Determinants of psychological distress and its course in the first year after diagnosis in rheumatoid arthritis patients

Depressive symptoms, pain and disability for adolescent patients with juvenile idiopathic arthritis: results from the Childhood Arthritis Prospective Study

Objectives

To determine if depressive symptoms assessed near diagnosis associate with future measures of pain, disability and disease for adolescent patients diagnosed with JIA.

Methods

Data were analysed from JIA patients aged 11–16 years recruited to the Childhood Arthritis Prospective Study, a UK-based inception cohort of childhood-onset arthritis. Depressive symptoms (using the Mood and Feelings Questionnaire; MFQ), active and limited joint count, disability score (Childhood Health Assessment Questionnaire), pain visual analogue scale and patient’s general evaluation visual analogue scale were collected. Associations between baseline measures (first visit to paediatric rheumatologist) were analysed using multiple linear regression. Linear mixed-effect models for change in the clinical measures of disease over 48 months were estimated including MFQ as an explanatory variable.

Results

Data from 102 patients were analysed. At baseline, median (IQR) age was 13.2 years (11.9–14.2 years) and 14.7% scored over the MFQ cut-off for major depressive disorder. At baseline, depressive symptoms significantly associated with all clinical measures of disease (P ⩽ 0.01). High baseline depressive symptoms scores predicted worse pain (P ⩽ 0.005) and disability (P ⩽ 0.001) 12 months later but not active and limited joint counts.

Conclusions

Adolescent patients with JIA and depressive symptoms had more active joints, pain and disability at the time of their first specialist appointment. The associations between baseline depression and both pain and disability continued for at least one year, however, this was not the case for active joint count.

Expert recommendations on the psychological needs of patients with rheumatoid arthritis

OBJECTIVE

To establish feasible and practical recommendations for the management of the psychological needs of patients with rheumatoid arthritis (RA) from the moment of diagnosis through the course of the disease.

METHODS

A nominal group meeting was held with an RA expert team including rheumatologists and psychologists, at which a guided discussion addressed the most important psychological and emotional needs in RA. Based on the comments collected, and a literature review, a matrix document of recommendations for telematics discussion was prepared, as well as a Delphi survey to test agreement with these recommendations. Agreement was defined if at least 80% of participants voted ≥ 7 (from 1, totally disagree to 10, totally agree). For each recommendation, the level of evidence and grading of recommendations was established following the Oxford criteria, and the degree of agreement through the Delphi.

RESULTS

Thirteen recommendations were established, addressing several key processes: (1) identification of psychological problems and needs in patients with RA, and a guideline for their management in daily practice; (2) communication with patients; (3) referral criteria to mental health professionals.

CONCLUSIONS

These recommendations are intended to help health care professionals openly address the psychological aspects of patients in daily practice to follow and treat them properly.

Personalized diet and exercise recommendations in early rheumatoid arthritis: A feasibility trial

BACKGROUND

Physical activity and diet have a positive influence on disease activity and cardiovascular risk in patients with rheumatoid arthritis (RA).

OBJECTIVE

We tested the feasibility and effect of a brief individualized counselling intervention on physical activity levels and fitness, and dietary intake, compared with standard of care.

METHODS

Thirty patients with inflammatory arthritis (<1 year duration) were assigned to standard of care or the intervention, which consisted of individualized visits with a dietetic intern and physiotherapist at two time points, to review age-specific strategies on diet and exercise. Primary outcomes included anthropometric measurements (height, weight, waist and hip circumference), nutritional intake, physical activity (pedometer steps) and physical fitness. Disease activity measures and biochemical testing (blood pressure measurement, inflammatory markers, cholesterol profile and random glucose) were collected. The changes in these outcomes from baseline to 6 months were assessed using paired t-tests between groups.

RESULTS

Thirteen patients in the intervention group and 10 in the control group completed the study. There were non-significant trends in improvements in physical activity, low-density lipoprotein cholesterol level and nutritional intake (vitamin C, iron, fibre, vitamin A and folate) in the intervention group.

CONCLUSIONS

Poor enrolment and high dropout rates in this short-term study highlighted the difficulty of behavioural change. Those continuing in the study and who received the intervention demonstrated a non-significantly improved activity level and nutritional intake that may benefit long-term outcomes.

Social relationships, mental health and wellbeing in physical disability: a systematic review

BACKGROUND

Research has consistently found that favourable exchange with one's proximal social environment has positive effects on both mental health and wellbeing. Adults with physical disabilities may have fewer opportunities of favourable exchange, and therefore the effects on mental health and wellbeing may be less advantageous. The aim of this study is to systematically review quantitative studies exploring associations of social relationships with mental health and wellbeing in persons with physical disabilities.

METHODS

The databases PubMed, PsycINFO and Scopus were searched for relevant studies published between 1995 and 2016. Data was extracted on study and participants' characteristics, independent and dependent variables, used measures and effects sizes of associations between social relationships and mental health or wellbeing. A narrative review was performed to synthesize findings along the constructs social support, social networks, negative social interactions, family functioning and relationship quality.

RESULTS

Of the 63 included studies, 47 were cross-sectional and 16 longitudinal. Most studies included a measure of social support (n = 58), while other concepts were less often studied (social networks n = 6; negative social interaction n = 3; family functioning n = 2; relationship quality n = 1). Over half of studies included depression as outcome (n = 33), followed by wellbeing (n = 14), composite mental health measures (n = 10), anxiety (n = 8), psychological distress (n = 7), posttraumatic stress disorder (n = 3), and hopelessness (n = 1). Although trends for associations of social support with mental health and wellbeing were consistent, around a quarter of studies failed to report significant associations. Social networks were related to depression, but not to other mental health or wellbeing measures. Family functioning, negative social interactions and relationship quality showed consistent associations with mental health and wellbeing, however, only few studies were available.

CONCLUSIONS

This review indicates that social relationships play an important role in mental health and wellbeing in persons with disabilities, although findings are less consistent than in general populations and strength of associations vary between constructs. Integrating persons with disabilities into social networks seems not sufficient and rehabilitation professionals together with affected persons and their peers should ensure that high quality relationships and tailored support are available.

The Relationship Between Self-Blame for the Onset of a Chronic Physical Health Condition and Emotional Distress: A Systematic Literature Review

OBJECTIVE

Past literature presents contrasting perspectives regarding the potential influence of self-blame on adjustment to illness. This systematic literature review aimed to summarize findings from all investigations to date that have explored the relationship between self-blame for the onset of a chronic physical health condition and emotional distress.

METHOD

Between November 2014 and February 2015, electronic databases were searched for relevant literature. Only those studies which assessed self-blame directly and related specifically to illness onset were included within the review. The methodological and reporting quality of all eligible articles was assessed, and themes within the findings were discussed using a narrative synthesis approach.

RESULTS

The majority of studies found self-blame to be associated with increased distress. However, several concerns with the quality of the reviewed articles may undermine the validity of their conclusions.

CONCLUSIONS

It is important for professionals supporting people with chronic physical health conditions to have an understanding of how of self-critical causal attributions might relate to emotional distress. Further research is required to understand the concept of self-blame, the factors that may encourage this belief and to develop reliable and valid measures of this experience. Copyright © 2016 John Wiley & Sons, Ltd.

KEY PRACTITIONER MESSAGE

What does this study add? The review presents an exploration of the role of self-blame in emotional adjustment following the diagnosis of a chronic physical health condition. This is the first review to synthesize findings from studies measuring self-blame beliefs directly and specifically for illness onset and their relationship to indicators of distress and wellbeing. Findings suggest that self-blame for illness onset is often associated with emotional distress for people with cancer, HIV/AIDS and cardiovascular disease. This has implications for how healthcare professionals respond to self-blaming beliefs in the context of illness. Research quality concerns are identified for many of the reviewed studies, highlighting a need for further research on this topic.

The relationship between coping and psychological and physical adjustment in rheumatoid arthritis: a literature review

AIM

This systematic review examines how specific coping strategies are associated with psychological and physical outcomes in rheumatoid arthritis.

BACKGROUND AND METHODS

Rheumatoid arthritis is a long-term condition that people cope with but it is unclear whether specific coping strategies have an effect on mood and function. Therefore a systematic review was undertaken of the coping with arthritis literature and 174 studies were initially included. Further examination determined that 31 studies (11 longitudinal and 20 cross sectional) were finally included in the review. The 31 studies were clinically and methodologically diverse; therefore the analysis of results was a qualitative synthesis. Coping strategies that contributed to the prediction of outcomes were allocated to a new structure for the classification of coping.

RESULTS

The results demonstrated there was not sufficient, consistent evidence to support the overall view that individual coping strategies contributed to longitudinal outcomes in rheumatoid arthritis. However, major differences in the design of included studies may have hindered the comparison of results. There was some evidence from longitudinal studies that patients who used resting, inactivity, etc. (helplessness category) experienced negative outcomes. Avoidance (escape) was the most common overall category associated with predominantly negative outcomes in both cross-sectional and longitudinal studies.

CONCLUSIONS

There was generally limited evidence to suggest an association between coping strategies and outcomes but the design of studies and the lack of clarity about coping strategies were identified as problems. This study used a new framework for the conceptualisation of coping strategies, thus contributing to further examining the utility of coping strategies and contributing to their redefinition.

RELEVANCE TO CLINICAL PRACTICE

The use of helplessness (inactivity and passive coping) and escape/avoidant coping strategies, including denial and wishful thinking, could be identified and addressed by nurses and other health professionals to reduce the associated negative outcomes.

Motivation-related predictors of physical activity engagement and vitality in rheumatoid arthritis patients

This study tests the Basic Psychological Needs Theory (within the Self-determination framework), in relation to the prediction of physical activity and well-being among rheumatoid arthritis patients. Motivation regulations for physical activity were also considered in the process model. A total of 207 patients (150 females, mean age = 58 ± 11 years) completed a questionnaire pack and structural equation modelling was used to test expected relationships. Autonomy support provided by important other(s) regarding physical activity positively predicted rheumatoid arthritis patients’ need satisfaction which positively related to autonomous reasons for physical activity participation. Autonomous motivation positively predicted reported physical activity participation levels and feelings of vitality.

Psychological distress across twelve months in patients with rheumatoid arthritis: the role of disease activity, disability, and mindfulness

OBJECTIVE

Mindfulness may diminish effects of adversities on psychological well-being in medical patients, but studies are scarce, especially in patients with rheumatoid arthritis (RA). The purpose was to examine the prospective moderating effect of mindfulness regarding psychological distress associated with disease activity and disability in patients with RA.

METHODS

Two-hundred-and-one patients with RA (mean age 57.4 ± 11.7, 55% women) completed questionnaires at baseline and at six and twelve month follow-up. Disease activity score was assessed by the rheumatologist.

RESULTS

Controlled for potential confounders, mixed linear model analyses showed a strong prospective association of higher baseline mindfulness with lower psychological distress up to the twelve month follow-up (p<.001). In addition, a mindfulness by disability by time interaction showed that higher baseline mindfulness was associated with lower disability related psychological distress at follow-up (p=.022).

CONCLUSION

Findings are in line with the hypothesis that mindfulness may protect against psychological distress associated with disability in RA. Potential benefits of mindfulness-based interventions for prevention should be examined in this population.

Self-efficacy as an appraisal that moderates the coping-emotion relationship: associations among people with rheumatoid arthritis

The way a coping strategy is expressed might depend on the nature of underlying efficacy expectations. For example, a cognitive coping strategy may have different content depending on efficacy beliefs underpinning the strategy's formulation and application. As such, self-efficacy (SE), as an appraisal, may moderate relationships between coping and outcomes: coping effects may differ depending on SE. This process was examined in 127 rheumatoid arthritis patients attending routine patient education/self-management programmes. Participants completed questionnaire measures of SE, coping, anxiety and depression at baseline and at 8 weeks follow-up. Regression analyses focused on coping and SE change variables, and their concurrent association with measures of change in anxiety and depression. Results highlighted contributions to these emotional variables from interactions between coping and SE. The nature of associations between coping and emotional outcomes was found to differ according to efficacy appraisals. This may have implications for clinical practice in that the adaptive significance of adjustment efforts may differ according to underlying SE.

An appraisal-based coping model of attachment and adjustment to arthritis

Guided by pain-related attachment models and coping theory, we used structural equation modeling to test an appraisal-based coping model of how insecure attachment was linked to arthritis adjustment in a sample of 365 people with arthritis. The structural equation modeling analyses revealed indirect and direct associations of anxious and avoidant attachment with greater appraisals of disease-related threat, less perceived social support to deal with this threat, and less coping efficacy. There was evidence of reappraisal processes for avoidant but not anxious attachment. Findings highlight the importance of considering attachment style when assessing how people cope with the daily challenges of arthritis.

The influence of perceived stress on the onset of arthritis in women: findings from the Australian Longitudinal Study on women's health

BACKGROUND

Psychosocial factors are considered as risk factors for some chronic diseases. A paucity of research exists surrounding the role of perceived stress in arthritis onset.

PURPOSE

Perceived stress as a risk factor for arthritis development was explored in an ageing cohort of Australian women.

METHODS

This study focused on 12,202 women from the 1946-1951 cohort who completed the Australian Longitudinal Study on Women's Health surveys in 2001, 2004 and 2007. Longitudinal associations were modelled, with and without a time lag.

RESULTS

Findings from the multivariate time lag modelling, excluding women with persistent joint pain, revealed that perceived stress predicted the onset of arthritis, with women experiencing minimal and moderate/high stress levels having a 1.7 and 2.4 times greater odds of developing arthritis 3 years later, respectively (p's < 0.001).

CONCLUSION

Chronically perceiving life as stressful is detrimental to future health. The findings provide support for perceived stress to be considered alongside other modifiable risk factors.

Prevalence and associated factors of depression among people living with HIV in two cities in China

OBJECTIVES

Depression has significant effects on morbidity and mortality in people living with HIV (PLWH). Current study estimated the rate of depressive disorder and identified the correlates of depressive disorder among PLWH in China.

METHODS

258 PLWH in China were recruited and interviewed with a structured questionnaire including measurements testing perceived stress, social support, perceived discrimination, and depression. Mediating effect of perceived stress between perceived discrimination and depression and moderating effect of social support on effect of perceived discrimination and perceived stress to depression were tested. Multivariate regression was used to examine the determinants of depression.

RESULTS

The prevalence of mild to severe depression is 71.9%. The relationship between the perceived discrimination and depression is fully mediated by perceived stress (perceived discrimination that was statistically significant (β=0.153) to depression became non-significant after adding perceived stress in the regression model). Interaction term between social support and perceived stress has negative effects (β=-0.117) and explained a significant amount of variance (R(2)=0.018) in depression. Lower income, and higher perceived stress predicted more depressive symptoms.

LIMITATIONS

Cross-sectional study and self-report bias are major limitations of this study.

CONCLUSION

Depression among PLWH is a severe problem in China. Primary health care workers need to be trained in recognition and treatment in depression. Stress management skills and social support for PLWH are warranted.

Negative and positive illness representations of rheumatoid arthritis: a latent profile analysis

This study extends previous work to consider whether individuals with rheumatoid arthritis (RA) can be categorised into groups with similar illness representations. Data from 227 RA patients attending outpatient clinics were collected prospectively at two time points, 6 months apart. The optimal number of illness representation groups at the baseline assessment was identified using latent profile analysis. Two groups of individuals sharing similar illness perception profiles were identified. The smaller group (43%), characterised by a negative representation of their illness, attributed more symptoms to their condition and reported stronger perceptions of the consequences, chronicity and cyclicality of their condition, and lower control compared to the positive representation group (57%). Cross-sectionally, membership of the negative representation group was associated with higher levels of pain and functional disability and, longitudinally, with increases in levels of pain, functional disability and distress. These data highlight the central role of illness perceptions in RA and suggest that individuals with RA can be categorised into groups with similar illness representations.

The impact of appearance concerns on depression and anxiety in rheumatoid arthritis

OBJECTIVES

Increased levels of anxiety and depression are commonly reported by patients with rheumatoid arthritis (RA) in comparison to the general population. Rather than the clinical features of the disease, this difference has been attributed to psychosocial factors. Patients with RA can develop joint swelling and disfigurement as a direct result of the disease, and experience concerns about their altered appearance. This study aimed to identify if appearance-specific issues contribute to our understanding of mood in RA, over and above demographic, functional and generalized psychosocial measures.

METHODS

A total of 89 patients with RA completed a series of psychosocial questionnaires measuring demographics, physical function, general cognitive processes and a number of appearance-specific concepts, to determine the contribution of appearance concerns to mood.

RESULTS

Hierarchical linear regression suggested that living status, optimism, social support and appearance-related social anxiety and avoidance are associated with levels of depression. The relationship between social support and depression was found to be mediated by appearance-related social anxiety and avoidance. Optimism remained the only variable significantly associated with anxiety.

CONCLUSION

These findings confirm the role of optimistic cognitions and a supportive environment in determining the mood of patients with RA and also establishes a possible link between depression and appearance concerns in this population. Interventions targeting social support, optimism and social anxiety and avoidance in relation to appearance are key in the improvement of depression in this patient group.

The relative importance of psychosocial factors in arthritis: findings from 10,509 Australian women

OBJECTIVE

To determine the relative importance of psychosocial factors in arthritis diagnosis in an ageing cohort of Australian women.

METHODS

This study focused on 10,509 women from the 1946-1951 cohort who responded to questions on arthritis in the fifth mailed population-based survey of the Australian Longitudinal Study on Women's Health conducted in 2007.

RESULTS

Arthritis was characterised by widespread psychosocial concerns, particularly relating to chronic stress and poor mental health. Univariate analyses revealed that in comparison to women without stress, women with moderate/high stress levels had a 2.5-fold increase in reporting arthritis. Experiencing ongoing negative interpersonal life events concerning illness of a family member/close friend and relationship difficulties was also associated with a 1.4-fold increase in the reporting of arthritis. Likewise, significantly reduced levels of optimism and perceived social support were noted (all associations p<.001). Psychiatric diagnosis was also associated with a two-fold increase in having arthritis (p<.001). Following adjustment for behavioural, demographic and health-related characteristics, anxiety was the only psychosocial factor associated with arthritis (OR=1.4, 95% CI=1.2, 1.7; p<.001).

CONCLUSION

This study examined, epidemiologically, the relative importance of psychosocial factors in arthritis in an ageing cohort of Australian women. The findings from this population-based study indicate that women with arthritis are more likely to report a range of psychosocial-related problems, particularly with regard to chronic stress perception and anxiety. Longitudinal analyses are required to examine the processes by which stress and psychosocial factors may contribute to arthritis risk and poor adaptation in terms of health-related quality of life.

[Assessment of depression in rheumatoid arthritis: a cross sectional study on 60 patients]

OBJECTIVE

To assess the prevalence of depression in a series of Tunisian patients with rheumatoid arthritis (RA) and to identify factors associated with its occurrence.

METHODS

We performed a cross sectional study on 60 patients with RA. The evaluation of depression was performed using the Montgomery and Asberg depression rating scale.

RESULTS

Our study revealed a high prevalence of depression in RA patients (45%). The main predictor factors of its occurrence were female gender, absence of professional activity, absence of social support, high activity of RA, impaired quality of life and existence of structural damage.

PERSPECTIVES

Our results highlight the importance of a good management of RA in order to prevent the occurrence of depression. They also underline the interest of screening for depression in RA patients to avoid its adverse effects on the course of RA.

Psychophysiological responses to stress after stress management training in patients with rheumatoid arthritis

Background

Stress management interventions may prove useful in preventing the detrimental effects of stress on health. This study assessed the effects of a stress management intervention on the psychophysiological response to stress in patients with rheumatoid arthritis (RA).

Methods

Seventy-four patients with RA, who were randomly assigned to either a control group or a group that received short-term stress management training, performed a standardized psychosocial stress task (Trier Social Stress Test; TSST) 1 week after the stress management training and at a 9-week follow-up. Psychological and physical functioning, and the acute psychophysiological response to the stress test were assessed.

Results

Patients in the intervention group showed significantly lower psychological distress levels of anxiety after the training than did the controls. While there were no between-group differences in stress-induced tension levels, and autonomic (α-amylase) or endocrine (cortisol) responses to the stress test 1 week after the intervention, levels of stress-induced tension and cortisol were significantly lower in the intervention group at the 9-week follow-up. Overall, the response to the intervention was particularly evident in a subgroup of patients with a psychological risk profile.

Conclusion

A relatively short stress management intervention can improve psychological functioning and influences the psychophysiological response to stress in patients with RA, particularly those psychologically at risk. These findings might help understand how stress can affect health and the role of individual differences in stress responsiveness.

Trial Registration

TrialRegister.nl NTR1193

Distinct psychological distress trajectories in rheumatoid arthritis: findings from an inception cohort

OBJECTIVE

As with other chronic physical illness, rates of depressive disorder are high in rheumatoid arthritis (RA). The aim of the current study was to identify distinct trajectories of psychological distress over 10 years in a cohort of RA patients recruited very early in the course of the disease.

METHODS

Psychological distress as measured by the Hospital Anxiety and Depression Scale total score was assessed annually in a subgroup of 784 patients enrolled in a multi-centre RA inception cohort (Early RA Study). A latent growth mixture modelling (GMM) approach was used to identify distinct psychological distress patterns.

RESULTS

Four distinct psychological distress trajectories were observed: low-stable (68%), high-stable (12%), high-decreasing (9%) and low-increasing (11%). Symptoms of pain, stiffness and functional impairment were significantly associated with levels of psychological distress at the time of diagnosis and after 3 years; serological markers of disease activity (ESR and CRP) were not.

CONCLUSIONS

Although the majority of individuals developing RA experience little or no impact of the effects of the disease on their psychological well-being, a significant proportion experience high levels of distress at some point which may be related to their subjective appraisal of their condition. Assessment and treatment of psychological distress should occur synchronously with somatic symptoms.

Tailored cognitive-behavioral therapy and exercise training for high-risk patients with fibromyalgia

OBJECTIVE

The treatment of patients with fibromyalgia (FM), a high-prevalence chronic pain condition with a high impact on both patients and society, poses a great challenge to clinicians due to a lack of effective treatments. In view of the large individual variability in outcome, selecting patients at risk of long-term dysfunction and offering tailored treatment may be promising for beneficial treatment effects.

METHODS

High-risk patients were selected and classified into 2 groups (pain-persistence and pain-avoidance groups) and subsequently randomized in groups to either a treatment condition (TC) or a waiting list control condition (WLC). Treatment consisted of 16 sessions of cognitive-behavioral therapy (CBT) and exercise training in groups, tailored to the patient's specific cognitive-behavioral pattern, delivered within 10 weeks. Physical and psychological functioning and impact of FM were assessed at baseline, posttreatment, and 6-month followup. Treatment effects were evaluated using a linear mixed model.

RESULTS

The treatment effects were significant for all primary outcomes, showing significant differences in physical (pain, fatigue, and functional disability) and psychological (negative mood and anxiety) functioning, and impact of FM for the TC in comparison with the WLC. Effect sizes in the TC were overall large, and reliable change indices indicated a clinically relevant improvement among the TC.

CONCLUSION

The presented results demonstrate for the first time that tailored CBT and exercise training for high-risk patients with FM is effective in improving short- and long-term physical and psychological functioning, indicating that tailoring treatment is likely to promote beneficial outcomes in FM and reduce the burden for patients and society.

Risk factors for longer term psychological distress in well-functioning fibromyalgia patients: a prospective study into prognostic factors

OBJECTIVE

Psychological distress is a key risk factor for long-term complaints in fibromyalgia (FM). Prognostic factors for psychological distress might facilitate an early identification of patients at risk to help prevent long-term dysfunction, especially for the relatively well-functioning patients showing little distress who are usually not considered for treatment. This study hence examines potential prognostic factors in this subgroup.

METHODS

Psychological distress, physical functioning, illness cognitions (helplessness, acceptance), pain-avoidance factors (passive pain-coping, fear of pain, hypervigilance), and social factors (social support, social reinforcement) was assessed in 78 low-distress FM patients at baseline and after a mean of 9 months (SD=3.3).

RESULTS

Baseline physical functioning did not predict changes in psychological distress, whereas a higher level of hypervigilance, less acceptance, and less perceived social support predicted an increase in psychological distress at follow-up.

CONCLUSION

Illness cognitions, pain-avoidance factors, and social support can be considered as prognostic factors predicting changes in psychological distress in FM. More research is needed to investigate additional factors that could also be implicated (e.g. personality factors, stressful events).

PRACTICE IMPLICATIONS

Timely assessment of illness cognitions, pain-avoidance factors, and social support may help identify subgroups of relatively well-functioning FM patients at risk of longer term aggravated psychological distress.

Emotion regulation in patients with rheumatic diseases: validity and responsiveness of the Emotional Approach Coping Scale (EAC)

BACKGROUND

Chronic rheumatic diseases are painful conditions which are not entirely controllable and can place high emotional demands on individuals. Increasing evidence has shown that emotion regulation in terms of actively processing and expressing disease-related emotions are likely to promote positive adjustment in patients with chronic diseases. The Emotional Approach Coping Scale (EAC) measures active attempts to acknowledge, understand, and express emotions. Although tested in other clinical samples, the EAC has not been validated for patients with rheumatic diseases. This study evaluated the data quality, internal consistency reliability, validity and responsiveness of the Norwegian version of the EAC for this group of patients.

METHODS

220 patients with different rheumatic diseases were included in a cross-sectional study in which data quality and internal consistency were assessed. Construct validity was assessed through comparisons with the Brief Approach/Avoidance Coping Questionnaire (BACQ) and the General Health Questionnaire (GHQ-20). Responsiveness was tested in a longitudinal pretest-posttest study of two different coping interventions, the Vitality Training Program (VTP) and a Self-Management Program (SMP).

RESULTS

The EAC had low levels of missing data. Results from principal component analysis supported two subscales, Emotional Expression and Emotional Processing, which had high Cronbach's alphas of 0.90 and 0.92, respectively. The EAC had correlations with approach-oriented items in the BACQ in the range 0.17-0.50. The EAC Expression scale had a significant negative correlation with the GHQ-20 of -0.13. As hypothesized, participation in the VTP significantly improved EAC scores, indicating responsiveness to change.

CONCLUSION

The EAC is an acceptable and valid instrument for measuring emotional processing and expression in patients with rheumatic diseases. The EAC scales were responsive to change in an intervention designed to promote emotion regulation. The instrument has not yet been tested for test-retest reliability, which is recommended in future studies.

Piloting education days for patients with early rheumatoid arthritis and their partners: a multidisciplinary approach

OBJECTIVES

To develop, pilot, refine and reassess an education day presented by a rheumatology multidisciplinary team (MDT) for recently diagnosed (less than six months) rheumatoid arthritis (RA) patients and their partners/carers.

METHODS

A patient education day was developed drawing on an assessment of local patient educational needs and preferences and input from a rheumatology MDT. Feedback from the first education day (2004) (Day 1; 12 patients; age range 19-63 years (median 46); 10 of whom were accompanied by a partner) informed the development of a second education day (2005) (Day 2; 19 patients; age range 36-75 years (median 57.5); 13 of whom were accompanied by a partner). Participants completed evaluation forms on both days and at follow-up between six and seven weeks later, rating each session on a 5-point scale on dimensions of 'informative', 'useful', 'interesting' and 'enjoyable'. A global rating of the day's 'usefulness' was completed at the end of each day on a 10-point scale. Participants were asked to write comments on each session and on aspects of the entire day. RA knowledge, and general and RA-specific self-efficacy were also measured on day 2 (and at follow-up) using the 12-item Patient Knowledge Questionnaire, the 10-item generalized self-efficacy scale and a four-item RA-specific self-efficacy scale. Both qualitative and quantitative methodologies were used in the analysis.

RESULTS

Ratings for individual sessions were all high, with no session being rated below 4 out of 5 (1 = 'totally disagree' to 5 = 'totally agree') on both days. The majority of patients (84%) and their partners (57%) responded to the follow-up. Many had used the information package distributed on the day. Some patients and their partners reported positive changes in RA management. Although patient knowledge did not increase significantly (medians 11 at both time points, p = 0.054) (Day 2), RA self-efficacy improved (baseline 11 and 14, respectively), suggesting that patients were more confident in managing their condition (p = 0.010).

CONCLUSIONS

The development of this 'local' education and information intervention was carried out in line with Medical Research Council guidelines, and the lessons learned from Day 1 informed further development for Day 2. A one-day format for education of early RA involving the rheumatology MDT was rated highly by participants and warrants further examination. Although this study was a small 'local' intervention, its strengths are that it informs the possibility of wider developments of this kind using a MDT.

Symptoms of Depression Predict the Trajectory of Pain Among Patients with Early Inflammatory Arthritis: A Path Analysis Approach to Assessing Change

Objective.

To assess the longitudinal relationships, including directionality, among chronic pain, symptoms of depression, and disease activity in patients with early inflammatory arthritis (EIA).

Methods.

One hundred eighty patients with EIA completed an examination, including swollen joint count, and were administered the Center for Epidemiological Studies Depression Scale (CES-D) and the McGill Pain Questionnaire (MPQ) at 2 timepoints 6 months apart. Cross-lagged panel path analysis was used to simultaneously assess concurrent and longitudinal relationships among pain, symptoms of depression, and number of swollen joints.

Results.

Pain, symptoms of depression, and number of swollen joints decreased over time (p < 0.001) and were prospectively linked to pain, symptoms of depression, and number of swollen joints, respectively, at 6 months. Symptoms of depression and pain were correlated with each other at baseline (0.47) and at 6-month followup assessments (0.28). Baseline symptoms of depression significantly predicted pain symptoms at 6 months (standardized regression coefficient = 0.28, p = 0.001), whereas pain and disease activity did not predict the course of any other variable after controlling for baseline values.

Conclusion.

Symptoms of depression predicted the trajectory of pain from baseline to 6 months. In addition, there were reciprocal/bidirectional associations between pain and symptoms of depression over time. More research is needed to better understand the relationship between pain and depressive symptoms and how to best manage patients with EIA who have high levels of both.

Tailored cognitive-behavioral therapy for fibromyalgia: two case studies

OBJECTIVE

To illustrate a multidisciplinary group treatment for patients with fibromyalgia (FM) tailored to the patient's cognitive-behavioral pattern.

METHOD

In a case-study design the tailored treatment approaches of two FM patients were described. One patient characterized by avoidance behavior (pain-avoidance pattern) participated in a group treatment aimed at changing pain-avoidance mechanisms and one patient characterized by continuing with activities in spite of pain (pain-persistence pattern) participated in a group treatment aimed at changing pain-persistence mechanisms. Assessments were made at baseline, post-treatment and at 6-months follow-up.

RESULTS

Comparison of the pretest, post-test and follow-up scores on pain, functional disability, fatigue and psychological distress showed clinically significant improvements for both patients.

CONCLUSION

The heterogeneity of patients regarding pain-related cognitive-behavioral mechanisms has been proposed to underlie varying treatment outcomes in FM patients. These results demonstrate that a group treatment tailored to pain-avoidance and pain-persistence patterns is feasible and can result in clinically significant changes for FM patients.

PRACTICE IMPLICATIONS

FM offers a great challenge for clinicians due to the lack of effective treatment options. These case studies suggests that tailored CBT and exercise training directed at specific patient patterns can contribute to the improvement of the care of FM patients.

Psychological well-being across 1 year with rheumatoid arthritis: coping resources as buffers of perceived stress

OBJECTIVES

Using the transactional model of stress and coping, the present study investigated whether specific coping resources act as buffers of the relationship between perceived stress and psychological well-being among rheumatoid arthritis (RA) patients.

DESIGN

A longitudinal observational study was carried out with assessments at baseline, 6 months and 1 year.

METHODS

Measures of perceived stress, coping resources (optimism/pessimism, social support and explicit active coping strategies) and psychological well-being (anxiety, depression and life satisfaction) were completed by 134 RA patients. Demographics, RA duration, pain, fatigue, functional disability, antidepressant use and physical comorbidities were recorded and statistically controlled for.

RESULTS

Perceived stress had the strongest relationship with psychological well-being at baseline, and affected anxiety after 6 months. Optimism and pessimism predicted psychological well-being across 1 year. Active behavioural coping buffered an association of stress with depression at baseline, while baseline active cognitive coping buffered the effect of baseline stress on life satisfaction after 6 months.

CONCLUSIONS

Patients with RA under greater perceived stress who do not use active coping strategies appear to be at risk of psychological comorbidity and may therefore benefit from interventions teaching specific active coping strategies. Larger observational studies and interventions are required to confirm and extend these findings.

Predictors of functional disability in rheumatoid arthritis: results from a 13-year prospective study

PURPOSE

To explore the role of distress and social support as modifiers of functional disability in rheumatoid arthritis (RA). We hypothesized that: (a) higher inflammatory activity, more joint tenderness and more pain lead to more disability, and (b) that more distress and less social support lead to more disability and accelerate the disablement process by moderating the effects of inflammatory activity, joint tenderness and pain.

METHODS

The study is a Dutch extension of the European Research on Incapacitating Diseases and Social Support (EURIDISS) which started with 292 patients. After five waves of data collection 129 still participated. Correlational and hierarchical regression analyses were performed.

RESULTS

In short-term RA, 68% of the variance in disability could be explained primarily by mean disability over the prior years. Other important predictors were inflammatory activity and pain. In long-term RA, 56% of the variance in disability could be explained primarily by mean disability over the prior years. Other important predictors were joint tenderness and pain. No clear moderator effects of distress and social support were found in short-term or long-term RA.

CONCLUSIONS

The results confirm the main pathway from pathology to disability in short-term and long-term RA, but do not provide support for the influence of distress and social support on the disablement process.

Role of age, sex, and obesity in the higher prevalence of arthritis among lower socioeconomic groups: a population-based survey

OBJECTIVE

To compare the prevalence of arthritis among population groups based on demographic, socioeconomic, and body mass index (BMI) characteristics; to investigate the combined influence of these factors on arthritis; and to assess the relationship between self-reported health and psychological distress and arthritis.

METHODS

Data from the Victorian Population Health Survey (n = 7,500) were used in the study. Psychological distress was assessed using the Kessler Psychological Distress scale, and self-reported health was assessed by a single item. Multiple logistic regression was used to investigate the combined influence of demographic and socioeconomic factors and BMI on arthritis.

RESULTS

Overall, 23% of Victorian adults (20% men and 26% women) reported having arthritis. The presence of arthritis was associated with high psychological distress (odds ratio [OR] 1.2; 95% confidence interval [95% CI] 1.1-1.4) and poor self-reported health (OR 1.9; 95% CI 1.7-2.1). Increased prevalence of arthritis was found in older age groups, lower education and income groups, and in people who were overweight or obese. Women had higher risk of arthritis, even after adjustment for age, residence, education, occupation, income, and BMI. Age and BMI independently predicted arthritis for men and women. For men, higher risk of arthritis was also associated with lower income.

CONCLUSION

Arthritis is a highly prevalent condition associated with poor health and high psychological distress. Prevalence of arthritis is disproportionately high among women and individuals from lower socioeconomic backgrounds. As the prevalence of arthritis is predicted to increase, careful consideration of causal factors, and setting priorities for resource allocation for the treatment and prevention of arthritis are required.

Disability, social support, and distress in rheumatoid arthritis: results from a thirteen-year prospective study

OBJECTIVE

To examine the strength and stability of the relationships between disease-related factors (joint tenderness, pain, and functional disability), social support, and distress over time, and to investigate to what extent disease-related factors and social support can predict distress in short-term and long-term rheumatoid arthritis (RA).

METHODS

The study was a Dutch extension of the European Research on Incapacitating Diseases and Social Support and started with 292 patients. After 5 waves of data collection, 129 patients remained. Composite measures were computed following the area under the curve approach. Interaction terms were computed between functional disability and social support satisfaction. Correlational and hierarchical regression analyses were performed.

RESULTS

In patients with short-term RA, disease-related factors and social support were important in determining distress. Also, a buffering effect of social companionship was found. In total, 51% of the variance in distress in short-term RA could be explained primarily by mean distress over the previous years. In patients with long-term RA, disease-related factors remained important in determining distress, but to a lesser extent. Seventeen percent of the variance in distress in long-term RA could be explained primarily by mean distress over the years before.

CONCLUSION

During the course of the disease, patients may learn to adjust to their disease and its consequences and are able to maintain a normal distress level. The effect of the disease on psychological distress decreased over the years. Some support for the buffering hypothesis of social support was found in short-term RA, but not in long-term RA.

Understanding the process of adjustment to illness

This article examines the literature relating to adjustment to physical illness. Adjustment is invariably defined in the literature as some aspect of psychological function. However, in reality, adjustment is a process that begins at the presentation of symptoms and continues throughout the course of the illness and responds to changes in illness status. Physical illness can be conceptualized as a stressor, the demands of which depend upon the characteristics and severity of the illness. Recent research confirms that many of the factors known to be associated with the development of psychological disorders in the absence of physical illness are also relevant to the development of psychological problems in those with ill health. The prevalence of psychological disorders is also generally found to be considerably higher amongst those with a variety of health problems. Nonetheless, a considerable number of patients who experience even the most devastating of illnesses seem able to adjust to illness without experiencing clinically significant psychological problems. The processes by which these people are able to adjust and, in many cases, find positive meaning in their experiences, are important to understand. While a number of models have been put forward to explain various aspects of adjustment to chronic illness, an integrated approach that describes how the process of adjustment evolves is needed. Such an understanding will allow clinicians to improve interventions that facilitate adjustment and potentially prevent long-term problems. Facilitating a patient's adjustment to illness must be a priority in providing an optimal level of health care.

Sociodemographic differences in quality of life in rheumatoid arthritis

Assessment of health-related quality of life (HR-QOL) in people with rheumatoid arthritis (RA) has become important in health research and can inform clinical care. Many studies have found sociodemographic differences in the HR-QOL of people with RA, and interpreting these differences can be challenging. Biological, health disparity, reporting and assessment instrument differences are a few of the possible explanations that should be considered when interpreting results. Our review of the evidence of sociodemographic differences in HR-QOL in people with RA produced 34 articles describing 49 studies.Typically, patients with RA who were older, female, less educated, non-employed and/or less affluent tended to have significantly lower HR-QOL than other groups. Some evidence also indicated that people with RA who are non-White or who live in rural settings may also tend to have lower HR-QOL scores, but the number of studies supporting these findings was sparse. Researchers and clinicians can optimise their assessment of HR-QOL by finding well validated instruments for the context they are working in. Additional research is needed to identify the exact causes of HR-QOL differences so that quality treatment can be provided to those in need.

Psychological distress and personality traits in early rheumatoid arthritis: a preliminary survey

OBJECTIVES

To investigate psychiatric manifestations, personality traits, and ego mechanisms of defense involved in early rheumatoid arthritis (RA).

METHODS

Twenty-two unselected early RA outpatients with disease duration less than 1 year participated in the study. The majority of participants were females (72.7%), married (81.8%), aged 51.0+/-14.6 years. Thirty-four subjects matched for age, sex and educational level served as "healthy" controls. General Heath Questionnaire, Symptom Distress Checklist, Defense Style Questionnaire and Hostility and Direction of Hostility Questionnaire were used; disease activity was estimated by disease activity for 28-joint indices score.

RESULTS

Seven patients (31.8%) presented psychological distress scores indicative of possible psychiatric caseness, expressing obsessive-compulsive symptoms and depression, as compared to six (17.6%) of controls. Social dysfunction distress and somatization were prominent psychiatric manifestations in early RA group. Early RA patients tend to adopt a less adaptive defense style than controls. Although disease activity was not correlated to psychological distress, a significant association between disease activity and patients' defensive style was observed: as the disease is exacerbated, there was a shift from "non-adaptive" to "immature image distorting or borderline" defense style, suggesting a rather fragile underlying personality structure.

CONCLUSION

Psychological distress is a relatively common experience in early RA. Social dysfunction, along with the less adaptive defense style, which under the stress of the disease exacerbation turns to "borderline", underlines the importance of a careful assessment and consultation in early RA patients in order to face the distress shortly after diagnosis and highlights potential risk factors for future adaptation to exacerbations of the disease.

Psychological stress as a predictor of psychological adjustment and health status in patients with rheumatoid arthritis

This study examined the extent to which perceived stress, social support, coping and clinical disease indicators predict physical, psychological and social adjustment in patients with rheumatoid arthritis (RA). Participants were 59 women recruited at an outpatient clinic at University College Hospital, Galway. A range of psychological measures was administered and disease status was assessed by physician ratings of joint involvement and blood assays of inflammatory indices. Findings from correlational and hierarchical regression analyses revealed a number of statistically significant relationships (p<.01). Perceived stress was a better predictor than disease severity of positive and negative emotionality. Coping explained variability on positive and negative affect. Social support was linked to level of social activity. Results demonstrated that disease status predicted illness related functioning but did not predict emotional or social adjustment. Results suggest that a cognitive behavioural intervention to facilitate patient adjustment could usefully include management of stress and its appraisal, the fostering of adaptive coping strategies and utilization of social support resources. It is concluded that improving patient adjustment to rheumatoid arthritis has implications for medical care seeking.

Predicting emotional response to unsuccessful fertility treatment: a prospective study

The predictive value of a comprehensive model with personality characteristics, stressor related cognitions, coping and social support was tested in a sample of 187 nonpregnant women. The emotional response to the unsuccessful treatment was predicted out of vulnerability factors assessed before the start of the treatment. The results indicated the importance of neuroticism as a vulnerability factor in emotional response to a severe stressor. They also underlined the importance of helplessness and marital dissatisfaction as additional risk factors, and acceptance and perceived social support as additional protective factors, in the development of anxiety and depression after a failed fertility treatment. From clinical point of view, these results suggest fertility-related cognitions and social support should receive attention when counselling women undergoing IVF or ICSI treatment.

Well-being in rheumatoid arthritis: the effects of disease duration and psychosocial factors

This study examined the multivariate relationships of psychosocial factors with well-being in rheumatoid arthritis (RA). Fifty-five patients with early RA (<six months), 52 with intermediate RA (one-seven years) and 47 with established RA (>seven years) completed questionnaires on psychosocial factors and psychological and physical well-being. Illness perceptions related to worse depression and life satisfaction (especially in early RA) and to longer morning stiffness (especially in intermediate RA). Optimism related to lower pain in early and intermediate RA. Social support related to lower fatigue in established RA. Indications for interventions targeted by disease duration are discussed.

Are there more than cross-sectional relationships of social support and support networks with functional limitations and psychological distress in early rheumatoid arthritis? The European Research on Incapacitating Diseases and Social Support Longitudinal

OBJECTIVE

To investigate whether greater social support and support network are cross-sectionally associated with less functional limitations and psychological distress in patients with early rheumatoid arthritis (RA); whether this association is constant over time; and whether increases in social support or support network are associated with less functional limitations and psychological distress.

METHODS

Subjects were from the European Research on Incapacitating Diseases and Social Support cohort and had early RA. Social support, support network, functional limitations (Health Assessment Questionnaire), and psychological distress (General Health Questionnaire) were assessed annually. Variance and covariance analyses with repeated measures were performed.

RESULTS

A total of 542 subjects were assessed for 3 years. On average, patients with a greater amount of specific social support or a stronger specific support network experienced less functional limitation and less psychological distress. Changes in a given subject's functional limitations and psychological distress did not depend on his or her baseline social support or support network. Neither social support nor support network change over time.

CONCLUSION

There may be a cross-sectional link between specific social support or support network and functional limitations and psychological distress, but no longitudinal association could be evidenced.

Development of web-based qualitative and quantitative data collection systems: Study on daily symptoms and coping strategies among Japanese rheumatoid arthritis patients

With the sharp rise in Internet access in recent years, the Internet is increasingly being used for research. We have developed two new systems using the Internet for both quantitative and qualitative data collection. One is a dynamic system for creating questionnaires and collecting responses and the other is an individual patient support follow-up system. These systems do not depend on the capacity of computers or servers and enable researchers to interact with participants privately and asynchronously. We have used these systems to collect data on daily symptoms and journal entries from 12 community-dwelling women with rheumatoid arthritis (RA) for a minimum of 1 month. The mean number of data submissions per month was 14.2 +/- 7.8, with the majority recording entries every day, and some submitting several times a day. The combination of two types of data elucidated the changes in coping and coping strategies in conjunction with changes in symptoms, even in a single day, and the coexistence of positive and negative coping. Research participants benefited from web-based symptom management and counseling resulting from 1 month of frequent interactions with the researcher. The use of the Internet for nursing research and interventions thus seems to show promising results.

Models of adjustment to chronic illness: Using the example of rheumatoid arthritis

There are a number of theoretical frameworks that attempt to explain how individuals may adjust to threats to health and serious physical illness. The three major paradigms that attempt to organize key components of health and adaptation to illness include the following: the biomedical model which emphasizes disease; psychological models of adaptation to illness; and biopsychosocial models with the latter two emphasizing health, functioning, and well-being. Each of these three major paradigms, including biomedical, psychosocial, and biopsychosocial frameworks, is discussed and critiqued in turn, and contributions and theoretical issues in terms of adjustment to chronic illness, particularly rheumatoid arthritis (RA), are highlighted. Furthermore, a biopsychosocial framework for conceptualizing adjustment to physical illness is proposed that incorporates elements from key existing biomedical and psychosocial models of adaptation to chronic physical health issues.