Clinicians' perspectives on psychological distress and meeting patients' support needs in rheumatology care settings

Background: People with inflammatory rheumatic diseases (IRDs) face challenges that include fluctuations in pain, fatigue and flares of disease activity, complex medical regimens, and decisions about when to seek clinical help with symptoms [1,2]. Evidence suggests levels of anxiety and depression are higher in people with IRDs compared to the general population [3]. Rheumatology teams report that psychologically distressed patients can have additional support needs and require more time. Patients’ concerns include health-related anxiety and difficulty accepting the diagnosis. This group can have poor outcomes and poor adherence to treatments. However, little is currently known about optimal ways to meet these patients’ support needs. Objectives: To understand rheumatology clinicians’ perspectives on psychological distress in care settings with the long-term aim to develop a proposed model/pathway of support.Methods: Telephone interviews were conducted with members of UK rheumatology teams who have clinical experience with patients experiencing distress. The semi-structured interviews explored both ‘what happens now’ (current clinical practice) and ‘what should happen’ (acceptable models of future psychological support provision). The semi-structured format provided flexibility to probe more deeply and develop new lines of enquiry based on participants’ responses. Results: Fourteen interviews were conducted with rheumatology clinicians including 2consultants, 4 nurses, 1 physiotherapist, 4 occupational therapists, 2 clinical psychologists and 1 podiatrist. Inductive thematic analysis was used to analyse the data. Two main themes represent the data. Main Theme 1 - ‘No one shoe fits all’ – the many manifestations of distress inpatients.‘I pick up on distress as increased motion…tearfulness and sadness I suppose, but also frustration, anger...A lot of helplessness comments’. Subthemes - 1. ‘Distress can be quite emotive and quite obvious, but then it can also hideaway’ 2. ‘They’re [patients] trying to manage their own conditions, but they’re also trying to manage life’.Main Theme 2 - ‘If Rheumatology could be interwoven with psychological principles – the need to attend to the psychological impact of IRDs, alongside the physical impact. ‘The physical and mental health side of things are so closely linked because one affects the other…after a while they[patients] don’t really know what’s affecting what’. Subthemes - 1. ‘Prioritising physical health…sometimes the stress gets not thought about’ 2. ‘Make best use of everyone in the team to work with patients who are struggling 3. ‘For the psychological side of things we don’t measure anything about that at all’.Conclusion: Distress can be obvious or hidden and cause issues for both patient and clinician. It can lead to poor engagement with care provision. Clinicians differ in their perceptions of distress and in their thresholds for dealing with distress and have described the inconsistency of support offered for distressed patients. They described the powerful link between physical and mental distress, the vicious cycle that can develop, and the benefits of incorporating a psychological approach to treatment. This study suggests psychological support should be embedded within the team as it is felt there is a need for speciality understanding and for patients’ emotional wellbeing to consistently be given equal priority to their physical wellbeing.

References:
1. Gettings L. Psychological well-being in rheumatoid arthritis: a review of the literature. Musculoskeletal care 2010;8(2):99-106. doi: 10.1002/msc.171[published Online First: 2010/03/17] 2. Homer D. Addressing psychological and social issues of rheumatoid arthritis within the consultation: a case report. Musculoskeletal care 2005;3(1):54-9. doi:10.1002/msc.26 [published Online First: 2006/10/17]
3. Isik A, Koca SS, Ozturk A, et al. Anxiety and depression in patients with rheumatoid arthritis. Clinical rheumatology 2007;26(6):872-8. doi:10.1007/s10067-006-0407-y [published Online First: 2006/08/31]