Intervention An acceptance-oriented cognitive-behavioral therapy in multimodal rehabilitation: A pre-post test evaluation in highly distressed patients with rheumatic diseases Johanna E. Vriezekolk a, *, Agnes M.M. Eijsbouts a , Wim G.J.M. van Lankveld b , Hanneke Beenackers a , Rinie Geenen c,d , Cornelia H.M. van den Ende a a Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands b HAN University of Applied Sciences, Nijmegen, The Netherlands c Department of Clinical and Health Psychology, Utrecht University, Utrecht, The Netherlands d Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands 1. Introduction Some patients with rheumatic diseases suffer from high levels of psychological distress and severely impaired daily functioning despite adequate medical treatment. Psychological distress refers to symptoms of depression or anxiety that impair the patient but do not need to meet the criteria for a clinical mood or anxiety disorder according to diagnostic criteria [1–3]. Highly distressed patients may be referred to multimodal rehabilitation programs for which small beneficial effects on disease activity, functional ability, and work status have been demonstrated [4]. A targeted treatment of psychological distress is, however, often not a priority in rehabilitation; a subgroup of patients still reports high levels of psychological distress after rehabilitation [5]. This suggests that the focus of current multimodal rehabilitation programs is too exclusively on reducing functional limitations and increasing social participation while insufficiently addressing patients’ psychological health status. Psychological distress is associated with a variety of negative outcomes in rheumatic diseases: more severe pain, fatigue, and disability [6–8], poor adherence to treatment regimens [9], decreased effects of medication [10], and increased health care utilization [11,12] and medical costs [13]. Cognitive-behavioral therapy (CBT) in patients with somatic diseases, including rheumatic diseases, can effectively improve physical and psycho- logical functioning and reduce long-term health care consumption [14–16]. Meta-analyses of randomized controlled trials in rheu- matoid arthritis (RA) and osteoarthritis (OA) demonstrated that CBT has been effective in improving pain, disability, coping, self- efficacy, and psychological distress with small to moderate effect Patient Education and Counseling xxx (2013) xxx–xxx * Corresponding author at: Department of Rheumatology, Sint Maartenskliniek, PO Box 9011, 6500 GM, Nijmegen, The Netherlands. Tel.: +31 24 365 9367; fax: +31 24 365 9154. E-mail address: j.vriezekolk@maartenskliniek.nl (J.E. Vriezekolk). A R T I C L E I N F O Article history: Received 25 July 2012 Received in revised form 24 January 2013 Accepted 25 January 2013 Keywords: Rehabilitation Cognitive-behavioral therapy Rheumatic diseases Depression Anxiety Quality of life Acceptance Coping flexibility A B S T R A C T Objective: To examine the potential effectiveness of a multimodal rehabilitation program including an acceptance-oriented cognitive-behavioral therapy for highly distressed patients with rheumatic diseases. Methods: An observational study employing a one-group pre-post test design (N = 25). The primary outcome was psychological distress. Secondary outcomes were quality of life, illness acceptance, and coping flexibility. Group pre-to-post and pre-to-12 months follow-up treatment changes were evaluated by paired-samples t-tests and Cohen’s effect sizes (d). Individual changes were evaluated by the reliable change index (RCI) and clinically significant change (CSC) parameters. Results: Significant effects were found post-treatment and maintained at 12 months in psychological distress (d > 0.80), illness acceptance (d = 1.48) and the SF-36 subscales role physical, vitality, and mental health (d  0.65). No significant effects were found for coping flexibility and the SF-36 subscales physical functioning, bodily pain, social functioning, and role emotional. Both a reliable (RCI) and clinically significant (CSC) improvement was observed for almost half of the highly distressed patients. Conclusion: The patients enrolled in the multimodal rehabilitation program showed improved psychological health status from pre to post-treatment. Practice implications: A randomized clinical trial is needed to confirm or refute the added value of an acceptance-oriented cognitive-behavioral therapy for highly distressed patients in rehabilitation. ß 2013 Elsevier Ireland Ltd. All rights reserved. G Model PEC-4463; No. of Pages 7 Please cite this article in press as: Vriezekolk JE, et al. An acceptance-oriented cognitive-behavioral therapy in multimodal rehabilitation: A pre-post test evaluation in highly distressed patients with rheumatic diseases. Patient Educ Couns (2013), http:// dx.doi.org/10.1016/j.pec.2013.01.018 Contents lists available at SciVerse ScienceDirect Patient Education and Counseling jo ur n al h o mep ag e: w ww .elsevier .co m /loc ate/p ated u co u 0738-3991/$ – see front matter ß 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.pec.2013.01.018