Longitudinal relationships among pain, sleep problems, and depression in rheumatoid arthritis.

This research evaluated the relationship between pain and sleep problems, and the role of pain and sleep problems in depression, in a sample of 242 patients who had been diagnosed with definite or classical rheumatoid arthritis (RA). Patients completed the Pain scale of the Arthritis Impact Measurement Scales, the Center for Epidemiological Studies Depression Scale, and self-reports of sleep disturbance at two data waves over a 2-year interval. Cross-sectional multiple regression analysis revealed that the sleep problems variable was independently associated with depression at Time 1. Longitudinal multiple regression analyses demonstrated that prior pain predicted subsequent adverse changes in sleep problems, whereas sleep problems did not affect pain over time, and prior pain and the interaction of high pain and high sleep problems were independently associated with depression from Time 1 to Time 2. These data suggest that pain may exacerbate sleeping difficulty in RA patients, and that both factors may contribute to depression over time.     

Attenuation of Hippocampal 11beta-Hydroxysteroid Dehydrogenase Type 1 by Chronic Psychosocial Stress in the Tree Shrew

11beta-hydroxysteroid dehydrogenase type 1 (11beta-HSD-1) catalyses the interconversion of active cortisol and corticosterone with inert cortisone and 11-dehydrocorticosterone, thus regulating glucocorticoid access to intracellular receptors. In rats, chronic glucocorticoid excess or stress increases 11beta-HSD-1 in the hippocampus, producing suggestions that it may attenuate the deleterious effects of chronic glucocorticoid excess. However, 11beta-HSD-1 predominantly catalyses 11beta-reduction in the intact liver and hippocampal cells, thus regenerating active glucocorticoids from inert substrate. We studied 11beta-HSD activity in the tissues of male tree shrews following 28 days of sustained psychosocial stress or exogenous administration of cortisol. In the hippocampus, chronic psychosocial stress attenuated 11-HSD-1 activity (69 +/- 9% of control), whereas cortisol alone had no effect. In the liver, both chronic stress and cortisol administration decreased 11beta-HSD-1 activity (47 +/- 11% and 49 +/- 4% fall, resp.). Attenuation of 11beta-HSD-1 within tissues may reflect a homeostatic mechanism designed to minimise the adverse effects of prolonged stress and/or glucocorticoid excess.     

Multiaxial taxonomy of fibromyalgia syndrome patients

Pain, disability, and depression are present in various degrees in patients with fibromyalgia syndrome. Cluster analysis was used in this research to ascertain the existence of subgroups of patients in a fibromyalgia sample based on these variables. Two clusters were defined: one characterized by high levels of pain, disability, and depression (n=51) and another characterized by low levels of pain, disability, and depression (n=67). Multivariate analysis of variance (MANOVA) confirmed differences between clusters on these health status factors and a second MANOVA revealed that the subgroup with a poorer health status reported greater passive coping, helplessness, and stress, and less satisfaction with social support, than the subgroup with better health status. Logistic regression indicated that the best discriminator of subgroup membership was helplessness. These results suggest that different approaches to patient management, particularly intervention strategies aimed at reducing helplessness, may be beneficial for patients with high levels of pain, disability, and depression.     

Psychological Factors that Link Socioeconomic Status to Depression/Anxiety in Patients with Systemic Lupus Erythematosus

Our analyses examined whether reserve capacity factors would explain the relationship between socioeconomic status (SES) and symptoms of depression/anxiety in patients with systemic lupus erythematosus (SLE). We assessed disease activity, depression/anxiety symptoms, and intrapersonal and interpersonal reserve capacity measures in 128 patients with SLE. Multiple meditational analyses revealed that intrapersonal and interpersonal psychosocial aspects of reserve capacity fully mediated the relationship between SES and depression/anxiety. Lower SES was indirectly associated with higher symptoms of depression and anxiety through the effects of psychosocial resilience. Interventions aimed at improving modifiable reserve capacity variables, such as self-esteem and optimism, may improve anxious/depressive symptomatology in patients with SLE.     

Models of family functioning and their contribution to patient outcomes in chronic pain

This paper analyzes the relationship between family functioning and chronic pain, and evaluates a model which integrates the role of family variables with the pain-coping process in patients with rheumatoid arthritis (RA) and fibromyalgia (FM). Family variables, assessed by subscales of the Family Environment Scale (FES), and different components of the pain-coping process varied significantly in their contribution to pain, psychological functioning, and disability in these two chronic pain disorders. High system maintenance control and low independence contributed significantly to pain in RA and FM, respectively, while low family cohesiveness contributed to psychological disturbances in FM subjects. Lack of promotion of activity and recreation in the family was associated with greater disability in both groups. In addition to family variables, helplessness proved to be a potent predictor of pain and psychological functioning in both groups, and disability in FM subjects. Pain-coping had its predominant influence on pain. As an exploratory test of the model, the data confirm the importance of examining this integrated framework in longitudinal, prospective studies, and its potential utility in clinical assessment and intervention.This research was supported by a Multipurpose Arthritis and Musculoskeletal Diseases Center grant AR40770 from the National Institute of Arthritis and Musculoskeletal Diseases at the University of California, San Diego. Portions of this paper were presented at the convention of the American Psychological Association, August 1992, in Washington, DC, and at the meeting of the Society of Behavioral Medicine, March 1993, in San Francisco.The authors gratefully acknowledge Teresa A. Krall, M.A., and Karen Schoenfeld-Smith, M.A. for their valuable assistance in statistical analysis for this article.     

The future of health psychology interventions.

Progress in health psychology interventions was reviewed to manage chronic illness, treat psychophysiological disorders, and provide complementary treatment for difficult medical symptoms. A closer synergy between research, clinical applications and public policy, and education and training was advocated to guide future work in these areas. Further, the importance of clinical input informing research directions, the need for interventions to focus on a broader range of individual difference and contextual factors, and for effectiveness studies to influence the adoption of treatments in clinical settings was emphasized. In accordance, greater effort should be devoted to disseminating information on treatment effectiveness to professional and lay groups to maximize the public health benefit of established intervention approaches.     

Social Support and Depression in Rheumatoid Arthritis: A One-Year Prospective Study1

Previous research on patients with rheumatoid arthritis (RA) has suggested that social support is beneficial for helping patients to adjust psychologically to the chronic and unpredictable episodes of pain. This study addresses whether support buffers the adverse effects of arthritis pain or whether support results in a decrease in the severity of pain regardless of pain levels in 233 RA patients. The results indicated that patients who reported higher satisfaction with their emotional support when experiencing higher levels of pain were less likely to be depressed than patients who do not perceive such support. The results were obtained after controlling the effects of demographic variables, functional disability variables, and the direct effects of pain and social support. However, moderating effects of emotional support were not found when this relationship was examined over a 6-month period. Rather, causal modeling suggested that both pain and emotional support contributed to a change in depression over two 6-month intervals. The results also suggested that depression may have an adverse effect on change in emotional support over a similar time frame.