{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,31]],"date-time":"2026-08-31T22:56:25Z","timestamp":1788216985736,"version":"build-2803163510"},"reference-count":48,"publisher":"American Medical Association (AMA)","issue":"5","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JAMA"],"published-print":{"date-parts":[[2026,8,4]]},"abstract":"\n Importance<\/jats:title>\n Cognitive behavioral therapy for chronic pain (CBT-CP) is a first-line nonpharmacological treatment, but uptake remains low due to multiple access barriers.<\/jats:p>\n <\/jats:sec>\n \n Objective<\/jats:title>\n To assess the effectiveness of self-directed CBT-CP with asynchronous, personalized feedback relative to clinician-delivered CBT-CP under usual clinical practice conditions.<\/jats:p>\n <\/jats:sec>\n \n Design, Setting, and Participants<\/jats:title>\n This randomized, open-label pragmatic superiority trial enrolled 764 patients with chronic musculoskeletal pain from 9 US Veterans Health Administration (VHA) health care systems from December 20, 2019, to February 20, 2024; follow-up was completed in February 2025.<\/jats:p>\n <\/jats:sec>\n \n Interventions<\/jats:title>\n Participants were allocated 1:1 to self-directed CBT-CP (n\u2009=\u2009384) or clinician-delivered CBT-CP (n\u2009=\u2009380). The self-directed group included 11 weeks of treatment with weekly personalized audio-recorded feedback provided by coaches. Feedback was based on participants\u2019 daily reports of pain coping skill practice, physical activity, and pain-relevant ratings collected by the interactive voice response system. Clinician-delivered CBT-CP included 4 to 11 weekly sessions provided under usual practice conditions.<\/jats:p>\n <\/jats:sec>\n \n Main Outcomes and Measures<\/jats:title>\n The primary outcome was patient-reported pain interference measured by the 7-item Brief Pain Inventory-Interference (BPI-I) subscale at 4 months (score range, 0-10; higher scores indicate worse function; minimum clinically important difference, 1). Secondary outcomes included BPI-I at 6 and 12 months; pain intensity, pain impact, catastrophizing, self-efficacy, sleep, global impression of change, depressive symptoms (all at 4 months); and treatment dose.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n \n Of the 764 randomized participants (mean age, 52.8 [SD, 12.3] years; 299 women [39.1%]; 289 Black [39.1%]; 399 White [54.0%]; and 107 Hispanic ethnicity [14.0%] and 186 participants [24%] who resided in a rural area), 583 participants (76%) completed the 4-month assessment and 523 (68%) the 12-month assessment. At 4 months, the self-directed CBT-CP was superior to clinician-delivered CBT-CP for reduction in pain interference (mean score, 5.26 vs 6.23, respectively; mean difference, \u22120.98; 95% CI, \u20131.31 to \u22120.65,\n P<\/jats:italic>\n \u2009&amp;lt;\u2009.001) and maintained superiority at 6 and 12 months. Self-directed CBT-CP was superior to clinician-delivered CBT-CP for all other outcomes at 4 months (\n P<\/jats:italic>\n \u2009\u2264\u2009.001). Participants in the self-directed CBT-CP group completed more expected treatment sessions than patients in the clinician-delivered CBT-CP group.\n <\/jats:p>\n <\/jats:sec>\n \n Conclusions and Relevance<\/jats:title>\n Self-directed CBT-CP was associated with modest improvements in pain interference at 4 months that were sustained to 12 months, small to moderate improvements in all secondary outcomes at 4 months, and higher session-completion rates, relative to clinician-delivered CBT-CP. Scalable, convenient self-directed CBT may be an effective alternative to clinician-delivered CBT that could increase uptake of CBT-CP.<\/jats:p>\n <\/jats:sec>\n \n Trial Registration<\/jats:title>\n \n ClinicalTrials.gov Identifier:\n NCT03469505<\/jats:ext-link>\n <\/jats:p>\n <\/jats:sec>","DOI":"10.1001\/jama.2026.7861","type":"journal-article","created":{"date-parts":[[2026,6,24]],"date-time":"2026-06-24T15:31:33Z","timestamp":1782315093000},"page":"400","source":"Crossref","is-referenced-by-count":1,"title":["Self-Directed vs Clinician-Delivered Cognitive Behavioral Therapy for Chronic Pain"],"prefix":"10.1001","volume":"336","author":[{"given":"Alicia A.","family":"Heapy","sequence":"first","affiliation":[{"name":"VA Connecticut Healthcare System, West Haven"},{"name":"Yale School of Medicine, New Haven, Connecticut"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mary A.","family":"Driscoll","sequence":"additional","affiliation":[{"name":"VA Connecticut Healthcare System, West Haven"},{"name":"Yale School of Medicine, New Haven, Connecticut"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sara","family":"Edmond","sequence":"additional","affiliation":[{"name":"VA Connecticut Healthcare System, West Haven"},{"name":"Yale School of Medicine, New Haven, Connecticut"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kathryn M.","family":"LaChappelle","sequence":"additional","affiliation":[{"name":"VA Connecticut Healthcare System, West Haven"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eugenia","family":"Buta","sequence":"additional","affiliation":[{"name":"Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, Connecticut"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Allison","family":"Halat","sequence":"additional","affiliation":[{"name":"VA Connecticut Healthcare System, West Haven"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sarah L.","family":"Krein","sequence":"additional","affiliation":[{"name":"VA Ann Arbor Center for Clinical Management Research Health Systems Research Center of Innovation, Ann Arbor, Michigan"},{"name":"University of Michigan Medical School, Ann Arbor"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Steve","family":"Martino","sequence":"additional","affiliation":[{"name":"VA Connecticut Healthcare System, West Haven"},{"name":"Yale School of Medicine, New Haven, Connecticut"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lynn","family":"DeBar","sequence":"additional","affiliation":[{"name":"Kaiser Permanente Center for Health Research, Portland, Oregon"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jennifer L.","family":"Murphy","sequence":"additional","affiliation":[{"name":"Pain Management, Opioid Safety, and Prescription Drug Monitoring Program, Veterans Health Administration, Washington, DC"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kristin","family":"Mattocks","sequence":"additional","affiliation":[{"name":"VA Central Western Massachusetts Healthcare System, Leeds"},{"name":"University of Massachusetts Medical School, Worcester"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Brian C.","family":"Coleman","sequence":"additional","affiliation":[{"name":"VA Connecticut Healthcare System, West Haven"},{"name":"Yale School of Medicine, New Haven, Connecticut"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christopher","family":"Ruser","sequence":"additional","affiliation":[{"name":"VA Connecticut Healthcare System, West Haven"},{"name":"Yale School of Medicine, New Haven, Connecticut"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"John D.","family":"Piette","sequence":"additional","affiliation":[{"name":"VA Ann Arbor Center for Clinical Management Research Health Systems Research Center of Innovation, Ann Arbor, Michigan"},{"name":"University of Michigan Medical School, Ann Arbor"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"R. Ross","family":"MacLean","sequence":"additional","affiliation":[{"name":"VA Connecticut Healthcare System, West Haven"},{"name":"Yale School of Medicine, New Haven, Connecticut"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Brett","family":"Ankawi","sequence":"additional","affiliation":[{"name":"VA Connecticut Healthcare System, West Haven"},{"name":"Yale School of Medicine, New Haven, Connecticut"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dana","family":"Cervone","sequence":"additional","affiliation":[{"name":"VA Connecticut Healthcare System, West Haven"},{"name":"Yale School of Medicine, New Haven, Connecticut"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Todd H.","family":"Wagner","sequence":"additional","affiliation":[{"name":"Health Economics Resource Center, VA Palo Alto, Menlo Park, California"},{"name":"Stanford University, Stanford, California"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Diana 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