title: The effects of written emotional disclosure and coping skills training in rheumatoid arthritis: a randomized clinical trial.
abstract: OBJECTIVE
  Two psychological interventions for rheumatoid arthritis (RA) are cognitive-behavioral coping skills training (CST) and written emotional disclosure (WED). These approaches have developed independently, and their combination may be more effective than either one alone. Furthermore, most studies of each intervention have methodological limitations, and each needs further testing.
  
  
  METHODS
  We randomized 264 adults with RA in a 2 × 2 factorial design to 1 of 2 writing conditions (WED vs. control writing) followed by 1 of 2 training conditions (CST vs. arthritis education control training). Patient-reported pain and functioning, blinded evaluations of disease activity and walking speed, and an inflammatory marker (C-reactive protein) were assessed at baseline and 1-, 4-, and 12-month follow-ups.
  
  
  RESULTS
  Completion of each intervention was high (>90% of patients), and attrition was low (10.2% at 12-month follow-up). Hierarchical linear modeling of treatment effects over the follow-up period, and analyses of covariance at each assessment point, revealed no interactions between writing and training; however, both interventions had main effects on outcomes, with small effect sizes. Compared with control training, CST decreased pain and psychological symptoms through 12 months. The effects of WED were mixed: Compared with control writing, WED reduced disease activity and physical disability at 1 month only, but WED had more pain than control writing on 1 of 2 measures at 4 and 12 months.
  
  
  CONCLUSIONS
  The combination of WED and CST does not improve outcomes, perhaps because each intervention has unique effects at different time points. CST improves health status in RA and is recommended for patients, whereas WED has limited benefits and needs strengthening or better targeting to appropriate patients.
authors.affiliation: Department of Psychology.
authors.forename: Mark A
authors.initials: MA
authors.lastname: Lumley
authors.affiliation: Department of Psychiatry and Behavioral Sciences, Duke University Medical Center.
authors.forename: Francis J
authors.initials: FJ
authors.lastname: Keefe
authors.affiliation: Department of Medicine.
authors.forename: Angelia
authors.initials: A
authors.lastname: Mosley-Williams
authors.affiliation: Department of Psychiatry and Behavioral Sciences, Duke University Medical Center.
authors.forename: John R
authors.initials: JR
authors.lastname: Rice
authors.affiliation: Department of Psychiatry and Behavioral Sciences, Duke University Medical Center.
authors.forename: Daphne
authors.initials: D
authors.lastname: McKee
authors.affiliation: Department of Psychiatry and Behavioral Sciences, Duke University Medical Center.
authors.forename: Sandra J
authors.initials: SJ
authors.lastname: Waters
authors.affiliation: Department of Psychology.
authors.forename: R Ty
authors.initials: RT
authors.lastname: Partridge
authors.affiliation: Department of Psychology.
authors.forename: Jennifer N
authors.initials: JN
authors.lastname: Carty
authors.affiliation: Department of Psychology.
authors.forename: Ainoa M
authors.initials: AM
authors.lastname: Coltri
authors.affiliation: Department of Psychology.
authors.forename: Anita
authors.initials: A
authors.lastname: Kalaj
authors.affiliation: Department of Psychology.
authors.forename: Jay L
authors.initials: JL
authors.lastname: Cohen
authors.affiliation: Department of Psychology.
authors.forename: Lynn C
authors.initials: LC
authors.lastname: Neely
authors.affiliation: Department of Social Work.
authors.forename: Jennifer K
authors.initials: JK
authors.lastname: Pahssen
authors.affiliation: Department of Psychiatry and Behavioral Sciences, Duke University Medical Center.
authors.forename: Mark A
authors.initials: MA
authors.lastname: Connelly
authors.affiliation: Department of Psychiatry and Behavioral Sciences, Duke University Medical Center.
authors.forename: Yelena B
authors.initials: YB
authors.lastname: Bouaziz
authors.affiliation: Department of Psychiatry and Behavioral Sciences, Duke University Medical Center.
authors.forename: Paul A
authors.initials: PA
authors.lastname: Riordan
mesh_terms: D000223:Adaptation, Psychological; D000328:Adult; D001172:Arthritis, Rheumatoid / Q000523:psychology*; D015415:Biomarkers / Q000097:blood; D002097:C-Reactive Protein / Q000378:metabolism; D015928:Cognitive Behavioral Therapy; D004644:Emotions; D005260:Female; D005500:Follow-Up Studies; D006266:Health Education; D006304:Health Status; D006801:Humans; D008297:Male; D008875:Middle Aged; D010353:Patient Education as Topic; D011340:Problem Solving; D012650:Self Disclosure; D016138:Walking; D014956:Writing
chemical_list: D015415:Biomarkers; D002097:C-Reactive Protein