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A Randomized Trial

Joshua M. Smyth, PhD; Arthur A. Stone, PhD; Adam Hurewitz, MD; Alan Kaell, MD

JAMA. 1999;281:1304-1309.

Context  Nonpharmacological treatments with little patient cost or risk are useful supplements to pharmacotherapy in the treatment of patients with chronic illness. Research has demonstrated that writing about emotionally traumatic experiences has a surprisingly beneficial effect on symptom reports, well-being, and health care use in healthy individuals.

Objective  To determine if writing about stressful life experiences affects disease status in patients with asthma or rheumatoid arthritis using standardized quantitative outcome measures.

Design  Randomized controlled trial conducted between October 1996 and December 1997.

Setting  Outpatient community residents drawn from private and institutional practice.

Patients  Volunteer sample of 112 patients with asthma (n=61) or rheumatoid arthritis (n=51) received the intervention; 107 completed the study, 58 in the asthma group and 49 in the rheumatoid arthritis group.

Intervention  Patients were assigned to write either about the most stressful event of their lives (n=71; 39 asthma, 32 rheumatoid arthritis) or about emotionally neutral topics (n=41; 22 asthma, 19 rheumatoid arthritis) (the control intervention).

Main Outcome Measures  Asthma patients were evaluated with spirometry and rheumatoid arthritis patients were clinically examined by a rheumatologist. Assessments were conducted at baseline and at 2 weeks and 2 months and 4 months after writing and were done blind to experimental condition.

Results  Of evaluable patients 4 months after treatment, asthma patients in the experimental group showed improvements in lung function (the mean percentage of predicted forced expiratory volume in 1 second [FEV₁] improved from 63.9% at baseline to 76.3% at the 4-month follow-up; P<.001), whereas control group patients showed no change. Rheumatoid arthritis patients in the experimental group showed improvements in overall disease activity (a mean reduction in disease severity from 1.65 to 1.19 [28%] on a scale of 0 [asymptomatic] to 4 [very severe] at the 4-month follow-up; P=.001), whereas control group patients did not change. Combining all completing patients, 33 (47.1%) of 70 experimental patients had clinically relevant improvement, whereas 9 (24.3%) of 37 control patients had improvement (P=.001).

Conclusion  Patients with mild to moderately severe asthma or rheumatoid arthritis who wrote about stressful life experiences had clinically relevant changes in health status at 4 months compared with those in the control group. These gains were beyond those attributable to the standard medical care that all participants were receiving. It remains unknown whether these health improvements will persist beyond 4 months or whether this exercise will prove effective with other diseases.

Author Affiliations: Department of Psychiatry (Drs Smyth and Stone) and Divisions of Pulmonary Medicine (Dr Hurewitz) and Rheumatology (Dr Kaell), State University of New York at Stony Brook School of Medicine, Stony Brook. Dr Smyth is now at the Department of Psychology, North Dakota State University, Fargo.

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