Writing Therapy to Reduce Asthma and RA Symptoms
Abstract & Commentary Synopsis: Taking a pen in hand is low cost, noninvasive, personal, and therapeutic. Source: Smyth JM, et al. JAMA 1999;281:1304-1309.To determine if writing about stressful life experiences affects disease status in asthma or rheumatoid arthritis (RA) patients using standardized quantitative outcome measures, we conducted a randomized controlled trial between October 1996 and December 1997. A volunteer sample of 112 patients with asthma (n = 61) or RA (n = 51) enrolled; 107 completed the study.
As the intervention, patients were assigned to write either about the most stressful event of their lives (n = 71; 39 asthma, 32 RA) or, as a control, about their plans for the day (n = 41; 22 asthma, 19 RA). Asthma patients were evaluated with spirometry and RA patients were examined by a rheumatologist at baseline, and at two weeks, two months, and four months. The evaluations were done blind to the experimental condition.
Of evaluable patients four months after treatment, asthma patients in the experimental group showed improvements in FEV1 (63.9% at baseline to 76.3% at four months; P < 0.001); controls showed no change. RA patients showed reduced mean disease severity from 1.65 to 1.19 (28% on a scale of 0 [asymptomatic] to 4 [very severe] at four months; P = 0.001); controls showed no change. Combining all completing patients, 33 of 70 (47.1%) experimental patients had clinically relevant improvement; nine of 37 (24.3%) controls also improved (P = 0.001).
COMMENT by John La Puma, MD, FACP
Every writer knows that writing can be therapeutic, even if it hurts. But only when it hurts? Smyth and colleagues excluded patients with a defined psychiatric disorder, in psychotherapy, or on mood-altering medications (including prednisone, > 10 mg/d). Patients were told that the investigators were interested in the patients’ experiences of stress. The patients did not discuss their writing with staff or other participants and wrote in private for 20 minutes on three consecutive days a week after completing baseline disease severity assessments, which were comparable.
Nearly all patients were Caucasian, well-educated (mean two to three years of college), and averaged a mean annual family income of $66K (RA) and $50K (asthma). Nearly all used medication regularly. Less than 10% of each group smoked, and 49% of each group got regular exercise.
Smyth et al report that observation of participants in similar writing sessions shows "considerable emotional upset during the writing sessions." These patients most commonly wrote about the death of a loved one, serious problems of a close other, and problems in relationships.
Not noted was whether and how medication regimens changed over time; to what mechanism physicians attributed patients’ assessed improvement; what patients thought of the intervention; or which symptoms specifically improved. Asthma patients’ FEV1 ratings improved at two weeks and at each follow-up visit; RA patients’ current clinical status assessment did not improve until four months.
Many physicians regularly receive long letters from patients describing household events and personal problems. The possibility of actually prescribing such writing assignments and asking patients to write expressively as part of their chronic disease management is intriguing and refreshing.
Structured, systematic trials assessing the usefulness of expressive writing are a logical, important next research step. Taking a pen in hand is low cost, noninvasive, and personal. Providing a writing tablet and 20 minutes free of other distractions are generous gifts. Prescribed by a caring clinician, the combination seems low risk and potentially therapeutic. (Dr. La Puma is Professor of Nutrition, Kendall College, Director, C.H.E.F. Clinic, C.H.E.F. Skills Research, Alexian Brothers Medical Center, Elk Grove Village, Ill.)
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