Mindfulness-Based Stress Reduction with Individuals Who Have Rheumatoid Arthritis: Evaluating Depression and Anxiety as Mediators of Change in Disease Activity
- 92 Downloads
Although the current randomized controlled trial has previously reported an effect of mindfulness-based stress reduction (MBSR) on improving disease activity in rheumatoid arthritis (RA), the possible mechanisms underlying this relationship remain unknown. This report presents secondary analyses examining anxiety and depression as potential mediators of the effect of MBSR on changes in RA disease activity. Fifty-one RA patients were randomized to either MBSR or to a wait-list control group. Depression and anxiety (Hospital and Anxiety Depression Scale) and RA disease activity (DAS28-CRP) were assessed at baseline (T1), post-treatment (T2), and at two (T3) and four (T4) months’ follow-up. Intention to treat (ITT) and per protocol (PP) analyses using multivariate analyses of variance showed that depression was lower in the MBSR than in the control group, post-treatment and at both follow-up time points. PP analyses suggested that anxiety was lower in the MBSR than in the control group post-treatment. In partial support of expectation, mediation analyses showed that a reduction in depression across the intervention (T2-T1) mediated the effect of MBSR on improvements in RA disease activity at both follow-up time points (T3-T1; T4-T1). This effect held across ITT and PP analyses. PP analyses also suggested an indirect effect of MBSR on RA disease activity via increased anxiety at T3, but not at T4. Together, findings suggest that improvements in depression (rather than anxiety) may mediate the effect of MBSR on RA disease activity. Screening for, and treating depression in RA with MBSR, may have downstream benefits for RA disease activity.
KeywordsRandomized controlled trial Mindfulness-based stress reduction RA disease activity Depression Mediation
FF: collaborated in designing and executing the study, conducted the data analyses and collaborated in the writing and editing of the manuscript. RB: collaborated with the design and writing of the study. AL: advised in relation to the data analyses used, and the writing up of results. NC: collaborated in the design and writing of the study. NC: collaborated in the design of the study and the writing and editing of the manuscript.
This study was funded by a grant from The Oakley Mental Health Foundation.
Compliance with Ethical Standards
All procedures performed in this study were in accordance with the ethical standards of the Northern Regional Ethics Committee (New Zealand) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent was obtained from all participants included in the study.
Conflict of Interest
The authors declare that they have no conflicts of interest.
- Armijo-Olivo, S., Warren, S., & Magee, D. (2009). Intention to treat analysis, compliance, drop-outs and how to deal with missing data in clinical research: a review. Physical Therapy Reviews, 14(1), 36–49.Google Scholar
- Baer, R. A. (2003). Mindfulness training as a clinical intervention: a conceptual and empirical review. Clinical Psychology: Science and Practice, 10, 125–143.Google Scholar
- Creswell, J. D. (2016). Mindfulness interventions. Annual Review of Psychology, 68, 491-516.Google Scholar
- Hayes, A. F. (2013). Introduction to mediation, moderation, and conditional process analysis: a regression-based approach. Guilford Press.Google Scholar
- Kabat-Zinn, J. (1990). Full catastrophe living: using the wisdom of your body and mind to face stress, pain and illness. New York: Bantam Dell.Google Scholar
- Kabat-Zinn, J. (2003). Mindfulness-based interventions in context: past, present, and future. Clinical Psychology: Science and Practice, 10, 144–156.Google Scholar
- Lee, T. J., Cameron, L. D., Wünsche, B., & Stevens, C. (2011). A randomized trial of computer-based communications using imagery and text information to alter representations of heart disease risk and motivate protective behaviour. British Journal of Health Psychology, 16(1), 72–91.CrossRefGoogle Scholar
- Lindsay, E. K., & Creswell, J. D. (2017). Mechanisms of mindfulness training: Monitor and Acceptance Theory (MAT). Clinical Psychology Review, 51, 48–59.Google Scholar
- Logue, M. B., Thomas, A. M., Barbee, J. G., Hoehn-Saric, R., Maddock, R. J., Schwab, J., et al. (1993). Generalized anxiety disorder patients seek evaluation for cardiological symptoms at the same frequency as patients with panic disorder. Journal of Psychiatric Research, 27(1), 55–59.CrossRefGoogle Scholar
- Matcham, F., Norton, S., Scott, D. L., Steer, S., & Hotopf, M. (2015). Symptoms of depression and anxiety predict treatment response and long-term physical health outcomes in rheumatoid arthritis: secondary analysis of a randomized controlled trial. Rheumatology, 55(2), 268-278.Google Scholar
- Pennebaker, J. W. (2000). Psychological factors influencing the reporting of physical symptoms. The science of self-report: implications for research and practice. Mahwah, NJ: Erlbaum, 299–315.Google Scholar
- Unnebrink, K., & Windeler, J. (2001). Intention‐to‐treat: methods for dealing with missing values in clinical trials of progressively deteriorating diseases. Statistics in Medicine, 20(24), 3931–3946.Google Scholar
- Urbaniak, G., & Plous, S. (2013). Research randomizer (version 4.0) [computer software]. Retrieved July, 7, 2013.Google Scholar
- Visvanathan, A., Galloway, J., Matcham, F., Hotopf, M., & Norton, S. (2016). The relationship between anxiety and disease characteristics in patients with rheumatoid arthritis: a cross-sectional observational study. Rheumatology, 55(suppl 1), i87–i88.Google Scholar
- Wells, G., Becker, J., Teng, J., Dougados, M., Schiff, M., Smolen, J., et al. (2009). Validation of the 28-joint Disease Activity Score (DAS28) and European League Against Rheumatism response criteria based on C-reactive protein against disease progression in patients with rheumatoid arthritis, and comparison with the DAS28 based on erythrocyte sedimentation rate. Annals of the Rheumatic Diseases, 68(6), 954–960.CrossRefGoogle Scholar
- Wolitzky-Taylor, K. B., Arch, J. J., Rosenfield, D., & Craske, M. G. (2012). Moderators and non-specific predictors of treatment outcome for anxiety disorders: a comparison of cognitive behavioral therapy to acceptance and commitment therapy. Journal of Consulting and Clinical Psychology, 80(5), 786-799.CrossRefGoogle Scholar
- Zangi, H. A., Mowinckel, P., Finset, A., Eriksson, L. R., Høystad, T. Ø., Lunde, A. K., et al. (2012). A mindfulness-based group intervention to reduce psychological distress and fatigue in patients with inflammatory rheumatic joint diseases: a randomised controlled trial. Annals of the Rheumatic Diseases, 71, 911–917.CrossRefGoogle Scholar
- Zautra, A., Davis, M., Reich, J., Nicassario, P., Tennen, H., Finan, P., et al. (2008). Comparison of cognitive behavioral and mindfulness meditation interventions on adaptation to rheumatoid arthritis for patients with and without history of recurrent depression. Journal of Consulting and Clinical Psychology, 76(3), 408–421.CrossRefGoogle Scholar
- Zeidan, F., Gordon, N. S., Merchant, J., & Goolkasian, P. (2010). The effects of brief mindfulness meditation training on experimentally induced pain. The Journal of Pain, 11(3), 199–209.Google Scholar
- Zeidan, F., Emerson, N. M., Farris, S. R., Ray, J. N., Jung, Y., McHaffie, J. G., & Coghill, R. C. (2015). Mindfulness meditation-based pain relief employs different neural mechanisms than placebo and sham mindfulness meditation-induced analgesia. Journal of Neuroscience, 35(46), 15307–15325.Google Scholar
- Zigmond, A. S., & Snaith, R. P. (1983). The hospital anxiety and depression scale. Acta Psychiatrica Scandinavica, 67(6), 361–370.Google Scholar