Decreases in health care resource utilization in patients with rheumatoid arthritis following a cognitive behavioral intervention

Cost-utility analysis of telephone-based cognitive behavior therapy in chronic obstructive pulmonary disease (COPD) patients with anxiety and depression comorbidities: an application for willingness to accept concept

BACKGROUND

This study evaluated the cost-utility of telephone-based cognitive behavioral therapy (TB-CBT) (experimental arm) in comparison with a placebo-befriending (control arm) program in COPD participants with mild to severe depression and/or anxiety.

METHODS

The decision rule was based on willingness-to-pay if there is an increased unit of effectiveness (a quality-adjusted life year [QALY] gain) and an increase in cost, and willingness-to-accept (WTA) if there is a reduced unit of effectiveness (a QALY loss) and decrease in cost (a cost-saving).

RESULTS

TB-CBT group was associated with a reduction in the incremental cost of AUS-$407.3 (p < 0.001, SE:34.1) plus a negative, nonsignificant incremental QALY gain of -0.008 (SE:0.011) per patient compared to control group. The point estimate of the mean incremental cost-utility ratio was AUS$50,284.0 cost saving per QALY sacrificed (the high value associated with small QALY value in the denominator). Ninety-five percent CI was AUS$13,426 cost sacrificed to AUS$32,018 cost gain (lower values associated with larger QALY values in the denominator). If the societal's minimum (flooring threshold) WTA is AUS$64,000 per QALY forgone, the probability of TB-CBT being cost-effective was 42% Conclusions: This study showed that TB-CBT can be recommended as a cost-saving and preventive approach over usual care plus befriending program.

Evaluation of coping strategies in established rheumatoid arthritis patients: emergence of concealment in an Asian cohort

AIM

To evaluate coping strategies of Asian RA patients and their associations with health-related quality of life (HRQoL).

METHODS

A cross-sectional sample of patients with established RA was evaluated using measures of coping (Coping in Rheumatoid Arthritis Questionnaire [C-RAQ]; appraisal of coping effectiveness and helplessness), HRQoL (Mental and Physical Components [MCS/PCS] of the Short Form 12v2; Rheumatoid Arthritis Impact of Disease score [RAID]) and clinical/laboratory assessments. Principal component analysis was conducted to identify coping strategies. Multiple linear regression analyses were performed to evaluate the associations between coping strategies and HRQoL outcomes.

RESULTS

The study sample comprised 101 patients, 81% female, 72.3% Chinese, mean age 54.2 ± 12.6 years. Five coping strategies were identified: Active problem solving (E = 5.36), Distancing (E = 2.30), Concealment (E = 1.89), Cognitive reframing (E = 1.55) and Emotional expression (E = 1.26). Concealment was consistently associated with PCS (r_s = -0.23, P = 0.049), MCS (r_s = -0.24, P = 0.04) and RAID (r_s = 0.39, P < 0.001), and was significant in the multivariate model to explain lower disease-specific HRQoL (RAID) even after adjusting for disease activity, coping effectiveness and helplessness (β = 0.20, P = 0.04). Emotional expression was associated with poorer physical HRQoL (PCS), after adjusting for disease severity, body mass index, coping effectiveness, helplessness and Concealment (β = -0.39, P < 0.001). Perceived coping-related helplessness was significant in multivariate correlates for PCS (β = -0.25, P = 0.036), MCS (β = -0.29, P = 0.02) and RAID (β = 0.53, P < 0.001), after adjusting for covariates.

CONCLUSION

Concealment and Emotional expression are associated with lower disease-specific HRQoL and physical HRQoL respectively, with the former coping strategy likely to be culture-specific. Interventions should tailor psychosocial support needs to address not only coping strategies, but patients' perception of their coping.

Behavior change, acceptance, and coping flexibility in highly distressed patients with rheumatic diseases: feasibility of a cognitive-behavioral therapy in multimodal rehabilitation

OBJECTIVE

To describe the development and feasibility of the integration of a cognitive-behavioral therapy (CBT) within a multimodal rehabilitation program for highly distressed patients with rheumatic diseases.

METHODS

Development included the detailed specification of the theoretical and empirical-based underpinnings of the CBT and the comprehensive description of its design and content. Feasibility was assessed by percentage of eligible patients, attrition and attendance rates, and patient satisfaction.

RESULTS

The developed CBT component seeks to decrease psychological distress and improve activities and participation across multiple life domains by accomplishing behavior change, acceptance, and coping flexibility. Motivational interviewing was applied to endorse patients' own reasons to change. Forty percent (35/87) of the eligible patients were admitted to the program. Attendance rate (>95%) was high. Patient satisfaction ranged from 6.8 to 8.0 (10-point scale).

CONCLUSION

Integrating CBT within a multimodal rehabilitation program is feasible. An acceptable proportion of the intended patient sample is eligible and patient's attendance and satisfaction is high.

PRACTICE IMPLICATIONS

Patients with impaired physical and psychosocial functioning despite adequate medical treatment pose a great challenge. Their treatment outcome may be improved by screening and selecting highly distressed patients and offering them a CBT embedded in multimodal rehabilitation program.

Psychological approaches to understanding and treating disease-related pain

Psychologists are increasingly involved in the assessment and treatment of disease-related pain such as pain secondary to arthritis or cancer. This review is divided into four sections. In the first section, we provide a conceptual background on this area that discusses the limitations of the biomedical model of disease-related pain and traces the evolution of psychosocial theories of pain. In the second section, we discuss special issues and challenges involved in working with persons having disease-related pain, including the reluctance of some persons to report pain and to become involved in psychological treatments for pain. Section three provides an overview of psychosocial research conducted on arthritis pain and cancer pain that addresses both psychosocial factors related to pain and psychosocial interventions for pain management. In the final section, we describe important future directions, including strategies for disseminating psychosocial treatments and disparities in pain management.

Effects of a stress-reduction program on psychological function, pain, and physical function of systemic lupus erythematosus patients: a randomized controlled trial

OBJECTIVE

To assess the effects of a stress-reduction program on pain, psychological function, and physical function in persons with systemic lupus erythematosus (SLE) who experience pain.

METHODS

Ninety-two SLE patients were assigned randomly to receive either biofeedback-assisted cognitive-behavioral treatment (BF/CBT), a symptom-monitoring support (SMS) intervention, or usual medical care (UC) alone.

RESULTS

BF/CBT participants had significantly greater reductions in pain and psychological dysfunction compared with the SMS group (pain, P = 0.044; psychological functioning, P < 0.001) and the UC group (pain, P = 0.028; psychological functioning, P < 0.001). BF/CBT had significantly greater improvement in perceived physical function compared with UC (P = 0.035), and improvement relative to SMS was marginally significant (P = 0.097). At a 9-month followup evaluation, BF/CBT continued to exhibit relative benefit compared with UC in psychological functioning (P = 0.023).

CONCLUSION

This study supports the utility of a brief stress management program for short-term improvement in pain, psychological function, and perceived physical function among persons with SLE who experience pain.

Gap between short- and long-term effects of patient education in rheumatoid arthritis patients: A systematic review

OBJECTIVE

To systematically review educational or psychoeducational interventions for patients with rheumatoid arthritis focusing on long-term effects, especially health status.

METHODS

Two independent reviewers appraised the methodologic quality of the included randomized controlled trials, published between 1980 and July 2002.

RESULTS

Validity scores of studies ranged from 3 to 9 (of 11). The 7 educational programs mainly improved knowledge and compliance in the short and long term, but there was no improvement in health status. All 4 psychoeducational programs improved coping behavior in the short term, 2 of them showing a positive long-term effect on physical or psychological health variables.

CONCLUSION

Methodologically better-designed studies had more difficulties demonstrating positive outcome results. Short-term effects in program targets are generally observed, whereas long-term changes in health status are not convincingly demonstrated. There is a need to find better strategies to enhance the transfer of short-term effects into gains in health status.

Investigating sleep disturbances in adults with rheumatoid arthritis

Rheumatoid arthritis (RA) is an autoimmune disease characterized by inflammation and joint involvement. Most adults with RA experience sleep disturbances, including longer times before falling asleep, numerous awakenings during the night, and early morning wakening, resulting in excessive daytime sleepiness and fatigue. This article will review what is known about sleep disturbances and the biologic basis in adults with RA, the influence of ovarian hormone levels in women with RA, how medications may influence sleep in RA, and complementary and alternative therapies that may be useful in reducing sleep disturbances.

Recent advances and future directions in the biopsychosocial assessment and treatment of arthritis

This article provides an overview of the emerging literature on biopsychosocial assessment and treatment for two of the most common forms of arthritis: osteoarthritis and rheumatoid arthritis. The article is divided into 3 parts. In the 1st part, the basic elements of the biopsychosocial approach to assessing and treating persons having arthritis is described. In the 2nd part, the authors evaluate studies of biopsychosocial approaches to the assessment of arthritis pain and disability. Six research areas are reviewed: learned helplessness, depression, stress, pain coping, self-efficacy, and the social context of arthritis. The 3rd part of the article reviews studies that testing the efficacy of biopsychosocial treatment approaches for persons having osteoarthritis and rheumatoid arthritis.

Patient education for adults with rheumatoid arthritis

BACKGROUND

Because of the unpredictability people with arthritis face on a daily basis, patient education programmes have become an effective complement to traditional medical treatment giving people with arthritis the strategies and the tools necessary to make daily decisions to cope with the disease.

OBJECTIVES

To assess the effectiveness of patient education interventions on health status in patients with rheumatoid arthritis.

SEARCH STRATEGY

We searched MEDLINE, EMBASE and PsycINFO and the Cochrane Controlled Trials Register. A selection of review articles (see references) were examined to identify further relevant publications. There was no language restriction.

SELECTION CRITERIA

Randomised controlled trials (RCT's) evaluating patient education interventions that included an instructional component and a non-intervention control group; pre- and post-test results available separately for RA, either in the publication or from the studies' authors; and study results presented in full, end-of-study report.

MAIN RESULTS

Twenty-four studies with relevant data were included. We found significant effects of patient education at first follow-up for scores on disability, joint counts, patient global assessment and psychological status. Physician global assessment was not assessed in any of the included studies. The two separate dimensions of psychological status: anxiety and depression showed no significant effects, nor did the dimensions of pain and disease activity. At final follow up no significant effects of patient education were found.

REVIEWER'S CONCLUSIONS

Patient education as provided in the studies reviewed here had moderate short-term effects on patient global assessment, and small short-term effects on disability, joint counts and psychological status. There were no long-term benefits.

Central nervous system mechanisms of pain in fibromyalgia and other musculoskeletal disorders: behavioral and psychologic treatment approaches

Pain is one of the most important and challenging consequences of musculoskeletal disorders. This article examines the role of central nervous system structures in the physiology of pain. It also describes the neuromatrix, a construct that provides a framework for understanding the interaction between physiologic mechanisms and psychosocial factors in the development and maintenance of chronic pain. This construct suggests that behavioral and psychologic interventions may alter the pain experience primarily through their effects on emotional states and cognitive processes. The literature on cognitive-behavioral interventions for patients with rheumatoid arthritis and osteoarthritis indicates that they are well-established treatments for these disorders. However, the efficacy of these interventions for patients with fibromyalgia has not been established. It is anticipated that the development of valid measures of readiness for behavioral change may allow investigators to identify the patients with musculoskeletal disorders who are most likely to benefit from cognitive-behavioral intervention.

Cognitive-behavioral treatment in unselected rheumatoid arthritis outpatients

OBJECTIVE

This trial was performed to evaluate the efficacy of an adjunctive cognitive-behavioral treatment compared with rheumatological treatment alone in unselected rheumatoid arthritis outpatients.

DESIGN

A prospective randomized control design was used. Change in medication during treatment was controlled by matching therapy- and control-group subjects according to this change in medication, sex, age, duration of disease, and functional class.

SETTING

A rheumatological outpatient clinic, University of Goettingen, Germany.

PATIENTS

Fifty-five consecutive outpatients with a diagnosis of rheumatoid arthritis (age 52.7 years, 74.5% female, duration of disease 9.4 years) finished the study.

INTERVENTIONS

Subjects received routine care by the rheumatologists and routine medical treatment. Cognitive-behavioral treatment subjects (n = 19) received adjunctive standardized cognitive-behavioral group treatment with 12 weekly sessions.

OUTCOME MEASURES

Outcome measures included disease activity variables, pain variables (pain intensity, affective pain), psychological symptoms, and coping.

RESULTS

Subjects mostly demonstrated an increasing disease activity during treatment; change in medication during treatment was necessary in some patients. In the cognitive-behavioral treatment group the course of rheumatoid arthritis seemed less progressive than in the control group. The core effects of cognitive-behavioral treatment pertain more to improved coping, emotional stabilization, and reduced impairment than to reduced pain intensity. Passive, emotion-focused coping, helplessness, depression, anxiety, affective pain, and fluctuation of pain are reduced, "Acceptance of Illness" is improved.

CONCLUSIONS

Cognitive-behavioral therapy has proven an effective adjunct to standard treatment of rheumatoid arthritis outpatients. These effects were shown in an unselected sample with increasing disease activity and with comparable changes in medication during treatment. We recommend cognitive-behavioral treatment as an desirable adjunct to standard medical treatment of rheumatoid arthritis.

Psychological and behavioral approaches to pain management for patients with rheumatic disease

This article reviews the efficacy of the psychological and behavioral pain management interventions that have been evaluated among adult patients with rheumatoid arthritis (RA), osteoarthritis (OA), and fibromyalgia (FM). Using published criteria for empirically validated interventions, it is concluded that cognitive-behavioral therapies and the Arthritis Self-Management Program represent well-established treatments for pain among patients with RA and OA. These interventions involve education, training in relaxation and other coping skills, and rehearsal of these skills in patients' home and work environments. There currently are no psychological or behavioral interventions for pain among FM patients that can be considered as well-established treatments. Future intervention research should use clinically meaningful change measures in addition to conventional tests of statistical significance, attend to the pain management needs of children, and assess whether outcomes produced in university-based treatment centers generalize to those in local treatment settings.

Advances in the treatment of fibromyalgia: current status and future directions

Despite significant efforts devoted to understanding the etiopathogenesis of fibromyalgia, its treatment still presents a challenge to practicing clinicians, who must recognize the disorder and quantify the different symptoms in order to treat it. This article discusses recent research to identify sensitive and reliable measures for determining response to treatment among patients with FM, and the elements of therapeutic programs (pharmacologic and nonpharmacologic) for patients with FM along with the empirical or theoretical basis for their use. Future directions, including the need for systematic, controlled outcome studies of therapies and evaluation of variables which may mediate the effects of treatment, as well as demonstration that the effects produced in outcome studies generalize to settings beyond those in which the studies are initially conducted, are also discussed.