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Background:The literature about the impact of Rheumatoid Arthritis (RA) on mental health is mostly focused on depression and anxiety. Yet, patients can experience stress without depressed mood or anxiety.Objectives:To examine the impact of RA on psychological stress excluding depression and anxiety focusing on 3 questions: 1) What is the stress level of RA patients compared to a control group? 2) Which types of stress do RA patients experience? 3) Which are risk factors to develop stress as an RA patient?Methods:Four scientific databases, EMBASE, PubMed (including MEDLINE), Web of Science Core Collection and Cochrane Library, were systematically searched from inception until 19/04/2020. Eligible studies included psychological stress in RA patients as outcome. Two reviewers (CV&AVB) independently screened titles and abstracts, and later full texts for eligibility. Full-text screening excluded studies without a separate RA population, with a focus on only anxiety and/or depression or not answering at least 1/3 research questions. Quality was appraised by MINORS/AXIS tools.Results:From 11 115 potentially relevant studies, 16 studies met the inclusion criteria (Table 1). Remarkably, 13 different stress measurement instruments were picked-up in this review. Work stress and interpersonal stress seem more prevalent in RA patients compared to healthy controls. Stress at disease onset was more prevalent in RA compared to osteoarthritis. Psychological stress was higher in patients with chronic pain compared to RA. Role stress, social stress and work stress were induced by RA. More disability, more pain, less social support, lower income, younger age and personality factors like excessive worrying, pessimism, and sensitivity to anxiety, seem to increase the risk for increased stress levels.Table 1.Included StudiesFirst AuthorYearCountryPopulationAgeMean ±SDStress InstrumentQuality AssessmentBugajska2010PolandN=437 PolishN=137 German>50y (71%)>50y (38%)SF36v2AXIS: 16/20Coty2017USAN=8054y ±12yRCQWAXIS: 17/20Cunha2016PortugalN=8058yDASS-21AXIS: 10/20Goulia2015GreeceN=16855y ±13ySCL-90RMINORS: 11/16Latman1996USARA, N=128OA, N=7956y63ySRRSAXIS: 20/20Mancuso2006USARA, N=122HC, N=12249y ±12y49y ±12yDUSOCSMINORS: 20/24Nyklicek2015The NetherlandsN=20157y ±12yPSSMINORS: 13/16Persson2005SwedenN=15852ySCL-90RMINORS: 12/16Rahim2018MalaysiaN=18952y ±11yDASS-21AXIS: 17/20Rice2017CanadaRA, N=226CP, N=22958y ±15y45y ±12yDASS-21AXIS: 17/20Rice2016CanadaRA, N=163CP, N=16756y ±13y45y ±11yDASS-21AXIS: 18/20Richter2018GermanyRA, N=163HC, N=16748y ±10y43y ±10yERIAXIS: 17/20Smith2002USARA, N=93OA, N=82HC, N=80RA, 62yOA, 65yHC, 62y1 question probing stressMINORS: 17/24Treharne2007UKN=13455yPSSMINORS: 11/16Turner-Cobb1998UKRA, N=13CP, N=2442y ±8y39y ±4yLEI/HUSMINORS: 17/24Zautra1997USAN=4155y ±10yISLEMINORS: 12/16Conclusion:This scoping review is to our knowledge the first to address the heterogeneity of measurement tools and definitions of stress in RA research. It provides the basis for further research, which is needed to predict different stress trajectories and respond to these with patient-centered interventions.Disclosure of Interests:None declared

Background:Rheumatoid arthritis (RA) is a chronic inflammatory auto-immune disease impacting both physical and mental wellbeing of patients. Cognitive behavioral therapy (CBT), a psycho-social intervention aiming to revert maladaptive thinking and dysfunctional behavior, could improve psychosocial wellbeing in patients with RA. However, it is unclear which CBT components are most successful in improving wellbeing and if certain subpopulations might be more sensitive to CBT therapy.Objectives:To summarize in a systematic literature review, the effect of CBT on psychosocial outcomes in RA, focussing on most successful components and which patient subgroups benefit most from CBT.Methods:A search was conducted with the support of a health sciences librarian at the KU Leuven Biomedical Library from inception until 28.06.2020 in 5 electronic databases: PubMed, EMBASE, Web of Science Core Collection, Cochrane Library and Cumulated Index to Nursing and Allied Health Literature (CINAHL). We included studies in English and Dutch involving patients >18 years old with RA, using cognitive behavioral approaches as intervention, with outcomes related to psychosocial variables. Two reviewers (CV&AVB) independently screened first the titles and abstracts of the studies, and later the full texts for eligibility. A third reviewer (DDC) was consulted if no consensus was found. Quality was assessed by the Critical Appraisals Skills Programme (CASP) RCT checklist.Results:In total, 18 of 1114 retrieved articles could be included (Table 1). Mean age of the participants ranged between 48-63 years with a mean disease duration between 13-16 years. The most used CBT techniques included relaxation training, attention diversion strategies, problem solving skills, goal setting, communication, and social skills training. CBT resulted in ameliorated psychosocial wellbeing related to more active coping styles, improved self-efficacy and reduced perception of disease stressors. Six/18 studies focused on a Ra patient subgroup with an increased psychosocial risk profile, such as high levels of depression. There was limited evidence for an improved treatment effect in these patients because of the elevated levels of psychological distress, but internal motivation seemed key for success.Table 1.Included studiesFirst AuthorYearCountryPopulationMean ageOutcomes assessedO`Leary1988USAN=3049ySelf-efficacy, Depression, Loneliness, perceived stressRadojevic1992USAN=5954yDepression, Anxiety, Pain copingGermond1993SAN=2449yCoping, Health Control, Stress, Mood, ImpactParker1995USAN=14160yLife stress, Daily stressors, helplessness, depression, anxiety, self-efficacy, impactKraaimaat1995NLN=4357yAnxiety, Depression, Social Support, Pain CopingSharpe2001UKN=5556yAnxiety, Depression, CopingEvers2002NLN=6454yAnxiety, Negative mood, Social functioning, Illness cognitions, coping, pain, complianceParker2003USAN=5456yDepression, Stressors, Stress, Anxiety, Helplessness, Self-efficacyVan Lankveld2004NLN=5850yDepression, Anxiety, Stressors, Coping, Social SupportZautra2008USAN=14252yAffect, Depression, Coping, Pain, CatastrophizingHammond2008UKN=16755ySelf-efficacy, distress, Control, Self-ManagementBarsky2010USAN=16853yDistressHewlett2011UKN=11760yAnxiety, Depression, FatigueSharpe2012AUN=10456yAnxiety, DepressionGarnefski2013NL, BEN=8248yDepression, Anxiety, Self-efficacyLumley2014USAN=26655yAnxiety, DepressionVermaak2015AUN=11354yDepression, Anxiety, Self-Efficacy, Distress, QoLHewlett2019UKN=31963yFatigue, Mood, QoL, Self-Efficacy, HelplessnessConclusion:Adding CBT to standard care induces modest improvements in psychosocial outcomes for patients with RA. CBT seems more successful if patients are motivated to reflect on their cognitions and behaviours. However, more research with large-scale studies, focusing also on the critical early disease phase, is needed to investigate the long-term benefits of CBT.Disclosure of Interests:None declared