Rheumatoid arthritis is a chronic polyarthritis of unknown cause affecting between 1 & and 3 % of the population. The term 'arthritis' is to some extent misleading as this disorder is a multisystem disease which can affect a number of other organs e.g. heart, nervous system, eyes, kidneys, lungs. It is a debilitating disorder in which drugs are helpful but not curative and patients often have to learn to cope with chronic or episodic pain, fatigue and psychological distress. Drug treatment both with non-steroidal anti-inflammatory drugs and disease-modifying anti-rheumatic drugs (such as sulphasalazine, methotrexate or gold) carries high side-effect levels, which can hugely affect adherence (Gotzche, 1989). For this and other reasons RA patients are high users of complementary therapies (Astin, 2002).
A substantial number of psychosocial interventions has been used in the management of RA patients. As in other areas these have included educational interventions, strategies to enhance self-management and more formal psychotherapies.
Riemsma (2002), in a Cochrane review on patient education in RA, include both counselling and behavioural treatment as well as information giving under the umbrella of 'patient education'. Note that this highlights a problem with terminology in this whole area of psychological medicine - the terms 'educational' and more commonly 'psycho-educational' are often used to describe activities as disparate as the handing out of leaflets and more formal CBT.
This review showed no significant effects for information-based education or for counselling (cf. diabetes) but showed significant effects for behavioural treatments with improvements in a range of outcome measures including depression, disability and patient-rated global assessment.
Disappointingly this review also concluded that any benefits appear to be short lived and their clinical significance unclear.
Astin (2002) provide the most recent and comprehensive meta-analysis of RCTs in this area. Twenty-five studies met their inclusion criteria. Thirteen of these were characterised as multimodel CBT studies; the others included group therapy, person-centred therapy, problem solving, narrative therapies and biofeedback (usually as part of a multimodel intervention). Significant but small pooled effect sizes were found at the end of the intervention for a number of outcomes including pain, functional disability, psychological status, coping skills and self-efficacy. At follow-up (which averaged 8.5 months) significant effect sizes were found for joint tenderness, coping skills and psychological status. As in other areas, the authors found it difficult to find differences in effect sizes for different kinds of intervention, although unlike the Riemsma review this was specifically a review of psy-chotherapies and did not include merely educational interventions. The authors tentatively conclude that adjuvant psychological interventions may be important in the management of RA. One potentially interesting conclusion of this meta-analysis concerns the timing of intervention. The findings suggest that intervention earlier in the course of the disease may produce more favourable outcomes. In one of the better quality studies included, Sharpe (2001) examined the efficacy of CBT in a group (n = 55) of patients with recent-onset seropositive RA. Cognitive behaviour therapy was effective in reducing both psychological and physical morbidity. Interestingly, the CBT group also showed reduction in its C reactive protein levels (an indicator of disease activity in RA).
The authors conclude that CBT when applied early in the course of RA may be a useful adjunctive therapy. This conclusion is also supported by the work of Sinclair & Wallston (2001), who looked at predictors of improvement with CBT in a group of women with RA and concluded that length of time since diagnosis (along with personal coping resources and pain coping behaviours) predicted response to intervention.
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