Intervention eases stress in asthma.(ADULT PSYCHIATRY)

MONTREAL -- Patients with chronic cardiopulmonary diseases are more likely to follow their doctors' recommendations if they leave the office feeling good about their efforts, rather than bad about their failures, according to new research in behavioral medicine.

"Most physicians try to scare their patients into quitting smoking or losing weight. They end up making patients feel bad, so they go out and eat a sundae to feel better," said Dr. Mary E. Charlson, the William T. Foley distinguished professor of medicine and executive director of the Center for Complementary and Integrative Medicine at Weill Cornell Medical College. New York, and principal investigator of the research.

"When we work with patients to try to help them make behavior changes, perhaps we need to think more about their feelings and their emotions rather than simply about the cognitive issues they face when trying to control their disease," co-investigator John P. Allegrante, Ph.D., professor and chair of department of health and behavior studies at Columbia University in New York, said in an interview.

They presented evidence at the annual meeting of the Society of Behavioral Medicine from three randomized, controlled trials showing the benefits of mood-boosting strategies on patient adherence to medical recommendations.

In the trials, 243 postangioplasty patients, 262 asthma patients, and 262 hypertensive patients were randomized to usual care, or an intervention designed to boost their mood and self-confidence. All of the subjects were instructed to follow medical recommendations that involved increased physical activity for the angioplasty and asthma patients, and medication adherence for the hypertensive patients.

Over a 1 -year period, the self-confidence and mood-boosting intervention resulted in a significant improvement in the hypertensive and angioplasty patients, compared with controls, Dr. Charlson reported. In the angioplasty trial, physical activity increased in both arms, but it was significantly greater in the intervention group (603 kcal a week) than in the control group (331 kcal).

"For the intervention group, that is equivalent to walking an extra 6 blocks a day, each week--a powerful effect," she said. Similarly, in the hypertension trial, although medication adherence dropped in both arms, it dropped less in the intervention group (53%), compared with the control group (37%), and there was more success in the intervention group for the secondary outcome of controlled blood pressure (54% intervention vs. 39% control). "We believe this was a result of treatment intensification in the intervention group," Dr. Charlson said. "They were visiting their physicians more and adjusting their medication more, which is why they achieved better blood pressure control."

In the asthma trial, there was no overall impact of the positive intervention, but a subgroup analysis revealed an interesting finding. In all three trials, subjects who had a high level of perceived stress experienced the most benefit from the positive intervention. "We believe that inducing a positive effect in patients protects against stress and the negative behavior that comes with stress," Dr. Charlson said.

Therefore, in the subgroup of highly stressed asthma subjects, physical activity increased by 606 kcal a week with the positive intervention, compared with a decrease of 551 kcal in the controls. In the subgroup of stressed angioplasty patients, mood-boosting resulted in increased activity of 373 kcal a week compared with a decrease of 160 kcal in the control group. And similarly, in the subgroup of stressed hypertensive patients, medication adherence was significantly better in the intervention group (45%), compared with the control group (35%). A combined analysis of all three studies suggests that positive mood and strong levels of self-confidence can directly improve patient adherence to specific behavior recommendations, across a range of illnesses and patient demographics, Dr. Charlson said.

The research was supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health.

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