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QUESTION: Does the addition of cognitive behavioural therapy (CBT) to medical management improve clinical outcomes in patients with rheumatoid arthritis (RA)?
3 hospital rheumatology clinics in or near London, UK.
56 patients who were 18–75 years of age, had had definite or classic RA for <2 years, and tested seropositive for RA. Exclusion criteria were history of mental illness or alcohol or drug abuse, or insufficient fluency in English. Follow up was 80% (mean age 55 y, 70% women).
Patients were allocated to routine medical management and CBT (n=23) or routine medical management alone (n=22). 2 psychologists provided CBT according to a treatment manual during eight 1 hour sessions over 8 weeks, which included an educational component plus self management skills (relaxation training, attention diversion, goal setting, pacing, problem solving, cognitive restructuring, assertiveness and communication, and management of flare ups or high risk situations).
Main outcome measures
Anxiety and depression (Hospital Anxiety and Depression Scales [HADS]), pain (self reports), disability (Health Assessment Questionnaire), joint inflammation (Ritchie Articular Index), and disease measures (erythrocyte sedimentation rate and C reactive protein concentration).
At follow up, patients in the CBT group were less depressed than at baseline, whereas those in the control group became more depressed (mean HADS depression score change –0.8 v 1.4, p=0.02). More patients in the CBT group than in the control group had improved joint inflammation scores at 6 months (p<0.05) (table). The groups did not differ for anxiety, pain ratings, disability ratings, or disease measures.
The addition of cognitive behavioural therapy to medical management reduced depression and joint inflammation at 6 months in patients with rheumatoid arthritis.
Evidence that psychological interventions can assist the course of certain medical treatments is increasing.1 Most often, the changes are in psychological dimensions that enhance participation in or response to medical interventions.1 Differences in research design, and in the type and timing of intervention, limit the clinical applicability of study findings.2
Sharpe et al add further support to the finding that CBT can reduce depressive symptoms in people with chronic illness, despite it often worsening in those patients without intervention. These changes persisted at 6 months follow up. The treatment group improved physically compared with the control group. This is an important contribution to the RA literature and to the position that psychological interventions in medicine affect physical functioning and can help treat active disease.
Perhaps the most important contribution is the evaluation of the timing of intervention: earlier interventions can be an effective adjunct to early post diagnostic medical treatment, and may have greater and perhaps more lasting effects than later interventions. The findings support the effectiveness of CBT as an adjunct to medical care early in the course of disease, but the study design does not test whether efficacy is enhanced by the earlier intervention.
The authors note that an alternative hypothesis to the effect of the CBT is that therapist attention, independent of intervention content, contributed to the changes. The authors acknowledge this possibility but noted that the addition of an attention control group was not feasible because of statistical power considerations. They also observed that people in the 15% dropout pool were younger, more impaired, and had more active disease. For that subgroup, it cannot be concluded that the intervention has the same potential for effect.
This well designed study supports the use of CBT early in the disease cycle of patients with RA. Before we regularly adopt such interventions in clinical practice, however, further research comparing earlier with later interventions is necessary, and the efficacy of the intervention needs to be evaluated in younger and more impaired people.
The manual used in the study by Sharpe et al was published as part of a thesis that is available for reference at Senate House, University of London, London, UK.
Sharpe, Ann Louise. A blind, randomised controlled trial of cognitive behavioural intervention for patients with recent onset rheumatoid arthritis preventing psychological and physical morbidity. Thesis (PhD). University of London, 1999. 403 leaves.
Details of the intervention are also provided in another study:
Sharpe L, Sensky T, Timberlake N, et al. The role of cognitive behavioural therapy in facilitating adaptation to illness in rheumatoid arthritis: a case series. Behavioural and Cognitive Psychotherapy 2001 July;29:303�9 http://www.journals.cup.org/
website extraAdditional references appear on the Evidence-Based Mental Health websitewww.ebmentalhealth.com
Source of funding: North Thames Regional Research and Development Programme.
For correspondence: Dr L Sharpe, Department of Psychology, Clinical Studies Unit F12, University of Sydney, New South Wales 2006, Australia. Fax +61 2 9351 7328.
A modified version of this abstract appears in Evidence-Based Nursing.
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