Wood BM, Murray R, McCabe R, et al. Self-management intervention for chronic pain in older adults: a randomised controlled trial. Pain. 2013;154:824–35.

  25. 25.

    Williams AC, Eccleston C, Morley S. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database Syst Rev. 2012;11:Cd007407.

  26. 26.

    Vowles KE, McCracken LM, O’Brien JZ. Acceptance and values-based action in chronic pain: a three-year follow-up analysis of treatment effectiveness and process. Behav Res Ther. 2011;49(11):748–55.

  27. 27.

    Kish L. Survey sampling. New York: Wiley; 1995.

  28. 28.

    Jonsdottir IH, Gudmundsdottir RM, Siemsen V, Gunnarsdottir T. HAM: Handbók um hugræna atferlismeðferð (6. útgáfa). [CBT: cognitive behaviour therapy manual (6th ed.)]. Mosfellsbær: Reykjalundur; 2010.

  29. 29.

    Crombez G, Valeyen JWS, Heuts PHTG, Lysens R. Pain-related fear is more disabling than pain itself: evidence on the role of pain-related fear in chronic back pain disability. Pain. 1999;80(1–2):329–39.

  30. 30.

    Dworkin RH, Turk DC, Farrar JT, Haythornthwaite JA, Jensen MP, Katz NP, et al. Core outcome measures for chronic pain clinical trials: IMMPACT recommendations. Pain. 2005;113(1–2):9–19.

  31. 31.

    Poiraudeau S, Rannou F, Baron G, Le Hennanff A, Coudeyre E, Rozenberg S, et al. Fear-avoidance beliefs about back pain in patients with subacute low back pain. Pain. 2006;124(3):305–11.

  32. 32.

    Vowles KE, McNeil DW, Gross RT, McDaniel ML, Mouse A, Bates M, et al. Effects of pain acceptance and pain control strategies on physical impairment in individuals with chronic low back pain. Behav Ther. 2007;38:412–25.

  33. 33.

    Gordon DB, Polomano RC, Pellino TA, Turk DC, McCracken LM, Sherwood G, et al. Revised American Pain Society Patient Outcome Questionnaire (APS-POQ-R) for quality improvement of pain management in hospitalized adults: preliminary psychometric evaluation. J Pain. 2010;11(11):1172–86.

  34. 34.

    Hjermstad MJ, Fayers PM, Haugen DF, Caraceni A, Hanks GW, Loge JH, et al. Studies comparing numerical rating scales, verbal rating scales, and visual analogue scales for assessment of pain intensity in adults: a systematic literature review. J Pain Symptom Manag. 2011;41(6):1073–93.

  35. 35.

    Waddell G, Newton M, Henderson I, Somerville D, Main CJA. Fear avoidance beliefs questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability. Pain. 1993;52:157–68.

  36. 36.

    Jonsdottir IH, Hreinsdottir EB, Kristbergsdottir H, Hjartardottir T, Olason M. Próffræðilegir eiginleikar íslenskrar þýðingar Fear-Avoidance Belief Questionnaire (FABQ) í klínísku þýði. [Psychometric properties of the Icelandic translation of Fear-Avoidance Belief Questionnaire (FABQ) in a patient population]. The 8th Annual Day of Science Reykjalundur Rehabilitation Centre; Mosfellsbaer, Iceland. 2011.

  37. 37.

    Beck AT, Steer RA, Brown GK. BDI-II, Beck Depression Inventory: manual. San Antonio: Psychological Corp.; 1996.

  38. 38.

    Harris CA, Joyce L. Psychometric properties of the Beck Depression Inventory-(BDI-II) in individuals with chronic pain. Pain. 2008;137(3):609–22.

  39. 39.

    Arnarson ÞÖ, Ólason DÞ, Smári J, Sigurðsson JF. The Beck Depression Inventory Second Edition (BDI-II): psychometric properties in Icelandic student and patient populations. Nord J Psychiatry. 2008;62(5):360–5.

  40. 40.

    Beck AT, Epstein N, Brown G, Steer RA. An inventory for measuring clinical anxiety: psychometric properties. J Consult Clin Psychol. 1988;56(6):893–7.

  41. 41.

    Sæmundsson BR, Þórsdóttir F, Kristjánsdóttir H, Ólason DÞ, Smári J, Sigurðsson JF. Psychometric properties of the Icelandic version of the Beck Anxiety Inventory in a clinical and a student population. Eur J Psychol Assess. 2011;27(2):133–41.

  42. 42.

    Ware Jr JE. SF-36 health survey update. Spine. 2000;25(24):3130–9.

  43. 43.

    Ware JE, Gandek B. Overview of the SF-36 health survey and the international quality of life assessment (IQOLA) project. J Clin Epidemiol. 1998;51(11):903–12.

  44. 44.

    Eiríksdóttir M. Próffræðileg athugun á The Short Form (36) Health Survey (SF-36) heilsukvarðanum [Psychometric properties of The Short Form (36) Health Survey (SF-36)]. Reykjavik: University of Iceland (Cand.psych.'s thesis); 2011.

  45. 45.

    Morley S, de Williams AC, Black S. A confirmatory factor analysis of the Beck Depression Inventory in chronic pain. Pain. 2002;99:289–98.

  46. 46.

    Novy DM, Nelson DV, Berry LA, Averill PM. What does the Beck Depression Inventory measure in chronic pain? A reappraisal. Pain. 1995;61:261–70.

  47. 47.

    Geisser ME, Roth RS, Robinson ME. Assessing depression among persons with chronic pain using the Center for Epidemiological Studies-Depression Scale and the Beck Depression Inventory: a comparative analysis. Clin J Pain. 1997;13:163–70.

  48. 48.

    Nakai M, Ke W. Review of the methods for handling missing data in longitudinal data analysis. Int J Math Anal. 2011;5(1):1–13.

  49. 49.

    Field A. Discovering statistics using SPSS. 3rd ed. London: SAGE Publications Ltd; 2009.

  50. 50.

    Schouten B, Cobben F, Bethlehem J. Indicators for the representativeness of survey response. SurvMethodol. 2009;35(1):101–13.

  51. 51.

    Bethlehem JG. Weighting nonresponse adjustments based on auxiliary information. In: Groves RM, Dilman DA, Elting JL, RJA L, editors. Survey nonresponse. New York: Wiley; 2002.

  52. 52.

    Groves RM, Heeringa SG. Responsive design for household surveys: tools for actively controlling survey errors and costs. J R Stat Soc A Stat Soc. 2006;169(3):439–57.

  53. 53.

    Olson K. Survey participation, nonresponse bias, measurement error bias, and total bias. Public Opin Q. 2006;70(5):737–58.

  54. 54.

    Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed. Hillsdale: Lawrence Erlbaum Associates; 1988.

  55. 55.

    Kirk RE. Practical significance: a concept whose time has come. Educ Psychol Meas. 1996;56(5):746–59.

  56. 56.

    OECD, Education at a glance 2011: OECD indicators, OECD Publishing. 2011. .

  57. 57.

    George SZ, Fritz JM, Childs JD. Investigation of elevated fear-avoidance beliefs for patients with low back pain: a secondary analysis involving patients enrolled in physical therapy clinical trials. J Orthop Sports Phys Ther. 2008;38(2):50–8.

  58. 58.

    Groves RM, Peytcheva E. The impact of nonresponse rates on nonresponse bias a meta-analysis. Public Opin Q. 2008;72(2):167–89.

  59. 59.

    Olason M. Outcome of an interdisciplinary pain management program in a rehabilitation clinic. Work. 2004;22(1):9–15.

  60. 60.

    Castillo RC, MacKenzie EJ, Wegener ST, Bosse MJ, Group LS. Prevalence of chronic pain seven years following limb threatening lower extremity trauma. Pain. 2006;124(3):321–9.

  61. 61.

    Sjøgren P, Ekholm O, Peuckmann V, Grønbæk M. Epidemiology of chronic pain in Denmark: an update. Eur J Pain. 2009;13(3):287–92.

  62. 62.

    Roth RS, Geisser ME. Educational achievement and chronic pain disability: mediating role of pain-related cognitions. Clin J Pain. 2002;18(5):286–96.

  63. 63.

    de Rooij A, van der Leeden M, Roorda LD, Steultjens MP, Dekker J. Predictors of outcome of multidisciplinary treatment in chronic widespread pain: an observational study. BMC Musculoskelet Disord. 2013;14(1):1.

  64. 64.

    Gagnon CM, Stanos SP, van der Ende G, Rader LR, Harden RN. Treatment outcomes for workers compensation patients in a U.S.-based interdisciplinary pain management program. Pain Pract. 2013;13(4):282–8.

  65. 65.

    Dworkin RH, Turk DC, Wyrwich KW, Beaton D, Cleeland CS, Farrar JT, et al. Interpreting the clinical importance of treatment outcomes in chronic pain clinical trials: IMMPACT recommendations. J Pain. 2008;9(2):105–21.

  66. 66.

    Turner JA. Comparison of group progressive-relaxation training and cognitive-behavioral group therapy for chronic low back pain. J Consult Clin Psychol. 1982;50(5):757.

  67. 67.

    Turk DC, Swanson KS, Tunks ER. Psychological approaches in the treatment of chronic pain patients-when pills, scalpels, and needles are not enough. [review]. Can J Psychiatr. 2008;53(4):213–23.

  68. 68.

    Fenton G, Morley SA. Tale of two RCTs: using randomized controlled trials to benchmark routine clinical (psychological) treatments for chronic pain. Pain. 2013;154:2108–19.

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We will like to thank the staff at the Reykjalundur Rehabilitation Center pain clinic.

We thank Professor Stephen Morley for invaluable advice in writing this paper and Anton Örn Karlsson for advice on statistics.


The study was funded by The Icelandic Research Center (RANNÍS).

Clinical Study Registration Number: VSNa2003060024/03.1

Some (but not all) of the findings presented here were reported at the IASP (International Association for the Study of Pain) 16th world congress in Japan 2016.

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Correspondence to Magnús Ólason.

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Ólason, M., Andrason, R.H., Jónsdóttir, I.H. et al. Cognitive Behavioral Therapy for Depression and Anxiety in an Interdisciplinary Rehabilitation Program for Chronic Pain: a Randomized Controlled Trial with a 3-Year Follow-up. Int.J. Behav. Med. 25, 55–66 (2018) doi:10.1007/s12529-017-9690-z

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  • Cognitive behavioral therapy
  • Chronic musculoskeletal pain
  • Depression and anxiety
  • Long-term follow-up
  • Pain management