Clinical Abstracts
August 1999; Volume 1: 71-72
With Comments from Charlea T. Massion, MD
Write On! Patients with Asthma or Rheumatoid Arthritis
Source: Smyth J, et al. Effects of writing about stressful experiences on symptom reduction in patients with asthma and rheumatoid arthritis. JAMA 1999;281:1304-1309.
Design and Setting: Oct 1996-Nov 1997 randomized, controlled clinical trial of volunteer, outpatient community residents.
Subjects: Sample of 112 patients with asthma (n = 61) or rheumatoid arthritis (RA) (n = 51) received the intervention; 107 completed the study (58 asthmatics and 49 arthritics). Mean age of the arthritics was 51.1 years; of the asthmatics, 41.2 years. About 70% of both groups were women. Study subjects had relatively high educational (14 years for both groups) and annual family income ($65K for arthritics and $50K for asthmatics) levels. The control and the experimental groups were well matched.
Treatment: All subjects wrote in private 20 min/d for three consecutive days. The experimental group was instructed to write about the most stressful event ever experienced (n = 71; 39 asthma, 32 RA), while the control group wrote a time management exercise designed to "reduce the day’s stress" (n = 41; 22 asthma, 19 RA). The writing tablet was dropped into a sealed box. The writings were read, but never discussed with the subjects.
Outcome Measures: Asthmatics were evaluated with spirometry (FEV1). Arthritics were clinically examined by a rheumatologist who used a standardized, quantitative method to rate diagnostic symptoms. Assessments were done at baseline, two weeks, two months, and four months after the writing sessions, and were done blind to experimental condition.
Results: Asthmatics in the experimental group showed improvements in lung function at each post-writing assessment, whereas the control group showed no change. Arthritics did not show significant improvement in overall disease activity until the assessment at four months, while the control group showed no change. Combining all the patients who completed the study, 33 (47.1%) of the 70 experimental subjects had clinically relevant improvement, whereas only nine (24.3%) of the 37 control subjects had improvement.
Funding: Fetzer Institute, Kalamazoo, MI.
Comments: Although there has been extensive research on improved health outcomes for healthy people who complete the "most traumatic life event" writing assignment (see The Capacity to Confide. In: Dreher H, ed. The Immune Power Personality: 7 Traits You Can Develop to Stay Healthy. New York, NY: Penguin Books; 1996), this is the first study of this technique in people with serious chronic illnesses. The outcomes were measured not by indirect tests (blood tests or frequency of physician visits) or by self-reported assessments, but by standard biomedical parameters: For asthmatics, a machine (spirometer); for arthritics, a standardized clinical exam.
David Spiegel, MD, a Stanford psychiatrist who has researched the survival effects of support groups for women with breast cancer, astutely notes in an accompanying editorial, "Were the authors to have provided similar outcome evidence about a new drug, it likely would be in widespread use within a short time. Why? We would think we understood the mechanism’ (whether we did or not) and there would be mediating industry to promote its use. Manufacturers of paper and pencils are not likely to push journaling as a treatment addition for the management of asthma and rheumatoid arthritis."
However, despite the lack of corporate interest in these interventions, physicians need to pay attention to the growing evidence that an individual’s psychophysiological reactions to an illness can have more impact on the disease outcome than some of our highest-tech drugs, machines and procedures. This study could cast a whole new perspective on the doctor’s waiting room: Do your structured writing there, and then, skip your visit with the physician!—for it’s certainly time to realize that, as Dr. Spiegel clarifies, "it is not simply mind over matter, but it is clear that mind matters."
August 1999; Volume 1: 71-72
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