1. Treatment Adherence in Fibromyalgia: Impact of Perceived Impairment,
Depression, and Self-Compassion
Kelley C. Pugh1, B.A., Andrea Kaniuka1, B.A., B.S., Jessica Kelliher Rabon1, M.A., Morgan K. Treaster1, B.A.,
Annemarie Weber2, B.S., Niko Kohls2, Ph.D., Fuschia M. Sirois3, Ph.D., Jameson K. Hirsch1, Ph.D.
1East Tennessee State University, 2Coburg University of Applied Sciences, 3University of Sheffield
ABSTRACT
Individuals with chronic health conditions such as fibromyalgia often fail to engage in treatment recommendations, perhaps due to the impact of disease on daily functioning and mood.
However, not all persons with fibromyalgia struggle with treatment adherence, perhaps due to individual- level protective factors, such as self-compassion, that may buffer disease impact and depression.
We examined the mediating role of depression in the relation between perceived impairment and treatment adherence; further, we examined the potential moderating role of self-compassion.
Supporting hypotheses, depression mediated the perceived impairment-adherence linkage, and self- compassion weakened the impairment-depression and depression-treatment adherence linkages.
HYPOTHESES
At the bivariate level, we hypothesized that perceived impairment and depression would be positively related, as would self-compassion and treatment adherence. We also hypothesized that impairment and depression would be inversely related to self-compassion and treatment adherence.
At the multivariate level, we hypothesized that depression would mediate the relation between perceived impairment and treatment adherence, and that self-compassion would moderate this mediating effect, such that self-compassion would weaken the linkages of the mediation model.
ANALYSES
Bivariate correlation analyses
Conditional indirect effect analyses, consistent with Hayes (2013), covarying age, race, and sex.
DISCUSSION
At the bivariate level, supporting hypotheses, impairment was positively associated with depression, and self-compassion was positively associated with adherence. Both impairment and depression were negatively associated with both self- compassion and adherence.
Supporting our multivariate hypothesis, depression mediated the impairment-adherence linkage, and self-compassion moderated the relation between impairment and depression, and between depression and adherence, weakening both associations.
Our findings support past research indicating the significant role of depression in fibromyalgia (McInnis, Matheson, & Anisman, 2014), and we extend this to include a deleterious effect on treatment adherence; for instance, perceived impairment may lower mood, with consequent discouragement for engaging in wellness behaviors and adhering to treatment.
The presence of self-compassion, while allowing an individual to recognize their impairment, may protect an individual from developing severely hopeless thoughts, perhaps through the aspect of common humanity (Neff, Kirkpatrick, & Rude, 2007).
Additionally, even if depression arises, self- compassion may exhibit itself in the form of self- kindness or self-care, which may take the form of persistence in treatment (Terry & Leary, 2011).
Our findings suggest that the extent to which a person with fibromyalgia is able to be self- compassionate, the “downward spiral” from impairment to distress to maladaptive health behaviors may be averted.
RESULTS
Bivariate Results:
Multivariate Results:
In moderated mediation analysis (10,000 bootstrapped samples), the pathway between impairment and depression was significant (β = , p < .0001) as well as the pathway between depression and adherence (β = .5387, p < .02). The direct pathway between impairment and adherence was also significant (β = , p < .05).
Self-compassion moderated the impairment- depressive symptom (β = , p < .001) and depressive symptom-adherence linkage (β = , p < .05), thereby weakening these relations.
Perceived Impairment
Depression
Treatment Adherence
.514 --
-.340
-.205
Self-Compassion
-.331
-.635
.252
METHOD
Participants:
Sample: (N=508) individuals with fibromyalgia, recruited online via national organizations and support groups
Age: M=47.72, SD=13.14
Sex: Female (n = 401, 95.7%)
Race: White (n = 383, 91.8%)
Measures:
Fibromyalgia Impact Questionnaire (FIQR)
Depression, Anxiety, and Stress Scales (DASS)
MOS Treatment Adherence Scale
Self-Compassion Scale - short form (SCS-SF)
Note: all correlations significant at p< .01
INTRODUCTION
Fibromyalgia is a chronic illness characterized by fatigue, sleep disturbances, and pain, and affects 2.7% of the global population (Quieroz, 2013).
People with chronic illnesses are often non-adherent to treatment (Dunbar-Jacob & Mortimer-Stephens, 2001), and fibromyalgia patients may be particularly susceptible to non-adherence due to distressing factors associated with the disease (Dobkin, Sita, & Sewitch, 2006).
Individuals with fibromyalgia are more likely to report poor mental health, notably depression (Arnold, 2008); for example, individuals with fibromyalgia are 3x more likely to experience depression compared to the general population (Gracely, Ceko, & Bushnell, 2012).
Persons with fibromyalgia who perceive greater impact of disease (e.g., perceived impairment) are more likely to report symptoms of psychopathology (Goldenberg, 2008), perhaps impacting treatment adherence.
However, not all fibromyalgia patients are non- adherent, perhaps due to protective factors which buffer risk, such as self-compassion.
Comprised of self-kindness, mindfulness, and a belief in common humanity (Neff, 2003b) , self-compassion is related to reduced risk for psychopathology (Neff et al., ), and better health, including better adherence in chronically ill populations (Neff, 2003b; Dowd & Jung, 2017).
Self-compassion may help to alleviate perceived impairment (e.g., self-kindness) and depressed mood (e.g., mindfulness), resulting in better treatment adherence; however, this premise has not been examined in a comprehensive model among fibromyalgia patients.
LIMITATIONS
Cross-sectional data precludes examination of causality; future, longitudinal research is needed.
Although representative of the fibromyalgia population, which is primarily female and middle age (Lawrence et al., 2008), our findings may not be generalizable to other illness groups.
Moderated Mediation Model
Depression
a2= .5387*
a1= .3049***
Self-Compassion
b2= *
b1= ***
IMPLICATIONS
Therapeutically addressing depression and perceptions of impairment (e.g., Cognitive- Behavioral Therapy) (Ehde, Dillworth, & Tuner, 2014) and enhancing self-compassion (e.g., mindfulness, changing critical self-talk) (Pinto-Gouveia, Duarte, Matos, & Frágaus, 2013) may weaken the impact of fibromyalgia- related impairment, ultimately increasing treatment adherence among individuals with fibromyalgia.
b3= .0022
Perceived Impairment
Treatment
Adherence
c= *
Figure 2. Illustration of the conditional indirect effects model. c = direct effect (Impairment related to Adherence); a1 = indirect effect (Impairment related to Depression); a2 = indirect effect (Depression related to Adherence); b1 = conditional effect of Self-Compassion on the relation between Impairment and Depression; b2 = conditional effect of Self-Compassion on the relation between Depression and Adherence; b3 = conditional effect of Self-Compassion on the relation between Impairment and Adherence.
* p<.05 ; ** p<.01; *** p<.001.