A controlled study of psychotherapy and amitriptyline used individually and in combination in the treatment of chronic intractable, 'psychogenic' pain.

This paper reports an investigation into the efficacy of flexible dosage amitriptyline (AMI) and brief psychotherapy individually and together in the treatment of chronic 'psychogenic' pain. The patients included in the study were drawn from those referred to a pain clinic and were randomly assigned to 1 of 4 groups: (1) AMI + psychotherapy (N = 26), twelve 45 min weekly sessions; (2) AMI + support (N = 26), six 15 min fortnightly sessions; (3) placebo tablet + psychotherapy (N = 26), twelve 45 min weekly sessions; (4) placebo tablet + support (N = 24), six 15 min fortnightly sessions. Outcome was assessed on categorical and continuous variables administered immediately post treatment. The results indicate that amitriptyline is effective in increasing the patients' activity level and the reduction of pain intensity. Psychotherapy increases pain intensity, but tends to improve productivity. There also appears to be a role for the use of amitriptyline in combination with psychotherapy, but their interaction is a complex one. Baseline factors associated with withdrawal from treatment are reported, as well as those associated with a positive response to amitriptyline and psychotherapy respectively. Our findings offer tentative guidelines for choosing between therapies and also underline the importance of assessing more than one outcome variable in evaluating outcome. The importance of carrying treatments out in the context of a multidisciplinary pain clinic is emphasised.