A randomized clinical trial of a psychoeducational intervention to improve outcomes in systemic lupus erythematosus

Systemic lupus erythematosus in a multiethnic cohort: LUMINA XXXV. Predictive factors of high disease activity over time

AIM

To ascertain the predictive factors of high levels of disease activity in systemic lupus erythematosus (SLE).

PATIENTS AND METHODS

Patients with SLE (American College of Radiology criteria), aged >or=16 years, with disease duration <or=5 years and of Hispanic (Texas and Puerto Rico), African American and Caucasian ethnicities, were included. The outcome was high disease activity at any time (Systemic Lupus Activity Measure-Revised >10). A basic multivariable model (including age, sex, ethnicity, health insurance, social support, abnormal illness-related behaviours, helplessness and prior disease activity) was first examined. Additional models were built by including other variables.

RESULTS

554 patients (100 Hispanics from Texas, 94 Hispanics from Puerto Rico, 199 African Americans, 161 Caucasians) and 2366 visits were analysed; 47% of the patients and 29% of the visits met the definition of high disease activity (more common among African Americans (72.0%) and Hispanics from Texas (71.3%) than among Caucasians (43.9%) and Hispanics from Puerto Rico (31.9%)). Variables found to predict high levels of disease activity were Hispanic (from Texas) and African American ethnicities, lack of health insurance, helplessness, abnormal illness-related behaviours and poor social support; age was negatively associated with high levels of disease activity. African admixture and anti-double-stranded DNA antibodies also predicted high levels of disease activity, as did prior disease activity. None of the human leucocyte antigen variables were retained in the models.

CONCLUSIONS

Socioeconomic-demographic (age, ethnicity, health insurance), behavioural and psychological variables are important mediators of high levels of disease activity in SLE during its course. Interventions aimed at modifiable factors may improve the outcomes of SLE.

Depression, fatigue, and pain in systemic lupus erythematosus (SLE): relationship to the American College of Rheumatology SLE neuropsychological battery

OBJECTIVE

To examine the frequency and reliability of depression, fatigue, and pain self-report measures in patients with systemic lupus erythematosus (SLE) and healthy controls, and to examine the relationship between a cognitive impairment index (CII) derived from the American College of Rheumatology neuropsychology research battery of tests for SLE (ACR-SLE battery) and measures of depression, pain, fatigue, and perceived cognitive dysfunction.

METHODS

Thirty-one patients with SLE with a history of overt neuropsychiatric symptoms (neuropsychiatric SLE [NPSLE]), 22 patients with SLE without overt neuropsychiatric symptoms (non-NPSLE), and 25 healthy controls completed the following measures at baseline and 1-month followup: ACR-SLE battery, perceived cognitive difficulties, depression, fatigue, and pain.

RESULTS

Patients with SLE (both NPSLE and non-NPSLE) showed higher symptoms of depression, higher levels of fatigue, greater pain, and more perceived cognitive problems. All measures except the Center for Epidemiologic Studies Depression scale (CES-D) demonstrated adequate reliability across the SLE groups at retest. Only patients with NPSLE had significant correlations between CII and depression, fatigue, and pain. Neither the non-NPSLE patients nor the controls had significant relationships with the CII and these behavioral measures.

CONCLUSION

Patients with SLE report higher levels of cognitive difficulties, depression, pain, and fatigue compared with controls. Reliability for all measures, except the CES-D, was established in the SLE group. Overall, results suggest that cognitive dysfunction, pain, fatigue, and depression in patients with NPSLE may represent global changes in the central nervous system that require ongoing evaluation and treatment.

Cancer-specific self-efficacy and psychosocial and functional adaptation to early stage breast cancer

BACKGROUND

Although self-efficacy is considered a key psychological resource in adapting to chronic physical illness, this construct has received less attention among individuals coping with cancer.

PURPOSE

To examine changes in cancer self-efficacy over time among women with early stage breast cancer and associations between task-specific domains of self-efficacy and specific psychological, relationship, and functional outcomes.

METHODS

Ninety-five women diagnosed with early stage breast cancer completed surveys postsurgery and 1 year later.

RESULTS

Cancer-related self-efficacy was relatively stable over 1 year, with only 2 domains of efficacy-(a) Activity Management and (b) Self-Satisfaction-evidencing significant increases over the 1-year time period. Cross-sectional findings were relatively consistent with predictions and suggested that specific domains of self-efficacy were more strongly related to relevant domains of adaptation. Longitudinal findings were not as consistent with the domain-specificity hypothesis but did suggest several predictive associations between self-efficacy and outcomes. Personal Management self-efficacy was associated with higher relationship satisfaction, higher Communication Self-Efficacy was associated with less functional impairment, and higher Affective Management self-efficacy was associated with higher self-esteem 1 year later.

CONCLUSIONS

Specific domains of cancer-related self-efficacy are most closely related to relevant areas of adaptation when considered cross-sectionally, but further study is needed to clarify the nature of these relationships over time.

Influence of coping skills on health-related quality of life in patients with systemic lupus erythematosus

OBJECTIVE

To identify coping strategies used by patients with systemic lupus erythematosus (SLE), and to assess the influence of main clinical and coping variables on health-related quality of life (HRQOL).

METHODS

We administered the Coping Orientation to Problems Experienced and the Short Form 36 questionnaire to a group of 144 patients with SLE and a group of 129 healthy controls. At the time of the psychological assessment, all patients underwent a complete clinical and laboratory evaluation.

RESULTS

SLE patients had higher scores in acceptance (P < 0.001) and turning to religion (P = 0.05) and lower scores in planning (P = 0.001), suppression of competing activities (P = 0.010), restraint coping (P = 0.031), focusing on and venting of emotion (P = 0.009), and strategies focused on problem (P = 0.012) compared with controls. By means of linear regression analysis, HRQOL in SLE patients seemed to be influenced positively by restraint coping and positive reinterpretation and growth, and negatively by focusing on and venting of emotion, behavioral disengagement, and mental disengagement. When clinical variables were added to the multivariate analysis for coping strategies, more significant regression models that included joint pain were obtained.

CONCLUSION

In facing stressful situations, patients with SLE tend to use coping skills that are generally adopted for events perceived as nonmodifiable. Strategies that show a passive attitude and joint pain seem to impair these patients' HRQOL.

Stress and coping strategies in systemic lupus erythematosus: a review

Systemic lupus erythematosus (SLE), a chronic and unpredictable disease accompanied by functional disability and a possible involvement of the central nervous system, leads to considerable psychological distress. A review of studies on stress and/or coping strategies in SLE since 1990 is presented. Many studies have investigated the place of major and minor stress and coping strategies in SLE morbidity (disease activity, organ damage, and physical and mental components of quality of life). Stress as a causal factor is not proved, but it seems to act as an exacerbating factor in disease activity and to have an impact on the quality of life. Coping strategies are more consistently associated with quality of life than with disease activity. Organ damage appears to be less associated with psychosocial factors than disease activity or quality of life. Despite the limitations of these studies, therapeutic interventions should be proposed to reduce psychological distress, to improve the quality of life and possibly to moderate the evolution of the disease.

"Joining the dots" for patients with systemic lupus erythematosus: personal perspectives of health care from a qualitative study

OBJECTIVES

To examine the perceptions of patients with systemic lupus erythematosus (SLE) about their health care provision in the United Kingdom.

METHODS

Semistructured interviews were conducted with 10 women aged 26 to 68 years who were diagnosed with SLE one to 12 years earlier. Interviews were audio recorded, transcribed verbatim, and analysed using interpretative phenomenological analysis to organise the themes of importance to participants.

RESULTS

Four themes emerged: diagnostic difficulties; understanding; communication; and integrated health care. Before diagnosis there was concern to appear legitimately ill and to have a label for the condition. After diagnosis participants still encountered health care professionals who were poorly informed about SLE. Family, friends, and employers did not understand the fluctuating nature of SLE, which often led to isolation. Participants felt that even health care professionals who specialised in SLE could not fully understand the psychosocial impact of the condition, and therefore did not provide information to meet those needs. Participants did not know which of the many health care professionals they had contact with to approach about their concerns. Lack of communication at an interdisciplinary level left them feeling that nobody was "joining the dots" for their health care.

CONCLUSIONS

Patients with SLE do not feel understood by health care providers or people close to them. Support from trained volunteers with SLE, as available at the open access lupus clinic in Dudley (West Midlands, UK), would ensure more adequate information from someone with personal experience. Such services may improve communication and help minimise SLE patients' isolation.

Neuropsychiatric Lupus

Nervous system disease in patients who have systemic lupus erythematosus (SLE) spans a wide spectrum of neurologic (N) and psychiatric (P) features that may be attributed to a primary manifestation of SLE, complications of the disease or its therapy, or a coincidental disease process. The etiology of primary NP disease is multifactorial and includes vascular injury of intracranial vessels, autoantibodies to neuronal antigens, ribosomes and phospholipid-associated proteins, and the intracranial generation of cytokines. In the absence of a diagnostic gold standard for most of the NP-SLE syndromes, a range of investigations are employed to support the clinical diagnosis and determine the severity of NP disease. Treatment remains largely empiric in the absence of controlled studies, and current strategies include the use of immunosuppressive therapies, appropriate symptomatic interventions, and the treatment of non-SLE factors.

Improvement of coping abilities in patients with systemic lupus erythematosus: a prospective study

OBJECTIVE

To evaluate a novel specific psychological intervention aimed at improving coping in patients with systemic lupus erythematosus (SLE).

METHODS

34 community living SLE patients were recruited for the study. Intervention was undertaken in groups of up to eight patients and in two blocks over six months each. Eight patients were enrolled as a waiting list group. The 18 group sessions focused on information about the disease and specific problems of SLE patients, combining psychoeducative and psychotherapeutic elements. Psychological and medical evaluations were conducted at baseline and after three, six, and 12 months, using validated instruments.

RESULTS

The 34 SLE patients (91% female, mean age 42 years) improved significantly over a six month period on most of the psychological measuring instruments applied, such as depression, anxiety, and overall mental burden. The waiting list group showed no significant changes.

CONCLUSIONS

Conceptualised psychoeducational support may produce a significant and sustained improvement in coping skills of SLE patients and hence in their quality of life.