Dr. Evers says she sometimes gets asked to consult with patients online via e-coaching. “We did a randomized controlled trial in patients with RA that showed it is as effective as a face-to-face encounter.” There are a lot of Web-based resources for self-help, she adds, although unguided sites are not as helpful as those with guides, particularly for their impact on daily life adjustment.
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Explore This IssueDecember 2017
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Dr. Matcham says, “A lot of what we use is self-help, which can be effective with lower levels of distress. But I also think it’s important to train rheumatology staff in basic mental health skills, such as how to manage conversations about mental health concerns.” She says rheumatologists also must “know what local resources are available to support their patients.” Sometimes in the UK health system, medical services will apply for money for a part-time psychologist as part of the clinical team. “That’s a really good model; it breaks down stigma and reinforces the perception that mental health and physical health are intertwined.”
Every rheumatologic group ideally would have a behavioral specialist embedded, freeing the rheumatologists to focus on treating their patients’ rheumatologic diseases, Dr. Hassett says. “Most doctors can at least get a mental health evaluation ordered. Some rheumatologists [may] feel comfortable treating a mild depression or anxiety and writing related prescriptions, although typically it is easier to send the patient back to the primary care physician, who may be more comfortable with handling psychiatric conditions. The important thing is to recognize the patient who is depressed and anxious and likely to do more poorly,” she says. “You don’t need a psychologist per se; other professionals have training in behavioral interventions, for example social workers, and those practitioners can bill for their services.”
The Importance of Attitude
Dr. Evers’ research on psychoneurobiology in chronic inflammatory conditions has pointed her toward studying the placebo effect—not merely that some patients can be tricked with a sugar pill, but that expectations of the patient and physician have an effect on response to treatment, both positive and negative. “Our research tells us the placebo effect has a major role. If there are negative expectations from treatment, there will be more side effects. But if patients are satisfied with their treatment, they will have a more positive experience and greater adherence to their treatment.”
How can doctors optimally utilize the placebo effect? “We are preparing a publication on guidelines with two major recommendations. First is the importance of transparently informing patients about the implications of the placebo effect—and that their expectations for treatment could play a huge role in the treatment’s efficacy,” Dr. Evers says. Patients must be informed about the placebo effect, but how they are told also has a role.