Mindfulness-based stress reduction to improve depression, pain and high patient global assessment in controlled rheumatoid arthritis

Lay Summary What does this mean for patients? Current treatments of rheumatoid arthritis (RA) aim to reduce inflammation. Physicians assume that control of inflammation will improve patient well-being. Although this is often the case, up to one in five patients with controlled inflammation still report high levels of pain, depressive and anxious symptoms, functional limitations, sleep problems and disease severity. We offered, at no cost to these patients, a standardized eight-session group mindfulness-based stress reduction (MBSR) programme when they presented for regular follow-up. Out of 65 eligible patients, 39 consented and 28 participated. Anticipated burden, especially the frequency and timing of group meetings, commuting issues, age and co-morbidities, were the most frequent barriers to participation. Up to 12 months after MBSR completion, anxiety, depression, sleep and function improved significantly. Patient interviews revealed that the previously mentioned benefits were maintained by the integration of effective coping strategies. However, pain levels and patient perception of disease activity were not changed. Patients with controlled RA need be informed that MBSR can induce lasting improvements in persistent distressing symptoms associated with disease. Knowing about the durable positive effects of MBSR might influence patients to overcome barriers to participation. Additional interventions might be needed to lower pain levels and perceived disease activity. Objective The aim was to improve distressing patient-reported outcomes (PROs) that persisted in RA patients with clinically controlled inflammation (controlled RA). Methods In a pragmatic pilot study, we offered mindfulness-based stress reduction (MBSR), a group intervention, to controlled RA patients who had high (>= 16) Centre for Evaluation Studies depression (CES-D) scores and/or patient general assessment of disease activity (PGA) at least 2/10 larger than evaluator general assessment (EGA) (PGA-EGA: Delta). Evaluations before, 6 and 12 months after MBSR included CES-D, PGA, modified HAQ, simple disease activity index (SDAI), anxiety (general anxiety disorder 7; GAD-7), coping strategies (coping with health injuries and problems; CHIP), sleep disturbance and pain. Facilitators and obstacles to recruitment and participation were identified. A subset of patients was interviewed for qualitative analysis of their experience. Results Out of 306 screened patients, 65 were referred, 39 (60%) agreed and 28 (43%) completed MBSR. Anticipated burden, timing and frequency of group meetings, commuting issues, age extremes and co-morbidities were barriers to participation. Up to 12 months after MBSR, anxiety, depression, emotion-oriented coping, sleep and function significantly improved. Nonetheless, no significant impact was observed on pain, PGA, Delta or SDAI. The interviews revealed that benefits, including integration of effective coping strategies, were maintained. Conclusion We addressed MBSR feasibility issues and selection of outcomes in controlled RA patients with distressing PROs. For patients who chose to participate in MBSR, lasting benefits were evident for anxiety, depression, sleep and function. Larger studies are required to evaluate the weaker impact of MBSR on RA-related pain and PGA.