Have you ever heard a person in poor health being told “Well, you’ve got to stay positive, that will help”? This seemingly common idea is currently under significant scientific investigation. Indeed, the debate about the degree to which psychological processes can directly influence physical health has received special attention recently. A special supplement of the Annals of Behavioural Medicine directly addressed this topic in February this year and a recent article in the Lancet explored this issue, cautioning us that the relationship between a positive psychological orientation and cancer survival remains unclear [1].

Linking the nervous system to the immune system

In a previous post, I discussed the direct and indirect links between beliefs about illness and physical health for people with heart disorders. What we did not consider however was how this direct influence may be happening. Enter “Psychoneuroimmunology” – the field of study exploring the direct link between the nervous system and immune system, including the endocrine system, covering hormones. The brain controls these systems. Part of psychoneuroimmunology is the study of degree to which the action of these systems is impacted on by mental health and the way we think and process information around us. This is of particular interest when we exam the relationship between psychological experience, nervous/immune/endocrine systems and health conditions.

One health condition much researched in relation to psychoneuroimmunology is cancer, not only because of the enormously high mortality and morbidity rates associated with cancer globally, but also the psychosocial context of cancer. Cancer was historically highly stigmatised with the idea that a cancer-prone personality existed [2]. The concept that one’s personal characteristics were related to the illness lead to the idea that adopting a positive, active personality would be protective. Within modern terms, scientists now investigate the degree to which psychology may directly influence cancer pathology.

Stress and cancer

Let us first look at the biological aspects of stress and cancer. In an opinion article based on a systematic review of the literature, Ondicova and Mravec (2010) explore how the nervous system affects cancer “etiopathogenesis”, or, in plain English, the biomedical cause and development of a disease or health condition [3]. Cortisol is released in response to physical and psychological stress, and appears to reduce immune cell function, which may influence tumour growth. Norepinephrine (also known as noradrenaline) is also released in response to stress when epinephrine (also known as adrenaline) is released. Norepinephrine is implicated in the psychobiology of depression. Norepinephrine has been shown to induce cancerous cell growth in mouse animal model studies [4], but reduce the migratory activity of human ovarian carcinoma cells [5]. However, other elements of the nervous system exist to protect us from stress. For example, prostaglandins, which are thought of as messenger molecules throughout the body, act on a huge variety of cells and processes, including muscle cells, blood cells and hormone regulation. These prostaglandins can actually decrease the number of malignant cells in animals [6]. Ondicova and Mravec state that “cancer can be thought of as a process that overcomes not only the protective mechanisms of the immune system but also the protective influences of the nervous system” [6]. Nevertheless, overall the studies of how biological responses to stress might influence tumour growth provide an unclear picture and there is a clear requirement for further studies to properly understand this issue.

The connection between cancer and psychology

So, then, what has this to do with psychology? Well, the link that has been hotly debated is that of positive psychology and cancer. Positive psychology researches happiness, quality of life and strengths, exploring how to ensure a sense of wellbeing. Research on optimism and benefit finding has suggested that having a positive outlook can influence illness progression and management. Specifically, a recent review article in a special issue exploring positive psychology and cancer considers how positive psychology might influence cancer pathology [7].

The review examines studies that show cortisol could be reduced by benefit-finding among breast cancer patients. Indeed, people who engaged in positive thinking (here self-enhancement and self-affirmation) had lower cardiovascular responses to stress. As such, the potential link between your conscious psychological experience and physical health is outlined. The argument then states that psychological responses to stress affect neuroendocrine and immune functioning, which in turn influence tumour growth. The authors of the review highlight the seemingly large and obvious link between mental health and cancer. Being able to adequately deal with stress should, according to this pathway, help protect us from cancer. However, other authors point to the lack of specific pathway and high quality evidence to support this link [3, 8].

Cognitions leading to stress affect biology

There is clearly a complex relationship between life experiences, cognitions, stress and illness, including cancer. Psychological experiences have a basis in brain chemistry and biology, and it appears that cognitions leading to stress then have an affect on biology. A basic example is that when stressed, we experience muscle tension and increased heart rate. The strength of the relationship between thoughts and pathologies such as cancer cannot yet be determined and as such, results should be viewed with a healthy scepticism. Psychological interventions to improve psychological health, reduce negative thinking, stress and anxiety may be beneficial not only for mental health and quality of life, but also potentially for physical health.

References

1. Ondicova K and Mravec B. Role of nervous system in cancer aetiopathogenesis. Lancet Oncol. 2010 Jun;11(6):596-601.
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2. Sontag, S. Illness as Metaphor. New York: Farrar, Straus & Giroux. 1978. ISBN 0-394-72844-0
3. Coyne JC and Tennen H. Positive psychology in cancer care: bad science, exaggerated claims, and unproven medicine. Ann Behav Med. 2010 Feb;39(1):16-26.
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4. Sood et al. Adrenergic modulation of focal adhesion kinase protects human ovarian cancer cells from anoikis. J Clin Invest. 2010 May 3;120(5):1515-23. doi: 10.1172/JCI40802. Epub 2010 Apr 12.
   View abstract
5. Bastian et al. The inhibitory effect of norepinephrine on the migration of ES-2 ovarian carcinoma cells involves a Rap1-dependent pathway. Cancer Lett. 2009 Feb 18;274(2):218-24. Epub 2008 Oct 11.
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6. Wang D and Dubois RN. Prostaglandins and cancer. Gut. 2006 Jan;55(1):115-22. Epub 2005 Aug 23.
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7. Aspinwall LG and Tedeschi RG. The value of positive psychology for health psychology: progress and pitfalls in examining the relation of positive phenomena to health. Ann Behav Med. 2010 Feb;39(1):4-15.
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8. Coyne et al. Positive psychology in cancer care: A story line resistant to evidence. Ann Behav Med. 2010 Feb;39(1):35-42.

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How you think about your health can have powerful impacts on how you experience your health. In a recent study with a group of cardiac patients, how people thought about their illness (termed “illness cognitions”) was found to have a direct impact on how people experience health and emotional wellbeing [1]. These illness cognitions also affected health indirectly by influencing the types of behaviours people were engaged in to cope with cardiac problems. This study brings to our attention the relevance of psychology in relation to medical illnesses.

Cardiac problems are hugely common across the globe. Cardiovascular disease is the leading cause of death globally and has a significant impact as a chronic disease on quality of life, the economy and healthcare utilisation [2]. Many causes of cardiac problems are preventable –- for example by avoiding smoking, taking adequate exercise and maintaining a healthy diet and weight. From a biomedical perspective, treatment for cardiac problems has significantly improved survival rates through drug therapies and surgical approaches [3]. This has caused the treatment focus switch from acute, or short-term, to chronic, or long-term. When living with a long-term health condition, the way people think about their illness becomes extremely important.

Two illness cognitions were focused on in the recent study. First, illness acceptance is an idea commonly talked about and is characterised by a focus on the positive aspects, realisation that the health condition is to be lived with, and an end to the search for a solution to remove the illness. Second, illness-related helplessness relates to feelings that an illness is uncontrollable and has severe consequences for everyday life. Researchers recruited 106 cardiac patients with a range of cardiac conditions. These patients completed questionnaires about their illness acceptance, illness helplessness and how they rated their own health. Six months later, the patients were again asked to complete questionnaires on illness acceptance, helplessness, subjective health and coping strategies they used to deal with their cardiac problems. The goal was to explore whether illness acceptance and helplessness could predict self-rated health. Coping behaviours were also studied. There are many different types of coping, such as soothing oneself, wishful thinking, emotional coping and reactions.

Using a complex statistical technique called “Structural Equation Modelling”, the researchers tested multiple relationships between different variables. The relationships between illness acceptance, illness helplessness, coping behaviours (of various types) and emotional well-being and physical functioning were tested. This method allows researchers to test the “path” between different variables: the degree to which one variable impacts another and whether this is direct or indirect through a third variable. The results showed both direct and indirect effects of illness acceptance and illness helplessness on the outcome variables of emotional well-being and physical functioning. Lower illness helplessness was related to better emotional well-being and better perceived physical health. This makes sense intuitively: feeling that nothing can be done about poor health is associated with feeling less happy and less able. Additionally, greater acceptance of illness was related directly to greater emotional and physical wellbeing.

Indirect effects were also seen. Greater helplessness was associated with more wishful thinking e.g. “If only I didn’t have this cardiac problem …”, as well as soothing strategies. These coping behaviours were associated with outcomes — more wishful thinking was related to poorer emotional wellbeing and more soothing coping was related to both poorer emotional and physical outcomes. Greater acceptance of illness was associated with less soothing coping and fewer emotional reactions, such as feeling angry. Again, these coping styles were related to the emotional and physical outcomes. This shows the complex nature of the relationships between thoughts, coping behaviours and emotional and physical outcomes.

Through this complex analysis, a simpler summary can be created with direct advice for healthcare: increasing acceptance and decreasing helplessness may improve health outcomes for people with cardiac problems. As with every study, these conclusions must be seen in relation to study limitations. Only subjective or self-reported outcomes of emotion and physical functioning were collected and there can be a large gap between what people report they can do and what they objectively are able to do. It is also vital to note that there were some types of coping that were unrelated to these illness cognitions — adherence to medical advice and “instrumental” coping (problem solving, e.g. locating information, self-management, etc.).

Cardiac disease is a physical illness, however the psychological elements are important to how the illness is experienced. Whilst taking medications, staying active, eating well, avoiding tobacco and alcohol are fundamentally important behaviours that a person should be engaged in, the way people with cardiac disease think is also important. Indeed, screening to identify people with cardiac disease who are showing helplessness and poor acceptance may be useful to select people at further risk. Additionally, interventions to promote healthy thinking as well as healthy behaviours may improve a person’s experience of living with cardiac disease.

References

1. Karademas and Hondronikola. The impact of illness acceptance and helplessness to subjective health, and their stability over time: a prospective study in a sample of cardiac patients. Psychol Health Med. 2010 May;15(3):336-46.
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2. Beaglehole et al. Poverty and human development: the global implications of cardiovascular disease. Circulation. 2007 Oct 23;116(17):1871-3.
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3. Weisfeldt and Zieman. Advances in the prevention and treatment of cardiovascular disease. Health Aff (Millwood). 2007 Jan-Feb;26(1):25-37.
   View abstract

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A new study published in The American Journal of Medicine highlights another reason not to light up that cigarette — smokers (current and former) are more likely to suffer from low back pain than people who have never smoked [1]. Although the association is moderate, it is strongest for chronic back pain and for adolescents.

By now, the vast majority of us know that smoking is bad for you. A number of health risks are associated with smoking. Indeed, many women are not aware that smoking is a risk factor for breast cancer [2]. However, there are other conditions associated with smoking besides the key conditions of cancer and heart disease. Previous research has looked at the link between the experience of low back pain and the potential risk factor of smoking [3-6]. The experience of back pain is widespread [7]. “Chronic” back pain is often of particular interest as it is associated with days lost from work and healthcare costs, in addition to the impact on the patient’s quality of life. In the UK, “persistent” back pain is that which has lasted more than 6 weeks [8]. In the US, “chronic” back pain is pain lasting more than 3 months [9]. The causes of back pain are often complex and unclear. In the present study, the association between back pain and smoking was assessed.

Often, the same topic is explored by multiple researchers who may find slightly different results when exploring the association between two things. In these cases, a systematic literature review is often helpful. This means that researchers locate, report, evaluate and collate results from all the identifiable studies that address the key question. A really useful tool then to make sense of research is the “meta-analysis”: the results from multiple studies are combined using statistical methods to come up with the strength of an association across many studies. In this case, researchers searched for studies that examined the link between smoking and back pain; 40 different research studies were included in their statistical analysis. The advantage of this method is clear then — we can put all the research together and find out what the general picture is. The researchers identified studies from all over the world to include in this meta-analysis.

The association between smoking and low back pain was found to be significant (not just caused by chance). The researchers used a statistic known as an “odds ratio” or “OR”. This statistic allows us to understand how big the association is between two things.

The OR for chronic back pain was 1.79 (95% Confidence interval = 1.27 — 2.50) for current smokers. As the OR is greater than 1 (and the confidence interval does not include 1) we can say there is a significant association between smoking and the experience of chronic back pain. In English, this means that a current smoker has around 1.79 times the odds of having chronic back pain than a non-smoker. A really interesting result of the study was that the link between smoking and back pain was strongest for chronic low back pain, which is the most disabling form of back pain. For pain in the last month, the last 12 months and chronic pain, former smokers had a lower prevalence of back pain. Thus, the association between having ever smoked and back pain is smaller than the association between still smoking and back pain.

So does this mean that smoking causes back pain? Well, no. This type of analysis cannot clearly say if something causes something else. Investigating and establishing cause is highly complex and all too often we attribute cause to things that are merely related. For example, one possibility is that people with back pain are more stressed, so they take up smoking. We could further explore this link by looking at time: if our sample of people report significantly more back pain after some of them take up smoking (on their own, of course, we could not encourage this!) but those who do not take up smoking do not report more back pain, the data would suggest that smoking is, in some way, causing back pain.

Generally speaking, we are not all that great at understanding probability and risk (and that appears to include many academic researchers). Several articles have been written that discuss the use and misuse of statistics like the “OR” [10]. Odds ratios are far less informative in situations where the health condition is more common — as back pain is. Therefore, it is really important to be aware of some of the limitations of this sort of research when trying to understand health information. Media reports that state that “Murders in New York Caused by Higher Ice-Cream Sales” are much more likely to sell papers than the more accurate “As Ice-Cream Sales Increase, So Do the Number of Murders in New York” (a commonly used example in statistics classes). Being aware of these issues helps us to better understand what health research actually does identify. We can also investigate a “causal mechanism”: how would smoking cause back pain? Suggestions include the possibility that smoking increases pro-inflammatory substances in the body, that smoking affects back pain as it increases the risk of osteoporosis, and that smoking reduces blood circulation leading to disc damage, which then leads to pain. All of these claims need to be further researched and the degree to which they really contribute to the causes of back pain explored before we can confidently state that “smoking causes back pain”.

References

1. Shiri et al. The association between smoking and low back pain: a meta-analysis. Am J Med. 2010 Jan;123(1):87.e7-35. DOI: 10.1016/j.amjmed.2009.05.028
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2. Peacey et al. Low levels of breast cancer risk awareness in young women: an international survey. Eur J Cancer. 2006 Oct;42(15):2585-9. Epub 2006 Jul 7.
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3. Scott et al. The association between cigarette smoking and back pain in adults. Spine 1999 Jun 1;24(11):1090-8.
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4. Feldman et al. Smoking. A risk factor for development of low back pain in adolescents. Spine 1999 Dec 1;24(23):2492-6.
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5. Goldberg et al. A review of the association between cigarette smoking and the development of nonspecific back pain and related outcomes. Spine 2000 Apr 15;25(8):995-1014.
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6. Alkherayf and Agbi. Cigarette smoking and chronic low back pain in the adult population. Clin Invest Med. 2009 Oct 1;32(5):E360-7.
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7. Strine and Hootman. US national prevalence and correlates of low back and neck pain among adults. Arthritis Rheum. 2007 May 15;57(4):656-65.
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8. National Institute for Health and Clinical Excellence: Early management of persistent non-specific low back pain. NICE Clinical Guideline 88. 2009 May.
9. Back Pain Information Page. National Institute of Neurological Disorders and Stroke. Accessed Feb 18, 2010.
10. Westergren et al. Information Point: Odds Ratios. Journal of Clinical Nursing. 2001 10,257-269.

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As you or perhaps your parents get older, would you want to be at home when recovering from an illness? Would the choice between home rehabilitation or visits to a day hospital make a difference to your recovery and health? Which is cheaper for the healthcare services? A recent study published in the journal Health Technology Assessment (HTA) shows that home-based care in the United Kingdom is no worse than attendance at a day hospital for older adults [1].

Under any nationally funded healthcare system, there is always an enormous pressure on resources. As such, it is vital to explore the outcomes of different types of care, keeping in mind the cost-effectiveness. Rehabilitation after illness is a vital part of healthcare, but is enormously costly. As the U.S. and European populations age, there is increasing pressure on the health services to deliver cost-effective rehabilitation for older patients [2]. Older patients often present with more complications following illness and take longer to recover, so this push to reduce costs must always take into account how well each intervention or mode of care works. With the emphasis on “quality of life” in healthcare (that simply being physically “healthy” is not the sole goal of healthcare, but that the experienced quality of ones life is highly important), rehabilitation care is further emphasised.

U.K. researchers conducted a randomised controlled trial, where patients were randomised to receive either day hospital care or home-based rehabilitation [1]. Eighty-nine older adults receiving rehabilitation care for a range of health conditions took part in the study; 90% of the participants were over 70 years of age. Measures of daily living activities (normal daily life tasks eg bathing, preparing food), quality of life, anxiety, depression and general health were taken. The scientists also collected data about health outcome and number of hospital admissions. The patients and their carers (informal carers in this case, such as spouse or friends) were followed for up to 12 months. Data were collected at 3 months, 6 months and 12 months following the start of the rehabilitation program. The home-based rehabilitation program and the day hospital both included services such as physiotherapy and occupational therapy, stroke rehabilitation and falls assessment — the key difference between the two types of care then being the venue.

Results of both patient outcomes and carer wellbeing showed that home-based rehabilitation “confers no particular disadvantage for patients and carers.” However, in this case, the cost of the home-based rehabilitation provision was not significantly different to that of day hospital rehabilitation. This suggests that although home-based care may appear on the surface to be more cost-effective, this is not always the case. This study then has important implications practice, most importantly perhaps is that rehabilitation providers must consider the local needs and characteristics of their population when providing care. Indeed, given there is no difference found in outcomes or costs, patients could potentially be given the choice. Local issues are clearly important, for example in a rural community home-based care may be vital if patients are restricted in access to transport.

This study did conclude that the two types of care are equivalent: rather they explored non-inferiority. This just establishes that one treatment is not worse than the other. This does not mean the two types of care are equivalent, indeed, this is impossible to show as there will always be differences [4]. Non-inferiority trials tell us if there are differences that are clinically important, i.e. if the treatment results in worse outcomes.

This study illustrates some of the complex issues around choice of services to be delivered through healthcare systems. As healthcare systems are increasingly scrutinised and reforms are planned, it is important to have a grasp of some of these issues to understand debates. On an individual level, this study shows that despite personal preferences and preconceived ideas, care in a day hospital is not superior to care within the home. Evaluating evidence may lead you then to choose a different type of care.

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References

1. Parker et al. Rehabilitation of older patients: day hospital compared with rehabilitation at home. A randomised controlled trial. Health Technol Assess. 2009 Aug;13(39):1-143, iii-iv.
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2. Miller DK. Effectiveness of acute rehabilitation services in geriatric evaluation and management units. Clin Geriatr Med. 2000 Nov;16(4):775-82.
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3. Pang J Jr. Partial hospitalization. An alternative to inpatient care. Psychiatr Clin North Am. 1985 Sep;8(3):587-95.
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4. Snapinn SM. Noninferiority trials. Curr Control Trials Cardiovasc Med. 2000;1(1):19-21.
   View abstract

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Heart disease is the leading killer in the U.S. and throughout most of Europe. People’s behaviour can protect and reduce risk of heart disease, and interventions to help people “self-manage” exist. But what is the best way to “self-manage”? A recent study shows that group programmes and self-directed programmes have remarkably different effects [1].

Self-management interventions exist for many health problems. They are notoriously difficult to define. One thorough definition is that it relates to activities undertaken by the person who has a “chronic” or “long-term” condition such as asthma, multiple sclerosis or arthritis. These activities include problem solving, decision making, resource utilization, the formation of a patient-provider partnership, action planning and self tailoring [2]. Interventions or programmes are designed around these activities to help support people to manage their own illness. The idea is that following attendance at a programme of some sort, the activities and skills learned will be continued to be used, thus improving health, maintaining fitness and/or quality of life and reducing the risk of future acute episodes of ill health. These interventions are popular for many reasons, including the relatively low cost to health service providers as interventions can be delivered by health-care professionals or by people with the relevant condition who have been trained, or a mixture of both. Self-management interventions also allow people with long-term conditions to be meet in a group with people with similar conditions. The experience of being in a group, knowing one is not alone and sharing stories is thought to play some part in the effectiveness of self-management interventions. But to what extent is this true?

Researchers at the University of Michigan explored the effect of the format of a self-management intervention for women with heart disease by comparing a “self-directed” programme to a “group” programme to a control group [1]. In the “self-directed” version, there was a single session with health educator followed by completing programme at home. The “group” programme consisted of 6 – 8 women meeting for around 2 hours once a week for six weeks. In the control condition, no intervention was presented. The aim was to investigate which intervention would most usefully effect symptom experience, health status and weight. To make the comparison of the “self-directed” and “group” interventions more equitable, the “self-directed” version included videos of group discussions to emulate the motivation and support that would be given in the “group” programme. Further, to ensure information was provided to all, the “self-directed” group also received telephone calls from a health educator.

The results revealed a remarkable difference. Eighteen months after the intervention, data were collected. For the “self-directed” intervention, cardiac symptoms such as chest pain and dizziness were reduced in number, frequency and impact. For the “group” intervention, weight loss and exercise capacity (in terms of how far a person can walk within a set time) were improved. This is despite the fact that the information and instructions provided in both programmes were the same.

So does this mean we should all join groups if we want to lose weight and exercise more but stay at home if we want to feel fewer symptoms? Not necessarily. This study, like all studies, has several limitations. Obviously, the women in the “self-directed” group were not observed, so we do not know to what extent they followed the intervention they were given. A diary record of what the women did could have been included in this study, but even that may not be an accurate picture of how well the intervention was followed. Another issue is that the women in the “group” may have experience a higher “dose” of the intervention – that is to say the they attended a meeting for approximately 2 hours per week, receiving a two hour “dose”. We do not know how much time the women in the “self-directed” intervention spent on their activities. Further, this study included a sample only of women who were white and high school educated. Therefore, we cannot say whether the same effect would be observed outside of this group of people. It would be interesting to see this issue investigated with other demographics, including men (who may be less amenable to group processes), different ethnic groups and educational levels.

What the results do suggest however is that being in a group may facilitate exercise and weight loss improvement for women with heart disease. But we still do not know how this occurs. A common problem in behavioural interventions, including self-management interventions, is that we simply do not know which bit of the intervention is working. The study suggests that the “group” part of the intervention is affecting how the intervention works. However, we do not know why. Is peer pressure a factor? Would these results be the same if we looked at people in relation to personality type? Would a shy, introverted sample show the same results?

There are many self-management interventions available today, in terms of both health service packages, “self-help” books and DVDs, information from health care professionals, charity groups and community organisations. Our health and its care is now a collaborative endeavour in which we are involved actively and with responsibility. Self-management is increasingly included in health policies. Researching and understanding whether such interventions work, which components work, what “dose” is needed and who they work for, is vital to our future health.

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References

1. Clark et al. Heart disease management by women: does intervention format matter? Health Educ Behav. 2009 Apr;36(2):394-409. Epub 2007 Dec 15.
   DOI: 10.1177/1090198107309458
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2. Lorig KR, Holman H. Self-management education: history, definition, outcomes, and mechanisms. Ann Behav Med. 2003 Aug;26(1):1-7.
   View abstract

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