SEARCH

SEARCH BY CITATION

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. REFERENCES

Objective

The aim of this study was to investigate whether a new cognitive–behavioral self-help program with minimal coaching could improve psychological well-being (depression, anxiety, and coping self-efficacy) in people with rheumatic disease and depressive symptoms.

Methods

In total, 82 persons with a rheumatic disease enrolled in a randomized controlled trial were allocated to either a group receiving the self-help program or a waiting list control condition group. For both groups, measurements were done at baseline, posttest, and followup. The outcome measures were the depression and anxiety scales of the Hospital Anxiety and Depression Scale and an adaptation of the Generalized Self-Efficacy Scale. Repeated-measures analyses of covariance were performed to evaluate changes in outcome measures from pretest to posttest and from posttest to followup.

Results

The results showed that the self-help program was effective in reducing symptoms of depression and anxiety and in strengthening coping self-efficacy. The positive effects remained after a followup period of 2 months.

Conclusion

This cost-effective program could very well be used as a first step in a stepped care approach or as one of the treatment possibilities in a matched care approach.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. REFERENCES

Rheumatic disease has been shown to have a substantial impact on daily quality of life and physical, social, and emotional well-being ([1]). Recent reviews have found that the prevalence estimates of major depressive disorders among people with rheumatic disease vary between 13% and 20% ([2]). In addition, a number of studies have confirmed that depression is significantly more common in people with rheumatic disease than in healthy individuals ([3, 4]). Depressive symptoms on their own have been found to be associated with poorer functional status, increased health care use, and higher work absence ([5]). A recent study has also shown that there is a high prevalence of anxiety symptoms in people with rheumatic disease ([6]) with or without comorbid depression. The improvement of emotional well-being for people with rheumatic disease should therefore be a major treatment goal. An important conclusion of the large-scale World Health Organization World Health Survey was that timely treatment of depressive disorders in people with a chronic disease is imperative. One of the important suggestions this survey gave was to start treating depression with easily accessible cost-effective interventions in primary care or community settings ([4]).

In order to keep the costs low and to reach a high proportion of the population, interventions could be delivered by means of self-help programs. In a recent meta-analysis, the evidence from studies examining self-help materials for people who have mental health problems was reviewed. The results showed that there was support for the use of self-help treatment manuals in depression ([7]). Self-help interventions may also help to reach people who experience barriers to entering psychotherapeutic services ([7, 8]). There is evidence that self-help interventions might also be effective for people with rheumatic disease. Self-help programs, such as the Arthritis Self-Management Program ([9]), which focuses on self-management–related issues like nutrition, physical exercise, and the use of medications, have been found to be effective in improving health conditions in patients with rheumatic disease. As far as we know, no self-help programs have been developed that explicitly focus on the emotional well-being of people with rheumatic disease.

The first 2 authors of the present study (NG and VK) prepared a cognitive–behavioral intervention program in booklet format for people with rheumatic disease and depressive symptoms. The intervention program involved an adaptation of an existing evidence-based self-help program for people with physical impairments that reflected 3 main evidence-based components: relaxation, working on changing maladaptive cognitions, and the attainment of personal life goals. The components of the original self-help program for people with physical impairments had been chosen after a needs assessment and a series of studies on the predictors of psychological well-being among people with various conditions that showed that tension, failing goal adjustment, and a cognitive style of rumination and catastrophizing were of main importance to the prevalence of depression ([10-15]). The exercises in the self-help program, which are intended to work on these components, are all based on common cognitive–behavioral therapeutic techniques. The self-help program has been proven to be effective for people with physical impairments in a randomized controlled trial ([16]).

The adapted specific self-help program for people with rheumatic disease included the same 3 main components (i.e., relaxation, working on changing maladaptive cognitions, and the attainment of personal life goals). Previous studies have shown the relevance of these components for people with rheumatic disease ([17-19]). The adapted program consisted of a rewording of introductory texts, examples, and exercises to more closely fit the population with rheumatic disease.

The present study investigated whether the new self-help intervention program including minimal coaching could improve psychological well-being in people with rheumatic disease. More specifically, the present study investigated whether this program could be effective in improving depressed mood (primary outcome) and anxiety and coping self-efficacy (secondary outcomes) in people with rheumatic disease.

Box 1. Significance & Innovations

  • In this study, a new self-help program that included minimal coaching and focused on relaxation, changing maladaptive cognitions, and attainment of personal life goals significantly improved depression, anxiety, and self-efficacy scores from pretest to posttest.
  • The positive effects of the program remained after a followup period of 2 months.
  • The program could easily be made available to a large number of people without the need for a waiting list and might be a good first step in a stepped care approach or as one of the treatment possibilities in a matched care approach.

PATIENTS AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. REFERENCES

Study design

The effectiveness of the self-help program was studied in a randomized controlled trial with 2 groups: a group receiving the cognitive–behavioral self-help program (CBS) and a waiting list control condition (WLC) group. Participants on the waiting list were not offered any intervention. All participants in the WLC group were offered the self-help program after the completion of the study. For both groups, measurements were recorded at baseline, posttest, and followup.

CBS

The self-help program for people with rheumatic disease consisted of a workbook, a work program, and a CD-ROM. Participants were asked to work on the intervention 4 days per week (1 hour per day) for a period of 4 weeks. During these 4 weeks, the participants received minimal coaching by psychology master students who were trained in basic therapeutic skills. The coaching consisted of a short weekly phone call (average length of 10 minutes) to the participant in order to provide support, ask about progress, motivate for continuation, and just to give praise for the efforts.

During the first week, the participants were asked to do relaxation exercises and to continue these exercises for the next 3 weeks. In the second and third weeks, the participants were taught to identify and change irrational cognitions and to practice counterconditioning. In the fourth week, the participants were guided to formulate a realistic, concrete goal and to improve their coping self-efficacy to reach this goal.

Participants

The inclusion criteria for participation in the study were having some form of rheumatic disease, being age ≥18 years, being able to read and speak Dutch, and having mild to moderate depressive symptoms. Initially, 85 persons fulfilled the criteria to participate and indicated that they were willing to participate; however, 3 of these persons did not complete the baseline questionnaire and did not give their written consent. Therefore, in total, 82 persons with a rheumatic disease enrolled in this study, 41 of whom were allocated to the CBS group and 41 to the WLC group.

Procedure

The participants were recruited through patient organization web sites of various rheumatic diseases in The Netherlands and Belgium. People who were interested in participation were referred to a web site that was developed for this study. On this web site, people were informed about the self-help program and the study. In addition, these people could determine if they met the inclusion criteria. To decide whether the criterion of mild to moderate depressive symptoms was fulfilled, people could complete a self-screening test, the Patient Health Questionnaire (PHQ-9) ([20]). People with severe depressive symptoms (scoring 15 or higher according to the criteria of the PHQ-9) were advised to contact their general practitioner and/or seek professional help instead of participating in the self-help program. After people had read the information on this web site, they could follow a link to indicate that they were willing to participate in this study. Subsequently, they received an e-mail with a link to the (online) pretest questionnaire. Before starting this questionnaire, an informed consent form had to be completed. After the participants completed the pretest questionnaire, they were randomly assigned to either the CBS group or the WLC group. Randomization was done by a computer-generated list of random numbers. Respondents who were allocated to the CBS group received the self-help program at home by regular mail. Immediately after the CBS group completed the intervention, both participants in the CBS and WLC groups completed the posttest. The followup assessment took place 2 months later.

The research was carried out in compliance with the Declaration of Helsinki. Permission for this study was obtained from the Ethics Committee at the Leiden University Psychology Department.

Materials

Motivation- and satisfaction-related items

At baseline, 2 items measuring motivation were included. The first was worded “How useful do you think the program will be for you,” with scoring possibilities ranging from 1 = not at all useful to 5 = very useful. The second was worded “How motivated are you to start with the self-help program,” with scoring possibilities ranging from 1 = not at all motivated to 5 = highly motivated. At posttest, 4 items were included regarding compliance and satisfaction. The first item measured usefulness of the intervention and was worded “How useful has the self-help program been for you?” Scoring for this item ranged from 1 = not at all useful to 5 = very useful. The second item measured satisfaction about the program and was worded “How satisfied are you with regard to the program,” with scoring ranging from 1 = not at all satisfied to 5 = very satisfied. The third item measured compliance and was worded “To what extent did you follow the instructions of the program?” The scoring possibilities of this item were 1 = not at all, 2 = partly, and 3 = followed all instructions. The fourth item measured usefulness of the coaching element and was worded “How useful have the telephone calls been for you?” Scoring for this item ranged from 1 = not at all useful to 5 = very useful.

Symptoms of depression and anxiety

Symptoms of depression and anxiety were measured by the Hospital Anxiety and Depression Scale (HADS). The HADS is a 14-item self-report screening scale originally designed to assess the presence of anxious and depressive states in the setting of a medical outpatient clinic ([21]). The instrument has been established as a frequently applied and convenient self-rating instrument to assess anxiety and depression with good specificity and sensitivity in populations with somatic and/or mental health problems ([22]). The HADS contains 2 subscales, 1 for anxiety and 1 for depression. An example item of the depression scale is “I can laugh and see the funny side of things.” An example item of the anxiety scale is “I get a sort of frightened feeling as if something awful is about to happen.” Both subscales consist of 7 items scored on 4-point scales (range 1–4). The total scores for each subscale are obtained by adding the 7 items and may range from 7–28, with higher scores indicating more severe symptoms. The psychometric properties of the HADS have been shown to be good in terms of factor structure, subscale intercorrelations, homogeneity, and internal consistency ([23]). Validity studies of the HADS reported good reliability and validity ([24]).

Coping self-efficacy

Coping self-efficacy was assessed by 8 questions specifically designed for the purpose of this study. The items are an adaptation from the Generalized Self-Efficacy Scale (GSES) ([25]). Some examples of items from the GSES are “It is clear to me how to cope with my physical impairments” and “I am confident that I can deal efficiently with unexpected events concerning my physical impairments.” The answers could be given on a 5-point Likert scale, where 1 = totally disagree and 5 = totally agree. Total scores are computed by adding all 8 individual items (range 8–40), with higher scores reflecting more coping self-efficacy ([26]). Validation studies of the GSES found this measure to have good reliability and validity ([25]).

Physical limitations

Health-related or physical limitations were measured by the physical functioning subscale (PF-10) of the Medical Outcomes Study Short Form 36 ([27]). The PF-10 consists of 10 items that assess the severity of health-related limitations during a variety of physical activities. Items are scored on 3-point scales (range 1–3). The total score is obtained by adding the 10 items (range 10–30). The scores are recoded in a way where higher scores indicate more health-related limitations. Reliability and validity of the PF-10 have been supported by various studies ([27]).

Pain

The severity of pain was measured by a single item worded “To what extent do you experience pain caused by your rheumatic disease?” This item could be answered on a 10-point scale, where 0 = no pain at all and 10 = very much pain.

Background characteristics

The following demographic characteristics were included: age, sex, educational level, and marital status. In addition, the type of the rheumatic disease was assessed, as well as the mean time since diagnosis and the mean time since the onset of physical impairments (in years).

Statistical analysis

The baseline background and disease characteristics were examined. Group differences in these variables were evaluated by independent t-tests and chi-square tests to determine the baseline equivalence of the study conditions. Baseline differences in demographic and disease characteristics between the study completers and dropouts were also evaluated with independent t-tests and chi-square tests.

To evaluate changes in the continuous outcome measures, 2 × 2 (group × time) repeated-measures analyses of covariance (ANCOVAs) were performed from pretest to posttest and from posttest to followup, with group as a between-groups factor and time as a within-subjects factor and with significant baseline measures set as covariates. These analyses were performed twice, first by analyzing the true scores and second by intent-to-treat analyses, with the last observation carried forward method used.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. REFERENCES

Patient flow

Of the 85 persons who had shown initial interest in participating, 82 were enrolled in the study. In total, 41 persons were allocated to the CBS group and 41 to the WLC group. In addition, 75 of the 82 persons completed the posttest (35 in the CBS group and 40 in the WLC group), while 7 persons dropped out (6 in the CBS group and 1 in the WLC group). Another 4 persons dropped out at followup (0 in the CBS group and 4 in the WLC group). See the flow chart in Figure 1 for the details.

image

Figure 1. Flow chart of participants through the study.

Download figure to PowerPoint

Baseline differences between the CBS and WLC groups

The baseline sample characteristics are shown in Table 1. Baseline background differences between the CBS and WLC participants were evaluated with t-tests and chi-square tests. No significant differences were found except for education level. There were significantly more higher-educated people in the CBS group compared to the WLC group. In addition, no significant baseline differences between the CBS and WLC groups were observed regarding symptoms of depression, anxiety, and coping self-efficacy. Therefore, only level of education was included as covariate in the subsequent ANCOVAs.

Table 1. Demographic and other background characteristics of the participants*
 Total (n = 82)CBS (n = 41)WLC (n = 41)
  1. Values are the mean ± SD unless otherwise indicated. CBS = cognitive–behavioral self-help program group; WLC = waiting list control condition group; MOS = Medical Outcomes Study; SF-36 = Short Form 36.

  2. a

    Significant difference between CBS and WLC (P ≤ 0.05).

Demographic characteristics   
Age, years48.37 ± 11.2549.12 ± 9.7947.61 ± 12.62
Sex, no. (%)   
Men7 (8.5)4 (9.8)3 (7.3)
Women75 (91.5)37 (90.2)38 (92.7)
Educational level, no. (%)   
Low/intermediate50 (61.0)20 (48.8)30 (73.2)a
Higher32 (39.0)21 (51.2)11 (26.8)
Marital status, no. (%)   
Single22 (26.8)8 (19.5)14 (34.1)
Married/cohabiting60 (73.2)33 (80.5)27 (65.9)
Type of rheumatic disease, no. (%)   
1. Inflammatory rheumatism33 (40.2)14 (34.1)19 (46.3)
2. Degenerative rheumatism4 (4.9)2 (4.9)2 (4.9)
3. Soft-tissue rheumatism19 (23.2)10 (24.4)9 (22.0)
4. Inflammatory rheumatism, +2 and/or 318 (22.0)10 (24.4)8 (19.5)
5. Degenerative rheumatism, +38 (9.8)5 (12.2)3 (7.3)
Other background characteristics   
Time since diagnosis, years8.18 ± 8.448.36 ± 8.727.98 ± 8.26
Time since physical limitations15.23 ± 11.9314.87 ± 10.8115.59 ± 13.09
MOS SF-36 physical limitation score18.65 ± 3.4918.63 ± 3.1218.66 ± 3.87
Severity of pain score7.38 ± 1.437.49 ± 1.577.27 ± 1.29

Differences between study completers and dropouts

The differences between the participants who dropped out (n = 7) and the participants who completed the study (n = 75) were tested for all variables mentioned in Table 1. No significant differences were observed, except for sex (χ2[1] = 11.55, P = 0.001). Three (42.9%) of the 7 men did not complete the intervention compared with 4 (5.3%) of the 75 women. No significant differences between study dropouts and completers were observed regarding symptoms of depression and anxiety; however, there was a significant difference between dropouts and completers concerning baseline self-efficacy (t[80] = 2.44, P = 0.017). The dropouts perceived their self-efficacy as significantly higher than those who continued the intervention.

Process measures with regard to motivation and evaluation of the intervention

The answers of the CBS participants for the questions about motivation at the baseline measurement showed that all participants thought that the intervention would be useful (a little useful by 17.1% and rather-to-highly useful by 82.9%) and all indicated that they felt motivated to follow the intervention (a little motivated by 7.3% and rather-to-highly motivated by 92.7%).

The answers of the CBS participants to the evaluative questions at the posttest measurement showed that the intervention was found useful by all participants (a little useful by 22.9% and rather-to-highly useful by 77.1%); 91.5% of the participants were rather-to-highly satisfied with regard to the intervention. Intervention compliance was reported by all participants (full compliance by 65.7% and partial compliance by 34.3%); 91.5% of the participants valued the coaching (22.9% valued it a little and 68.6% valued it rather to very much).

Effectiveness of the intervention

In Table 2, the mean depression, anxiety, and self-efficacy scores at baseline, posttest, and followup are shown for the total group and for the CBS and WLC groups separately. To evaluate the significance of changes in the scores over time, 2 × 2 (group × time) repeated-measures ANCOVAs were performed from pretest to posttest and from posttest to followup, with the level of education as a covariate.

Table 2. Observed baseline, posttest, and followup depression, anxiety, and self-efficacy scores*
 TotalaCBSbWLCc
  1. Values are the mean ± SD. CBS = cognitive–behavioral self-help program group; WLC = waiting list control condition group.

  2. a

    Baseline n = 82, posttest n = 75, followup n = 71.

  3. b

    Baseline n = 41, posttest n = 35, followup n = 35.

  4. c

    Baseline n = 41, posttest n = 40, followup n = 36.

Depression   
Baseline depression16.17 ± 3.3016.41 ± 3.2215.92 ± 3.40
First posttest depression14.72 ± 3.4713.66 ± 3.0615.65 ± 3.58
Second posttest depression14.35 ± 3.9413.29 ± 3.2415.32 ± 4.30
Anxiety   
Baseline anxiety17.28 ± 3.5516.95 ± 3.2017.61 ± 3.87
First posttest anxiety15.77 ± 3.7714.63 ± 2.9116.78 ± 4.17
Second posttest anxiety15.56 ± 3.7614.56 ± 3.3316.49 ± 3.93
Self-efficacy   
Baseline self-efficacy23.48 ± 5.2623.66 ± 5.1623.29 ± 5.45
First posttest self-efficacy26.73 ± 5.7728.94 ± 4.3624.80 ± 6.20
Second posttest self-efficacy26.03 ± 5.5527.18 ± 4.4424.97 ± 6.29

Table 3 shows the results of the ANCOVAs on true scores. These results show that the intervention significantly improved depression, anxiety, and self-efficacy scores from pretest to posttest and that no significant relapse was found in depression and anxiety scores from posttest to followup. There was a significant change in self-efficacy from posttest to followup. The inspection of the mean scores in Table 2 indicates that this change reflected a small (but significant) relapse in self-efficacy scores. However, another ANCOVA (data not shown) showed that self-efficacy at followup still showed significant improvement compared with pretest self-efficacy (Wilks' λ = 0.91, F[1,68] = 56.44, P = 0.01).

Table 3. Generalized linear model with repeated measurements: multivariate effects for time × condition*
 Wilks' λF(df)η2P
  1. a

    Results are controlled for the main effect of time (independent of condition) and covariate level of education.

Effects on depression scores (time × condition)a    
From pretest to posttest0.8314.45 (1,72)0.170.000
From posttest to followup1.000.00 (1,72)0.000.973
Effects on anxiety scores (time × condition)a    
From pretest to posttest0.935.30 (1,72)0.070.024
From posttest to followup0.990.06 (1,68)0.000.807
Effects on self-efficacy scores (time × condition)a    
From pretest to posttest0.7129.35 (1,72)0.290.000
From posttest to followup0.935.43 (1,68)0.070.023

Table 4 shows the results of the ANCOVAs by intent-to-treat analyses, with the last observation carried forward method used. The results were fully comparable to the analyses on true scores.

Table 4. Generalized linear model with repeated measurements: multivariate effects for time × condition, by intent-to-treat analysis (last observation carried forward)*
 Wilks' λF(df)η2P
  1. a

    Results are controlled for the main effect of time (independent of condition) and covariate level of education.

Effects on depression scores (time × condition)a    
From pretest to posttest0.8612.54 (1,79)0.140.001
From posttest to followup1.000.01 (1,79)0.000.996
Effects on anxiety scores (time × condition)a    
From pretest to posttest0.954.17 (1,79)0.050.044
From posttest to followup1.000.09 (1,79)0.000.766
Effects on self-efficacy scores (time × condition)a    
From pretest to posttest0.8020.26 (1,79)0.200.000
From posttest to followup0.945.10 (1,79)0.060.027

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. REFERENCES

The results of this study show that a self-help intervention program with minimal coaching that focuses on relaxation, changing maladaptive cognitions, and attainment of personal life goals was effective in reducing symptoms of depression and anxiety and in strengthening coping self-efficacy in people with rheumatic disease compared with a WLC group. In addition, participants in the intervention group indicated that they valued the intervention and were compliant with the intervention instructions. The positive effects of the intervention remained after a followup period of 2 months. This is a promising finding, given that, at present, many people who have rheumatic diseases and depressive symptoms do not obtain the psychological treatment they need. Because a self-help intervention program can be delivered through postal mail or through the internet, a high number of people can be reached, while existing barriers to psychological treatment can be overcome ([7]).

The finding that a CBS may have positive effects on depression and anxiety is not new ([28, 29]). In previous studies, the positive effects of self-help on depression and anxiety were already confirmed in people with acquired physical impairments, human immunodeficiency virus, acquired hearing loss, and peripheral arterial disease ([16, 30, 31]). The present study adds to this evidence by suggesting that an adapted form of this self-help program may also be beneficial to help people with rheumatic disease reduce the symptoms of depression and anxiety. The present study is unique in that it also showed that the intervention was highly effective for the enhancement of coping self-efficacy. Improvement of coping self-efficacy is important because this may give people the tools to adequately adjust to and cope with the impairments caused by rheumatic disease for the remainder of their lives. Higher self-efficacy may also help to prevent future development of psychological problems.

Despite the encouraging results, this study had some limitations. An important one is the use of only a WLC group. The observed treatment outcomes could theoretically be the result of additional attention, expectations, or other nonspecific effects in the intervention group. To rule out the notion that any kind of intervention could generate similar effects, future research should improve the design by including other control groups that take into account such nonspecific effects. For example, inclusion of an attention-only, information-only, and/or a relaxation-only control group could be useful, in which the participants receive regular short telephone calls or e-mails asking them how they are doing and for information about facts from cognitive–behavioral therapy and/or a relaxation exercise, but without any actual therapeutic intervention. In addition, comparing intervention groups with and without coaching would be helpful to discern the unique and additional effects of coaching. If the design will get more complicated, it will become more appropriate to use the generalized estimating equation model or mixed-effects model to analyze the data, especially if noncategorical predictors and time-dependent covariates will be included.

Other limitations include the use of self-report instruments and the fact that the participants were recruited through special web sites, which limits generalizability. In addition, although the sample size was large enough to investigate the group by time effects, it was too small to perform any secondary analyses, such as studying to what extent patient characteristics influenced the effectiveness of self-help programs. The dropout analyses showed that significantly more men than women dropped out of the study. However, because of the small number of men who participated in the study (only 7), it is difficult to draw conclusions from this finding. Future studies could further investigate the question of whether women have more treatment compliance to self-help than men.

It should also be known that, in addition to many advantages, there are also disadvantages to self-help interventions. The most important disadvantage of participating in a self-help program is that the participant needs to have the motivation and self-discipline to complete the program. A lack of motivation or self-discipline may result in attrition and a lower commitment to complete the program. To minimize the number of study dropouts, we included only minimal guidance in the program, which has proven to be important ([32]). We suggest that future studies investigate individual differences in motivation and self-discipline skills in relation to dropout, treatment compliance, and effectiveness and to compare the effectiveness of self-help programs with and without minimal guidance.

For practice implications, given the high prevalence of depressive symptoms among people with rheumatic diseases, effective psychological interventions are urgently needed. The present study suggests that a CBS might be an effective tool for filling this need. In order to draw more firm conclusions, however, future studies should use larger sample sizes and a more sophisticated design, including using control groups other than a WLC group, in order to rule out the influence of nonspecific effects on treatment success. If our results are confirmed, a self-help program can be more cost-effective for individuals and for the health care system as a whole in contrast to interventions that require extensive clinical contact. In addition, it can easily be made available to a large number of people without the need for a waiting list. The program could very well be used as a first step in a stepped care approach or as one of the treatment possibilities in a matched care approach. Future studies should also focus on determining which persons benefit most from self-help interventions and under what circumstances.

AUTHOR CONTRIBUTIONS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. REFERENCES

All authors were involved in drafting the article or revising it critically for important intellectual content, and all authors approved the final version to be published. Dr. Garnefski had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study conception and design. Garnefski, Kraaij.

Acquisition of data. Garnefski, Kraaij, Benoist, Bout, Karels, Smit.

Analysis and interpretation of data. Garnefski, Kraaij, Benoist, Bout, Karels, Smit.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. REFERENCES
  • 1
    Uhlig T, Loge JH, Kristiansen IS, Kvien IK.Quantification of reduced health-related quality of life in patients with rheumatoid arthritis compared to the general population.J Rheumatol2007;34:12417.
  • 2
    Clarke DM, Currie KC.Depression, anxiety and their relationship with chronic diseases: a review of the epidemiology, risk and treatment evidence.Med J Aust2009;190:S5460.
  • 3
    Dickens C, McGowan L, Clark-Carter D, Creed F.Depression in rheumatoid arthritis: a systematic review of the literature with meta-analysis.Psychosom Med2002;64:5260.
  • 4
    Moussavi S, Chatterji S, Verdes E, Tandon A, Patel V, Ustun B.Depression, chronic diseases, and decrements in health: results from the World Health Surveys.Lancet2007;370:8518.
  • 5
    Stein MB, Cox BJ, Afifi TO, Belik S, Sareen J.Does co-morbid depressive illness magnify the impact of chronic physical illness? A population-based perspective.Psychol Med2006;36:58796.
  • 6
    Covic T, Cumming SV, Pallant JF, Manolios N, Emery P, Conaghan PG, et al.Depression and anxiety in patients with rheumatoid arthritis: prevalence rates based on a comparison of the Depression, Anxiety and Stress Scale (DASS) and the Hospital, Anxiety, and Depression Scale (HADS).BMC Psychiatry2012;12:6.
  • 7
    Papworth M.Issues and outcomes associated with adult mental health self-help materials: a ‘second order’ review or ‘qualitative meta-review’.J Ment Health2006;15:387409.
  • 8
    Sobel DS.Rethinking medicine: improving health outcomes with cost-effective psychosocial interventions.Psychosom Med1995;57:23444.
  • 9
    Lorig K, Ritter PL, Plant K.A disease-specific self-help program compared with a generalized chronic disease self-help program for arthritis patients.Arthritis Rheum2005;53:9507.
  • 10
    Garnefski N, Grol M, Kraaij V, Hamming J.Cognitive coping and goal adjustment in people with peripheral arterial disease: relationships with depressive symptoms.Patient Educ Couns2009;76:1327.
  • 11
    Garnefski N, Koopman H, Kraaij V, ten Cate R.Cognitive emotion regulation strategies and psychological adjustment in adolescents with a chronic disease.J Adolesc2009;32:44954.
  • 12
    Garnefski N, Kraaij V.Do cognitive coping and goal adjustment strategies shortly after myocardial infarction predict depressive outcomes one year later?J Cardiovasc Nurs2010;25:3839.
  • 13
    Garnefski N, Kraaij V, De Graaf M, Karels L.Cognitive coping and goal-related coping in visually impaired people: relationships with depressive symptoms.Disabil Rehabil2010;32:1427.
  • 14
    Garnefski N, Kraaij V, Schroevers MJ, Aarnink J, van der Heiden DJ, van Es SM, et al.Cognitive coping and goal adjustment after first-time myocardial infarction: relationships with symptoms of depression.Behav Med2009;35:7986.
  • 15
    Schroevers M, Kraaij V, Garnefski N.How do cancer patients manage unattainable personal goals and regulate their emotions? An examination of the relations between goal adjustment, cognitive emotion-regulation strategies, and positive and negative affect.Br J Health Psychol2008;13:55162.
  • 16
    Garnefski N, Kraaij V, Schroevers M.Effects of a cognitive behavioral self-help program on depressed mood for people with acquired chronic physical impairments: a pilot randomized controlled trial.Patient Educ Couns2011;85:3047.
  • 17
    Barsky AJ, Aher DK, Orav EJ, Nestoriuc Y, Liang MH, Berman IT, et al.A randomized trial of three psychosocial treatments for the symptoms of rheumatoid arthritis.Semin Arthritis Rheum2010;40:22232.
  • 18
    Sinclair VG, Wallston K.Psychological vulnerability predicts increases in depressive symptoms in individuals with rheumatoid arthritis.Nurs Res2010;59:1406.
  • 19
    Knittle KP, De Gucht V, Hurkmans EJ, Vliet Vlieland TP, Peeters AJ, Ronday HK, et al.Effect of self-efficacy and physical activity goal achievement on arthritis pain and quality of life in patients with rheumatoid arthritis.Arthritis Care Res2011;63:16139.
  • 20
    Kroenke K, Spitzer RL, Williams JB.The PHQ-9: validity of a brief depression severity measure.J Gen Intern Med2001;16:60613.
  • 21
    Zigmond AS, Snaith RP.The Hospital Anxiety and Depression Scale.Acta Psychiatr Scand1983;67:36170.
  • 22
    Herrmann C.International experiences with the Hospital Anxiety and Depression Scale: a review of validation data and clinical results.J Psychosom Res1997;42:1741.
  • 23
    Spinhoven P, Ormel J, Sloekers PP, Kempen GI, Speckens AE, Van Hemert AE.A validation study of the Hospital Anxiety and Depression Scale (HADS) in different groups of Dutch subjects.Psychol Med1997;27:36370.
  • 24
    Bjelland I, Dahl AA, Tangen Haug T, Neckelmann D.The validity of the Hospital Anxiety and Depression Scale: an updated literature review.J Psychosom Res2002;52:6977.
  • 25
    Schwarzer R, Jerusalem M. Generalized self-efficacy scale. In: Weinman J, Wright S, Johnston M, editors.Measures in health psychology: a user's portfolio. Causal and control beliefs.Windsor (England):Nelson;1995. p.357.
  • 26
    Luszczynska A, Scholz U, Schwarzer R.The General Self-Efficacy Scale: multicultural validation studies.J Psychol2005;139:43957.
  • 27
    McHorney CA, Ware JE, Lu R, Sherbourne CD.MOS 36-ltem Short-Form Health Survey (SF-36): III. Tests of data quality, scaling assumptions, and reliability across diverse patient groups.Med Care1994;32:4066.
  • 28
    Gellatly J, Bower P, Hennessy S, Richards D, Gilbody S, Lovell K.What makes self-help interventions effective in the management of depressive symptoms? Meta-analysis and meta-regression.Psychol Med2007;37:121728.
  • 29
    Morgan AJ, Jorm AF.Self-help interventions for depressive disorders and depressive symptoms: a systematic review.Ann Gen Psychiatry2008;7:123.
  • 30
    Garnefski N, Kraaij V.Effects of a cognitive behavioral self-help program on emotional problems for people with acquired hearing loss: a randomized controlled trial.J Deaf Stud Deaf Educ2012;17:7584.
  • 31
    Kraaij V, van Emmerik A, Garnefski N, Schroevers MJ, Lo-Fo-Wong D, van Empelen P, et al.Effects of a cognitive behavioral self-help program and a computerized structured writing intervention on depressed mood for HIV-infected people: a pilot randomized controlled trial.Patient Educ Couns2010;80:2004.
  • 32
    Jernelov S, Lekander M, Blom K, Rydh S, Ljotsson B, Axelsson J, et al.Efficacy of a behavioral self-help treatment with or without therapist guidance for co-morbid and primary insomnia: a randomized controlled trial.BMC Psychiatry2012;12:5.