Disability and Rehabilitation, 2010; 32(10): 836–844

RESEARCH PAPER

Poor psychological health status among patients with inflammatory

rheumatic diseases and osteoarthritis in multidisciplinary
rehabilitation: Need for a routine psychological assessment
Disabil Rehabil Downloaded from informahealthcare.com by UWS University of Western Sydney library on 04/26/11

JOHANNA VRIEZEKOLK1, AGNES EIJSBOUTS1, ANDREA EVERS2,

ANNEMIEK STENGER1, FRANK VAN DEN HOOGEN1 & WIM VAN LANKVELD1
1
Sint Maartenskliniek, Department of Rheumatology, Nijmegen, The Netherlands and 2Radboud University Nijmegen
Medical Center, Department of Medical Psychology, Nijmegen, The Netherlands

Accepted September 2009

Abstract
Purpose. To examine psychological health status among patients with inflammatory rheumatic diseases (i.e. rheumatoid
arthritis, psoriatic arthritis, and ankylosing spondylitis) and osteoarthritis in multidisciplinary rehabilitation, and to describe
For personal use only.

changes in psychological distress, illness cognitions, and pain coping from pre- to post-treatment.
Method. Eighty-nine patients referred to multidisciplinary rehabilitation completed a set of questionnaires to assess pain
(AIMS2-SF), physical functioning (AIMS2-SF), psychological distress (IRGL), illness cognitions (ICQ) and pain coping
(PCI) at pre- and post-treatment. Changes in physical functioning, pain, and psychological health status were determined.
On the basis of the cut-off scores of psychological distress, distressed, and non-distressed patients were compared on physical
and psychological outcomes.
Results. Psychological distress was found in 64% of the study sample. In addition, high levels of helplessness and worrying,
low levels of acceptance, and moderate levels of physical functioning were found. After treatment, positive changes in pain,
psychological distress, and illness cognitions were observed. However, 69% (29/42) of the distressed patients at baseline still
experienced elevated levels of psychological distress and maladaptive cognitions.
Conclusions. Psychological distress and maladaptive illness cognitions are important characteristics of this study sample, and
psychological distress remains high after rehabilitation. More attention should be given to the appropriate assessment and
treatment of psychological distress within multidisciplinary rehabilitation.

Keywords: Rheumatic diseases, osteoarthritis, pain, depression, anxiety, illness cognitions, pain coping

Introduction Positive effects of multidisciplinary rehabilitation

Multidisciplinary rehabilitation is generally used as
an adjunctive to pharmacological treatment in the
management of rheumatic diseases. Multidisciplin-
ary rehabilitation includes a variety of non-pharma-
cological treatment modalities: for example, physical
therapy, occupational therapy, nurse care, and
psychosocial support. Generally, the goals of multi-
disciplinary rehabilitation are to preserve and im-
prove patient’s quality of life by improving disease
activity, functional ability, psychological and social
health, and vocational status [1].
in rheumatoid arthritis (RA) have been demon-
strated [2,3]. Several randomised controlled studies
have shown that multidisciplinary rehabilitation can
be more effective than regular out-patient care on
disease activity, functional ability, and employment
status [4–7]. Most multidisciplinary rehabilitation
programmes are primarily aimed at improving
physical functioning, and activities and participation
in daily life. Hence, improving patients’ psychologi-
cal health is not a common distinct treatment goal in
multidisciplinary rehabilitation. As a result, psycho-
logical functioning has received little attention in

Correspondence: Ms. JE Vriezekolk, Sint Maartenskliniek, Department of Rheumatology, PO Box 9011, 6500 GM Nijmegen, The Netherlands.
Tel: þ31-24-365-9367. Fax: þ31-24-365-9154. E-mail: j.vriezekolk@maartenskliniek.nl
ISSN 0963-8288 print/ISSN 1464-5165 online ª 2010 Informa UK Ltd.
DOI: 10.3109/09638280903323250

rehabilitation research. Indeed, findings on psycho-
logical and social health outcomes in multidisciplin-
ary rehabilitation are scarce [4,7].
It has become increasingly clear that psychological
distress, such as depressive and anxiety symptoms, is
common in patients with chronic musculoskeletal
pain [8–10]. Individuals with rheumatic diseases are
more likely to be depressed than healthy individuals
[8]. The reported prevalence of psychological dis-
tress, as measured with self-report depression and
anxiety scales, ranges from 33% to 40% [11,12].
Importantly, psychological distress has been found to
Disabil Rehabil Downloaded from informahealthcare.com by UWS University of Western Sydney library on 04/26/11
be associated with poor physical and psychosocial
functioning [13], and with increased health care use
[14,15]. Research has demonstrated that patients
with elevated levels of depressed mood and anxiety
report worse physical functioning and increased
levels of pain [9,16–19], maladaptive illness cogni-
tions [20–23], and passive pain coping strategies
[23–25]. Moreover, several studies have shown the
predictive value of psychological distress for poor
long term outcomes [15,26,27]. These findings
suggest that patients’ psychological health status
may compromise the effectiveness of multidisciplin-
ary rehabilitation.
For personal use only.
To optimise treatment goals and improve the
content of multidisciplinary rehabilitation programmes
accordingly, information with respect to psychological
health status of patients in multidisciplinary rehabilita-
tion is needed. To our knowledge, no studies have been
conducted to comprehensively investigate the psycho-
logical health status among patients with arthritis in
multidisciplinary rehabilitation.
Accordingly, the aim of this prospective study was
to examine the psychological health status among
patients with inflammatory rheumatic diseases and
osteoarthritis (OA) in multidisciplinary rehabilita-
tion, and to describe changes in psychological
distress, illness cognitions, and pain coping from
pre- to post-treatment.
Materials and methods
Patients
One hundred twenty-three patients with inflamma-
tory rheumatic diseases (i.e. RA, psoriatic arthritis,
and ankylosing spondylitis) and OA, as diagnosed by
the rheumatologist, were referred to multidisciplin-
ary rehabilitation at the rheumatology day-care unit
of the Sint Maartenskliniek. Patients were con-
sidered eligible for multidisciplinary rehabilitation,
if the rheumatologist judged that the patient suffered
from physical limitations and participation restric-
tions in two or more health domains (e.g. daily life,
work, social activities, and leisure) despite adequate
Distress among patients in rehabilitation 837
pharmacological and/or mono-disciplinary non-
pharmacological treatment. The inclusion criteria for
patients’ study participation were: (1) referral by
rheumatologist to multidisciplinary rehabilitation, (2)
age 18 years, and (3) fluency in spoken and written
Dutch. Of the 123 consecutively referred patients,
113 patients (92%) were recruited for this study: two
patients did not meet the study inclusion criteria
and eight patients declined study participation. After
assessment and team conference by the various
health professionals of the multidisciplinary team, 14
patients (12%) were excluded from multidisciplinary
rehabilitation for various reasons, e.g. referral to
primary care or other hospital treatment. Figure 1
depicts the flow of patients through the study. Of the
remaining 99 patients eligible for the multidisciplinary
rehabilitation, 10 patients deferred from treatment or
did not complete the rehabilitation programme. No
post-treatment data of these patients were available.
Therefore, 89 patients who completed the multi-
disciplinary rehabilitation and provided data on base-
line assessment composed the sample for this study.
Seventy-three patients provided post-treatment data,
whereas 16 patients (18%) did not return the set of
questionnaires at post-treatment assessment. Ethical
approval from the local Medical Ethics Committee
and informed consent from all participants were
obtained.
Data collection
After referral for multidisciplinary rehabilitation,
patients were contacted by the researcher to partici-
pate in the study. Participants received a set of
questionnaires and an informed consent by mail, and
were asked to complete the questionnaires at home
before their scheduled multidisciplinary rehabilita-
tion assessment. At the assessment day, patients were
seen by the researcher who explained the details of
the study, after which the informed consent was
signed, and the set of questionnaires handed over.
Two weeks after completion of the rehabilitation
programme, patients received a second set of
questionnaires by mail and were instructed to return
the questionnaires using a stamped return envelope
that was included. During the assessment for multi-
disciplinary rehabilitation, disease-related variables
were recorded by the rheumatologist.
Self-report questionnaires
Patients completed a set of questionnaires to
assess demographic data, pain, physical functioning,
psychological distress, illness cognitions, and pain
coping.
 838 J. Vriezekolk et al.
Disabil Rehabil Downloaded from informahealthcare.com by UWS University of Western Sydney library on 04/26/11
For personal use only.
Figure 1. Flowchart patients in multidisciplinary rehabilitation 2006.
Pain was assessed by the Symptom scale of the
Dutch Arthritis Impact Measurement Scales Short
version (AIMS2-SF). This scale measures the
intensity and frequency of pain and morning stiffness
on a 5-point Likert scale. The AIMS2-SF has
demonstrated to be reliable, valid and sensitive to
change across different rheumatic diseases [28–30].
Internal reliability for the Symptom scale in this
study was a ¼ 0.74.
Physical functioning was assessed by the Physical
scale of the AIMS2-SF. This 12-item scale measures
the perceived functional disability on a 5-point Likert
scale with scoring alternatives ranging from ‘every
day’ to ‘never’. Internal consistency in this study was
a ¼ 0.86.
Psychological distress was measured by the Anxiety
and Depressed Mood scales of the Impact of
Rheumatic Diseases on General Health and Lifestyle
questionnaire (IRGL) [31]. The IRGL is a ques-
tionnaire, which assesses physical, psychological, and
social health in patients with rheumatic diseases and
has shown excellent psychometric properties [32,33].
The Anxiety scale is a shortened version of the Dutch
State Anxiety scale (10 items) [34], assessing anxiety
levels in the last month. The Depressed Mood scale
(six items) is derived from Zwart and Spooren’s
questionnaire [35] and measures mood states over
the previous week. Cronbach’s alpha in the present
study was 0.93 for depressed mood and 0.91 for
anxiety and were consistent with previous findings
[36].
Illness cognitions were measured by the Illness
Cognition Questionnaire (ICQ) [37], a generic
questionnaire assessing different ways of cognitively
(re)evaluating the inherently aversive character
of a chronic disease: Helplessness as a way of
emphasising the aversive meaning of the disease,
Acceptance as a way to diminish the aversive
meaning, and Perceived Benefits as a way of adding
a positive meaning to the disease. In this study two

scales were used: Helplessness (e.g. ‘My illness
controls my life’) and Acceptance (e.g. ‘I have
learned to live with my illness’). Internal consistency
in this study was 0.90 for helplessness and 0.92 for
acceptance.
Pain coping was measured by the Pain Coping
Inventory (PCI) [38]. This 33-item questionnaire
measures active and passive pain coping strategies on
a 4-point Likert scale ranging from ‘hardly ever’ to ‘very
often’. Six coping strategies are assessed: Pain trans-
formation, Distraction, Reducing demands, Retreat-
ing, Worrying, and Resting. The PCI has demonstrated
Disabil Rehabil Downloaded from informahealthcare.com by UWS University of Western Sydney library on 04/26/11
good psychometric properties across different chronic
pain disorders. Cronbach’s alphas in this study ranged
between 0.61 and 0.80 for the subscales.
Content of treatment
Treatment modalities and duration of the multi-
disciplinary rehabilitation were assessed by extracting
data from weekly programme schedules that are used
for individual treatment planning. Initial assessment
was carried out by a rheumatologist, a physical
therapist, an occupational therapist, and a specialised
For personal use only.
nurse, and – if indicated by the rheumatologist – a
social worker or psychologist. The assessment con-
sisted of a standardised interview (e.g. case history)
and physical examination by various health profes-
sionals of the multidisciplinary team to assess disease
related data, functional limitations, and activities and
participation limitations of daily life. After the assess-
ment and team conference, the patients were offered
an individualised rehabilitation programme targeting
patients’ individual treatment goals. The programme
consisted of, if considered appropriate, the following
components: (1) physical therapy (individual and
group exercises), involving restoring mobility, muscle
strength, and physical fitness, relaxation exercises,
hydrotherapy; (2) occupational therapy; (3) counsel-
ling by a social worker or psychologist; and (4)
specialised nurse care. The health professionals of the
multidisciplinary team were not privy to the self-
reported physical and psychological health status of
the patients at baseline, prior to and during the
multidisciplinary rehabilitation.
On average, patients received a 6-weeks, 2 days a
week, intensive rehabilitation programme. Mean
(SD) duration of the rehabilitation was 28.0 (8.4) h.
All patients received physical therapy (M ¼ 5.9 h,
SD ¼ 2.4 h), occupational therapy (M ¼ 4.5 h, SD ¼
1.4 h), and specialised nurse care (M ¼ 3.0 h,
SD ¼ 0.9 h). In addition, 84% of the patients received
hydrotherapy (M ¼ 5.3 h, SD ¼ 1.9 h), and 57% of
the patients received relaxation exercises (M ¼ 3.1 h,
SD ¼ 1.6 h). About 76% of the patients were seen by a
social worker (M ¼ 4.3 h, SD ¼ 1.5 h), 12 patients
Distress among patients in rehabilitation 839
(14%) were seen by a clinical psychologist (M ¼ 3.5 h,
SD ¼ 1.3 h).
Statistical analysis
The distributions of the study variables were
inspected. Descriptive statistics were provided as
mean and standard deviation (SD) or median (IQR)
for continuous variables and percentages for catego-
rical variables. On the basis of IRGL cut-off scores of
depressed mood and/or anxiety scores from previous
research in RA outpatient groups [16,23,39], a
dichotomised variable was computed for psycholo-
gical distress. Specifically, patients were classified as
distressed when patients scored either 6 on the self-
reported Depressed Mood scale of the IRGL, or
patients scored 23 on the IRGL Anxiety scale,
reflecting (sub)clinical levels of depression and
anxiety. Differences between subgroups (i.e. diag-
nostic and distressed versus non-distressed) were
tested with Pearson’s w2 tests, respectively Fisher’s
exact test for categorical or nominal variables and
univariate analyses of variance for continuous vari-
ables on all study variables. To examine the effect of
multidisciplinary rehabilitation on physical function-
ing, pain, and psychological health status, paired
samples t-tests or unpaired samples t-test were
performed, if appropriate. Type I error was con-
trolled for by applying a Bonferroni correction
(a/total number of comparisons).
All tests were 2-sided, and p values 5 0.004, after
Bonferroni correction, were considered significant.
The Statistical Package for the Social Sciences,
Windows version 14.0, was used.
Results
Study sample
Ten patients, who completed the baseline assess-
ment but did not complete the rehabilitation
programme, were compared with the 89 patients,
who completed multidisciplinary rehabilitation, on
all study variables. No significant differences were
found. In addition, no significant differences on
demographic variables, disease-related variables,
physical functioning, pain, and psychological health
status between the completers and the non-com-
pleters of the post-treatment data were found (data
not shown).
Demographic and disease-related characteristics. In
Table I, demographic and disease-related character-
istics of the study sample are displayed. Mean age of
89 patients was 53.1 years (SD ¼ 13.8). The majority
 840 J. Vriezekolk et al.

Table I. Demographic and disease characteristics of study sample Physical functioning and psychological health status at
(N ¼ 89). baseline. In Table II, mean + SD scores on physical
Study sample functioning and psychological health status of the
study sample at baseline are displayed. Moderate
Demographic characteristics levels of physical functioning were observed, whereas
Age (mean, SD) 53.1 (13.8) years
high levels of pain, depressed mood, and anxiety
Gender (female, %) 72%
Education (%) were found. Furthermore, high levels of maladaptive
57 years 14% illness cognitions and passive pain coping strategies
7–12 years 42% (i.e. retreating, worrying, and resting) were observed.
412 years 44% Fifty-seven patients (64%) were classified as dis-
Marital status (married, %) 69%
tressed, whereas 32 patients (36%) were classified as
Employment (%) 40%
non-distressed.
Disabil Rehabil Downloaded from informahealthcare.com by UWS University of Western Sydney library on 04/26/11

Disease-related characteristics In the distressed group, mean levels of depressed

Diagnosis (%)
mood was 9.9 (SD ¼ 4.3) and mean levels of anxiety
Inflammatory rheumatic diseases 58%
Osteoarthritis 42% was 27.1 (SD ¼ 4.5). The distressed patients re-
Disease duration (median, IQR) 8 (3–14) years ported significantly higher levels of helplessness
Duration of complaints (median, IQR) 14 (5.5–23.5) years (F(1,87) ¼ 24.58, p 5 0.001), lower levels of accep-
More than one rheumatic 34% tance (F(1,87) ¼ 21.60, p 5 0.001), and higher levels
condition (yes, %)
of worrying (F(1,88) ¼ 18.90, p 5 0.001) compared
Medication use (%)
Antidepressants 12% with the non-distressed patients. No significant
Paracetamol 40% differences were found in physical functioning, pain,
NSAIDs 64% and the remaining pain coping strategies. Likewise,
Opioids 12% no significant differences were found between the
DMARDs 26%
TNF alpha-blockers 9%
non-distressed and distressed patients with respect to
Health care use 56 month (%) 74% content and duration of the multidisciplinary reha-
For personal use only.

(not including pharmacological bilitation (data not shown).

treatment)

NSAIDs, non-steroidal anti-inflammatory drugs; DMARDs,

disease-modifying anti-rheumatic drugs. Pre- to post-treatment changes in psychological distress,
illness cognitions, and pain coping

of patients were female (72%), married (69%), and
not currently employed (60%). Median disease
duration was 8 years (258–758: 3–14 years), and
83% of the patients used one or more analgesics.
Fifty-two patients (58%) were diagnosed with
inflammatory rheumatic diseases and 37 patients
(42%) were diagnosed with OA by the consultant
rheumatologist. In 30 patients (34%) more than one
rheumatic condition (e.g. OA (7), oligo arthritis (2),
polymyalgia rheumatica (1), bursitis/tendonitis (4),
osteoporosis (5), fibromyalgia (5), hernia nuclei
pulposi (4), and joint hypermobility (2)) was
reported, indicating the complexity of our study
sample.
Except for age, no significant differences between
the diagnostic subgroups with respect to demo-
graphic and disease-related variables were found.
Patients with OA were significantly older (mean age
59.2 years, SD ¼ 9.0) than patients with inflamma-
tory rheumatic diseases (mean age 48.7 years,
SD ¼ 15.0). In addition, no significant differences
in physical functioning, pain, psychological distress,
illness cognitions, and pain coping between diag-
nostic subgroups were found (F’s 5 1.97,
P’s 4 0.16). Subsequently, data of the diagnostic
subgroups were merged.
In Table II, mean + SD scores on physical function-
ing and psychological health status of the study
sample at pre- and post-treatment are displayed.
Significant pre- to post-treatment changes for pain,
depressed mood, anxiety, helplessness, acceptance,
and distraction were observed. A trend toward
improvement was observed for physical functioning
and worrying. No significant differences were found
on the remaining variables. The percentage of
distressed patients dropped from 64% to 45% after
treatment. Overall, decreased levels of pain, psycho-
logical distress, and helplessness were found,
whereas increased levels of acceptance and distrac-
tion were observed.
Differences in outcomes of multidisciplinary rehabilitation
between distressed versus non-distressed patients
In Table III, outcomes on (mean + SD) physical
functioning, pain, and psychological health status of
distressed and non-distressed patients are presented.
No significant statistically differences between dis-
tressed and non-distressed patients were found on
physical functioning, pain, illness cognitions, and
pain coping strategies. After multidisciplinary
 Distress among patients in rehabilitation 841

Table II. Mean scores + SD of study sample on physical functioning and psychological health status at pre- and post-treatment.

Pre-treatment (N ¼ 89) Post-treatment (N ¼ 73) P-value*

Physical functioning
Physical (AIMS2-SF, range 0–10) 3.0 + 1.7 2.6 + 1.6 0.01
Pain (AIMS2-SF, range 0–10) 6.7 + 1.9 5.6 + 2.1 5 0.001
Psychological distress
Depressed mood (IRGL, range 0–21) 7.1 + 5.2 4.9 + 3.9 0.002
Anxiety (IRGL, range 10–40) 23.2 + 6.6 20.8 + 5.9 0.004
Illness cognitions and pain coping
Illness cognitions (ICQ, range 6–24)
Helplessness 14.4 + 4.2 12.6 + 3.6 0.003
Acceptance 13.3 + 3.8 15.2 + 3.9 5 0.001
Pain coping strategies (PCI, range 0–4)
Disabil Rehabil Downloaded from informahealthcare.com by UWS University of Western Sydney library on 04/26/11

Pain transformation 2.3 + 0.6 2.3 + 0.5 ns

Distraction 2.2 + 0.5 2.4 + 0.5 5 0.001
Reducing demands 2.2 + 0.7 2.3 + 0.6 0.38
Retreating 1.9 + 0.6 1.9 + 0.6 0.52
Worrying 2.1 + 0.5 1.9 + 0.5 0.006
Resting 2.4 + 0.6 2.5 + 0.4 0.08

AIMS2-SF, Arthritis Impact Measurement Scales – Short Form; IRGL, Impact of Rheumatic diseases on General health and Lifestyle
questionnaire; ICQ, Illness Cognition Questionnaire; PCI, Pain Coping Inventory. Higher scores indicate worse physical functioning and
psychological health status, more pronounced levels of illness cognitions and more frequent use of pain coping strategies.
*Paired-Samples T-test. Significant differences are indicated in italic at p 5 0.004 (Bonferroni correction applied).

Table III. Post-treatment scores (mean + SD) with respect to physical functioning and psychological health status of non-distressed versus
distressed patients.
For personal use only.

Post-treatment Non-distressed (N ¼ 29){ Distressed (N ¼ 44){ P-value*

Physical functioning
Physical (AIMS2-SF, range 0–10) 2.2 + 1.7 2.8 + 1.6 0.15
Pain (AIMS2-SF, range 0–10) 5.0 + 2.2 5.8 + 1.9 0.25
Psychological distress
Depressed mood (IRGL, range 0–21) 2.3 + 2.5 6.7 + 3.8 5 0.001
Anxiety (IRGL, range 10–40) 16.7 + 3.9 23.6 + 5.4 5 0.001
Illness cognitions and pain coping
Illness cognitions (ICQ, range 6–24)
Helplessness 11.4 + 2.7 13.4 + 3.9 0.02
Acceptance 16.6 + 3.2 14.2 + 3.9 0.01
Pain coping strategies (PCI, range 0–4)
Pain transformation 2.2 + 0.5 2.4 + 0.5 0.23
Distraction 2.5 + 0.6 2.3 + 0.4 0.20
Reducing demands 2.4 + 0.6 2.3 + 0.6 0.30
Retreating 1.8 + 0.7 1.9 + 0.5 0.58
Worrying 1.7 + 0.4 2.0 + 0.5 0.01
Resting 2.5 + 0.4 2.4 + 0.5 0.52

*Significant differences between groups are indicated in italic at p 5 0.004 (Bonferroni correction applied).
{
Of the 32 non-distressed patients, 29 provided post-treatment data. Of the 57 distressed patients, 44 provided post-treatment data.

rehabilitation, 69% (29/42) of the distressed patients
at baseline could still be classified as highly
distressed. Size of differences in helplessness, accep-
tance, and worrying between non-distressed and
distressed patients were *0.5 standard deviation.
Discussion
Poor psychological health status is a prominent
feature among our patients in multidisciplinary
rehabilitation. Compared with previous studies of
outpatients with RA, patients referred to multi-
disciplinary rehabilitation showed higher levels of
psychological distress and maladaptive illness cogni-
tions, whereas similar levels of physical functioning
were observed [29,32,37,38]. Sixty-four percent of
the patients with inflammatory rheumatic diseases or
OA showed elevated levels of psychological distress
based on cut-off scores of depressed mood and/or
anxiety from norm groups of psychiatric outpatients
[16,39]. Furthermore, distressed patients reported
high levels of helplessness and worrying, as well as
low levels of acceptance.
 842 J. Vriezekolk et al.
The prevalence rate of psychological distress (64%)
found among our patients in multidisciplinary reha-
bilitation is considerably higher compared with
reported distress rates in out-patient samples
[11,12,27]. A recent 10-year longitudinal study of
patients with recent onset RA found stable rates of
clinically important elevated levels of anxiety in a range
of 20–30% and depression in a range of 5–13% [27].
To date, no studies in multidisciplinary rehabilitation
have reported prevalence rates of depression and/or
anxiety among patients with rheumatic diseases.
Therefore, our findings should be taken with caution
Disabil Rehabil Downloaded from informahealthcare.com by UWS University of Western Sydney library on 04/26/11
and await confirmation from other studies in multi-
disciplinary rehabilitation.
In line with previous findings, distressed patients
reported higher levels of helplessness and worrying,
as well as lower levels of acceptance compared with
non-distressed patients [39]. In particular, maladap-
tive illness cognitions seem to characterise our
distressed patient group, whereas pain coping
strategies did not differ from out-patients with RA
[38].
Favourable changes in pain, psychological distress,
illness cognitions, and pain coping were demonstrated
in this patient sample. However, of the 42 distressed
For personal use only.
patients at baseline, 29 patients (69%) still reported
clinically important elevated levels of depressive
symptoms and anxiety after multidisciplinary rehabili-
tation. Moreover, distressed patients still reported
higher levels of maladaptive illness cognitions than
non-distressed patients after treatment.
Although the emphasis of our rehabilitation
programme was on improving physical functioning
and improving activities and participation in daily
life, a decrease of psychological distress in the
distressed group was observed. Patient education
and psychosocial support is an integrated part of our
multidisciplinary rehabilitation. Hence, 76% of our
patients received counselling by a social worker. The
latter may partly explain the positive effect on
patients’ psychological health status. However, this
positive effect might also be attributed to regression
to the mean or attention placebo.
A large proportion (69%) of our distressed patients
still reported elevated levels of psychological distress
after multidisciplinary rehabilitation. This finding
suggests that patient education and psychosocial
support do not sufficiently address patients’ psycholo-
gical problems. Indeed, a recent meta-analysis of
patient education interventions in patients with RA
found only small short-term effects on physical and
psychosocial outcomes [40]. Moreover, the need to
refer patients with poor psychological health status to a
psychologist in multidisciplinary rehabilitation, was
insufficiently recognised by the rheumatologist. Psy-
chological treatment is available in our clinic, but only
12 patients with elevated levels of psychological distress
at baseline received brief psychological counselling
(*3.5 h), whereas the other 30 distressed patients did
not receive treatment for their depressive and anxiety
symptoms.
Appropriate recognition of psychological distress
and maladaptive illness cognitions is a first step in
optimising multidisciplinary rehabilitation care. A
recent study by Sleath et al. [41] showed that
depressive symptoms are not often addressed in
physician-patient communication during clinical
visits. Patients who were rated by their rheumatol-
ogist as having worse functional status (i.e. more
restricted from participating in their normal activ-
ities) were more than twice as likely to have
moderately severe to severe symptoms of depression.
On the basis of our study findings, we recommend
the implementation of a routine psychological
assessment to assess patients’ psychological health
status when referred to multidisciplinary rehabilita-
tion. Identifying psychological distress and maladap-
tive illness cognitions is possible through appropriate
screening and evaluation methods. Several self-
report measures of psychological distress are avail-
able that can be incorporated into routine intake
assessments for multidisciplinary rehabilitation. In-
struments such as the Hospital Anxiety Depression
Scale [42] and the Center for Epidemiologic Studies
Depression Scale [43,44] have been used in studies
of patients with rheumatic diseases and have cut-off
scores for detecting severe depressive symptoms.
Other validated self-report measures, such as the
Arthritis Helplessness Index [45], the Illness cogni-
tion Questionnaire [37], and the Chronic Pain
Acceptance Questionnaire [46] may also signal the
presence of maladaptive psychological functioning
and need for psychosocial treatment. Thereafter, the
multidisciplinary rehabilitation team may discuss the
meaning and significance of patient’s psychological
health status for the setting of treatment goals and to
determine the need for an adjunctive psychological
intervention.
A growing number of studies in RA and OA have
shown that psychological interventions, in particular
cognitive-behavioural treatment, can improve psy-
chological distress and coping, as well as pain and
physical functioning in selected patient groups
[47,48]. Customising treatments to patient charac-
teristics, in terms of patient selection or timing of
treatment, has been suggested as a way to optimise
treatment effectiveness [49]. For instance, results of
a tailored approach suggest that particularly patients
with elevated levels of psychological distress benefit
from psychological interventions [39].
A few limitations of this study should be noted.
First, we studied a secondary care patient sample,
implying a selection bias that requires some caution
in generalising our findings. Second, no control

group was included in this study. The improvements
found in psychological distress and illness cognitions
cannot be firmly contributed to the intervention, but
may have occurred because of regression to the mean
or attention placebo. Third, examination of the
effectiveness of the various treatment modalities of
the multidisciplinary rehabilitation separately was
not possible because of a lack of variety in treatment
modalities offered, hence small sample size. Fourth,
only self-report measurements were used. A social
desirability bias cannot be ruled out; patients may
want to stress the urgency of the need to multi-
Disabil Rehabil Downloaded from informahealthcare.com by UWS University of Western Sydney library on 04/26/11
disciplinary treatment by inflating symptoms and
perceived limitations of arthritis in daily life.
In this study, psychological health status of
patients in multidisciplinary rehabilitation has been
comprehensively described. Our findings support the
need for a psychological assessment to be incorpo-
rated in multidisciplinary rehabilitation as distressed
patients are not adequately recognised in clinical
practice. Despite several limitations, our study
contributes to the growing awareness of the need to
respond to patients’ psychosocial needs in rheuma-
tology care. Further research may focus on develop-
ing feasible screening instruments for detecting
For personal use only.
psychosocial needs among patients with rheumatic
diseases and OA in multidisciplinary rehabilitation.
Declaration of interest: The authors report no
conflicts of interest. The authors alone are respon-
sible for the content and writing of the article.
References
1. Vliet Vlieland TP, Li LC, MacKay C, Badley EM. Does
everybody need a team? J Rheumatol 2006;33:1897–1899.
2. Spiegel JS, Spiegel TM, Ward NB. Are rehabilitation
programs for rheumatoid arthritis patients effective? Semin
Arthritis Rheum 1987;16:260–270.
3. Vliet Vlieland TP, Hazes JM. Efficacy of multidisciplinary
team care programs in rheumatoid arthritis. Semin Arthritis
Rheum 1997;27:110–122.
4. Ahlmen M, Sullivan M, Bjelle A. Team versus non-team
outpatient care in rheumatoid arthritis. A comprehensive
outcome evaluation including an overall health measure.
Arthritis Rheum 1988;31:471–479.
5. Hill J, Thorpe R, Bird H. Outcomes for patients with RA: a
rheumatology nurse practitioners clinic compared to standard
outpatient care. Musculoskeletal Care 2003;1:5–20.
6. Tijhuis GJ, Zwinderman AH, Hazes JM, van den Hout WB,
Breedveld FC, Vliet Vlieland TP. A randomized comparison
of care provided by a clinical nurse specialist, an inpatient
team, and a day patient team in rheumatoid arthritis. Arthritis
Rheum 2002;47:525–531.
7. Vliet Vlieland TP, Zwinderman AH, Vandenbroucke JP,
Breedveld FC, Hazes JM. A randomized clinical trial of in-
patient multidisciplinary treatment versus routine out-patient
care in active rheumatoid arthritis. Br J Rheumatol
1996;35:475–482.
8. Dickens C, McGowan L, Clark-Carter D, Creed F. Depres-
sion in rheumatoid arthritis: a systematic review of the
Distress among patients in rehabilitation 843
literature with meta-analysis. Psychosom Med 2002;64:
52–60.
9. Rosemann T, Backenstrass M, Joest K, Rosemann A,
Szecsenyi J, Laux G. Predictors of depression in a sample of
1,021 primary care patients with osteoarthritis. Arthritis
Rheum 2007;57:415–422.
10. Sale JE, Gignac M, Hawker G. The relationship between
disease symptoms, life events, coping and treatment, and
depression among older adults with osteoarthritis. J Rheuma-
tol 2008;35:335–342.
11. Covic T, Tyson G, Spencer D, Howe G. Depression in
rheumatoid arthritis patients: demographic, clinical, and
psychological predictors. J Psychosom Res 2006;60:469–
476.
12. Hawley DJ, Wolfe F. Depression is not more common in
rheumatoid arthritis: a 10-year longitudinal study of 6,153
patients with rheumatic disease. J Rheumatol 1993;20:2025–
2031.
13. Keefe FJ, Smith SJ, Buffington AL, Gibson J, Studts JL,
Caldwell DS. Recent advances and future directions in the
biopsychosocial assessment and treatment of arthritis. J
Consult Clin Psychol 2002;70:640–655.
14. DiMatteo MR, Lepper HS, Croghan TW. Depression is a risk
factor for noncompliance with medical treatment: meta-
analysis of the effects of anxiety and depression on patient
adherence. Arch Intern Med 2000;160:2101–2107.
15. Hawley DJ, Wolfe F. Anxiety and depression in patients with
rheumatoid arthritis: a prospective study of 400 patients. J
Rheumatol 1988;15:932–941.
16. Evers AW, Kraaimaat FW, Geenen R, Bijlsma JW. Determi-
nants of psychological distress and its course in the first year
after diagnosis in rheumatoid arthritis patients. J Behav Med
1997;20:489–504.
17. Parker JC, Wright GE. The implications of depression for
pain and disability in rheumatoid arthritis. Arthritis Care Res
1995;8:279–283.
18. Smith BW, Zautra AJ. The effects of anxiety and depression
on weekly pain in women with arthritis. Pain 2008;138:354–
361.
19. Soderlin MK, Hakala M, Nieminen P. Anxiety and depres-
sion in a community-based rheumatoid arthritis population.
Scand J Rheumatol 2000;29:177–183.
20. Edwards RR, Bingham CO III, Bathon J, Haythornthwaite JA.
Catastrophizing and pain in arthritis, fibromyalgia, and
other rheumatic diseases. Arthritis Rheum 2006;55:325–
332.
21. McCracken LM, Eccleston C. Coping or acceptance: what to
do about chronic pain? Pain 2003;105:197–204.
22. McCracken LM, Eccleston C. A prospective study of
acceptance of pain and patient functioning with chronic pain.
Pain 2005;118:164–169.
23. Evers AW, Kraaimaat FW, Geenen R, Jacobs JW, Bijlsma JW.
Longterm predictors of anxiety and depressed mood in early
rheumatoid arthritis: a 3 and 5 year followup. J Rheumatol
2002;29:2327–2336.
24. Covic T, Adamson B, Hough M. The impact of passive
coping on rheumatoid arthritis pain. Rheumatology (Oxford)
2000;39:1027–1030.
25. van Lankveld W, Naring G, van ’t Pad Bosch P, van de Putte
L. The negative effect of decreasing the level of activity in
coping with pain in rheumatoid arthritis: an increase in
psychological distress and disease impact. J Behav Med
2000;23:377–391.
26. Katz PP, Yelin EH. Prevalence and correlates of depressive
symptoms among persons with rheumatoid arthritis. J
Rheumatol 1993;20:790–796.
27. Odegard S, Finset A, Mowinckel P, Kvien TK, Uhlig T. Pain
and psychological health status over a 10-year period in
 844 J. Vriezekolk et al.
patients with recent onset rheumatoid arthritis. Ann Rheum
Dis 2007;66:1195–1201.
28. Ren XS, Kazis L, Meenan RF. Short-form Arthritis Impact
Measurement Scales 2: tests of reliability and validity among
patients with osteoarthritis. Arthritis Care Res 1999;12:163–171.
29. Taal E, Rasker JJ, Riemsma RP. Psychometric properties of a
Dutch short form of the Arthritis Impact Measurement Scales
2 (Dutch-AIMS2-SF). Rheumatology (Oxford) 2003;42:427–
434.
30. Taal E, Rasker JJ, Riemsma RP. Sensitivity to change of
AIMS2 and AIMS2-SF components in comparison to
M-HAQ and VAS-pain. Ann Rheum Dis 2004;63:1655–
1658.
31. Huiskes CJAE, Kraaimaat FW, Bijlsma JWJ. Handleiding bij
de zelfbeoordelingsvragenlijst Invloed van Reuma op Gezond-
Disabil Rehabil Downloaded from informahealthcare.com by UWS University of Western Sydney library on 04/26/11
heid en Leefwijze: de IRGL [Manual of the self-report
questionnaire Impact of Rheumatic diseases on General
Health and Lifestyle: The IRGL]. Lisse, NL: Swets &
Zeitlinger; 1990.
32. Evers AW, Taal E, Kraaimaat FW, Jacobs JW, Abdel-Nasser
A, Rasker JJ, Bijlsma JW. A comparison of two recently
developed health status instruments for patients with arthritis:
Dutch-AIMS2 and IRGL. Arthritis Impact Measurement
Scales. Impact of Rheumatic diseases on General health and
Lifestyle. Br J Rheumatol 1998;37:157-64.
33. Geenen R, Jacobs JW, Godaert G, Kraaimaat FW, Brons MR,
van der Heide A, Bijlsma JW. Stability of health status
measurement in rheumatoid arthritis. Br J Rheumatol
1995;34:1162–1166.
34. van der Ploeg HM, Defares PB, Spielberger CD. Handleiding
For personal use only.
bij de ZelfBeoordelingsVragenlijst ZBV [Manual to the
ZelfBeoordelingsVragenlijst ZBV]. Lisse, NL: Swets &
Zeitlinger; 1980.
35. Zwart FM, Garssen B, Spooren J, Kraaimaat FW. Een
stemmingslijst voor depressies [A self-report mood scale for
depression]. Utrecht, NL: University of Utrecht, University of
Amsterdam; 1986.
36. Huiskes CJAE, Kraaimaat FW, Bijlsma JWJ. Development
of a self-report questionnaire to assess the impact of rheu-
matic diseases on health and lifestyle. J Rehab Sci 1990;3:65–
70.
37. Evers AW, Kraaimaat FW, van Lankveld W, Jongen PJ,
Jacobs JW, Bijlsma JW. Beyond unfavorable thinking: the
illness cognition questionnaire for chronic diseases. J Consult
Clin Psychol 2001;69:1026–1036.
38. Kraaimaat FW, Evers AW. Pain-coping strategies in chronic
pain patients: psychometric characteristics of the pain-coping
inventory (PCI). Int J Behav Med 2003;10:343–363.
39. Evers AW, Kraaimaat FW, van Riel PL, de Jong AJ. Tailored
cognitive-behavioral therapy in early rheumatoid arthritis for
patients at risk: a randomized controlled trial. Pain 2002;100:
141–153.
40. Riemsma RP, Kirwan JR, Taal E, Rasker JJ. Patient education
for adults with rheumatoid arthritis. Cochrane Database Syst
Rev 2003;2:CD003688.
41. Sleath B, Chewning B, de Vellis BM, Weinberger M, de Vellis
RF, Tudor G, Beard A. Communication about depression
during rheumatoid arthritis patient visits. Arthritis Rheum
2008;59:186–191.
42. Herrmann C. International experiences with the Hospital
Anxiety and Depression Scale – a review of validation data and
clinical results. J Psychosom Res 1997;42:17–41.
43. Martens MP, Parker JC, Smarr KL, Hewett JE, Slaughter JR,
Walker SE. Assessment of depression in rheumatoid
arthritis: a modified version of the center for epidemiologic
studies depression scale. Arthritis Rheum 2003;49:549–555.
44. Rhee SH, Petroski GF, Parker JC, Smarr KL, Wright GE,
Multon KD, Buchholz JL, Komatireddy GR. A confirmatory
factor analysis of the Center for Epidemiologic Studies
Depression Scale in rheumatoid arthritis patients: additional
evidence for a four-factor model. Arthritis Care Res
1999;12:392–400.
45. Nicassio PM, Wallston KA, Callahan LF, Herbert M, Pincus
T. The measurement of helplessness in rheumatoid arthritis.
The development of the arthritis helplessness index. J
Rheumatol 1985;12:462–467.
46. McCracken LM, Vowles KE, Eccleston C. Acceptance of
chronic pain: component analysis and a revised assessment
method. Pain 2004;107:159–166.
47. Astin JA, Beckner W, Soeken K, Hochberg MC, Berman B.
Psychological interventions for rheumatoid arthritis: a meta-
analysis of randomized controlled trials. Arthritis Rheum
2002;47:291–302.
48. Dixon KE, Keefe FJ, Scipio CD, Perri LM, Abernethy AP.
Psychological interventions for arthritis pain manage-
ment in adults: a meta-analysis. Health Psychol 2007;26:
241–250.
49. Turk DC. The potential of treatment matching for subgroups
of patients with chronic pain: lumping versus splitting. Clin J
Pain 2005;21:44–55.