Article

Efficacy of Cognitive Behavioural Therapy for the Treatment of Chronic Stress in Patients with Lupus Erythematosus: A Randomized Controlled Trial

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Abstract

Chronic stress worsens the quality of life (QOL) of lupus patients by affecting their physical and psychological status. The effectiveness of a cognitive-behavioural intervention in a group of patients with lupus and high levels of daily stress was investigated. Forty-five patients with lupus and high levels of daily stress were randomly assigned to a control group (CG) or a therapy group (TG); they received cognitive behavioural therapy (CBT) which consisted of ten consecutive weekly sessions. The following variables were evaluated at baseline and at 3, 9 and 15 months: (1) stress, anxiety, depression, (2) Systemic Lupus Erythematosus Disease Activity Index, somatic symptoms, number of flares, (3) anti-nDNA antibodies, complement fractions C3 and C4 and (4) QOL. A multivariate analysis of repeated measures and various analyses of variance were carried out. We found a significant reduction in the level of depression, anxiety and daily stress in the TG compared to the CG and a significant improvement in QOL and somatic symptoms in the TG throughout the entire follow-up period. We did not find any significant changes in the immunological parameters. CBT is effective in dealing with patients suffering from lupus and high levels of daily stress as it significantly reduces the incidence of psychological disorders associated with lupus and improves and maintains patients' QOL, despite there being no significant reduction in the disease activity index.

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... 18 ( Tratamiento psicológico en pacientes lupus eritematoso sistémico: Una revisión sistemática con respecto al origen de los artículos incluidos en esta revisión, dos se llevaron a cabo en españa (Navarrete, Peralta, Sabio, Coín et al., 2010;Navarrete, Peralta, Sabio, Martínez et al., 2010); dos en Estados Unidos (Danoff-Burg, Agee, Romanoff, Kremer y Strosberg, 2006; Jolly, Peters, Mikolaitis, Evans y Block, 2014); dos en Irán (Mapar, Mirzaeyan, Hasan y Kazem, 2015;Yeganeh y Hajializadeh, 2015); uno en Australia (Goodman, Morrissey, Graham y Bossingham, 2005) y uno en Alemania (Haupt et al., 2005). ...
... la edad de los pacientes estuvo comprendida entre los 18 y los 65 años, excepto en el estudio de goodman et al. (2005) en el que no se informó de este dato. Dos de los estudios no indicaron el sexo de los participantes (goodman et al., 2005;Mapar et al., 2015); un estudio incluyó solo mujeres (Yeganeh y Hajializadeh, 2015) y los cinco restantes incorporaron grupos mixtos compuestos por hombres y mujeres, siendo más prevalente el sexo femenino (Danoff-Burg et al., 2006;Haupt et al., 2005;Jolly et al., 2014;Navarrete, Peralta, Sabio, Coín et al., 2010;Navarrete, Peralta, Sabio, Martínez et al., 2010). Dos estudios emplearon muestras combinadas con pacientes con les y artritis reumatoide (Danoff-Burg et al., 2006;Yeganeh y Hajializadeh, 2015), un estudio utilizó muestras combinadas de pacientes con les y lcc (Navarrete, peralta sabio, coín et al., 2010), y por último, en el resto de ensayos, la totalidad de los participantes presentaron LES (Goodman et al., 2005;Haupt et al., 2005;Mapar et al., 2015;Navarrete, Peralta, Sabio, Martínez et al., 2010) y LEC (Jolly et al., 2014). ...
... Dos de los estudios no indicaron el sexo de los participantes (goodman et al., 2005;Mapar et al., 2015); un estudio incluyó solo mujeres (Yeganeh y Hajializadeh, 2015) y los cinco restantes incorporaron grupos mixtos compuestos por hombres y mujeres, siendo más prevalente el sexo femenino (Danoff-Burg et al., 2006;Haupt et al., 2005;Jolly et al., 2014;Navarrete, Peralta, Sabio, Coín et al., 2010;Navarrete, Peralta, Sabio, Martínez et al., 2010). Dos estudios emplearon muestras combinadas con pacientes con les y artritis reumatoide (Danoff-Burg et al., 2006;Yeganeh y Hajializadeh, 2015), un estudio utilizó muestras combinadas de pacientes con les y lcc (Navarrete, peralta sabio, coín et al., 2010), y por último, en el resto de ensayos, la totalidad de los participantes presentaron LES (Goodman et al., 2005;Haupt et al., 2005;Mapar et al., 2015;Navarrete, Peralta, Sabio, Martínez et al., 2010) y LEC (Jolly et al., 2014). ...
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The purpose of this systematic review was to explore psychological interventions applied to patients with systemic lupus erythematosus (SLE) and analyze their usefulness in promoting a favorable adaptation in the psychological, social and physical area. A comprehensive search bases Scopus, Medline, PsycINFO and Cochrane Library data was performed and empirical research published between 2005 and 2016 were selected studies reflected different therapeutic options: cognitive behavioral therapy, emotional writing, and mindfulness training a combination of group psychoeducation and psychotherapy. The results show that these interventions can positively impact the quality of life, anxiety, depression, stress, mental health, body image, disease management, interpersonal relationships, fatigue, and pain. However, studies have significant methodological limitations that prevent definitive conclusions. Therefore, it is considered essential to perform randomized controlled trials of higher methodological quality to quantify the effectiveness of psychological interventions in sle and establish the superiority of one treatment over another.
... Numerosos estudios han mostrado que mediante terapias cognitivo-conductuales se consigue controlar el estrés, así como variables asociadas a éste: ansiedad (Hofmann y Smits, 2008;Navarrete-Navarrete et al., 2010;Öst, 2008; Peralta-Ramírez, Robles-Ortega, Navarrete-Navarrete y Jiménez-Alonso, 2009), depresión (Navarrete-Navarrete et al., 2010;Peralta-Ramírez et al., 2009;Spangler, Simons, Monroe y Thase, 1997), felicidad (Lyubomirsky, King y Diener, 2005;Schiffrin y Nelson, 2010), sentido del humor (Grases, Trías, Sánchez y Zárate, 2010), optimismo (Carver y Scheier, 2002;Shifren y Hooker, 1995), somatizaciones, hostilidad (López, Kasanzew y López, 2007), entre otras. ...
... Numerosos estudios han mostrado que mediante terapias cognitivo-conductuales se consigue controlar el estrés, así como variables asociadas a éste: ansiedad (Hofmann y Smits, 2008;Navarrete-Navarrete et al., 2010;Öst, 2008; Peralta-Ramírez, Robles-Ortega, Navarrete-Navarrete y Jiménez-Alonso, 2009), depresión (Navarrete-Navarrete et al., 2010;Peralta-Ramírez et al., 2009;Spangler, Simons, Monroe y Thase, 1997), felicidad (Lyubomirsky, King y Diener, 2005;Schiffrin y Nelson, 2010), sentido del humor (Grases, Trías, Sánchez y Zárate, 2010), optimismo (Carver y Scheier, 2002;Shifren y Hooker, 1995), somatizaciones, hostilidad (López, Kasanzew y López, 2007), entre otras. ...
... Debido al fuerte impacto que este trastorno puede llegar a suponer en las personas, se han desarrollado programas en diferentes muestras de población tratando de paliar dichas consecuencias (Navarrete-Navarrete et al., 2010;Peralta-Ramírez, et al., 2009;. En concreto, Butler, Chapman, Forman y Beck (2006) examinaron 16 meta-análisis de los efectos de la terapia cognitivo-conductual y encontraron mejoras en una gran variedad de problemas entre los que destacaban depresión mayor, trastorno de ansiedad generalizada y trastorno de estrés post-traumático. ...
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El objetivo de este estudio ha sido comprobar la posibilidad de modulación de variables de personalidad (tales como algunos de los Cinco Grandes Factores, o la personalidad resistente) a través de la aplicación de un programa de afrontamiento del estrés. Para ello, han participado 26 personas del ámbito universitario con alto estrés percibido, distribuidas en dos grupos (grupo de tratamiento y grupo de control). Los instrumentos de evaluación seleccionados se clasificaron en dos grupos: variables psicológicas y emocionales y variables de personalidad. Los resultados encontrados mediantes un ANOVA de medidas repetidas mostraron que existía interacción momento x grupo en las variables optimismo, extraversión y responsabilidad, correspondientes al Modelo de los Cinco Grandes Factores, mostrando un incremento de las puntuaciones en estas variables en el grupo terapia y no encontrándose dicha interacción en el grupo control. Las puntuaciones en los componentes de neuroticismo, amabilidad, apertura a la experiencia y personalidad resistente no se modificaron en ninguno de los dos grupos. Este estudio apoya la idea de que modificando determinados parámetros emocionales relacionados con el estrés mediante terapia cognitivo-conductual se pueden ver modulados algunos factores de personalidad.
... Studies were selected for the narrative review based on their relevance to support and self-management strategies for lupus and rheumatic patients. Evidence-based self-management programs designed to encourage social support and promote health education, among lupus patients, have resulted in reductions in pain, improvements in function, and delays in disability [3,15,[18][19][20][21][22][23][24][25][26]. Specifically, arthritis self-management education delivered in smallgroup, home study, computer, and Internet formats have yielded significant improvements in health distress, self-reported global health, and activity limitation, with trends toward improved self-efficacy and stress management [3,4,25,27,28]. ...
... Nevertheless, many of these interventions were effective in improving disease status and management in rheumatic patients. These interventions led to significant improvements in depression [20,21,23,41], patient limitations or physical functioning [3,4,20,41,42], health distress [4; 20,41], fatigue [4,20,23,41,43], pain [3,4,20,41], self-efficacy [4,20,28,41,43,44], anxiety [21], stress [4,21,45], quality of life [21], vitality and health perceptions [42], mental health [42,43], self-esteem [22], psychological or psychosocial functioning [3,22], illness intrusiveness [25], communication [43], coping [23,43], social support [43], distress [45] [44], and health status [28]. ...
... Nevertheless, many of these interventions were effective in improving disease status and management in rheumatic patients. These interventions led to significant improvements in depression [20,21,23,41], patient limitations or physical functioning [3,4,20,41,42], health distress [4; 20,41], fatigue [4,20,23,41,43], pain [3,4,20,41], self-efficacy [4,20,28,41,43,44], anxiety [21], stress [4,21,45], quality of life [21], vitality and health perceptions [42], mental health [42,43], self-esteem [22], psychological or psychosocial functioning [3,22], illness intrusiveness [25], communication [43], coping [23,43], social support [43], distress [45] [44], and health status [28]. ...
... There are few studies evaluating the effectiveness of psychotherapy on autoimmune diseases. These studies have shown improvement in coping, quality of life, depression, anxiety, relationship, self-esteem and general health by psychotherapy and psychosocial support in SLE patients [18][19][20]. However they presented some weakness like small sample sizes [19,20], lack of randomization [19] and positive results only in a few domains [18]. ...
... These studies have shown improvement in coping, quality of life, depression, anxiety, relationship, self-esteem and general health by psychotherapy and psychosocial support in SLE patients [18][19][20]. However they presented some weakness like small sample sizes [19,20], lack of randomization [19] and positive results only in a few domains [18]. ...
... The field of this study is the interface between medicine and psychoanalysis using the psychosomatic concepts and techniques as adjunctive help to patients with physical diseases. Psychotherapeutic treatment can lead patients to better coping with illness and increase the adherence to medical treatment [18][19][20]. ...
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Background: Systemic Lupus Erythematosus (SLE) is an autoimmune disease which impairs the quality of life. The objective of study was to evaluate the effectiveness of Brief Group Psychoanalytic Psychotherapy to improve quality of life, depression, anxiety and coping strategies in SLE patients. Methods: In a randomized clinical trial, 80 female SLE patients were allocated into two groups: therapy group (n = 37) and control group (n = 43). Therapy group (TG) attended weekly psychotherapy sessions for 20 weeks; control group (CG) remained on a waiting list. Both groups received standard medical care. Questionnaires and scales were applied by blinded evaluators at baseline (T1) and after 20 weeks (T2): Socioeconomic Status, SLE International Collaborating Clinic/American College of Rheumatology-Damage Index, SLE International Disease Activity, SLE Specific Symptom Checklist, SLE Quality of life, Hospital Anxiety Depression Scale, Coping Strategies Inventory. Intent to treat intra- and inter-group analysis was performed for all variables in T1 and T2 using Qui-square, t-Student, Mann-Whitney and Wilcoxon tests. Analysis of Variance was used to compare categorical variables over time. P < 0.05 was considered significant. Results: The mean age of patients was 42 years; 54% were white, with mean disease duration of years 12. At baseline, both groups were homogeneous in all variables, including medications. After 20 weeks of psychotherapy TG was significantly different from CG, with lower frequency of symptoms (p = 0.001), lower level of anxiety (p = 0.019) and depression (p = 0.022), better index in five of six domains of quality of life scale (p ≤ 0.005), including total SLEQOL (p < 0.001) and with higher positive planful problem solving strategy (p = 0.017). No change in disease activity score was observed in both groups. Conclusions: Psychoanalytic psychotherapy was effective to improve many domains of quality of life and one positive coping skill and to reduce SLE symptoms, anxiety and depression levels. Brief group psychotherapy can be a useful tool to complement medical care in SLE patients. Trial registration: Number NCT01840709 .
... Of these, six trials comprising 394 participants were deemed eligible for inclusion in further analyses ( Table 1). Two of the eligible studies were conducted in the United States [26,27], two studies were conducted in Spain [29,30], one in Canada [31] and one study was from South Korea [28]. Psychological interventions employed in these studies included cognitive behavioral treatment (CBT), theory-based educational, self-management, or psychosocial interventions, and biofeedback-CBT. ...
... Two studies involving 96 participants [26,29] reported on disease activity after the intervention was initiated. A fixed effects model evaluation revealed no significant differences between CBT and control groups in disease activity after three or nine months of intervention ( Fig. 2A). ...
... Three studies involving 137 SLE patients [26,28,29] evaluated depression. Analysis using a fixed effects model revealed that intervention with CBT significantly reduced measures of depression (P ¼ 0.01) (Fig. 2D). ...
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Objective To objectively evaluate the effectiveness of psychological interventions for improving health-related quality of life in patients with systemic lupus erythematosus (SLE). Design and review methods Databases including Ovid-Medline, PubMed, Web of Science, EBSCOhost, the Cochrane Library and Embase were electronically searched to identify randomized controlled trials published from inception through November 2013 involving psychological intervention in SLE patients. Studies that measured physiological function, life vitality, depression, pain degree, disease activity, severity of fatigue, and physical and mental component summaries as outcomes were included. Trials involving patients with multiple diseases or received simultaneous psychological interventions or combinations of other interventions were excluded. Two independent investigators screened the identified articles, extracted the data, and assessed the methodological quality of the included studies. Qualitative descriptions were conducted and quantitative analysis was performed with RevMan software (version 5.2). Results A total of six randomized controlled trials comprising 394 participants were included in the study. Meta-analyses showed that psychological interventions significantly reduced the degree of depression (standard mean difference = -0.44, 95% confidence interval [CI]:-0.78–0.10; P=0.01] and improved the status of the physical health component summary (mean difference =8.85, 95%CI: 3.69–14.00; P=0.00] in SLE patients. However, there was no significant effect of psychological intervention on disease activity, degree of pain, fatigue or the mental health component summary. Conclusions The results show that psychological interventions can effectively improve the health-related quality of life in patients with SLE. The full benefit and clinical performance of psychological care requires further investigation by a series of multicenter, large sample size randomized controlled trails.
... However, there is a subset of patients (approximately 40%) that remain in discomfort and they can benefit from psychosocial interventions (Dobkin et al., 2001). None of the studies found significant immunological changes in the index of disease activity (Navarrete-Navarrete et al., 2010;Sohng, 2003). ...
... The literature reviewed suggests that there is a benefit for patients receiving psychological treatment in coping adjunct with medical treatment, along with achieving effects such as reduction in anxiety and depression (Navarrete-Navarrete et al., 2010). ...
... This type of treatment significantly reduces the incidence of psychological and social disorders with sle and improves and maintains hrqol. The introduction of therapy from the time of initial diagnosis may be useful, since patients may need to know how to deal with stress more effectively at that time (Navarrete-Navarrete et al., 2010) The social issues are an important aspect to be considered. Da Costa et al. (2000) indicate that improving qol in patients with sle requires a specific orientation towards modifiable psychosocial factors. ...
Article
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Backgorund: Systemic lupus erythematosus (SLE) is characterized by uncertain prognosis, severe symptoms and a negative impact on quality of life (QOL) of patients. Purpose: The aim of this review is to generate a comprehensive approach in order to improve psychological intervention in these patients. Methods: A qualitative review of articles indexed in MEDLINE, PsycINFO and SCOPUS up to July 2015 was conducted. Articles reporting SLE, coping strategies and QOL were included. Results: Twenty-four studies were found, covering different research designs, forms of assessment and intervention. Coping strategies and their relationship with QOL were analyzed in order to describe the best strategies for dealing with SLE. Conclusions: There are no adaptive or maladaptive strategies, and the suitability of these depends on the situation that a patient could sustain; nevertheless, an active coping style seems to help preserve the QOL. The main goal of psychological intervention should be diversify and expand the number of coping strategies used by patients.
... Since the World Health Organization advocates that QoL reflects on individuals' perceptions that their needs are being met, or that they are being denied opportunities to achieve happiness and self-realization, regardless of their physical state of health or social and economic conditions [2], therapies and/or treatments are used for these patients, in order to minimize the implications imposed by the disease and improve the quality of life. Randomized clinical trials (RCTs) that demonstrated the effects of these therapies and/or treatments on the health aspect in general, reported an improvement in quality of life [3,4]. However, the studies have relatively small samples. ...
... Navarrete et al [3,7], assessed in two studies the QoL of patients with SLE who participated in cognitive behavioral therapy (n = 79). It was observed that the CBT group provided a significant improvement in the QoL of these patients when compared to the control groups (-17.66 95% CI: -26.69 to -8.63, p = 0.0001, I 2 = 7%) (Additional file 1). ...
... During 15 months, Navarrete et al [3,7] performed a CBT program with SLE patients and the control groups received conventional care. It was shown that the group that performed CBT presented a reduction in the level of depression and anxiety, improvement in the level of physical function and vitality, as well as an improvement in the general perception of health and a statistically significant improvement in the QoL. ...
Article
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Introduction: Systemic lupus erythematosus (SLE) is a multi-systemic, chronic inflammatory disease of autoimmune nature, which can impair performance in daily life activities, causing to a compromised quality of life. Thus, the aim of this study was to evaluate the effect of therapies, such as physical activity, cognitive behavioral therapy, pharmacological treatment and phytotherapy in the quality of life of patients with systemic lupus erythematosus. Materials and methods: A systematic review with a meta-analysis of randomized clinical trials was conducted by searching the PubMed database, including studies comparing patients who participated in cognitive therapy, physical activity, pharmacological treatment or phytotherapeutic treatment. Results: Of the seven studies included in this meta-analysis, a significant difference was observed in the quality of life of patients with lupus who participated in the intervention groups compared to the control groups (- 10.27 95% CI: - 15, 77 at - 4.77, p = 0.0003, I2 = 0%). Conclusion: Interventions improve the Quality of life of patients with SLE. However, the methodological quality of the included articles and the sizes of the samples for being small propose that new randomized clinical trials be performed.
... Of the seven psychosocial intervention studies identified, two were non-randomized controlled trials (non-RCTs, one being a single group pretest-posttest design study 29 and one being a non-equivalent control group pretest-posttest design study), 33 and five were RCTs. 27,28,[30][31][32] The two non-RCTs demonstrated a decrease in fatigue or an improvement in vitality. 29,33 Of the five RCTs, only one demonstrated a reduction in fatigue. ...
... 29,33 Of the five RCTs, only one demonstrated a reduction in fatigue. 30 The other four trials showed that psychosocial interventions resulted in either no significant decrease in fatigue when compared with standard usual care 27,28,32 or were equally effective in reducing fatigue when compared with placebo (ie, symptom monitoring only). 28,31 The RCT that demonstrated a decrease in fatigue compared a psychoeducational intervention with an attention placebo control. ...
Article
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Among the host of distressing pathophysiological and psychosocial symptoms, fatigue is the most prevalent complaint in patients with systemic lupus erythematosus (SLE). This review is to update the current findings on non-pharmacological, pharmacological, and modality strategies to manage fatigue in patients with SLE and to provide some recommendations on optimal management of fatigue based on the best available evidence. We performed a systematic literature search of the PubMed and Scopus databases to identify publications on fatigue management in patients with SLE. Based on the studies reported in the literature, we identified nine intervention strategies that have the potential to alleviate fatigue in patients with SLE. Of the nine strategies, aerobic exercise and belimumab seem to have the strongest evidence of treatment efficacy. N-acetylcysteine and ultraviolet-A1 phototherapy demonstrated low-to-moderate levels of evidence. Psychosocial interventions, dietary manipulation (low calorie or glycemic index diet) aiming for weight loss, vitamin D supplementation, and acupuncture all had weak evidence. Dehydroepiandrosterone is not recommended due to a lack of evidence for its efficacy. In addition to taking treatment efficacy and side effects into consideration, clinicians should consider factors such as cost of treatment, commitments, and burden to the patient when selecting fatigue management strategies for patients with SLE. Any comorbidities, such as psychological distress, chronic pain, sleep disturbance, obesity, or hypovitaminosis D, associated with fatigue should be addressed.
... It is the most used and recommended measure of quality of life associated with health and is considered the instrument of choice to measure it in SLE (v.g. Alarcón et al., 2004;Doria et al., 2004;Freire et al., 2007;Greco et al., 2004;Jolly, 2005;Moore et al., 2000;Navarrete et al., 2010;Rinaldi et al., 2006;Thumboo & Strand, 2007;Yelin et al., 2009). The scores obtained in each subscale (0-100) follow a gradient of "higher score, better state of health". ...
... Definitely, this work has provided evidence about how a short 10-hour protocol based on ACT can improve the functioning and quality of life of people with SLE; the conceptualization of psychological problems and the loss of quality of life suffered by patients with SLE as experiential avoidance problems is novel; the protocol studied is shorter than the ACT protocols that have been studied (Haupt et al., 2005;Navarrete et al., 2010) and is similar to those studied in the most recent period (Rafie et al., 2020;Sahebari et al., 2019), a fact that favors adherence to treatments and reduces interference in the daily life of the participants (Seawell & Danoff-Burg, 2004); has demonstrated the potentiality of application of the treatment in other chronic diseases, some of them frequent comorbilities of SLE; and, it has shown that it is not necessary for patients to be within clinical ranges in order to benefit from this protocol, as was the case in the study by Quirosa (2011). For all these reasons, we believe that this company has value for the health authorities insofar as its group format and its short duration reduce the necessary investment both in terms of money and time. ...
Article
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Systemic lupus erythematosus (SLE) is a systemic autoimmune rheumatic disease of unknown etiology that mainly affects women of reproductive age. SLE causes a series of physical and psychological symptoms that, due to its chronic course, lead to a diminished quality of life. Acceptance and Commitment Therapy (ACT) is accumulating evidence supporting its usefulness in improving the psychological problems associated with SLE although research remains scarce. The aim of this study was to study the efficacy of a 10-hour brief ACT intervention protocol in group format in 15 patients with SLE from Navarra. Nine belonged to the experimental group (n1 = 9) and six to the control group (n2 = 6). Measures related to psychological flexibility processes and quality of life were taken before the intervention (pre), at the end (post), at one month and after three months (follow-up). The participants in the experimental group showed a substantial improvement in the degree of acceptance of pain and in variables focused on quality of life with respect to the control group. The improvements tended to be sustained over time. These results suggest that brief, group-based ACT interventions show promise for intervention in patients with SLE.
... Case reports from the three SSc patients who participated suggested that this format was feasible and that pain was improved following the therapy [92]. CBT has been shown to be efficacious in improved pain in numerous clinical trials for rheumatic diseases such as lupus [93,94] and rheumatoid arthritis [95,96] and has been included in recommendations established by the American College of Rheumatology Pain Management Task Force [3]. ...
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Purpose of review Pain is one of the most common quality of life concerns in systemic sclerosis (SSc). This review summarizes the literature on risk factors and potential clinical assessment and treatment strategies. Recent findings SSc pain is associated with, but not defined by, disease parameters and severity. The extant literature suggests that psychosocial factors such as mental health are relevant to pain. Brief pain screenings can be followed by a more comprehensive assessment to help inform intervention strategies for affected patients. The literature on pain management is relatively small, but numerous studies and clinical practice recommendations suggest that there are multiple avenues for intervention. These include medical treatments, physical activity and rehabilitation programs, and psychotherapeutic techniques. Summary There are many promising approaches to SSc pain treatment. Future research should include systematic evaluation of treatments that have been proposed in SSc and/or have demonstrated efficacy in other chronic pain or rheumatic samples. Particular attention should be paid to treatments that include a non-pharmacological component and are more easily accessible for patients.
... A strength of this study is its focus on an understudied population which differs from prior studies that had samples composed of predominately Caucasians or Caucasian women [7,11,23,35]. Thus, these findings deepen our understanding of an understudied population with more lupus disease activity and damage, and faster disease progression [7]. ...
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Lupus is a chronic debilitating rheumatic autoimmune disease that disproportionately affects African American women. A phenomenological approach was used to conduct confidential semi-structured qualitative interviews to explore "lived experiences" of coping and self-efficacy among 10 African American women diagnosed with lupus. Six major themes identified included self-awareness, religion and spirituality, a sense of connectedness, stigma, empowerment, and peer perceptions. These themes highlighted human agency and coping self-efficacy exhibited by African American women that facilitate chronic disease management and self-care. Perceptions of coping self-efficacy varied and the women's "use of self" was instrumental to their individualized way of coping with their lupus diagnosis. Study findings increase cultural awareness, understanding, and potentially empathy from providers, employers/colleagues, and family members about African American women's experiences of living with lupus.
... A nonrandomized controlled study consisting of an 8-weeks psychoeducational group intervention for 17 patients with SLE who reported cognitive dysfunction, but were not globally impaired on neuropsychological testing, suggest that memory self-efficacy improves after participation [319]. However, a systematic review that explored the effect of the psychological intervention in people with SLE revealed that mental components assessed in 3 groups [316,320,321], did not significantly differ between intervention and control groups [317]. In older patients with SLE and vascular risk factors, aspirin addition was suggested especially for cases with progressive impairment [322]. ...
Article
Neuropsychiatric (NP) involvement in Systemic Lupus Erythematosus (SLE), can be a severe and troubling manifestation of the disease that heavily impacts patient's health, quality of life and disease outcome. It is one of the most complex expressions of SLE which can affect central, peripheral and autonomous nervous system. Complex interrelated pathogenetic mechanisms, including genetic factors, vasculopathy, vascular occlusion, neuroendocrine-immune imbalance, tissue and neuronal damage mediated by autoantibodies, inflammatory mediators, blood brain barrier dysfunction and direct neuronal cell death can be all involved. About NPSLE a number of issues are still matter of debate: from classification and burden of NPSLE to attribution and diagnosis. The role of neuroimaging and new methods of investigation still remain pivotal and rapidly evolving as well as is the increasing knowledge in the pathogenesis. Overall, two main pathogenetic pathways have been recognized yielding different clinical phenotypes: a predominant ischemic-vascular one involving large and small blood vessels, mediated by aPL, immune complexes and leuko-agglutination which it is manifested with more frequent focal NP clinical pictures and a predominantly inflammatory-neurotoxic one mediated by complement activation, increased permeability of the BBB, intrathecal migration of autoantibodies, local production of immune complexes and pro-inflammatory cytokines and other inflammatory mediators usually appearing as diffuse NP manifestations. In the attempt to depict a journey throughout NPSLE from diagnosis to a reasoned therapeutic approach, classification, epidemiology, attribution, risk factors, diagnostic challenges, neuroimaging techniques and pathogenesis will be considered in this narrative review based on the most relevant and recent published data.
... Treatment of symptoms related to autoimmune disorders is multifaceted and primarily involves education and pharmacologic management of physical symptoms, as well as addressing related cardiovascular risk factors, associated infections, psychological issues, and treatment complications [10][11][12][13][14]. Treatment of psychological issues may be an additional component of care [15,16]. ...
... Psychasthenia is also one of the most common and disabling symptoms of SLE affecting more than 80% of the lupus patients (8). Cognitive behavioral therapies in stress management are recognized as effective approaches for the reduction of psychological consequences (9). In this regard, acceptance and commitment therapy (ACT) is one of the mostly employed treatments. ...
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Objective: The aim of this study was to evaluate the efficacy of acceptance and commitment therapy (ACT) in the reduction of disappointment, psychological distress, and psychasthenia among patients with systemic lupus erythematosus (SLE). Method: This quasi-experimental study was conducted on 24 females with lupus who referred to the Rheumatoid Disease Research Center (RDRC) of Ghaem hospital in Mashhad, Iran. This study had a pretest-posttest control group design. The participants were randomly assigned into 2 groups of experimental and control. The experimental group was treated with ACT. Data were collected using the Beck’s Hopelessness Scale, Kessler’s Psychological Distress Inventory, and Krupp’s Psychasthenia Inventory. Results: Mean age and mean duration of illness were 37.25±4.61 and 5.12±2.33 years, respectively. The mean disappointment score and psychological distress in the experimental group were lower compared to those in control group at the post experimental stage (P
... Two of the studies reviewed by Liang et al. presented information on CBT. These projects were conducted by Navarrete-Navarrete and colleagues and both presented valuable information on CBT [28,29]. ...
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This paper reviews information on Systemic Lupus Erythematosus (SLE) in children. Children with this chronic illness often experience pain related to their condition. They also can experience social isolation. This paper reviews psychosocial information on peer support and cognitive behavioral pain management strategies. The information presented in this paper provides new insights for health professionals assisting children and families in coping with psychological facets of this disease. Research focusing on ways by which peers and friends can support the child’s use of psychological pain management strategies will provide new information for the literature.
... Es necesario aclarar que, a pesar de los criterios de selección, algunos de los artículos se relacionaban con condiciones crónicas de patología no oncológica, entre las cuales se [23], el VIH [24,25], el lupus eritematoso sistémico [26], la dermatitis atópica [27], secuelas de enfermedad cerebrovascular [28,29], el dolor crónico de espalda y cuello [6,[30][31][32], así como la fatiga crónica [33]. Sin embargo, de los 136 artículos referenciados, el 69 % (n = 94) correspondía a intervenciones realizadas con población oncológica, entre los cuales las poblaciones descritas son cáncer de seno y sus complicaciones en mujeres (48 %) [34,35], y sobrevivientes de cáncer de próstata en hombres (6,4 %) [36]; mientras que el excedente correspondía a las demás patologías crónicas que afectan la percepción de calidad de vida de los pacientes, no relacionadas a patología oncológica [11]. ...
Article
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p> Resumen En el paciente médicamente enfermo, las intervenciones farmacológicas o psicoterapéuticas habituales caen en desuso por particularidades propias de la hospitalización y la comorbilidad física; por ello se hace necesario identificar diferentes estrategias que permitan incidir benéficamente en la calidad de vida de este grupo de pacientes. Objetivo : Realizar una revisión narrativa de la literatura que permita identificar estrategias terapéuticas que hayan demostrado efectividad en el proceso de este grupo de pacientes. Metodología : Revisión narrativa de literatura. Resultados : Se identificaron 10 corrientes terapéuticas no farmacológicas que han demostrado mejoría en indicadores como percepción de dolor, mejoría en calidad de vida, regulación de alteraciones del patrón de sueño, fatiga, en el contexto de pacientes con enfermedad crónica, que puede encontrarse en entornos tan diversos como son los pacientes de oncología o de las unidades de dolor crónico. Conclusiones : Las intervenciones no farmacológicas han demostrado efectividad en el control de síntomas físicos y emocionales en pacientes con enfermedad crónica y son herramientas con las que debe contar el profesional en salud mental.</p
... A strength of this study is its focus on an understudied population which differs from prior studies that had samples composed of predominately Caucasians or Caucasian women [7,11,23,35]. Thus, these findings deepen our understanding of an understudied population with more lupus disease activity and damage, and faster disease progression [7]. ...
... Its main objective was to provide participants with psychological tools that gave them greater control over the different stressful situations they confront throughout their pregnancy. The programme teaches them strategies to face stress in an optimal way [39][40][41][42]. The sessions were composed as follows: (1) psychoeducation: what stress is, characteristics, identification of stressors, responses and consequences; (2) deactivation techniques (thematic imagination along with diaphragmatic breathing); (3) cognitive restructuring: cognitive distortions; (4) cognitive restructuring: irrational beliefs; (5) Alternative thought control strategies -self-instructional training and time organisation; (6) training in social skills: assertiveness, basic assertive rights, saying no and asking for a change of behavior; (7) Relationship between anger and stress: emotional self-regulation; (8) optimism and good humourrecapitulation. ...
Article
Objective To demonstrate the effectiveness of a cognitive behavioural therapy for stress management in pregnant women in the reduction of psychological stress and hair cortisol levels. Methods The trial was controlled and randomised, with a total of 78 pregnant women: control group (n-39) and Cognitive Behavioural Therapy group (n-39). To test the therapy's efficacy, an evaluation of the primary outcome (hair cortisol levels) and secondary outcomes (psychological stress, psychopathological symptomatology and resilience) was conducted before and after the treatment. The therapy was conducted during 8 sessions (one per week) in a group setting. The study was registered as a Randomised Controlled Trial with the code NCT03404141. Results The results showed a group time interaction between hair cortisol levels, psychological stress (perceived and pregnancy-specific), and in the exacerbation and severity of psychopathological symptoms. These variables presented reductions after treatment only in the Cognitive Behavioural Therapy group. Conclusions Using a novel way of assessing chronic stress (psychological and objective measures as hair cortisol levels), this is the first study that has shown a decrease in both the levels of cortisol in hair and in psychological stress. This decline could have implications for maternal and fetal health.
... In general,pediatric populations, intrapersonal therapy and cognitive behavioral therapy are efficacious in treating depression [100,101]. Likewise, studies in adult RA and SLE patients show that CBT is efficacious in treating symptoms of depression and anxiety [102,103]. ...
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Purpose of review To review the current evidence for the management of mental disorders for youth with rheumatologic diseases, and elucidate gaps in knowledge requiring further investigation to improve management of mental health conditions for these patients. Recent findings Depression and anxiety are common in youth with pediatric rheumatologic diseases and are associated with poor adherence, quality of life, and long-term outcomes. They have a complex etiology and require consideration of overall disease management as well as contributing psychosocial factors. Increasing evidence indicates that current screening strategies fail to fully support this patient population and that many patients with mental health problems go untreated. Summary Effective strategies to approach mental health in pediatric rheumatology patients are likely those that incorporate both behavioral and pharmacological therapies, and include families and social support. Preliminary evidence shows that adopting screening practices in pediatric rheumatology clinics will improve detection of mental disorders and is acceptable to patients and families. Broad mental health screening strategies should be considered for youth with rheumatologic diseases. Further research is necessary to better understand which treatments are most effective for depression, anxiety, and other forms of mental disorders observed in pediatric rheumatology.
... Outside of the pandemic, a number of randomized controlled trials have been done regarding psychological management strategies for patients with autoimmune disorders. Findings from controlled clinical trials in SLE suggest that cognitive behavioral therapy (with a focus on stress management) is effective in reducing depression, anxiety, and stress (54), that mindfulness-based cognitive therapy is effective in improving psychological symptoms and health-related quality of life (55), and that peer-led self-management education is effective in improving physical health-related quality of life (56). Meta-analytic data have shown cognitive behavioral therapy to be effective in reducing psychological symptoms, such as depression, in rheumatoid arthritis (57). ...
Article
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Although the coronavirus disease 2019 (COVID‐19) pandemic has been associated with increased psychological distress globally, it poses unique challenges to persons who are potentially more vulnerable to its effects, including patients with autoimmune disease. In this article, we review the published literature and media reports to determine factors that may contribute to mental health challenges in persons with autoimmune disease. We then explore existing mental health interventions that have been developed for use in COVID‐19 and in patients with autoimmune disorders in general. We identified several potential contributors to psychological distress in patients with autoimmune disease during the pandemic, as follows: feelings of discrimination related to societal response to COVID‐19, fear of infection and uncertainty related to immunosuppressive medication, diminished access to usual care and resources, previous health‐related trauma, and the exacerbating effect of social isolation. Drawing from existing literature, we synthesize the identified evidence to develop a proposed framework for researching and managing mental health challenges in autoimmune disease during the pandemic and its aftermath.
... A cognitive-behavioral therapy approach yielded similar results by leading to increased production of interleukins in patients with breast cancer during the six months following psychological treatment [12]. However, contrasting results were found in women with autoimmune disease for whom cognitive-behavioral therapy changed emotional variables and enhanced quality of life without altering immunological parame- ters [13]. In recent years, interest in optimizing immune function has led to investigating the efficacy of alternative techniques in modulating immune system activity in healthy individuals, such as the practice of Hatha yoga in normal adults [14], or of aerobic exercise in elderly people [15] . ...
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The aging process involves a decline in immune functioning that renders elderly people more vulnerable to disease. In residential programs for the aged, it is vital to diminish their risk of disease, promote their independence, and augment their psychological well-being and quality of life. We performed a randomized controlled study, evaluating the ability of a relaxation technique based on Benson’s relaxation response to enhance psychological well-being and modulate the immune parameters of elderly people living in a geriatric residence when compared to a waitlist control group. The study included a 2-week intervention period and a 3-month follow-up period. The main outcome variables were psychological well-being and quality of life, biomedical variables, immune changes from the pre-treatment to post-treatment and follow-up periods. Our findings reveal significant differences between the experimental and control groups in CD19, CD71, CD97, CD134, and CD137 lymphocyte subpopulations at the end of treatment. Furthermore, there was a decrease in negative affect, psychological discomfort, and symptom perception in the treatment group, which increased participants’ quality of life scores at the three-month follow-up. This study represents a first approach to the application of a passive relaxation technique in residential programs for the elderly. The method appears to be effective in enhancing psychological well-being and modulating immune activity in a group of elderly people. This relaxation technique could be considered an option for achieving health benefits with a low cost for residential programs, but further studies using this technique in larger samples of older people are needed to confirm the trends observed in the present study. Trial registration International Standard Randomised Controlled Trial Number Register ISRCTN85410212
... Además, la gravedad de esta psicopatología está asociada con una percepción alta de amenaza a la vida y un bajo apoyo emocional 20 . En este sentido, la presencia de factores de protección frente a estos síntomas de ansiedad, estrés, o depresión, tales como herramientas de control y afrontamiento al estrés, supondría un alto valor adaptativo para garantizar la calidad de vida tanto física como psicológica y la prevención de posibles brotes o empeoramiento del curso de la enfermedad 21 . ...
Article
Resumen Antecedentes y objetivo: Las pacientes con lupus eritematoso sistémico (LES) son más vulnerables a presentar mayores niveles de estrés y síntomas psicopatológicos que la población general sana, por lo que el brote de la COVID-19 podría alterar su estado psicológico. El objetivo fue analizar el impacto psicológico de la pandemia y del confinamiento sobre los niveles de estrés y sintomatología psicopatológica en pacientes con LES. Pacientes y método: En este estudio transversal se compararon niveles de estrés mediante la Escala de Estrés Percibido y el Inventario de Vulnerabilidad al Estrés, y síntomas psicopatológicos mediante el Inventario de síntomas SCL-90-R, en pacientes con LES durante el periodo de confinamiento (grupo 1; n=276) con respecto a pacientes con LES evaluadas en un período anterior a la pandemia (grupo 2; n=152). Resultados: La comparación entre ambos grupos mostró que existían diferencias estadísticamente significativas en vulnerabilidad al estrés (p<0,0001), depresión (p≤0,05), ansiedad (p≤0,05), ansiedad fóbica (p<0,0001), sensibilidad interpersonal (p≤0,043), y psicoticismo (p≤0,023). En estas variables el grupo de pacientes con lupus en confinamiento obtuvo puntuaciones superiores. Conclusiones: El confinamiento y la amenaza del brote por COVID-19 ha tenido importantes repercusiones el estado psicológico de las pacientes con LES, mostrando altos niveles de estrés, ansiedad y depresión. Estos hallazgos muestran su vulnerabilidad ante una alerta de salud pública, y señala la necesidad de realizar un abordaje psicológico de estas pacientes mientras dure el estado de emergencia sanitaria, así como ante posibles rebrotes del virus.
... Furthermore, the severity of this psychopathology is associated with a high perception of threat to life and low emotional support 20 . In this sense, the presence of protective factors against these symptoms of anxiety, stress, or depression, such as stress control and coping tools, would be of high adaptive value to guarantee both physical and psychological quality of life and the prevention of possible exacerbations or worsening of the course of the disease 21 . ...
Article
Background and objective Patients with systemic lupus erythematosus (SLE) are more vulnerable to higher levels of stress and psychopathological symptoms than the general healthy population. Therefore, the COVID-19 outbreak could alter their psychological state. The objective was to analyze the psychological impact of the pandemic and confinement on stress levels and psychopathological symptoms in patients with SLE. Patients and method In this cross-sectional study, stress levels were compared with the Perceived Stress Scale, the Stress Vulnerability Inventory and psychopathological symptoms of the SCL-90-R Symptom Inventory in patients with SLE during the period of confinement (group 1; n = 276) in comparison to patients with SLE evaluated in a period before the pandemic (group 2; n = 152). Results The comparison between both groups showed there were statistically significant differences in vulnerability to stress (p < 0.0001), depression (p ≤ 0.05), anxiety (p ≤ 0.05), phobic anxiety (p < 0.0001), interpersonal sensitivity (p ≤ 0.043), and psychoticism (p ≤ 0.023). In these variables, the group of patients with lupus in confinement obtained higher scores. Conclusions The confinement and threat of the COVID-19 outbreak had important repercussions on the psychological state of patients with SLE with high levels of stress, anxiety, and depression. These findings show their vulnerability to a public health alert and indicate the need to carry out a psychological approach to these patients while the state of health emergency lasts as well as to possible outbreaks of the virus.
... It has been reported that mental stress or stress can cause immune system disorders through the neuroendocrine system and promote or aggravate SLE. Psychological supports and programs are effective in dealing with patients suffering from SLE and high levels of daily stress as it significantly reduces the incidence of psychological disorders associated with SLE and improves and maintains the QOL of patient, despite there being no significant reduction in the disease activity index [20]. ...
Article
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Objectives. Systemic lupus erythematosus (SLE) is a complex and relapsing autoimmune disease and worsens the quality of life (QOL) of patients by affecting their physical and psychological status. The effectiveness of psychoeducational interventions on patients with active SLE was investigated. Methods. Eight-five patients with active SLE were randomly assigned to an observation group or a control group; patients in the observation group received psychoeducational interventions. The following variables were evaluated within a week after admission, 3 and 6 months after psychoeducational intervention: the World Health Organization Quality of Life Instrument- (WHOQOL-) BREF scores, the Medical Outcomes Study Short Form 36 (SF-36) scores, the Beck Depression Inventory, and Spielberger’s State-Trait Anxiety Inventory (STAI). Results. We found that scores of all four domains of the WHOQOL-BREF scale were remarkably increased 3 months after psychoeducational intervention in the intervention group and significantly higher than the control group (P
... Delivery of PCST programs to patients with SLE could have a positive impact on outcomes and quality of life, but this evidence base needs to be established. A few small trials have examined psychological interventions that incorporate aspects of pain coping, showing positive impacts on both psychological and physical health measures in patients with SLE [12][13][14][15][16]. Although these studies show promise for coping skills interventions as a component of SLE care, most previously studied interventions involve multiple in-person visits or group sessions, which can limit reach and participation. ...
Article
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Background Patients with Systemic Lupus Erythematosus (SLE) often experience pain and other symptoms that negatively impact quality of life. Interventions that enhance the use of behavioral and cognitive coping strategies may lead to improved outcomes among patients with SLE. Pain coping skills training (PCST) programs have been shown to improve outcomes among patients with other rheumatic conditions, but there have been no trials of PCST among patients with SLE. This study was a preliminary assessment of the feasibility and efficacy of painTRAINER, an automated, internet-based PCST program, among patients with SLE. Methods Participants (n = 60) with SLE from one health care system were randomly assigned with equal allocation to painTRAINER or a wait list control group. PainTRAINER involves 8 modules; participants were instructed to complete one module weekly, along with practice activities for each cognitive or behavioral coping skill. Outcome measures were assessed at baseline and 9-week follow-up, including the Pain Catastrophizing Scale, PROMIS Subscales (Pain Interference, Physical Function, Sleep Disturbance, Anxiety, Depression, Fatigue and Participation), and the LupusPRO questionnaire. Mean changes in outcomes from baseline to follow up and Cohen’s d effect sizes were computed. Results Effect sizes for the painTRAINER group (relative to the wait list group) were small, with changes being greatest for the PROMIS Depression score (d = − 0.32). Among those randomized to the painTRAINER group, 50% accessed the program (“painTRAINER users”). Most of those who did not access the program stated that they did not receive instructions via email. Effect sizes for “painTRAINER users” (relative to wait list) were larger than for the whole painTRAINER group: Pain Catastrophizing d = − 0.60, PROMIS Pain Interference d = − 0.3., PROMIS Depression d = − 0.44, LupusPRO Health-Related Quality of Life d = 0.30. Conclusions PainTRAINER users reported meaningful improvements in multiple physical and psychological outcomes, supporting the potential of PCST programs to benefit individuals with SLE. However, strategies are needed to improve engagement with the program and tailor content to comprehensively address key SLE symptoms and challenges. Trial registration NCT03933839, May 1, 2019.
... Navarette-Navarette et al. studied the role of cognitive behavioral therapy (CBT) in a randomized controlled trial that included 34 SLE patients followed over 15 months, with high levels of daily stress. They found significant reductions in levels of anxiety, depression, and daily stress in the CBT group compared to controls, but no significant differences in disease activity [57]. ...
... Furthermore, interventions targeting coping, support, and patient activation have been more frequently examined in literature as supplemental approaches to provide comprehensive disease management. These initiatives have utilized a variety of delivery methods including peer-to-peer, lay professional delivery, and healthcare professional mediated programs with varying levels of success in reducing disease activity, improving psychological symptoms, and increasing patient activation (Braden et al., 1993;Peterson et al., 1993;Maisiak et al., 1996;Edworthy et al., 2003;Sohng, 2003;Karlson et al., 2004;Lorig et al., 2004;Goodman et al., 2005;Ng and Chan, 2007;Navarrete et al., 2010;Drenkard et al., 2012;Balasubramanian et al., 2014;Lee et al., 2014;Williams et al., 2014Williams et al., , 2018. Therefore, a methodologic comparison of sociobehavioral interventions for African American SLE patients is warranted to determine if a specific delivery method is associated with increased self-efficacy or coping and patient activation. ...
Article
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Introduction: Systemic lupus erythematosus (SLE) is a chronic inflammatory disease in which the immune system attacks healthy tissues. While pharmaceutical therapies are an important part of disease management, behavioral interventions have been implemented to increase patients’ disease self-management skills, provide social support, and encourage patients to take a more active role in their care. Methods: Three interventions are considered in this study; peer-to-peer methodology, patient support group, and a patient navigator program that were implemented among largely African American women with SLE at the Medical University of South Carolina (MUSC). Outcomes of interest were patient activation and lupus self-efficacy. We used a Least Squares Means model to analyze change in total patient activation and lupus self-efficacy independently in each cohort. We adjusted for demographic variables of age, education, income, employment, and insurance. Results: In both unadjusted and adjusted models for patient activation, there were no statistically significant differences among the three intervention methodologies when comparing changes from baseline to post intervention. Differences in total coping score from baseline to post intervention in the patient navigator group (−101.23, p -value 0.04) and differences in scores comparing the patient navigator with the support group were statistically significant (116.96, p -value 0.038). However, only the difference in total coping from baseline to post intervention for the patient navigator program remained statistically significant (−98.78, p -value 0.04) in the adjusted model. Conclusion: Tailored interventions are a critical pathway toward improving disease self-management among SLE patients. Interventions should consider including patient navigation because this method was shown to be superior in improving self-efficacy (coping scores).
... In addition to conventional therapies for this population, complementary interventions offer new options with the aim of improving general health, reducing side effects and treatment costs 15 . The most well-established and prevalent integrative therapy for mind and body is the practice of cognitive-behavioral therapy (CBT), the one most used to treat various mental disorders, reduce stress and psychological symptoms in people with chronic diseases, due to its structure and flexible content 16,17 . Mindfulness-based interventions (MBIs) are part of the "third wave of CBT" and have been arousing interest concerning their effectiveness in clinical disorders and physical diseases, as they deal with mental and physical aspects 18,19 . ...
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Introduction: Chronic kidney disease (CKD) is a serious public health problem worldwide, leading to a series of physical and psychological comorbidities, in addition to costly treatments, lifestyle and dietary restrictions. There is evidence that mindfulness-based interventions (MBIs) offer complementary treatment for people with chronic illnesses, including CKD, with the aim of improving overall health, reducing side effects and treatment costs. This review aims to investigate the MBIs impact on people with CKD undergoing hemodialysis, and to identify the methodological quality of the current literature in order to support future studies. Methods: We ran searches in five databases (MEDLINE via PubMed, PsycINFO, Embase, Web of Science and Scopus) in July 2020. The papers were selected and evaluated by two reviewers independently, using predefined criteria, including the Cochrane Group's risk of bias tool and its recommendations (CRD42020192936). Results: Of the 175 studies found, 6 randomized controlled trials met the inclusion criteria, and ranged from 2014 to 2019. There were significant improvements in symptoms of anxiety, depression, self-efficacy, sleep quality, and quality of life (n=3) in the groups submitted to the intervention, in addition to physical measures such as blood pressure, heart rate and respiratory rate (n=1). Conclusions: MBIs can offer a promising and safe complementary therapy for people with CKD undergoing hemodialysis, acting on quality of life and physical aspects of the disease.
... In a study of 100 polycystic ovarian syndrome sufferers, aged 13 to 30 years of age, an Indian study found strong correlation between stress levels (reflected in a 6.64% increase in salivary cortisol in PCOS patients) and overweight status, increasing future risk of insulin resistance and PCOS-related metabolic disruptions [62]. Another Spanish study in 45 SLE patients (all female) found that cognitive behavioral therapy did alleviate somatic symptoms in sufferers compared to controls, highlighting the effect of stress on chronic disease exacerbation [63]. Additionally, immune competence and resistance to disease depends on low levels of stress hormones and sufferers of ME/CFS were found to have higher levels of inflammatory biomarkers while activity of NK cells and CD16+CD56+ lymphocytes were found to be compromised in 57 Japanese shift work nurses suffering from fatigue [20,64]. ...
Article
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The modern woman has taken her rightful place in society as a worker, a caregiver, a mother, and a world citizen. However, along with the privileges of these roles comes the great cost of stress and resultant exhaustion and fatigue. Psychosocial, physical, cultural, and disease-related realms of stress act as strands of a web that serve to bind and hinder women with chronic stress. New areas of research, such as exercise intervention, improved social programs (e.g., childcare), and supplementation are constantly evaluated for effectiveness alongside traditional remedies such as exercise. This review will highlight some of the key issues regarding stress in women and explore reports of new treatment modalities in light of the specific requirements of the modern woman.
... In adults, early identification of depression, including subthreshold symptoms, decreases the risk for major depression and suicide [55,56], improves social function, increases productivity, and decreases absenteeism [57,58]. Specifically, cognitive-behavioral intervention in adults with SLE has led to significant reduction in the level of depression and anxiety compared to controls and an overall improvement in quality of life scores [59]. ...
Article
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Youth with rheumatologic diseases have a high prevalence of comorbid mental health disorders. Individuals with comorbid mental health disorders are at increased risk for adverse outcomes related to mental health as well as their underlying rheumatologic disease. Early identification and treatment of mental health disorders has been shown to improve outcomes, but current systems of care fall short in providing adequate mental health services to those in need. Pediatric rheumatologists are uniquely positioned to provide mental health screening and intervention for youth with rheumatologic diseases due to the frequency of patient encounters and ongoing therapeutic relationship with patients and families. However, additional training is likely required for pediatric rheumatologists to provide effective mental health care, and focusing efforts on providing trainees with mental health education is key to building competency. Potential opportunities for improved mental health education include development of clinical guidelines regarding mental health screening and management within pediatric rheumatology settings and incorporation of mental health didactics, workshops, and interdisciplinary clinic experiences into pediatric rheumatology fellowship curricula. Additional steps include mental health education for patients and families and focus on system change, targeting integration of medical and mental health care. Research is needed to better define the scope of the problem, determine effective strategies for equipping pediatric rheumatologists with skills in mental health intervention, and develop and implement sustainable systems for delivery of optimal mental health care to youth with rheumatologic diseases.
Article
Systemic Lupus Erythematosus (SLE) is associated with significant mortality, morbidity, and cost for the individual patient and society. In the United States, African Americans have three to four times greater prevalence of lupus, risk of developing lupus at an earlier age, and lupus-related disease activity, organ damage, and mortality compared with Caucasians. Evidence-based self-management interventions that incorporate both social support and health education have reduced pain, improved function, and delayed disability among lupus patients. However, African Americans and women are still disproportionately impacted by lupus. This paper presents the argument that peer mentoring may be an especially effective intervention approach for African American women with SLE. SLE peers with a track record of success in lupus management have a personal perspective that clinicians often lack. This commonality and credibility can establish trust, increase communication, and in turn decrease disparities in health care outcomes.
Article
This article provides an overview of the role of psychological factors and psychiatric disorders in the adjustment to systemic lupus erythematosus (SLE) and how to conceptualize their relationship with disease activity. Depression and anxiety disorders are highly prevalent in SLE. Depression poses a variety of health risks for afflicted patients and is associated with increased healthcare utilization and work disability. In addition, research has also shown that factors such as illness beliefs, coping, social support and life stress affect SLE health outcomes, highlighting the need for psychological screening and management. The contribution of psychological factors and disease activity to lupus fatigue is analyzed, emphasizing the importance of a multidimensional approach to understanding this troublesome symptom that affects the majority of SLE patients. At present, there is little behavioral intervention research in SLE. The findings suggest that a closer alliance between rheumatology, behavioral medicine and health psychology would facilitate SLE research and clinical care in the future.
Article
This study aims to determine whether it is possible to modify executive function in stressed individuals by means of cognitive-behavioral therapy for stress management. Thirty-one people with high levels of perceived stress were recruited into the study (treatment group = 18; wait-list group = 13). The treatment group received 14 weeks of stress management program. Psychological and executive function variables were evaluated in both groups pre and post-intervention. The treatment group showed improved psychological variables of perceived stress ( t = 5.492; p = .001), vulnerability to stress ( t = 4.061; p = .001) and superstitious thinking ( t = 2.961; p = .009). Likewise, the results showed statistically significant differences in personality variables related to executive function, positive urgency ( t = 3.585; p = .002) and sensitivity to reward ( t = –2.201; p = .042), which improved after the therapy. These variables showed a moderate to high effect size (oscillates between 1.30 for perceived stress and .566 for sensitivity to reward). The cognitive-behavioral therapy for stress management may be an appropriate strategy for improving personality construct components related to executive function, however effects of the therapy are not showed on performance on the tests of executive function applied, as presented studies previous.
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Background Stress is common in patients with Systemic Lupus Erythematosus (SLE), and is associated with depression, fatigue, and disease flares. Stress may be modifiable and identifying those at high risk allows clinicians and allied health care professionals to develop a multidisciplinary management plan to direct appropriate resources. This study is aimed at identifying predictors of high stress over time among patients with SLE. Methods Longitudinal data from two interviews of the Lupus Outcomes Study 2 years apart from 726 patients with SLE were analyzed for stress, measured using the Perceived Stress Scale (PSS; high-stress PSS ≥6). T -test and Chi-square analyses compared patient characteristics by high-stress status. Logistic regressions were conducted with high stress as the dependent variable. Covariates included demographics, disease features, quality of life (QOL), health care utilization (HCU), and comorbidities. QoL was measured using the SF-36 form (Physical Component Score, PCS; Mental Component Score, MCS) and MOS Cognitive Functioning Scale (CFS). HCU indicated having established care with a rheumatologist, use of an emergency room or hospitalization, and quality of care. P ≤ 0.05 were considered significant. Results The mean age of the cohort was 50.6 (12.5) years, 92% were women and 68% were Caucasian. The mean (SD) PSS was 5.3 (3.6), and high stress (PSS >6) was noted in 253 participants. Those with high stress were more frequently below the poverty line and less commonly employed. They had a greater prevalence of comorbidities and HCU; and worse disease severity (activity, flare, damage) and QOL. In regression analyses, high stress (baseline) was associated with younger age, married status, worse QOL, and presence of diabetes. Better QOL (PCS, MCS) independently predicted decreased odds of high stress, while high stress (baseline) predicted high stress (OR 3.16, 95% CI 1.85, 5.37, p < 0.0001) at follow-up, after adjusting for demographics, disease features, HCU, and comorbidities. Conclusion Patients with SLE should be routinely screened for QOL and stress during their clinical care, to identify those at risk for poor health outcomes. This information can facilitate multidisciplinary management for those at risk for worse health outcomes.
Article
Background: Systemic Lupus Erythematosus (SLE) is a chronic autoimmune disorder with significant disparate impact on African American women. The current study sought to highlight how the Peer Approaches to Lupus Self-management (PALS) intervention worked bi-directionally wherein both women with SLE leading the disease self-management program (mentors), and those participants who served as mentees, were empowered toward greater disease self-efficacy. Methods: Data was captured for this study in two formats from the seven mentors participating in the pilot study: 1) mentor logs and 2) mentor interviews with the principle investigator. This information was then analyzed for themes relating to their experience within the study. Results: We found that empowerment was facilitated by mentors taking their mentorship responsibilities seriously and seeking several avenues for collaboratively developing success with their mentees. Mentors reported that although challenges arose, their desire for success resulted in multiple approaches to be flexible and responsive to the needs of their mentees. Additionally, reciprocity was found to be a vital element of the program. Conclusions: Key thematic areas supported our ability to demonstrate the usefulness of a peer mentoring program for SLE disease self-management on evoking empowerment through reciprocal relationships among mentors and mentees within our study population. Furthermore the feedback from PALS participants yielded very rich and contextual information that can be used as a thematic guide for developing and refining evidence-based interventions that seek to incorporate empowerment into disease self-management efforts for women suffering from SLE.
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Objectives: This study was conducted to determine the efficacy of mindfulness-based cognitive therapy (MBCT) on psychological symptoms and quality of life (QoL) in patients with systemic lupus erythematosus (SLE). Methods: We conducted a randomized single-blind clinical trial in patients with SLE referred from the Imam Ali Clinic in Shahrekord, southwest Iran. The patients (46 in total in two groups of 23 each) were randomly assigned into the experimental and control groups. Both groups underwent routine medical care, and the experimental group underwent eight group sessions of MBCT in addition to routine care. The patient(,)s QoL was assessed using the General Health Questionnaire-28 and 36-Item Short Form Health Survey before, after, and six months after intervention (follow-up). Results: A significant difference was seen in psychological symptoms and QoL between MBCT and control groups immediately after the intervention and at follow-up (p ≤ 0.050). However, the difference was not significant for the physical components of QoL (p ≥ 0.050). Conclusions: MBCT contributed to decreased psychological symptoms and improved QoL in patients with SLE with a stable effect on psychological symptoms and psychological components of QoL, but an unstable effect on physical components.
Article
Although the pathogenesis of autoimmunity is not fully understood, it is thought to involve genetic, hormonal, immunologic, and environmental factors. Stress has been evaluated as a potential trigger for autoimmunity and disease flares in patients with systemic lupus erythematosus (SLE). The physiologic changes that occur with stress involve numerous catecholamines, hormones, and cytokines that communicate intricately with the immune system. There is some evidence that these systems may be dysregulated in patients with autoimmune disease. Mindfulness-based techniques are practices aimed at mitigating stress response and have been shown to improve quality of life in general population. This review will discuss pathophysiology of chronic stress as it relates to SLE, evidence behind mindfulness-based practices in these patients, and directions for future research.
Article
Background: Non-pharmacologic therapies have been deemed as potentially beneficial for patients with systemic lupus erythematosus. We conducted an updated review to determine the effects of these therapies to inform practice. Methods: A literature search was performed using PubMed (MEDLINE), EMBASE, Cochrane, PsychINFO, the Cumulative Index to Nursing and Allied Health Literature, Web of Science, and Google Scholar from inception until August 2018. We included randomized controlled trials of non-pharmacologic therapies in systemic lupus erythematosus patients with sample size ≥10. Systemic lupus erythematosus was defined by 1982 or 1997 American College of Rheumatology criteria. Studies were synthesized separately by patient-reported outcomes and disease activity. Due to the heterogeneity of interventions and comparisons, a meta-analysis was not performed. Results: A total of 15 randomized controlled trials involving 846 participants met the inclusion criteria. Of the 15 trials, eight used exercise interventions, six used psychological interventions (one group psychotherapy, three cognitive behavioral therapies, one psychoeducation, one mindfulness-based cognitive therapy) and one used electro-acupuncture. Five of 15 studies utilized control groups consisting of usual medical care. Other studies included control interventions of relaxation, attention placebo, symptom monitoring support, education, minimal needling, isotonic and resistance exercise. Compared with the control conditions, non-pharmacological interventions were associated with a significant improvement in fatigue in three out of six studies. Three out of eight studies reported improved anxiety and depression, and one study reported improved pain after interventions. Seven out of 11 studies reported improvement in overall quality of life in at least one domain of the Short-Form Health Survey. Of note, no studies demonstrated an improvement in disease activity after 5-52 weeks of non-pharmacological therapies. Conclusion: This review showed promising results for physical exercise and psychological interventions as adjuncts to traditional medical therapy for improvement in fatigue, depression, pain and quality of life for systemic lupus erythematosus. Further high-quality randomized controlled trials with longer follow-up periods are warranted.
Article
OBJECTIVE. Our objective was to assess the efficacy of occupational therapy–related interventions for adults with systemic lupus erythematosus (SLE). METHOD. We reviewed intervention studies published from 2000 to 2017. The method used for conducting the review was based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The PEDro scale was used to evaluate methodological quality. Risk of bias was appraised with methods described by the Cochrane Methods Group. RESULTS. The final analysis included 20 studies (10 physical activity and 10 psychoeducational). Moderate evidence supports physical activity to improve depression, fatigue, exercise tolerance, and function without exacerbation of disease symptoms. Strong evidence supports psychoeducational interventions using cognitive–behavioral approaches to improve pain, depression, anxiety, perceived stress, quality of life, and function. Moderate evidence supports patient education and self-management interventions for pain, depression, anxiety, perceived stress, quality of life, and function. CONCLUSION. Further research on occupation-based interventions for people with SLE is needed.
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Lupus is a systemic chronic inflammatory disease that attacks connective tissue and characterized by changes in immunological responses. Lupus is experienced by women in early adulthood. These developmental tasks in early adulthood are not an easy thing to live for an Odapus woman, so they often cause stress. This study aims to determine the effectiveness of Stress Inoculation Training to reduce stress in Odapus. This study uses a single group pretest posttest design. Measurements were made twice, namely before (pretest) and after (posttest) with 4 rearch subjects who had expressed their willingness through informed consent. Data collection was carried out using a Perceived Stress Scale (PSS) with reliability 0.78. Data analyzed by Wilcoxon Signed Rank Test. The results of data analysis show that Asymp. Sig (2-tailed) is 0.066 (≥0.05) which means that there is no significant difference between the pretest and posttest scores, however the intervention of Stress Inoculation Training (SIT) has a significant effect on reducing anxiety (r = 0.64). Keywords: Stress Inoculation Training (SIT); Stress; Odapus.  Abstrak Lupus merupakan penyakit inflamasi kronik sistemik yang menyerang jaringan ikat dan ditandai dengan adanya perubahan respon imunologi. Lupus banyak dialami oleh wanita pada masa dewasa awal. Tugas-tugas perkembangan pada masa dewasa awal ini bukanlah hal yang mudah untuk dijalani bagi seorang wanita Odapus, sehingga seringkali menyebabkan stres. Penelitian ini bertujuan untuk mengetahui efektivitas Stress Inoculation Training untuk menurunkan stres pada Odapus. Penelitian ini menggunakan desain single group pretest posttest design. Pengukuran dilakukan sebanyak 2 kali, yaitu sebelum (pretest) dan sesudah (posttest) dengan subjek penelitian sebanyak 4 orang yang telah menyatakan kesediaannya melalui informed consent. Pengumpulan data dilakukan menggunakan alat ukur Perceived Stress Scale (PSS) dengan reliabilitas sebesar 0,78. Analisis data yang digunakan adalah Wilcoxon Signed Rank Test. Hasil analisis data menunjukkan bahwa Asymp. Sig (2-tailed) adalah sebesar 0,066 (≥0,05) yang berarti tidak ada perbedaan yang signifikan antara skor pretest dan posttest, namun demikian intervensi Stress Inoculation Training (SIT) terbukti memiliki efek yang besar terhadap penurunan kecemasan (r=0.64). Kata Kunci: Stress Inoculation Training; Stres; Odapus; Lupus
Article
Objective: The Type 1 and Type 2 SLE categorization system was recently proposed in order to validate the patients' perspective of disease and to capture a more comprehensive spectrum of symptoms. The objective of this study was to characterize the clinical manifestations of SLE subtypes and to determine the correlation between the patient- and physician-reported measures used in the model. Methods: This was a cross-sectional study of SLE patients in a university clinic. Patients completed the Systemic Lupus Activity Questionnaire (SLAQ) and 2011 ACR Fibromyalgia (FM) criteria. Active SLE was defined as SLEDAI ≥6, clinical SLEDAI ≥4, or active lupus nephritis. We identified 4 groups: Type 1 SLE (active SLE without FM), Type 2 SLE (inactive SLE with FM), Mixed SLE (active SLE with FM), Minimal SLE (inactive SLE without FM). Results: In this cohort of 212 patients (92% female, mean age 45 years), 30% had Type 1 SLE, 8% had Type 2 SLE, 13% had Mixed SLE and 49% had minimal SLE. Regardless of SLE disease activity, patients with FM (21%), reported higher SLAQ scores, patient global assessment scores, and self-reported lupus flare which resulted in discordance between patient- and physician- reported measures. Conclusion: Fatigue, widespread pain, sleep dysfunction, and mood disorders are common symptoms in SLE. Identifying these symptoms as Type 2 SLE may be a method to improve patient communication and understanding. The level of Type 2 SLE impacts patients' perception of disease and self-reported symptoms. The SLAQ may need to be re-interpreted based on the fibromyalgia severity scale.
Article
Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that may affect every organ. The multiple pathogenic mechanisms and heterogeneous phenotypes of SLE present unique challenges in the management of this complex disease. This article discusses new SLE therapies from the last 10 years. We will address new information in the realms of lifestyle interventions, antimalarials, nonsteroidal anti-inflammatory drugs, glucocorticoids, immunosuppressive disease modifying antirheumatic drugs, biological therapies, and other modalities as they pertain to SLE.
Article
Background: Patients with systemic lupus erythematous (SLE) experience psychological comorbidities and impaired quality of life (QOL). We conducted a systematic review to examine the efficacy of non-pharmacological interventions for improving psychological outcomes and/or QOL in patients with SLE. To expand on a previous systematic review in this area and enhance our understanding of efficacious interventions for this population, our search included quasi-experimental and experimental studies of interventions delivered or supported by remote methods (including digitally) or in person. Methods: A comprehensive literature search was conducted with a research librarian using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and was registered before data extraction on the international prospective register of systematic reviews PROSPERO Web site (CRD42020154962). The search included controlled-vocabulary and title/abstract terms related to non-pharmacological interventions for SLE published through October 2019 in MEDLINE (Ovid), Cochrane Library databases (Wiley), Embase (Elsevier), CINAHL (EBSCO), PsycINFO (EBSCO), Web of Science (Clarivate), ACM Digital (Association of Computer Machinery), and IEEE Xplore. Studies were synthesized using a systematic narrative synthesis framework. Risk of bias was assessed. Results: Twenty-three studies were included: 21 randomized controlled trials and two quasi-experimental studies. Non-pharmacological diet, physical activity, psychological, and course-based interventions improved QOL and psychological outcomes, and were delivered in traditional settings (e.g., hospital) or remotely. No studies assessing digital non-pharmacological interventions were identified in our search. Quality assessments showed serious risk of bias for the two quasi-experimental studies, and high risk of bias in a subset of experimental studies. Conclusions: Non-pharmacological interventions benefit patients with SLE. Future research should include more representative samples in rigorous evaluations and consider ways to incorporate digital technologies to increase accessibility.
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Objective: Non-pharmacological interventions support patients with connective tissue diseases to better cope with and self-manage their diseases. This study aimed to map existing evidence on non-pharmacological interventions in patients with systemic lupus erythematosus (SLE), systemic sclerosis (SSc) and mixed connective tissue diseases regarding content, feasibility and potential suitability in an e-health setting. Methods: A literature search was performed in eight different databases in July 2020. The intervention's content was extracted using the 'Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide'. A Sankey diagram and descriptive statistics were used to analyse the data and illustrate the relationships between the interventions. Results: Of 8198 identified records, 119 papers were eligible. One hundred and four of them (87.4%) were conducted between 2000 and 2020, mainly in the USA (SLE n=24 (21.2%), SSc n=16 (14.2%)), Brazil (SLE n=8 (7.1%), SSc n=5 (4.4%)) and Italy (SLE n=0 (0%), SSc n=12 (10.6%)). Fifty-two studies (SLE n=24 (21.2%), SSc n=28 (24.8%)) used multicomponent interventions. The single interventions were physical exercises (SLE n=16 (14.2%), SSc n=17 (15.0%)), coaching/counselling (SLE n=11 (18.0%), SSc n=0 (0%)) and education (SLE n=2 (1.8%), SSc n=3 (2.7%)). Primary outcomes focused on physical function (SLE n=1 (0.9%), SSc n=15 (13.3%)), mouth opening in SSc (n=4 (5.9%)) and physical capacity (SLE n=2 (1.8%), SSc n=1 (0.9%)). No interventions for mixed connective tissue disease were found. Conclusion: There was a great variety in the intervention's content due to differences in body structure, activity limitations and participation restrictions in SLE and SSc. These results highlight the need for personalised, multicomponent, non-pharmacological interventions, which could be delivered as e-health interventions.
Article
Aim of the work To evaluate the impact of group psychotherapy and patient education on disease activity, quality of life, psychological symptoms, perceived stress, satisfaction to treatment, and medication adherence in systemic lupus erythematosus (SLE) patients. Patients and methods This study recruited 80 SLE patients divided equally into intervention and control groups, the intervention group received 12 sessions of group psychotherapy and patient education. SLE disease activity index (SLEDAI) was assessed. The following questionnaires were conducted: Symptom Checklist-90-Revised (SCL-90-R), perceived stress scale (PSS), Short Form 36 (SF36), Treatment Satisfaction Questionnaire for Medications (TSQM), and Medication Adherence Rating Scale-5 (MARS-5). Results The mean age of the patients was 32.3 ± 7.4 years and disease duration 7.5 ± 5.7 years. They were 77 females and 3 males. At baseline, the SLEDAI, global severity index of SCL-90-R, PSS, SF36, TSQM and MARS-5 were comparable between both groups. After 3 months of the psycho-educational program, the intervention group exhibited significant improvement of SCL-90-R: anxiety (p = 0.052), depression (p = 0.002), global severity index (p = 0.001), PSS (p < 0.001), SF36 [limitations due to emotional problem (p < 0.001), emotional well-being (p < 0.001), MCS (p = 0.029), PCS (p = 0.001)], TSQM [effectiveness (p < 0.001), convenience (p = 0.026), side effects (p = 0.001), global satisfaction (p = 0.005) scores] and MARS-5 (p < 0.001) with no significant difference in SLEDAI (p = 0.802). Conclusion Integration of a psycho-educational program in the management of SLE patients was associated with improvement of depression, anxiety, perceived stress, quality of life, satisfaction with treatment, and medication adherence, with no impact on disease activity.
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A 36-item short-form (SF-36) was constructed to survey health status in the Medical Outcomes Study. The SF-36 was designed for use in clinical practice and research, health policy evaluations, and general population surveys. The SF-36 includes one multi-item scale that assesses eight health concepts: 1) limitations in physical activities because of health problems; 2) limitations in social activities because of physical or emotional problems; 3) limitations in usual role activities because of physical health problems; 4) bodily pain; 5) general mental health (psychological distress and well-being); 6) limitations in usual role activities because of emotional problems; 7) vitality (energy and fatigue); and 8) general health perceptions. The survey was constructed for self-administration by persons 14 years of age and older, and for administration by a trained interviewer in person or by telephone. The history of the development of the SF-36, the origin of specific items, and the logic underlying their selection are summarized. The content and features of the SF-36 are compared with the 20-item Medical Outcomes Study short-form.
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Atrial fibrillation affects an estimated 2.5 million Americans and incurs an average annual stroke risk of 4.5% per year. Despite warfarin reducing stroke risk by approximately 66%, prior studies show warfarin usage rates to be about 50%. However, the methods that define warfarin as "inappropriate underutilization" might not be sensitive enough to pick up relative contraindications. We assessed the inappropriate underutilization of warfarin in atrial fibrillation patients at our hospital by abstracting individual patient charts. Medical records were reviewed to determine stroke risk factors, warfarin use, and documented contraindications to warfarin use in 364 consecutive patients with atrial fibrillation. Amongst 364 atrial fibrillation patients, 54.6% received warfarin anticoagulation. Overall, 29.5 % of patients had documented reasons for not prescribing warfarin. Primary reasons listed by treating physicians included: gastrointestinal bleed 10.7%, secondary/transient atrial fibrillation 8.2%, and fall risk 6.3%. Only 7.1% of the patients had no documented reasons for the lack of warfarin use. Consistent with previous reports, 45.4% of patients in this atrial fibrillation cohort were not prescribed warfarin. However, after reviewing medical charts for documented reasons why warfarin was not used, the inappropriate underutilization rate was only 7.1%. These findings suggest that studies utilizing administrative database and ICD-9 CM coding might overestimate warfarin underutilization.
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The authors tested the hypothesis that individuals with a variety of severe chronic illnesses and the healthy elderly exhibit a loss of flexibility in their response to a variety of stressors, compared with healthy adults. A card sort game designed to assess self-reported coping behavior under different stressful life situations was used to compare healthy adults with individuals with multiple sclerosis, rheumatoid arthritis, systemic lupus erythematosus, and the elderly. The healthy adults were found to exhibit more variability than any of the illness groups or the elderly. Healthy function is marked by a complex type of variability.
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Warfarin reduces the risk of stroke in patients with atrial fibrillation but increases the risk of hemorrhage and is difficult to use. Dabigatran is a new oral direct thrombin inhibitor. In this noninferiority trial, we randomly assigned 18,113 patients who had atrial fibrillation and a risk of stroke to receive, in a blinded fashion, fixed doses of dabigatran--110 mg or 150 mg twice daily--or, in an unblinded fashion, adjusted-dose warfarin. The median duration of the follow-up period was 2.0 years. The primary outcome was stroke or systemic embolism. Rates of the primary outcome were 1.69% per year in the warfarin group, as compared with 1.53% per year in the group that received 110 mg of dabigatran (relative risk with dabigatran, 0.91; 95% confidence interval [CI], 0.74 to 1.11; P<0.001 for noninferiority) and 1.11% per year in the group that received 150 mg of dabigatran (relative risk, 0.66; 95% CI, 0.53 to 0.82; P<0.001 for superiority). The rate of major bleeding was 3.36% per year in the warfarin group, as compared with 2.71% per year in the group receiving 110 mg of dabigatran (P=0.003) and 3.11% per year in the group receiving 150 mg of dabigatran (P=0.31). The rate of hemorrhagic stroke was 0.38% per year in the warfarin group, as compared with 0.12% per year with 110 mg of dabigatran (P<0.001) and 0.10% per year with 150 mg of dabigatran (P<0.001). The mortality rate was 4.13% per year in the warfarin group, as compared with 3.75% per year with 110 mg of dabigatran (P=0.13) and 3.64% per year with 150 mg of dabigatran (P=0.051). In patients with atrial fibrillation, dabigatran given at a dose of 110 mg was associated with rates of stroke and systemic embolism that were similar to those associated with warfarin, as well as lower rates of major hemorrhage. Dabigatran administered at a dose of 150 mg, as compared with warfarin, was associated with lower rates of stroke and systemic embolism but similar rates of major hemorrhage. (ClinicalTrials.gov number, NCT00262600.)
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A new decontaminated hassles measure for adults, the Survey of Recent Life Experiences, was developed and validated. An initial pool of 92 items was administered to 100 subjects along with the Perceived Stress Scale. Fifty-one items were selected, based on significant correlations with the latter scale. The alpha reliability of the resultant final form of the Survey of Recent Life Experiences and its correlation with perceived stress were both high. In a separate cross-replication sample of 136 adults, the alpha reliability of the Survey and its correlation against the Perceived Stress Scale remained acceptably high. Moreover, separate-sex analyses supported the reliability and validity of the Survey of Recent Life Experiences across gender. Factor analysis of the Survey yielded six interpretable factors. Intercorrelations among subscales based on these factors were generally modest, suggesting that the scale is relatively free from contamination by psychological distress.
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This study tested hypotheses about the consistency of specified outcomes with strength of program treatment indexed by time spent in a given activity in the Systemic Lupus Erythematosus Self-Help (SLESH) course. Participants had significant increases in enabling skills and in use of relaxation and exercise activities. Participants also had significantly less depression. Consistency between amount of time spent in class and significant changes over time was demonstrated by analysis of treatment strength-response for perception of limitations, depression, enabling skill and for use of rest, relaxation, heat, and exercise activities.
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Systemic lupus erythematosus (SLE) is a chronic autoimmune disease characterized by flare-ups, the causes of which are not known. In accordance with new concepts in stress research, this study investigated whether daily psychosocial stressors interfere with immunological processes in SLE. Because such processes are unique to each individual, single-case design using time-series analysis (Box and Jenkins) was applied. A 40-year-old woman with SLE (last flare-up September 1995) was interviewed initially to determine major life events and difficulties (using the Life Events and Difficulties Schedule) in the previous 2 years. She was then observed for 63 days. Urine neopterin, an immunological parameter demonstrated to parallel disease activity in SLE patients, was measured in daily overnight urine. Daily incidents were identified weekly by the Incidents and Hassles Inventory and independently rated. Intervening factors, including infections, medication, and lifestyle, were controlled. Retrospectively, data obtained from the Life Events and Difficulties Schedule indicated that major life events and difficulties had preceded the patient's last flare-up in 1995. Although there were no clinical signs of SLE during this prospective study of 63 days, cross-correlational analyses revealed that "moderately" stressful incidents associated with higher levels of emotional irritation (lag 0: +0.271, p < .05) predicted an increase in urine neopterin the following day (lag 1: +0.441, p < .05). Moreover, a 7-day cyclicity in neopterin levels that corresponded to the weekly examinations and interviews was found. This study showed a causal relationship between psychosocial stressors and urine neopterin concentrations that may be related to SLE disease activity. Furthermore, the workability of an integrative approach using single-case design and time-series analysis in psychoneuroimmunology was demonstrated for the first time.
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This study investigated the complex biochemical responses to personally meaningful everyday stressors in a patient with systemic lupus erythematosus (SLE). For this purpose, a 52 year-old woman with SLE collected her entire urine for 56 days on a 12-h basis for the determination of cortisol as well as neopterin, a cellular immune parameter. Additionally, using questionnaires, daily notes and interviews, extensive psychosocial and psychological time-series data were collected every 12 h. Cross-correlational analyses of the resulting time-series revealed that stressful incidents were associated with cyclic fluctuations in both urine cortisol and urine neopterin. Specifically, whenever the patient anticipated a moderately stressful incident, urine cortisol initially increased 24 h before the incident and then decreased 12 h before the incident. Moderate stressors not anticipated by the patient were associated with an initial increase 24 h following the incident and then with a decrease after a total of 36 h. Moreover, stressors having to do with the patient's extramarital relationship were followed initially by a decrease in urine neopterin after 36 h and then by an increase after a total of 60 h. Our findings indicate that when investigating the relationship between psychosocial stressors and biochemical activity in SLE, appropriate consideration of the data's dynamic nature may be necessary to avoid flawed conclusions.
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The aetiology of systemic lupus erythematosus (SLE) remains unclear. Clinical observations and a small number of studies performed so far suggest an association between psychological stress and self-reported symptoms of SLE patients. This longitudinal study was designed to investigate whether daily psychological stress is associated with flares in SLE patients, measured by clinical and laboratory parameters. Female SLE patients (n = 41) were followed over a period of six months. Daily stress was monitored by a hand-held PC diary programmed with 44 items based on standardized measures and clinical experience. Once every four weeks patients visited the outpatient clinic for medical evaluation. Disease activity was evaluated using the European Consensus Lupus Activity Measurement (ECLAM), laboratory parameters, and intake of steroids. Classification and regression tree (CART) patient-wise analyses revealed that SLE patients with vs. without flares using complement and ECLAM as activity measures show greater negative self-ratings in mood, and social duties (p < 0.01). In addition, mixed model analysis of variance showed that daily hassles with social relationships were significantly associated with flares in SLE measured by an increase in steroid medication >5mg/d (p < 0.01). These results suggest that psychological stress is associated with flares in SLE. Particularly daily stress with social relationships and social duties may be factors to be related to the course of disease activity in SLE.
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Antithrombotic therapy can prevent strokes and transient ischemic attacks (TIAs) in carefully selected patients who have chronic nonvalvular atrial fibrillation (NVAF). Our objectives were 3-fold: to document the use of warfarin and aspirin therapy in Missouri Medicare beneficiaries with chronic NVAF; to identify factors associated with warfarin and aspirin underuse; and to determine the association between prescription of warfarin and aspirin at hospital discharge and adverse outcomes in this elderly, frail population. We linked chart reviews from all Missouri hospitals to Medicare claims data from 1993 to 1996. From chart reviews, we documented Medicare beneficiaries' demographic factors, comorbid conditions, and antithrombotic therapy prescribed at the time of hospital discharge. From Medicare claims, we determined the date of outcomes-death from any cause or hospitalization for an ischemic event (a stroke, a TIA, or a myocardial infarction). Only 328 (55%) of the 597 Medicare beneficiaries were prescribed antithrombotic therapy at hospital discharge: 34% received warfarin and 21% received aspirin. Advanced age, female gender, and rural residency predicted underuse of antithrombotic therapy. After controlling for these factors, as well as stroke risk factors and contraindications to anticoagulation, the prescription of warfarin was associated with a 24% relative risk reduction (RRR) in adverse outcomes (P=0.003). Prescription of aspirin was associated with a nonsignificant 5% RRR in these events (P=0.56). The underuse of antithrombotic therapy in Medicare beneficiaries who have NVAF is associated with measurable adverse outcomes. The benefit of warfarin therapy may extend to frail, elderly patients, a group that was excluded from randomized controlled trials. The role of antiplatelet therapy in this population deserves further study because many of these patients have relative contraindications to warfarin.
Article
Background: Vitamin K antagonists reduce the risk of stroke in patients with atrial fibrillation but are considered unsuitable in many patients, who usually receive aspirin instead. We investigated the hypothesis that the addition of clopidogrel to aspirin would reduce the risk of vascular events in patients with atrial fibrillation. Methods: A total of 7554 patients with atrial fibrillation who had an increased risk of stroke and for whom vitamin K-antagonist therapy was unsuitable were randomly assigned to receive clopidogrel (75 mg) or placebo, once daily, in addition to aspirin. The primary outcome was the composite of stroke, myocardial infarction, non-central nervous system systemic embolism, or death from vascular causes. Results: At a median of 3.6 years of follow-up, major vascular events had occurred in 832 patients receiving clopidogrel (6.8% per year) and in 924 patients receiving placebo (7.6% per year) (relative risk with clopidogrel, 0.89; 95% confidence interval [CI], 0.81 to 0.98; P=0.01). The difference was primarily due to a reduction in the rate of stroke with clopidogrel. Stroke occurred in 296 patients receiving clopidogrel (2.4% per year) and 408 patients receiving placebo (3.3% per year) (relative risk, 0.72; 95% CI, 0.62 to 0.83; P<0.001). Myocardial infarction occurred in 90 patients receiving clopidogrel (0.7% per year) and in 115 receiving placebo (0.9% per year) (relative risk, 0.78; 95% CI, 0.59 to 1.03; P=0.08). Major bleeding occurred in 251 patients receiving clopidogrel (2.0% per year) and in 162 patients receiving placebo (1.3% per year) (relative risk, 1.57; 95% CI, 1.29 to 1.92; P<0.001). Conclusions: In patients with atrial fibrillation for whom vitamin K-antagonist therapy was unsuitable, the addition of clopidogrel to aspirin reduced the risk of major vascular events, especially stroke, and increased the risk of major hemorrhage. (ClinicalTrials.gov number, NCT00249873.)
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Psychosocial factors influence the course and the outcome of chronic somatic diseases. This is also valid for rheumatic diseases like rheumatoid arthritis, spondyloarthropathies, systemic collagen vascular diseases, and fibromyalgia syndrome. The article summarises the evidence-based findings and it illustrates possibilities of psychosomatic treatment in rheumatic diseases by means of three case reports.
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Research studies focusing on the psychometric properties of the Beck Depression Inventory (BDI) with psychiatric and nonpsychiatric samples were reviewed for the years 1961 through June, 1986. A meta-analysis of the BDI's internal consistency estimates yielded a mean coefficient alpha of 0.86 for psychiatric patients and 0.81 for nonpsychiatric subjects. The concurrent validitus of the BDI with respect to clinical ratings and the Hamilton Psychiatric Rating Scale for Depression (HRSD) were also high. The mean correlations of the BDI samples with clinical ratings and the HRSD were 0. 72 and 0.73, respectively, for psychiatric patients. With nonpsychiatric subjects, the mean correlations of the BDI with clinical ratings and the HRSD were 0.60 and 0.74, respectively. Recent evidence indicates that the BDI discriminates subtypes of depression and differentiates depression from anxiety.
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Warfarin dramatically reduces the risk for ischemic stroke in nonvalvular atrial fibrillation, but its use among ambulatory patients with atrial fibrillation has not been widely studied. To assess the rates and predictors of warfarin use in ambulatory patients with nonvalvular atrial fibrillation. Cross-sectional study. Large health maintenance organization. 13428 patients with a confirmed ambulatory diagnosis of nonvalvular atrial fibrillation and known warfarin status between 1 July 1996 and 31 December 1997. Data from automated pharmacy, laboratory, and clinical-administrative databases were used to determine the prevalence and determinants of warfarin use in the 3 months before or after the identified diagnosis of atrial fibrillation. Of 11082 patients with nonvalvular atrial fibrillation and no known contraindications, 55% received warfarin. Warfarin use was substantially lower in patients who were younger than 55 years of age (44.3%) and those who were 85 years of age or older (35.4%). Only 59.3% of patients with one or more risk factors for stroke and no contraindications were receiving warfarin. Among a subset of "ideal" candidates to receive warfarin (persons 65 to 74 years of age who had no contraindications and had previous stroke, hypertension, or both), 62.1% had evidence of warfarin use. Among our entire cohort, the strongest predictors of receiving warfarin were previous stroke (adjusted odds ratio, 2.55 [95% CI, 2.23 to 2.92]), heart failure (odds ratio, 1.63 [CI, 1.51 to 1.77]), previous intracranial hemorrhage (odds ratio, 0.33 [CI, 0.21 to 0.52]), age 85 years or older (odds ratio, 0.35 [CI, 0.31 to 0.40]), and previous gastrointestinal hemorrhage (odds ratio, 0.47 [CI, 0.40 to 0.57]). In a large, contemporary cohort of ambulatory patients with atrial fibrillation who received care within a health maintenance organization, warfarin use was considerably higher than in other reported studies. Although the reasons why physicians did not prescribe warfarin could not be elucidated, many apparently eligible patients with atrial fibrillation and at least one additional risk factor for stroke, especially hypertension, did not receive anticoagulation. Interventions are needed to increase the use of warfarin for stroke prevention among appropriate candidates.
Article
Contemporary clinical risk stratification schemata for predicting stroke and thromboembolism (TE) in patients with atrial fibrillation (AF) are largely derived from risk factors identified from trial cohorts. Thus, many potential risk factors have not been included. We refined the 2006 Birmingham/National Institute for Health and Clinical Excellence (NICE) stroke risk stratification schema into a risk factor-based approach by reclassifying and/or incorporating additional new risk factors where relevant. This schema was then compared with existing stroke risk stratification schema in a real-world cohort of patients with AF (n = 1,084) from the Euro Heart Survey for AF. Risk categorization differed widely between the different schemes compared. Patients classified as high risk ranged from 10.2% with the Framingham schema to 75.7% with the Birmingham 2009 schema. The classic CHADS(2) (Congestive heart failure, Hypertension, Age > 75, Diabetes, prior Stroke/transient ischemic attack) schema categorized the largest proportion (61.9%) into the intermediate-risk strata, whereas the Birmingham 2009 schema classified 15.1% into this category. The Birmingham 2009 schema classified only 9.2% as low risk, whereas the Framingham scheme categorized 48.3% as low risk. Calculated C-statistics suggested modest predictive value of all schema for TE. The Birmingham 2009 schema fared marginally better (C-statistic, 0.606) than CHADS(2). However, those classified as low risk by the Birmingham 2009 and NICE schema were truly low risk with no TE events recorded, whereas TE events occurred in 1.4% of low-risk CHADS(2) subjects. When expressed as a scoring system, the Birmingham 2009 schema (CHA(2)DS(2)-VASc acronym) showed an increase in TE rate with increasing scores (P value for trend = .003). Our novel, simple stroke risk stratification schema, based on a risk factor approach, provides some improvement in predictive value for TE over the CHADS(2) schema, with low event rates in low-risk subjects and the classification of only a small proportion of subjects into the intermediate-risk category. This schema could improve our approach to stroke risk stratification in patients with AF.
Article
Atrial fibrillation is the most common sustained cardiac arrhythmia, which is associated with a high risk of stroke and thromboembolism. Increasing evidence suggests that the thrombogenic tendency in atrial fibrillation is related to several underlying pathophysiological mechanisms. Abnormal changes in flow are evident by stasis in the left atrium, and seen as spontaneous echocontrast. Abnormal changes in vessel walls-essentially, anatomical and structural defects-include progressive atrial dilatation, endocardial denudation, and oedematous or fibroelastic infiltration of the extracellular matrix. Additionally, abnormal changes in blood constituents are well described, and include haemostatic and platelet activation, as well as inflammation and growth factor changes. These changes result in the fulfilment of Virchow's triad for thrombogenesis, and accord with a prothrombotic or hypercoagulable state in this arrhythmia. In this Review, we present an overview of the established and purported mechanisms for thrombogenesis in atrial fibrillation.
Article
Coronary heart disease (CHD) is the leading cause of death and disability in the United States and in highly industrialized countries. Many modifiable psychosocial risk factors have been identified and can affect the course of cardiac illness. These include the negative emotional states of depression, anxiety, stress, anger/hostility, and social isolation. Anxiety has been found to increase the risk of developing CHD in healthy subjects and can lead to worsening of existing CHD. There is much overlap and confusion throughout the research literature between what authors define as anxiety, stress, Type A behavioral pattern, and anger/hostility.There is a need for better screening within the practice of cardiology for these psychosocial risk factors to ensure better integration of mental health services. Established screening tools such as the Beck Anxiety Inventory, Patient Health Questionnaire-9, Zung Self-Rating Anxiety Scale, and the Hamilton Anxiety Scale are described and compared with the newer Screening Tool for Psychologic Distress as part of the initial work-up of every cardiac patient. Recommendations are made using the author's Anxiety Treatment Algorithm regarding when to refer to a mental health professional along with how to reduce stigma and provide more integrated care. The diagnosis and treatment of anxiety disorders is reviewed, with attention to selective serotonin reuptake inhibitors, benzodiazepines, cognitive-behavioral therapy, stress reduction, and behavioral medicine group programs. These group programs are recommended because they help to overcome social isolation and counsel patients on how to adapt to a healthy lifestyle. Better clinical outcome research is needed that specifically addresses the question of whether the treatment of anxiety and anxiety disorders can affect the course of cardiac illness.
Article
The question of whether stress poses a risk for cancer progression has been difficult to answer. A randomized clinical trial tested the hypothesis that cancer patients coping with their recent diagnosis but receiving a psychologic intervention would have improved survival compared with patients who were only assessed. A total of 227 patients who were surgically treated for regional breast cancer participated. Before beginning adjuvant cancer therapies, patients were assessed with psychologic and behavioral measures and had a health evaluation, and a 60-mL blood sample was drawn. Patients were randomized to Psychologic Intervention plus assessment or Assessment only study arms. The intervention was psychologist led; conducted in small groups; and included strategies to reduce stress, improve mood, alter health behaviors, and maintain adherence to cancer treatment and care. Earlier articles demonstrated that, compared with the Assessment arm, the Intervention arm improved across all of the latter secondary outcomes. Immunity was also enhanced. After a median of 11 years of follow-up, disease recurrence was reported to occur in 62 of 212 (29%) women and death was reported for 54 of 227 (24%) women. Using Cox proportional hazards analysis, multivariate comparison of survival was conducted. As predicted, patients in the Intervention arm were found to have a reduced risk of breast cancer recurrence (hazards ratio [HR] of 0.55; P = .034) and death from breast cancer (HR of 0.44; P = .016) compared with patients in the Assessment only arm. Follow-up analyses also demonstrated that Intervention patients had a reduced risk of death from all causes (HR of 0.51; P = .028). Psychologic interventions as delivered and studied here can improve survival.
Article
Oral anticoagulation (OAC) therapy is effective in atrial fibrillation but requires vigilance to maintain the international normalized ratio in the therapeutic range. This report examines how differences in time in therapeutic range (TTR) between centers and between countries affect the outcomes of OAC therapy. In a posthoc analysis, the TTRs of patients on OAC in a randomized trial of OAC versus clopidogrel plus aspirin (Atrial Fibrillation Clopidogrel Trial With Irbesartan for Prevention of Vascular Events [ACTIVE W]) were used to calculate the mean TTR for each of 526 centers and 15 countries. Proportional-hazards analysis, with and without adjustment for baseline variables, was performed, with patients stratified by TTR quartile and country. A wide variation in TTRs was found between centers, with mean TTRs for centers in the 4 quartiles of 44%, 60%, 69%, and 78%. For patients at centers below the median TTR (65%), no treatment benefit was demonstrated as measured by relative risk for vascular events of clopidogrel plus aspirin versus OAC (relative risk, 0.93; 95% confidence interval, 0.70 to 1.24; P=0.61). However, for patients at centers with a TTR above the study median, OAC had a marked benefit, reducing vascular events by >2-fold (relative risk, 2.14; 95% confidence interval, 1.61 to 2.85; P<0.0001). Mean TTR also varied between countries from 46% to 78%; relative risk (clopidogrel plus aspirin versus OAC) varied from 0.6 to 3.6 (a 5-fold difference). A population-average model predicted that a TTR of 58% would be needed to be confident that patients would benefit from being on OAC. A wide variation exists in international normalized ratio control, as measured by TTR, between clinical centers and between countries, which has a major impact on the treatment benefit of OAC therapy. For centers and countries, a target threshold TTR exists (estimated between 58% and 65%) below which there appears to be little benefit of OAC over antiplatelet therapy.
Article
We conducted a systematic review and meta-analysis to determine the efficacy of psychological interventions for premenstrual syndrome. We systematically searched and selected studies that enrolled women with premenstrual syndrome in which investigators randomly assigned them to a psychological intervention or to a control intervention. Trials were included irrespective of their outcomes and, when possible, we conducted meta-analyses. Nine randomized trials, of which 5 tested cognitive behavioural therapy, contributed data to the meta-analyses. Low quality evidence (design and implementation weaknesses of the studies, possible reporting bias) suggests that cognitive behavioural therapy significantly reduces both anxiety (effect size [ES] = -0.58; 95% confidence interval [CI] = -1.15 to -0.01; number needed to treat [NNT] = 5), and depression (ES = -0.55; 95% CI = -1.05 to -0.05; NNT = 5), and also suggests a possible beneficial effect on behavioural changes (ES = -0.70; 95% CI = -1.29 to -0.10; NNT = 4) and interference of symptoms on daily living (ES = -0.78; 95% CI = -1.53 to -0.03; NNT = 4). Results provide much more limited support for monitoring as a form of therapy and suggest the ineffectiveness of education. Low quality evidence from randomized trials suggests that cognitive behavioural therapy may have important beneficial effects in managing symptoms associated with premenstrual syndrome.
Article
Dabigatran etexilate is an orally administered prodrug of dabigatran, which is a potent, concentration-dependent inhibitor of thrombus formation and thrombin-induced platelet aggregation. ▲ Dabigatran etexilate pharmacokinetics were linear across a wide dosage range. There were no clinically important pharmacokinetic interactions with digoxin (a P-glycoprotein substrate), pantoprazole (a proton-pump inhibitor) or drugs that are substrates and/or inhibitors of hepatic cytochrome P450 enzymes. ▲ In two large, randomized, double-blind trials of the prevention of venous thromboembolism (VTE) in patients undergoing total hip or total knee replacement surgery, orally administered dabigatran etexilate 220 mg/day was noninferior to subcutaneous enoxaparin sodium 40 mg/day for the primary composite endpoint of total VTE events or all-cause mortality during the treatment period. ▲ There were no significant differences between dabigatran etexilate and enoxaparin sodium in major VTE events and VTE-related mortality. Across trials, ≤0.5% of patients experienced a symptomatic pulmonary embolus or died. ▲ Dabigatran etexilate was generally well tolerated. In patients undergoing total hip or total knee replacement surgery, there was no significant difference between dabigatran etexilate and enoxaparin sodium recipients in the incidence of major or minor bleeding.
Article
Patients with systemic lupus erythematosus (SLE) and a comparison group of patients with rheumatoid arthritis (RA) completed the Dutch Everyday Problem Checklist and the Dutch Arthritis Impact Measurement Scale measuring physical and psychosocial aspects of illness. Both scales were completed 9 times at 6-week intervals. In addition several hematological and serological parameters were assayed. Analysis over several time points resulted in only weak correlations between the variables under study. The most remarkable finding of this study was that in SLE patients number and intensity of daily stressors are more strongly related to physical and psychosocial status than in RA patients.
Article
This paper presents evidence from three samples, two of college students and one of participants in a community smoking-cessation program, for the reliability and validity of a 14-item instrument, the Perceived Stress Scale (PSS), designed to measure the degree to which situations in one's life are appraised as stressful. The PSS showed adequate reliability and, as predicted, was correlated with life-event scores, depressive and physical symptomatology, utilization of health services, social anxiety, and smoking-reduction maintenance. In all comparisons, the PSS was a better predictor of the outcome in question than were life-event scores. When compared to a depressive symptomatology scale, the PSS was found to measure a different and independently predictive construct. Additional data indicate adequate reliability and validity of a four-item version of the PSS for telephone interviews. The PSS is suggested for examining the role of nonspecific appraised stress in the etiology of disease and behavioral disorders and as an outcome measure of experienced levels of stress.
Article
Forty-one subjects diagnosed with systemic lupus erythematosus (SLE) were recruited from across the United States. Regressions were conducted to evaluate the relation among stress, depression, anxiety, anger, and SLE symptom complaints. Negative weighting of major life events predicted symptom history. Significant hierarchical regressions using negative weighting of major life events, impact of daily stress, depression, anxiety, and anger were found for severity of joint pain, abdominal distress, and rash. Analyses using 1-day-lagged predictors yielded similar results. Within-subject analyses suggested that there was much individual variability in the strength of the stress-illness relation. Thus, some individuals appeared to be stress responders, while others did not. Findings for impact of minor life events and depression were consistent across the different levels of analyses. It was concluded that stress, depression, anxiety, and anger are associated with, and may exacerbate, self-reported symptomatology of SLE patients.
Article
To determine the minimal clinically important difference (MCID) of warfarin therapy for the treatment of nonvalvular atrial fibrillation from the perspective of patients using 2 different elicitation methods. All patients completed 2 face-to-face interviews, which were 2 weeks apart. For each interview, they were randomized to receive 1 of 2 elicitation methods: ping-ponging or starting at the known efficacy. The practices of 2 university-affiliated family medicine centers (8 physicians each), 14 community-based family physicians, and 2 cardiologists. Sixty-four patients with nonvalvular atrial fibrillation who were initiated with warfarin therapy at least 3 months before the study. During each interview, the patients' MCIDs were determined by using (1) a pictorial flip chart to describe atrial fibrillation; the consequences of a minor stroke, a major stroke, and a major bleeding episode; the chance of stroke if not taking warfarin; the chance of a major bleeding episode if taking warfarin; examples of the inconvenience, minor side effects, and costs of warfarin therapy; and then (2) 1 of the 2 elicitation methods to determine their MCIDs (the smallest reduction in stroke risk at which the patients were willing to take warfarin). Patients' knowledge of their stroke risk, acceptability of the interview process, and factors determining their preferences were also assessed. Given a baseline risk of having a stroke in the next 2 years, if not taking warfarin, of 10 of 100, the mean MCID was 2.01 of 100 (95% confidence interval, 1.60-2.42). Fifty-two percent of the patients would take warfarin for an absolute decrease in stroke risk of 1% over 2 years. Before eliciting their MCIDs, patients showed poor knowledge of their stroke risk, which improved afterward. The interview process was well accepted by the patients. The MCID using the ping-ponging elicitation method was 1.015 of 100 smaller compared with use of the starting at the known efficacy method (P = .01). We were able to determine the MCID of warfarin therapy for the prevention of stroke from the perspective of patients with nonvalvular atrial fibrillation. Their MCIDs were much smaller than those that have been implied by some experts and clinicians. The interview process, using the flip chart approach, appeared to improve the patients' knowledge of their disease and its consequences and treatment. The method used to elicit the patients' MCIDs can have a clinically important effect on patient responses. The method used in our study can be generalized to other conditions and, thus, could be helpful in 3 ways: (1) from a clinical decision-making perspective, it could facilitate patient-physician communication; (2) it could clarify the patient perspective when interpreting the results of previously completed trials; and (3) it could be used to derive more clinically relevant sample sizes for randomized treatment trials.
Article
The prevalence of atrial fibrillation (AF) increases dramatically with advancing patient age, and, as a result, this condition is common in persons residing in the long-term care setting. To assess the knowledge and attitudes of physicians regarding the use of warfarin for stroke prevention in patients with atrial fibrillation in long-term care facilities. We surveyed physicians actively providing primary care to older patients in 30 long-term care facilities located in New England, Quebec, and Ontario. Physicians were requested to complete a structured questionnaire about use of warfarin therapy for stroke prevention in patients with AF residing in long-term care facilities. The questionnaire included two clinical scenarios designed to provide substantial contrasts in patient characteristics including underlying comorbidity, functional status, bleeding risk, and stroke risk. A total of 269 physicians were asked to participate in the survey, and 182 (67.7%) completed the questionnaire between February 1, 1995, and July 31, 1995. Only 47% of respondents indicated that the benefits of warfarin therapy "greatly outweigh the risks" in this setting; the remainder of physicians indicated that benefits only "slightly outweigh the risks" (34%) or that risks "outweigh benefits" (19%). The most frequently cited contraindications to warfarin use were: excessive risk of falls (71%), history of gastrointestinal bleeding (71%), history of other non-central nervous system bleeding (36%), and history of cerebrovascular hemorrhage (25%). Among the 164 physicians who reported using the international normalized ratio to monitor warfarin therapy, 27% indicated a target range with a lower limit less than 2, 71% indicated a target range between 2 and 3, and 2% indicated an upper limit greater than 3. Among respondents who answered questions about the two clinical scenarios, estimates of the risk of a stroke without warfarin therapy and the risk of an intracranial hemorrhage with therapy varied widely. Our findings suggest that many uncertainties surround the decision to prescribe warfarin to patients with AF in the long-term care setting, as well as questions about the appropriate intensity of this treatment when it is prescribed. Concerns about the risks of bleeding appear to prevail over stroke prevention when physicians make such prescribing decisions.