The effects of written emotional disclosure and coping skills training in rheumatoid arthritis: a randomized clinical trial.

OBJECTIVE: Two psychological interventions for rheumatoid arthritis (RA) are cognitive-behavioral coping skills training (CST) and written emotional disclosure (WED). These approaches have developed independently, and their combination may be more effective than either one alone. Furthermore, most studies of each intervention have methodological limitations, and each needs further testing. METHOD: We randomized 264 adults with RA in a 2 × 2 factorial design to 1 of 2 writing conditions (WED vs. control writing) followed by 1 of 2 training conditions (CST vs. arthritis education control training). Patient-reported pain and functioning, blinded evaluations of disease activity and walking speed, and an inflammatory marker (C-reactive protein) were assessed at baseline and 1-, 4-, and 12-month follow-ups. RESULTS: Completion of each intervention was high (>90% of patients), and attrition was low (10.2% at 12-month follow-up). Hierarchical linear modeling of treatment effects over the follow-up period, and analyses of covariance at each assessment point, revealed no interactions between writing and training; however, both interventions had main effects on outcomes, with small effect sizes. Compared with control training, CST decreased pain and psychological symptoms through 12 months. The effects of WED were mixed: Compared with control writing, WED reduced disease activity and physical disability at 1 month only, but WED had more pain than control writing on 1 of 2 measures at 4 and 12 months. CONCLUSIONS: The combination of WED and CST does not improve outcomes, perhaps because each intervention has unique effects at different time points. CST improves health status in RA and is recommended for patients, whereas WED has limited benefits and needs strengthening or better targeting to appropriate patients.

Does emotional disclosure about stress improve health in rheumatoid arthritis? Randomized, controlled trials of written and spoken disclosure.

Studies of the effects of disclosing stressful experiences among patients with rheumatoid arthritis (RA) have yielded inconsistent findings, perhaps due to different disclosure methods--writing or speaking--and various methodological limitations. We randomized adults with RA to a writing (n=88) or speaking (to a recorder) sample (n=93), and within each sample, to either disclosure or 1 of 2 control groups (positive or neutral events), which conducted four 20-minute, at-home sessions. Follow-up evaluations at 1, 3, and 6 months included self-reported, behavioral, physiological, and blinded physician-assessed outcomes. In both writing and speaking samples, the disclosure and control groups were comparably credible, and the linguistic content differed as expected. Covariance analyses at each follow-up point indicated that written disclosure had minimal effects compared with combined controls--only pain was reduced at 1 and 6 months, but no other outcomes improved. Spoken disclosure led to faster walking speed at 3 months, and reduced pain, swollen joints, and physician-rated disease activity at 6 months, but there were no effects on other outcomes. Latent growth curve modeling examined differences in the trajectory of change over follow-up. Written disclosure improved affective pain and walking speed; spoken disclosure showed only a marginal benefit on sensory pain. In both analyses, the few benefits of disclosure occurred relative to both positive and neutral control groups. We conclude that both written and spoken disclosure have modest benefits for patients with RA, particularly at 6 months, but these effects are limited in scope and consistency.

Pain, executive functioning, and affect in patients with rheumatoid arthritis.

OBJECTIVES: Rheumatoid arthritis (RA) is a chronic inflammatory disease resulting in substantial pain. The physical and emotional effects of RA are well known, but little attention has been given to the potential cognitive effects of RA pain, although intact executive functioning in patients with chronic illness is crucial for the successful completion of many daily activities. We examined the relationship between pain and executive functioning in patients with RA, and also considered the influence of positive and negative affect in the relationship between pain and executive functioning. METHODS: A sample of 157 adults with RA completed measures of pain and positive and negative affect and were tested for working memory and selective attention using the Letter Number Sequencing subtest from the Wechsler Adult Intelligence Scale-Third Edition and the Stroop Color Word Test tests, respectively. RESULTS: Consistent with prior research, pain was inversely related to executive functioning, with higher pain levels associated with poorer performance on executive functioning tasks. This relationship was not moderated or mediated by negative affect; however, positive affect moderated the relationship between pain and executive functioning. For patients high in positive affect there was a significant inverse relationship between pain and executive functioning, whereas there was no such relationship for patients low in positive affect. DISCUSSION: These findings are discussed in the context of cognitive research on the effects of positive affect on executive functioning and functional neuroanatomical research suggesting neurocognitive mechanisms for such moderation.

Disease severity and domain-specific arthritis self-efficacy: relationships to pain and functioning in patients with rheumatoid arthritis.

OBJECTIVE: To examine the degree to which disease severity and domains of self-efficacy (pain, function, and other symptoms) explain pain and functioning in rheumatoid arthritis (RA) patients. METHODS: Patients (n = 263) completed the Arthritis Impact Measurement Scales 2 to assess pain and functioning (physical, affective, and social), the Arthritis Self-Efficacy Scale to assess 3 self-efficacy domains (pain, physical function, and other). Disease severity was assessed with C-reactive protein level, physician's rating, and abnormal joint count. Structural equation modeling was used to examine 3 hypotheses: does disease severity have a direct relationship with pain and each area of functioning, does disease severity have a direct relationship with each arthritis self-efficacy domain, and do the self-efficacy domains mediate the relationship between disease severity and RA pain and each area of functioning. RESULTS: Disease severity was related to pain, physical functioning, and each self-efficacy domain (beta = 0.28-0.56, P < 0.001). Each self-efficacy domain was related to its respective domain of functioning (e.g., self-efficacy for pain was related to pain; beta = 0.36-0.54, P < 0.001). Self-efficacy mediated the relationship between disease severity and pain and functioning (beta = 0.12-0.19, P < 0.001). Self-efficacy for pain control and to perform functional tasks accounted for 32-42% of disease severity's total effect on their respective outcomes (e.g., self-efficacy for pain control accounted for 32% of disease severity's total effect on pain). Variance accounted for by the total model was 52% for pain, 53% for physical functioning, and 44% for affective and social functioning. CONCLUSION: Disease severity and self-efficacy both impact RA functioning, and intervening in these areas may lead to better outcomes.

Pain and functioning of rheumatoid arthritis patients based on marital status: is a distressed marriage preferable to no marriage?

UNLABELLED: Relationships may influence adjustment to chronic pain conditions such as rheumatoid arthritis (RA). We examined how both marital status and marital adjustment were related to pain, physical disability, and psychological disability in 255 adults with RA. Among married participants (n = 158), better marital adjustment (assessed using the Locke-Wallace Marital Adjustment Scale) was correlated with less pain and physical and psychological disability (all P values < .05). Married participants were divided into distressed (n = 44) and nondistressed (n = 114) subgroups and compared with unmarried participants (n = 97). Controlling for demographics and disease severity, unmarried participants had higher affective pain (P = .009) and higher psychological disability (P = .02) than only the nondistressed married participants, but unmarried participants did not differ from distressed married participants. These findings suggest that being married in itself is not associated with better health in RA but that being in a well-adjusted or nondistressed marriage is linked with less pain and better functioning. PERSPECTIVE: This study examined relationships of marital status and marital adjustment to pain and physical and psychological disability in RA. Findings underscore the importance of considering not only marital status but also degree of marital adjustment in RA and may inform clinical interventions in this population.

Arthritis quality indicators for the Veterans Administration: implications for electronic data collection, storage format, quality assessment, and clinical decision support.

The Veterans Administration (VA) uses information technology and performance measures to improve quality and efficiency. The VA stores all patient data electronically. Manual quality assessment audits are performed every three months. They are time consuming and expensive. Automated reviews would be more efficient. But the patient records are neither sufficiently coded nor structured to allow for full machine interpretability. Evidence-based rheumatology quality indicators have been proposed for inclusion in the quality data set. Automated reviews for some conditions would be possible with modification to some VA electronic data entry screens and to the underlying data repository. This effort would risk the imposition of untenable data entry and workflow burdens upon clinicians. This paper outlines some specific considerations for one disease, rheumatoid arthritis.

The health effects of at-home written emotional disclosure in fibromyalgia: a randomized trial.

BACKGROUND: The presence and severity of the chronic pain syndrome fibromyalgia (FM) is associated with unresolved stress and emotional regulation difficulties. Written emotional disclosure is intended to reduce stress and may improve health of people with FM. PURPOSE: This study tests the effects of at-home, written emotional disclosure about stressful experiences on the health of people with FM and uses multiple follow-ups to track the time course of effects of disclosure. METHODS: Adults with FM (intention-to-treat, n=83; completers, n=72) were randomized to write for 4 days at home about either stressful experiences (disclosure group) or neutral time management (control group). Group differences in immediate mood effects and changes in health from baseline to 1-month and 3-month follow-ups were examined. RESULTS: Written disclosure led to an immediate increase in negative mood, which did not attenuate across the 4 writing days. Repeated-measures analyses from baseline to each follow-up point were conducted on both intention-to-treat and completer samples, which showed similar outcomes. At 1 month, disclosure led to few health benefits, but control writing led to less negative affect and more perceived support than did disclosure. At 3-month follow-up, these negative affect and social support effects disappeared, and written disclosure led to a greater reduction in global impact, poor sleep, health care utilization, and (marginally) physical disability than did control writing. Interpretation of these apparent benefits needs to be made cautiously, however, because the disclosure group had somewhat poorer health than controls at baseline and the control group showed some minor worsening over time. CONCLUSIONS: Written emotional disclosure can be conducted at home, and there is tentative evidence that disclosure benefits the health of people with FM. The benefits, however, may be delayed for several months after writing and may be of limited clinical significance.

Alexithymia and pain in three chronic pain samples: comparing Caucasians and African Americans.

OBJECTIVE: African Americans often report greater pain than do Caucasians, but the factors responsible for this discrepancy are not known. We examined whether alexithymia-the trait of difficulty identifying and describing one's feelings and lacking introspection-may contribute to this ethnic group difference. We tested whether the mean level of alexithymia is higher, and whether alexithymia and pain are more highly correlated, among African Americans than among Caucasians in patients with chronic pain disorders. DESIGN: Three cross-sectional, correlational studies were conducted on three separate samples of patients with chronic pain. Analyses examined the full sample and then Caucasians and African Americans separately. SETTING AND PATIENTS: Patients were recruited primarily from treatment settings. Samples were patients with rheumatoid arthritis (N = 155), migraine headaches (N = 160), or systemic lupus erythematosus (N = 123), and each sample included only Caucasians or African Americans. MEASURES: The Toronto Alexithymia Scale-20 assessed global alexithymia and three alexithymia facets. Pain severity, functional disability, or symptoms were also measured on each sample. RESULTS: Similar findings occurred across all three samples. African Americans had only slightly higher mean alexithymia levels than did Caucasians, and this was partly accounted for by socioeconomic differences between groups. More importantly, alexithymia correlated only weakly with pain or symptom severity for each full sample, but the two ethnic groups showed different patterns. Alexithymia correlated positively with pain severity among African Americans, but was uncorrelated with pain among Caucasians, even after covarying for various socioeconomic variables. CONCLUSIONS: Alexithymia is more correlated with pain severity among African Americans with chronic pain disorders than among Caucasians, potentially contributing to the higher pain reports among African Americans.

Computer applications in clinical practice.

PURPOSE OF REVIEW: The prospects of improved practice efficiencies and better treatment outcomes have recently focused political attention at high levels upon the use of information technology (IT) in routine clinical care in the US, UK and elsewhere. Providers who treat musculoskeletal diseases need to become familiar with emerging governmental policies, IT industry trends, data standards and communication protocols to equip themselves with a basis on which to evaluate and influence the development of these technologies, which in turn will influence the shape of clinical practice. RECENT FINDINGS: The articles cited are categorized into the topics of government policy regarding electronic medical records (EMRs); data definitions and databases; computers in outpatient clinical encounters; EMRs; patient self-entry of historical data; computer physician order entry; personal digital assistants; and e-mail, the Internet, and the patient/physician encounter. SUMMARY: Government agencies in the US, UK, and elsewhere are at various stages in the implementation of national health information infrastructures. US officials are playing a greater role in prompting physicians to use EMRs and in setting standards for EMR systems. A study by the American College of Rheumatology observed, 'Increasing requirements for provider compliance with quality and outcomes reporting, HIPAA regulations, medical error reduction, including Medicare e-prescribing mandates, and downward pressure on practice revenues will ultimately drive the adoption of EMRs in office practice.' Nonuse will equate to a non-viable practice. Rheumatologists who would control their own destinies must acquaint themselves with, adopt, and exert influence on the development of these technologies with all deliberate speed.

Usability of a computer-assisted interview system for the unaided self-entry of patient data in an urban rheumatology clinic.

OBJECTIVE: This study quantified the ease of use for patients and providers of a microcomputer-based, computer-assisted interview (CAI) system for the serial collection of the American College of Rheumatology Patient Assessment (ACRPA) questionnaire in routine outpatient clinical care in an urban rheumatology clinic. DESIGN: A cross-sectional survey was used. MEASUREMENTS: The answers of 93 respondents to a computer use questionnaire mailed to the 130 participants of a previous validation study of the CAI system were analyzed. For a 30-month period, the percentage of patient visits during which complete ACRPA questionnaire data were obtained with the system was determined. RESULTS: The computer system provided cost and labor savings in the collection of 2,476 questionnaires for 2,964 patients visits over 30 months for a capture rate of 83.5%. In the last 12 of those months, 1,035 questionnaires were collected for 1,062 patient visits (97.5% capture). There were no missing data. The prestudy capture rate was 13.5%, with 33% of surveys having complete data. Patients rated the overall usability of the system as good (mean = 1.34, standard deviation = 0.61) on a scale of 0-2, where 2 = good, but expressed difficulty with mouse manipulation and concerns about the privacy of the data entry environment. CONCLUSION The system proved easy to use and cost-effective for the (mostly) unaided self-entry of self-report data for each patient for each visit in routine outpatient clinical care in an urban rheumatology clinic.

Barriers to treatment adherence among African American and white women with systemic lupus erythematosus.

OBJECTIVE: To determine whether African Americans with systemic lupus erythematosus (SLE) have poorer treatment adherence than whites, and to determine ethnic group differences in barriers to adherence, and how barriers affect adherence. METHODS: We compared 68 African American and 54 white women with SLE on 19 potential barriers, on 2 adherence behaviors during the past year, and on how the potential barriers relate to each nonadherence behavior. RESULTS: African Americans and whites were similar on most barriers, although African Americans were more likely to rely on religion and were more concerned about long-term medication effects. The 2 ethnic groups were comparable on medication nonadherence, but whites tended to have poorer clinic appointment adherence than African Americans. Finally, we found that barriers related to negative affect (depression, medication concerns, physical symptoms) as well as short-term memory problems and the need for child or elder care were associated with nonadherence among African Americans, whereas perceived treatment inefficacy and lacking trust in physicians were associated with nonadherence among whites. CONCLUSION: Relationships between adherence barriers and nonadherence may be ethnicity specific, suggesting that interventions to address barriers should be targeted to specific groups.