A Systematic Review and Meta-analysis of IPS Supported Employment for Young Adults with Mental Health Conditions.

Young adults with mental health conditions want to work and advance their education, but many need help attaining these goals. Individual Placement and Support (IPS), originally developed for working-age adults with serious mental illness, is an evidence-based employment model that may benefit young adults. This study is the first systematic review and meta-analysis of randomized controlled trials (RCTs) of IPS for this population. We conducted a systematic review of the effectiveness of IPS for young adults with mental health conditions, supplementing our electronic search of the published literature with secondary analyses of two published RCTs. Using meta-analysis, we evaluated employment rate, job duration, and education rate. Seven studies met the inclusion criteria. Four evaluated IPS for young adults with early psychosis and three evaluated IPS for other young adult subgroups. All found a significantly higher employment rate for IPS than the control group. Overall, 208 (58.3%) of 357 IPS participants and 110 (32.4%) of 340 control participants were competitively employed during follow-up, yielding an overall risk ratio of 1.69 (95% CI 1.43, 1.99), z = 6.24, p < 0.001. Six of the seven studies also reported longer job duration for IPS than the control group, yielding an overall g = 0.34 (95% CI 0.09, 0.58), z = 2.72, p < 0.01. None of four RCTs examining education outcomes found a significant difference favoring IPS, but the overall risk ratio was significant: 1.33 (95% CI 1.06, 1.66), z = 2.51, p < 0.01. Although the empirical literature is limited, IPS appears to be effective in helping young adults with serious mental illness or early psychosis gain and keep competitive jobs. The impact of IPS on education outcomes is unclear. Future research should evaluate the generalizability of these findings to the broad range of young adults with mental health conditions needing help with their employment goals.

Clinical effectiveness of music interventions for dementia and depression in elderly care (MIDDEL): Australian cohort of an international pragmatic cluster-randomised controlled trial.

BACKGROUND: Dementia and depression are highly prevalent and comorbid conditions among older adults living in care homes and are associated with individual distress and rising societal costs. Effective, scalable, and feasible interventions are needed. Music interventions have shown promising effects, but the current evidence base is inconclusive. The present study aimed to determine the effectiveness of two different music interventions on the depressive symptoms of people with dementia living in residential aged care. METHODS: We implemented a 2 × 2 factorial cluster-randomised controlled trial to determine whether group music therapy (GMT) is more effective than no GMT with standard care, or recreational choir singing (RCS) is more effective than no RCS with standard care, for reducing depressive symptoms and other secondary outcomes in people with dementia with mild to severe depressive symptoms living in residential aged care. Care home units with at least ten residents were allocated to GMT, RCS, GMT plus RCS, or standard care, using a computer-generated list with block randomisation (block size four). The protocolised interventions were delivered by music therapists (GMT) and community musicians (RCS). The primary outcome was Montgomery-Åsberg Depression Rating Scale score at 6 months, assessed by a masked assessor and analysed on an intention-to-treat basis using linear mixed-effects models, which examined the effects of GMT versus no-GMT and RCS versus no-RCS, as well as interaction effects of GMT and RCS. We report on the Australian cohort of an international trial. This trial is registered with ClinicalTrials.gov, NCT03496675, and anzctr.org.au, ACTRN12618000156280. FINDINGS: Between June 15, 2018, and Feb 18, 2020, we approached 12 RAC facilities with 26 eligible care home units and, excluding six units who could not be enrolled due to COVID-19 lockdowns, we screened 818 residents. Between July 18, 2018, and Nov 26, 2019, 20 care home units were randomised (318 residents). Recruitment ceased on March 17, 2020, due to COVID-19. The primary endpoint, available from 20 care home units (214 residents), suggested beneficial effects of RCS (mean difference -4·25, 95% CI -7·89 to -0·62; p=0·0221) but not GMT (mean difference -0·44, -4·32 to 3·43; p=0·8224). No related serious adverse events occurred. INTERPRETATION: Our study supports implementing recreational choir singing as a clinically relevant therapeutic intervention in reducing depressive symptoms for people with dementia in the Australian care home context. FUNDING: National Health and Medical Research Council, Australia.

The Impact of Music on Stress Biomarkers: Protocol of a Substudy of the Cluster-Randomized Controlled Trial Music Interventions for Dementia and Depression in ELderly Care (MIDDEL).

Recently, a large cluster-randomized controlled trial was designed-Music Interventions for Dementia and Depression in ELderly care (MIDDEL)-to assess the effectiveness of music interventions on depression in care home residents with dementia (ClinicalTrials.gov NCT03496675). To understand the pathophysiological mechanisms, we observed the effect of repeated music interventions on stress in this population since chronic stress was associated with depression and an increased risk for dementia. An exploratory study was designed to assess: (1) changes in hair cortisol concentrations as an indicator of longer-term stress; (2) whether baseline stress is a predictor of therapy outcome; (3) pre- and post-treatment effects on salivary α-amylase and cortisol response as an indicator of immediate stress in 180-200 care home residents with dementia and depressive symptoms who partake in the MIDDEL trial. Insights into mediatory effects of stress to explain the effect of music interventions will be gained. Hair cortisol concentrations were assessed at baseline and at 3, 6, and 12 months along with the Perceived Stress Scale. Salivary α-amylase and cortisol concentrations were assessed at 1, 3, and 6 months. Saliva was collected just before a session and 15 and 60 min after a session, along with a stress Visual Analogue Scale.

The Individual Placement and Support (IPS) in Pain Trial: A Randomized Controlled Trial of IPS for Patients with Chronic Pain Conditions.

OBJECTIVES: Although complex pain conditions require an interdisciplinary approach, employment services are rarely provided in pain centers. Individual Placement and Support (IPS) is an effective approach to increase work participation among patients with severe mental illness, and recent evidence suggests that this method can be successfully repurposed for new target groups. We aimed to investigate the effectiveness of IPS integrated with interdisciplinary treatment as usual (TAU) for patients with chronic pain in a tertiary pain center. METHODS: A randomized controlled trial comparing IPS integrated with TAU (n = 38) with TAU alone (n = 20) was conducted. Participants were patients with chronic pain who were 18-65 years of age and currently on long-term sick leave or disability benefits or unemployed. The primary outcome was employment within 12 months after enrollment, with additional long-term follow-up after 24 months. Secondary outcomes included health and quality of life, measured at baseline, 6 months, and 12 months. RESULTS: During 12-month follow-up, 52.8% in the IPS group and 38.9% in the TAU group had attained employment. The difference increased during 24-month follow-up but did not reach statistical significance. Findings on secondary outcomes were generally nonsignificant. CONCLUSIONS: The IPS in Pain trial is the first study to evaluate the effect of IPS for patients with chronic pain conditions. It shows that IPS can be integrated into the daily practice of interdisciplinary pain treatment, with employment rates exceeding 50% in 1 year and a clear trend in favor of the IPS group. Results did not, however, reach significance. Larger randomized controlled trials are needed to draw clear conclusions about effectiveness.

Development of the workplace inclusion questionnaire (WIQ).

AIMS: To develop a questionnaire to examine attitudes among employees and managers to include people with various health problems into their work group, and to test the questionnaire in one relevant population within the labour market. METHODS: A questionnaire was developed through a process involving discussions in a scientific forum and pilot testing with group discussions. The final questionnaire, which was tested in a survey study of managers and employees in 33 Norwegian kindergartens (N=485), contained 10 short case stories followed by questions concerning workplace inclusion. The case stories described individuals with musculoskeletal and mental disorders, as well as individuals with potentially stigmatising behavioural history and lifestyle, and control cases. Risk ratios with 95% confidence intervals (CIs) were used to compare the case stories. Cases with high risk ratios had an increased risk of not being included compared to a control case. RESULTS: Attitudes for workplace inclusion varied between the different case stories. Cases portraying mental illness had the highest risk ratios, indicating that employees and managers are less likely to include people with mental illness than people with musculoskeletal illness. Furthermore, unspecific or chronic illness had higher risk ratios than specific and acute illness. The most important barriers also varied between case stories. CONCLUSIONS: The workplace inclusion questionnaire fulfills the need for a quantitative measure of attitudes to include individuals with various health problems into the workplace. Comparison of risk ratios showed clear differences between case stories, indicating that the workplace inclusion questionnaire is a valuable tool to measure the variance in workplace inclusion.

A mixed methods study of employers' and employees' evaluations of job seekers with a mental illness, disability, or of a cultural minority.

BACKGROUND: Groups in society that are under-represented in the workforce encounter various barriers in the job-seeking process. Some of these barriers are found on the employer's side of the table. OBJECTIVE: This study investigates supervisors' and employees' assessments of job seekers with different forms of disabilities, health issues, or with a minority background. It also investigates respondents' previous experience with such colleagues, and whether supervisor status affects their assessments. METHODS: A survey was distributed among supervisors (n = 305) and employees (n = 925) using a vignette design with ten characters, inquiring about willingness to include such an employee in their work group. The vignettes described job seekers with either a mental illness, a physical disability or a cultural minority. Risk ratio (RR) was calculated for being assessed positively, using a vignette character describing a single mother as reference. RESULTS: Vignette characters describing mental health issues and physical disabilities were less likely to be assessed positively than the reference case, except for the vignette describing audio impairment. Cultural minorities were assessed as positive, or more positively than the reference case. Supervisors and employees generally agreed in their assessments of vignette characters, and previous experience was consistently associated with a more positive assessment of the character in question. Various barriers to include the least favoured vignette characters were identified. CONCLUSIONS: Although some findings are promising with regard to increasing work participation for underrepresented groups, barriers pertaining to some of the vignette characters should be addressed in vocational rehabilitation efforts, as well as in organizations seeking to enhance equal opportunities and diversity.

Opportunities and challenges around adapting supported employment interventions for people with chronic low back pain: modified nominal group technique.

PURPOSE: To identify and rank opportunities and challenges around adapting supported employment interventions for people with chronic low back pain (LBP). METHODS: Delegates from an international back and neck research forum were invited to join an expert panel. A modified nominal group technique (NGT) was used with four stages: silent generation, round robin, clarification, and ranking. Ranked items were reported back and ratified by the panel. RESULTS: Nine experienced researchers working in the fields related to LBP and disability joined the panel. Forty-eight items were generated and grouped into 12 categories of opportunities/challenges. Categories ranked most important related respectively to policy and legislation, ensuring operational integration across different systems, funding interventions, and managing attitudes towards work and health, workplace flexibility, availability of "good" work for this client group, dissonance between client and system aims, timing of interventions, and intervention development. CONCLUSIONS: An expert panel believes the most important opportunities/challenges around adapting supporting employment interventions for people with chronic LBP are facilitating integration/communication between systems and institutions providing intervention components, optimising research outputs for informing policy needs, and encouraging discussion around funding mechanisms for research and interventions. Addressing these factors may help improve the quality and impact of future interventions.Implications for rehabilitationInteraction pathways between health, employment, and social systems need to be improved to effectively deliver intervention components that necessarily span these systems.Research-policy communication needs to be improved by researchers and policy makers, so that research outputs can be consumed by policy makers, and so that researchers recognise the gaps in knowledge needed to underpin policy.Improvements in research-policy communication and coordination would facilitate the delivery of research output at a time when it is likely to make the most impact on policy-making.Discussion and clarification surrounding funding mechanisms for research and interventions may facilitate innovation generally.

Individual placement and support for young adults at risk of early work disability (the SEED trial). A randomized controlled trial.

Objectives Individual placement and support (IPS) is an effective approach for helping people with severe mental illness gain employment. This study aimed to investigate if IPS can be effectively repurposed to support young adults at risk of early work disability due to various social and health related problems. Methods A randomized controlled trial including 96 young adults (18‒29 years; 68% men) was conducted in Norway. Participants were not in employment, education, or training, received temporary benefits due to social or health-related problems, and were eligible for traditional vocational rehabilitation (TVR). Participants were randomized to IPS (N=50) or TVR (N=46). Self-reported data were collected at baseline and at 6- and 12-months follow-up. The primary outcome was obtaining any paid employment in the competitive labor market during follow-up. Secondary outcomes were physical and mental health, well-being, coping, alcohol consumption, and drug use. Results Significantly more IPS participants obtained competitive employment compared to TVR participants during 12-months follow-up (48% versus 8%; odds ratio 10.39, 95% confidence interval 2.79‒38.68). The IPS group reported significantly better outcomes than the TVR group in subjective health complaints, helplessness, and hopelessness. In post hoc analyses adjusted for baseline and missing data, the IPS group reported significantly better outcomes on these measures in addition to level of disability, optimism about future well-being, and drug use. Conclusions IPS is effective for young adults at risk of early work disability. IPS was superior to TVR in increasing competitive employment and promoted improvements in some non-vocational outcomes. IPS services should be offered to improve employment rates in this vulnerable group.

A short history of individual placement and support in Norway.

OBJECTIVE: Norway is a high-income and high-cost society with a generous welfare system, and it has the largest mental health-related unemployment gap of the OECD countries. The aim of the current article was to present a short history of Individual Placement and Support (IPS) services to increase work participation in Norway. METHOD: We provide a narrative overview of the developments and research on IPS in Norway, from the introduction of supported employment to recent and ongoing randomized controlled trials (RCTs) investigating the effectiveness of IPS for various target groups. FINDINGS: While vocational rehabilitation services in Norway have traditionally followed a train-then-place approach, the introduction of supported employment in the early 1990s led to a range of new initiatives to increase work participation. Early implementations were inspired by supported employment but did not follow the evidence-based IPS methodology. More recent developments include a shift toward evidence-based IPS, and the first Norwegian RCT of IPS showed effectiveness on both work- and health-related outcomes among people with moderate to severe mental illness. Several ongoing trials are currently investigating IPS for new target groups, including chronic pain patients and refugees. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The results suggest that IPS is more effective than traditional approaches to increase work participation, even in the Norwegian context of a high-cost welfare society. IPS has shown effectiveness in severe as well as more common types of mental illness in Norway, and results from ongoing trials will further reveal whether IPS may be expanded to various new target groups. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Barriers to employment for people with severe mental illness and criminal justice involvement.

Background: People with severe mental illness (SMI) and criminal justice involvement (CJI) are able to achieve competitive employment when provided with evidence-based services, but outcomes are modest compared to studies of SMI in general.Aims: To investigate barriers to employment facing people with SMI and CJI receiving employment services.Method: Employment service providers assessed top three barriers to employment for 87 people with SMI and CJI enrolled in a randomized controlled trial comparing a job club program to supported employment. Main barriers were identified and differences between programs were analyzed. Associations between barriers and client background characteristics were investigated.Results: The most common barriers were failure to engage and disengagement from services, followed by substance abuse. Staff from the two employment programs reported similar barriers.Conclusions: Engagement problems were the single most important barrier to employment across programs. Surprisingly, criminal history was rarely mentioned. This may be explained by barriers arising earlier in the process, before achieving employer contact. The results call for recognition and awareness of the importance of motivational issues as well as factors that may inhibit engagement in services, highlighting possible augmentations to evidence-based employment services that may be necessary in the rehabilitation of this patient group.

A randomized controlled multicenter trial of individual placement and support for patients with moderate-to-severe mental illness.

Objectives The aim of this study was to evaluate the effectiveness of individual placement and support (IPS) for people struggling with work participation due to moderate-to-severe mental illness. The study was conducted in Norway, a setting characterized by a comprehensive welfare system and strong employment protection legislation. Methods A randomized controlled multicenter trial including 410 participants was conducted. The intervention group received IPS according to the IPS manual. The control group received high-quality usual care. The main outcome was competitive employment at 12- and 18-months follow-up, based on objective registry data. Changes in mental health and health-related quality of life were secondary outcomes. Results At 12-months follow-up, 36.6% of participants in the IPS group and 27.1% of participants in the control group were in competitive employment, while the difference was slightly higher (37.4% versus 27.1%) at 18-months follow-up. Furthermore, IPS yielded positive effects on all the secondary outcomes compared to the control group (all P<0.05). Conclusions The IPS model of supported employment was superior to high-quality usual care on both vocational and non-vocational outcomes for people with moderate-to-severe mental illness, even in a policy context characterized by high job security and a comprehensive welfare system.

Young adults at risk of early work disability: who are they?

BACKGROUND: Young adults that are not in education, training or employment represent a problem across European countries. While some are cases of temporary transitions or short-term inactivity, others represent a more vulnerable group at risk of early work disability. Early exclusion from the labor market represents long lives exposed to detrimental effects of unemployment on health and well-being, and constitutes an economic burden for society. There is need for more knowledge about young adults who are at risk of early work disability but have not yet reached the point of more permanent exclusion. This study aims to investigate social and health-related problems in a Norwegian sample of young adults at risk of early work disability, and their self-perceived causes of illness. METHODS: Baseline data from participants in the SEED-trial (N = 96), a randomized controlled trial comparing individual placement and support to traditional vocational rehabilitation in young adults at risk of early work disability, were analyzed. Background, health behaviors, adverse social experiences, disability level, physical and mental health, social support, coping, and self-perceived causal attributions of illness were measured. Gender differences were analyzed using chi-square and t-tests. RESULTS: Mean age was 24, and 68% were men. One third reported reading and writing difficulties, and 40% had less than high-school education. The majority had experienced bullying (66%) or violence (39%), and 53% reported hazardous alcohol use. Psychological distress was the most prevalent health problem (52%), and women generally had more physical and mental health problems than men. Self-perceived causal attributions of illness were mainly related to relational problems, followed by health behaviors, heredity/genetics, and external environmental factors. CONCLUSIONS: The study provides a deeper insight into a vulnerable group with substantial challenges related to adverse social experiences, psychological distress, and alcohol use, who emphasized relational problems as the main causal factor for their illness. Findings suggest a need for broader focus on psychological and social factors in vocational rehabilitation efforts targeting young adults at risk of early work disability. Furthermore, gender-specific approaches may be warranted and should be followed up in future studies. TRIAL REGISTRATION: Clinicaltrials.gov: NCT02375074 . Retrospectively registered December 3rd 2014.

Protocol for the Individual Placement and Support (IPS) in Pain Trial: A randomized controlled trial investigating the effectiveness of IPS for patients with chronic pain.

BACKGROUND: Work disability involves large costs to the society as well as to the individual. Work disability is common among people with chronic pain conditions, yet few effective interventions exist. Individual Placement and Support (IPS) is an evidence-based work rehabilitation model originally developed to help people with severe mental illness obtain and maintain employment. The effectiveness of IPS for patients with severe mental illness is well documented, but the model has never before been tested for patients with chronic pain. METHODS/DESIGN: The aim of the IPS in Pain trial is to investigate the effectiveness of IPS as an integrated part of the interdisciplinary treatment for patients with chronic pain in a hospital outpatient clinic. The study is a randomized controlled trial comparing pain treatment with integrated IPS to treatment as usual in unemployed patients suffering from various chronic pain conditions. The primary outcome of the study is labor market participation during 12 months after enrollment, and secondary outcomes include physical and mental health and well-being, collected at baseline, 6, and 12 months. Finally, there will be an additional long-term follow-up for the primary outcome, which will be collected through a brief phone interview at 24 months. DISCUSSION: The IPS in Pain trial will be the first report of the effectiveness of the IPS model of supported employment applied in an outpatient setting for chronic pain patients. It will thus provide important information about the effectiveness of repurposing IPS to a new patient group in great need of job support. TRIAL REGISTRATION: Clinicaltrials.gov: NCT02697656 . Registered January 15th, 2016.

Protocol for the SEED-trial: Supported Employment and preventing Early Disability.

BACKGROUND: Early withdrawal or exclusion from the labor market leads to significant personal and societal costs. In Norway, the increasing numbers of young adults receiving disability pension is a growing problem. While a large body of research demonstrates positive effects of Supported Employment (SE) in patients with severe mental illness, no studies have yet investigated the effectiveness of SE in young adults with a range of social and health conditions who are receiving benefits. METHODS/DESIGN: The SEED-trial is a randomized controlled trial (RCT) comparing traditional vocational rehabilitation (TVR) to SE in 124 unemployed individuals between the ages of 18-29 who are receiving benefits due to various social- or health-related problems. The primary outcome is labor market participation during the first year after enrollment. Secondary outcomes include physical and mental health, health behaviors, and well-being, collected at baseline, 6, and 12 months. A cost-benefit analysis will also be conducted. DISCUSSION: The SEED-trial is the first RCT to compare SE to TVR in this important and vulnerable group, at risk of being excluded from working life at an early age. TRIAL REGISTRATION: Clinicaltrials.gov, registration number NCT02375074 . Registered on December 3rd 2014.

Cortisol, Health, and Coping in Patients with Nonspecific Low Back Pain.

Subjective health complaints (SHC), including nonspecific low back pain (LBP) as the most common single complaint, are the main reasons for long-term sick leave in many western countries. These complaints are often attributed to "stress". Cortisol has frequently been considered a biomarker reflecting sustained physiological HPA-axis activity, and is characterized by a high cortisol awakening response (CAR) and low evening values. The aim of the study was to investigate whether LBP patients had a normal characteristic cortisol profile, and whether possible deviations were related to coping and health. 305 patients on long-term sick leave for LBP participated in the study, and saliva cortisol profiles were compared to a reference population consisting of Danish workers. Cortisol was measured upon awakening, after 30 min, and in the evening. Additionally, patients answered questionnaires about SHC, fatigue, pain, coping, and social support. The patients showed a seemingly normal cortisol profile. However, CAR was larger among patients compared to the reference population. Patients with low cortisol reactivity had more SHC, pain, and fatigue, and those with higher evening cortisol reported higher scores on coping. The results are discussed in terms of theory, practical considerations, and possible mechanisms for the association between cortisol, health, and coping.

Protocol for the effect evaluation of Individual Placement and Support (IPS): a randomized controlled multicenter trial of IPS versus treatment as usual for patients with moderate to severe mental illness in Norway.

BACKGROUND: Roughly one third of disability pensions in Norway are issued for mental and behavioral disorders, and vocational rehabilitation offered to this group has traditionally been dominated by train-and-place approaches with assisted or sheltered employment. Based on a more innovative place-and-train approach, Individual Placement and Support (IPS) involves supported employment in real-life competitive work settings, and has shown great promise for patients with severe mental illness. METHODS/DESIGN: The study is a multicenter Randomized Controlled Trial (RCT) of IPS in a Norwegian context, involving an effect evaluation, a process evaluation, and a cost/benefit analysis. IPS will be compared to high quality treatment as usual (TAU), with labor market participation and educational activity at 12 months post inclusion as the primary outcome. The primary outcome will be measured using register data, and the project will also include complete follow-up up to 4 years after inclusion for long-term outcome data. Secondary outcomes include mental health status, disability and quality of life, collected through survey questionnaires at baseline, and after 6 and 12 months. Participants will include patients undergoing treatment for moderate to severe mental illness who are either unemployed or on sickness or social benefits. The estimated total sample size of 400-500 will be randomly assigned to the interventions. To be eligible, participants must have an expressed desire to work, and sufficient Norwegian reading and writing skills to fill out the questionnaires. DISCUSSION: The Effect Evaluation of Individual Placement and Support (IPS) will be one of the largest randomized controlled trials to date investigating the effectiveness of IPS on competitive employment, and the first study to evaluate the effectiveness of IPS for patients with moderate to severe mental illness within a Norwegian context. TRIAL REGISTRATION: Clinicaltrials.gov: NCT01964092 . Registered October 16th, 2013.

Assessing the role of cognitive behavioral therapy in the management of chronic nonspecific back pain.

PURPOSE: The aim of this study is to provide a narrative review of the current state of knowledge of the role of cognitive behavioral therapy (CBT) in the management of chronic nonspecific back pain. METHODS: A literature search on all studies published up until July 2012 (PubMed and PsycINFO) was performed. The search string consisted of 4 steps: cognitive behavioral therapy/treatment/management/modification/intervention, chronic, back pain (MeSH term) or low back pain (MeSH term), and randomized controlled trial (MeSH term). The conclusions are based on the results from randomized controlled trials (RCTs) and reviews of RCTs. Interventions were not required to be pure CBT interventions, but were required to include both cognitive and behavioral components. RESULTS: The search yielded 108 studies, with 46 included in the analysis. Eligible intervention studies were categorized as CBT compared to wait-list controls/treatment as usual, physical treatments/exercise, information/education, biofeedback, operant behavioral treatment, lumbar spinal fusion surgery, and relaxation training. The results showed that CBT is a beneficial treatment for chronic back pain on a wide range of relevant variables, especially when compared to wait-list controls/treatment as usual. With regards to the other comparison treatments, results were mixed and inconclusive. CONCLUSION: The results of this review suggest that CBT is a beneficial treatment for chronic nonspecific back pain, leading to improvements in a wide range of relevant cognitive, behavioral and physical variables. This is especially evident when CBT is compared to treatment as usual or wait-list controls, but mixed and inconclusive when compared with various other treatments. Multidisciplinary and transdisciplinary interventions that integrate CBT with other approaches may represent the future direction of management of chronic back pain, with treatments modified for specific circumstances and stakeholders. There is a need for future intervention studies to be specific in their use of cognitive behavioral elements, in order for results to be comparable.