- Email: [email protected]
Reaching rheumatologists
Journal of Psychosomatic Research 67 (2009) 367 – 368
Editorial
Reaching rheumatologists In the current issue of the Journal of Psychosomatic Research, three articles originating from the United Kingdom, Japan, and Spain all speak the same language— and I am not referring to English. Their words call attention to mind–body unity using different methodologies and various clinical and psychosocial measures with two distinct conditions: rheumatoid arthritis (RA) and fibromyalgia (FM). Implicitly, they remind us to consider the whole person rather than particular body parts (e.g., joints) or systems (e.g., immune). They ask us to incorporate patients' perspectives, including what is “on their minds” such as: hard-to-find-evidence for pain (e.g., FM), difficult-tomeasure fatigue (pervasive in autoimmune diseases), concerns about body image changes (often resulting from longterm corticosteroid use), fears about future disability, loss of gainful employment, and so on. For the past 15 years, I have been reaching out to rheumatologists in a language they understand, that is, empiricism. Working with multidisciplinary teams, including rheumatologists, physiotherapists, and biostatisticians, I have conducted studies of patients with lupus, RA, juvenile idiopathic arthritis, and FM, documenting mind–body unity employing cross-sectional and longitudinal research designs as well as randomized clinical trials. In the process, I have grown to appreciate my medical colleagues: their expertise, their sincere desire to care for the many patients crowded in their waiting rooms, and their relative lack of knowledge concerning psychosocial factors that may influence patient outcomes or how psychosocial interventions may complement their therapies. I suspect that few rheumatologists will read Lera et al.'s [1] work concerning whether the addition of cognitive behavior therapy (CBT) to multidisciplinary treatment increases the response to treatment of women with FM, in part not only because many are not convinced that FM is rheumatologic disorder, but also because they are often uninformed about what CBT has to offer their patients. Overlooking this article would be unfortunate because the study is original and addresses an important health servicerelated issue. While “real world” clinic-based multidisciplinary treatment for FM usually includes CBT [2], identifying for whom this component of the “treatment package” is helpful contributes to evidence-based referral practices. While not without its limitations (e.g., it was 0022-3999/09/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.jpsychores.2009.09.005
underpowered at the 6-month follow-up), Lera et al.'s [1] work is worthy of note because it is a randomized clinical trial that includes a physician-rated measure (tender point counts) along with patient reports of FM disability and quality of life. While CBT may be helpful for selected FM patients, mindfulness-based stress reduction (MBSR) is gaining attention in the field of mind–body medicine. In 2009, Rosenzweig et al. [3] published in the Journal of Psychosomatic Research results that also specified for whom a psychosocial intervention works best. A mixed sample of chronic pain patients, including those with arthritis and FM, was offered MBSR, and it was shown that after the program, patients with arthritis reported significantly less pain and disability, reported reductions in psychological distress, and had the largest treatment effects, whereas patients with FM had the smallest improvements with regard to pain and quality of life. One way to reach rheumatologists is to address topics that are relevant to them, such as adherence to medications, health service utilization, and disability. Kojima et al. [4] and Graves et al. [5] have done this in their respective examinations of the correlations between psychosocial and clinical variables in patients with RA. Employing factor analyses, a novel approach to organizing and interpreting complex data sets, Kojima et al. [4] found that disease activity was independent from psychosocial factors, such as social support or depression. Moreover, no significant associations were found between disease activity and mental or physical quality of life. In Graves et al. [5], disease activity was not associated with psychological functioning or illness beliefs. Do these findings indicate that the mind and body are separate after all? I think not. Rather, they remind us to consider the “two faces of medicine,” that is, curing and healing [6]. Variables such as periarticular bone loss and erosions or joint damage in RA reflect the disease activity that physicians aim to cure, whereas variables such as effective coping and improvements in pain are in the domain of healing. Research methods require us to break all of these important facets of illness into pieces we can define, measure, and investigate, but we need to recall that they are part of a whole and it is a human being who seeks both
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Editorial / Journal of Psychosomatic Research 67 (2009) 367–368
cure (when possible) and a therapeutic relationship that fosters healing. This may be offered by the physician [7] or another health care professional. Another point to consider is the scientific method used to elucidate how the body and mind function together. Crosssectional studies fail to answer important questions concerning chronic illness progression. For example, Dobkin et al. [8] found that predictors of health status in women with FM differed when using cross-sectional (baseline) data compared to 6-month longitudinal data. While more challenging and costly to conduct, prospective studies such as one reported in this journal are crucial. Early RA patients were examined at the time of diagnosis and observed 1, 3, and 5 years later. Direct effects, as well as mediating and moderating effects of stress-vulnerability factors on clinical outcomes, were examined. While no significant effects were found at the 1-year follow-up, disease activity at the 3- and 5-year follow-ups was predicted by coping and social support at the time of diagnosis. Specifically, avoidance coping was significantly related to an increase in disease activity at the 3- and 5-year followups; social support was inversely related to an increase in disease activity at the 3-year follow-up [9]. Not only is it vital to study chronic illness, such as RA, over the long haul, the use of randomized clinical trails of psychosocial interventions is a powerful means of demonstrating how the body and mind are connected. For example, Pradhan et al. [10] randomly assigned RA patients to MBSR or a wait-list control group who received usual medical care. In this psychosocial program, patients are taught directly about how the mind and body influence each other; they learn ways of reducing automatic reactivity and arousal by practicing various forms of meditation. Significant improvements in psychological distress and well-being were reported following MBSR despite there being no change in disease activity. In another randomized clinical trial, Zautra et al. [11], similar to Lera et al., were able to determine for whom a particular type of psychosocial intervention was most beneficial. Comparisons between CBT, MBSR, and an education-only control group were made in 144 RA patients pre- and posttreatment as well as 6 months later. In this study, CBT and MBSR were both helpful but in different ways. CBT provided better cognitive control over pain, whereas MBSR provided better emotional regulation. Importantly, it was shown that RA patients with a history of depression who were in the MBSR group showed significant improvements on physician-assessed joint swelling and tenderness. Given that depression is common in RA, this study reminds us to screen for it and refer patients in need of adjunct services accordingly.
Can we speak a common language for the benefit of our patients? I think so. By taking an interdisciplinary approach in theory, research, and practice, we acknowledge the complexity of health and disease in an inclusive manner. As Zautra [12] in a commentary in this journal said, “Much more can be learned when the gatekeepers within each of the core disciplines display a greater openness to thinking outside their own circles.” Patricia L. Dobkin Department of Medicine McGill University, Montreal, Canada E-mail address: [email protected] References [1] Lera S, Gelman SM, López MJ, Abenoza M, Zorrilla JG, Castro-Fornieles J, Salamero M. Multidisciplinary treatment of fibromyalgia: does cognitive behavior therapy increase the response to treatment? J Psychosom Res 2009;67:433–41. [2] Dobkin PL, Ionescu-Ittu R, Abrahamowicz M, Baron M, Bernatsky S, Sita A. Predictors of adherence to an integrated multimodal program for fibromyalgia. J Rheumatol 2008;35:2255–64. [3] Rosenzweig S, Greeson JM, Reibel DK, Green JS, Jasser SA, Beasley E. Mindfulness-based stress reduction for chronic pain conditions: variation in treatment outcomes and role of home meditation practice. J Psychosom Res 2009. doi:10.1016/j.jpsychores.2009.03.010 [In Press]. [4] Kojima M, Kojima T, Ishiguro N, Oguchi T, Oba M, Tsuchiya H, Sugiura F, Furukawa TA, Suzuki S, Tokudome S. Psychosocial factors, disease status, and quality of life in patients with rheumatoid arthritis. J Psychosom Res 2009;67:425–31. [5] Graves H, Scott DL, Lempp H, Weinman J. Illness beliefs predict disability in rheumatoid arthritis. J Psychosom Res 2009;67:417–23. [6] Hutchinson TA, Hutchinson N, Arnaert A. Whole person care: encompassing the two faces of medicine. Can Med Assoc J 2009;180: 845–6. [7] Dobkin PL. Fostering healing through mindfulness in the context of medical practice. Curr Oncol 2009;16:4–6. [8] Dobkin PL, De Civita M, Abrahamowicz M, Baron M, Bernatsky S. Predictors of health status in women with fibromyalgia: a prospective study. Int J Behav Med 2006;13:101–8. [9] Evers AW, Kraaimaat FW, Geenen R, Jacobs JW, Bijlsma JW. Stressvulnerability factors as long-term predictors of disease activity in early rheumatoid arthritis. J Psychosom Res 2003;55:293–302. [10] Pradhan EK, Baumgarten M, Langenberg P, Handwerger B, Gilpin AK, Magyari T, Hochberg MC, Berman BM. Effect of mindfulnessbased stress reduction in rheumatoid arthritis patients. Arthritis Rheum 2007;57:1134–42. [11] Zautra AJ, Davis MC, Reich JW, Nicassario P, Tennen H, Finan P, Kratz A, Parrish B, Irwin MR. Comparison of cognitive behavioral and mindfulness meditation interventions on adaptation to rheumatoid arthritis for patients with and without history of recurrent depression. J Consult Clin Psychol 2008;76:408–21. [12] Zautra AJ. Comment on “stress-vulnerability factors as long-term predictors of disease activity in early rheumatoid arthritis”. J Psychosom Res 2003;55:303–4.
Editorial
Reaching rheumatologists In the current issue of the Journal of Psychosomatic Research, three articles originating from the United Kingdom, Japan, and Spain all speak the same language— and I am not referring to English. Their words call attention to mind–body unity using different methodologies and various clinical and psychosocial measures with two distinct conditions: rheumatoid arthritis (RA) and fibromyalgia (FM). Implicitly, they remind us to consider the whole person rather than particular body parts (e.g., joints) or systems (e.g., immune). They ask us to incorporate patients' perspectives, including what is “on their minds” such as: hard-to-find-evidence for pain (e.g., FM), difficult-tomeasure fatigue (pervasive in autoimmune diseases), concerns about body image changes (often resulting from longterm corticosteroid use), fears about future disability, loss of gainful employment, and so on. For the past 15 years, I have been reaching out to rheumatologists in a language they understand, that is, empiricism. Working with multidisciplinary teams, including rheumatologists, physiotherapists, and biostatisticians, I have conducted studies of patients with lupus, RA, juvenile idiopathic arthritis, and FM, documenting mind–body unity employing cross-sectional and longitudinal research designs as well as randomized clinical trials. In the process, I have grown to appreciate my medical colleagues: their expertise, their sincere desire to care for the many patients crowded in their waiting rooms, and their relative lack of knowledge concerning psychosocial factors that may influence patient outcomes or how psychosocial interventions may complement their therapies. I suspect that few rheumatologists will read Lera et al.'s [1] work concerning whether the addition of cognitive behavior therapy (CBT) to multidisciplinary treatment increases the response to treatment of women with FM, in part not only because many are not convinced that FM is rheumatologic disorder, but also because they are often uninformed about what CBT has to offer their patients. Overlooking this article would be unfortunate because the study is original and addresses an important health servicerelated issue. While “real world” clinic-based multidisciplinary treatment for FM usually includes CBT [2], identifying for whom this component of the “treatment package” is helpful contributes to evidence-based referral practices. While not without its limitations (e.g., it was 0022-3999/09/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.jpsychores.2009.09.005
underpowered at the 6-month follow-up), Lera et al.'s [1] work is worthy of note because it is a randomized clinical trial that includes a physician-rated measure (tender point counts) along with patient reports of FM disability and quality of life. While CBT may be helpful for selected FM patients, mindfulness-based stress reduction (MBSR) is gaining attention in the field of mind–body medicine. In 2009, Rosenzweig et al. [3] published in the Journal of Psychosomatic Research results that also specified for whom a psychosocial intervention works best. A mixed sample of chronic pain patients, including those with arthritis and FM, was offered MBSR, and it was shown that after the program, patients with arthritis reported significantly less pain and disability, reported reductions in psychological distress, and had the largest treatment effects, whereas patients with FM had the smallest improvements with regard to pain and quality of life. One way to reach rheumatologists is to address topics that are relevant to them, such as adherence to medications, health service utilization, and disability. Kojima et al. [4] and Graves et al. [5] have done this in their respective examinations of the correlations between psychosocial and clinical variables in patients with RA. Employing factor analyses, a novel approach to organizing and interpreting complex data sets, Kojima et al. [4] found that disease activity was independent from psychosocial factors, such as social support or depression. Moreover, no significant associations were found between disease activity and mental or physical quality of life. In Graves et al. [5], disease activity was not associated with psychological functioning or illness beliefs. Do these findings indicate that the mind and body are separate after all? I think not. Rather, they remind us to consider the “two faces of medicine,” that is, curing and healing [6]. Variables such as periarticular bone loss and erosions or joint damage in RA reflect the disease activity that physicians aim to cure, whereas variables such as effective coping and improvements in pain are in the domain of healing. Research methods require us to break all of these important facets of illness into pieces we can define, measure, and investigate, but we need to recall that they are part of a whole and it is a human being who seeks both
368
Editorial / Journal of Psychosomatic Research 67 (2009) 367–368
cure (when possible) and a therapeutic relationship that fosters healing. This may be offered by the physician [7] or another health care professional. Another point to consider is the scientific method used to elucidate how the body and mind function together. Crosssectional studies fail to answer important questions concerning chronic illness progression. For example, Dobkin et al. [8] found that predictors of health status in women with FM differed when using cross-sectional (baseline) data compared to 6-month longitudinal data. While more challenging and costly to conduct, prospective studies such as one reported in this journal are crucial. Early RA patients were examined at the time of diagnosis and observed 1, 3, and 5 years later. Direct effects, as well as mediating and moderating effects of stress-vulnerability factors on clinical outcomes, were examined. While no significant effects were found at the 1-year follow-up, disease activity at the 3- and 5-year follow-ups was predicted by coping and social support at the time of diagnosis. Specifically, avoidance coping was significantly related to an increase in disease activity at the 3- and 5-year followups; social support was inversely related to an increase in disease activity at the 3-year follow-up [9]. Not only is it vital to study chronic illness, such as RA, over the long haul, the use of randomized clinical trails of psychosocial interventions is a powerful means of demonstrating how the body and mind are connected. For example, Pradhan et al. [10] randomly assigned RA patients to MBSR or a wait-list control group who received usual medical care. In this psychosocial program, patients are taught directly about how the mind and body influence each other; they learn ways of reducing automatic reactivity and arousal by practicing various forms of meditation. Significant improvements in psychological distress and well-being were reported following MBSR despite there being no change in disease activity. In another randomized clinical trial, Zautra et al. [11], similar to Lera et al., were able to determine for whom a particular type of psychosocial intervention was most beneficial. Comparisons between CBT, MBSR, and an education-only control group were made in 144 RA patients pre- and posttreatment as well as 6 months later. In this study, CBT and MBSR were both helpful but in different ways. CBT provided better cognitive control over pain, whereas MBSR provided better emotional regulation. Importantly, it was shown that RA patients with a history of depression who were in the MBSR group showed significant improvements on physician-assessed joint swelling and tenderness. Given that depression is common in RA, this study reminds us to screen for it and refer patients in need of adjunct services accordingly.
Can we speak a common language for the benefit of our patients? I think so. By taking an interdisciplinary approach in theory, research, and practice, we acknowledge the complexity of health and disease in an inclusive manner. As Zautra [12] in a commentary in this journal said, “Much more can be learned when the gatekeepers within each of the core disciplines display a greater openness to thinking outside their own circles.” Patricia L. Dobkin Department of Medicine McGill University, Montreal, Canada E-mail address: [email protected] References [1] Lera S, Gelman SM, López MJ, Abenoza M, Zorrilla JG, Castro-Fornieles J, Salamero M. Multidisciplinary treatment of fibromyalgia: does cognitive behavior therapy increase the response to treatment? J Psychosom Res 2009;67:433–41. [2] Dobkin PL, Ionescu-Ittu R, Abrahamowicz M, Baron M, Bernatsky S, Sita A. Predictors of adherence to an integrated multimodal program for fibromyalgia. J Rheumatol 2008;35:2255–64. [3] Rosenzweig S, Greeson JM, Reibel DK, Green JS, Jasser SA, Beasley E. Mindfulness-based stress reduction for chronic pain conditions: variation in treatment outcomes and role of home meditation practice. J Psychosom Res 2009. doi:10.1016/j.jpsychores.2009.03.010 [In Press]. [4] Kojima M, Kojima T, Ishiguro N, Oguchi T, Oba M, Tsuchiya H, Sugiura F, Furukawa TA, Suzuki S, Tokudome S. Psychosocial factors, disease status, and quality of life in patients with rheumatoid arthritis. J Psychosom Res 2009;67:425–31. [5] Graves H, Scott DL, Lempp H, Weinman J. Illness beliefs predict disability in rheumatoid arthritis. J Psychosom Res 2009;67:417–23. [6] Hutchinson TA, Hutchinson N, Arnaert A. Whole person care: encompassing the two faces of medicine. Can Med Assoc J 2009;180: 845–6. [7] Dobkin PL. Fostering healing through mindfulness in the context of medical practice. Curr Oncol 2009;16:4–6. [8] Dobkin PL, De Civita M, Abrahamowicz M, Baron M, Bernatsky S. Predictors of health status in women with fibromyalgia: a prospective study. Int J Behav Med 2006;13:101–8. [9] Evers AW, Kraaimaat FW, Geenen R, Jacobs JW, Bijlsma JW. Stressvulnerability factors as long-term predictors of disease activity in early rheumatoid arthritis. J Psychosom Res 2003;55:293–302. [10] Pradhan EK, Baumgarten M, Langenberg P, Handwerger B, Gilpin AK, Magyari T, Hochberg MC, Berman BM. Effect of mindfulnessbased stress reduction in rheumatoid arthritis patients. Arthritis Rheum 2007;57:1134–42. [11] Zautra AJ, Davis MC, Reich JW, Nicassario P, Tennen H, Finan P, Kratz A, Parrish B, Irwin MR. Comparison of cognitive behavioral and mindfulness meditation interventions on adaptation to rheumatoid arthritis for patients with and without history of recurrent depression. J Consult Clin Psychol 2008;76:408–21. [12] Zautra AJ. Comment on “stress-vulnerability factors as long-term predictors of disease activity in early rheumatoid arthritis”. J Psychosom Res 2003;55:303–4.