Effects of psychological interventions for adults with systemic lupus erythematosus: a network meta-analysis

Effects of psychological interventions for adults with systemic lupus erythematosus: a network meta-analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Effects of psychological interventions for adults with systemic lupus erythematosus: a network meta-analysis Yanan Sun, Fang Wang, Mengmeng Zhao This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4509580/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Psychological interventions have been demonstrated to be effective in patients with systemic lupus erythematosus (SLE). However, limited evidence on the effects of different psychological interventions were provided by previous studies or traditional meta-analysis. Methods This updated meta-analysis aimed to synthesize and analyze the effectiveness of psychological interventions on SLE patients.PubMed, Embase, Web of Science, and the Cochrane Library were systematically searched. Inclusion criteria included 1) adults with SLE; 2) effects of psychological interventions were assessed; 3) outcomes of psychological impact and disease activity in the intervention group and control group were reported; 4) randomized controlled trials. We calculated standardized mean difference (SMD) of outcomes with the respective 95% confidence interval (CIs). Heterogeneity between enrolled studies was evaluated using the I2 statistics. Results Seven studies with 574 SLE patients were included in this meta-analysis. The SMDs for mean change in fatigue, physical function, mental health, pain, depression, and disease activity scores from the beginning to the end of the follow-up interval in the psychological intervention group and control group was − 0.48 [(95% CI: -0.64, -0.04), z=-2.24, p = 0.0251; I2 = 41%, p = 0.1669], 0.27 [(95% CI: 0.06, 0.49), z = 2.47, p = 0.0137; I2 = 1%, p = 0.3892], 0.17 [(95% CI: -0.27, 0.60), z = 0.75, p = 0.4519; I2 = 72%, p = 0.0274], 0.26 [(95% CI: -0.16, 0.68), z = 1.23, p = 0.2200; I2 = 0%, p = 0.3783], -0.67 [(95% CI: -1.60, 0.26), z=-1. 42, p = 0.1570; I2 = 89%, p < 0.0001], and − 0.02 [(95% CI: -0.24, 0.20), z=-0.17, p = 0.8652; I2 = 0%, p = 0.6718]. Conclusions This meta-analysis indicates that psychological intervention effectively improves fatigue and physical function in patients with SLE. psychological interventions systemic lupus erythematosus effect meta-analysis Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Introduction Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that manifests a wide range of organ involvement [ 1 ]. The clinical characteristics of lupus are usually challenging because this disease may be unpredictable, affects organs of different severity, and becomes complex due to organ damage and increased complications [ 1 ]. The estimated incidence rates of SLE worldwide range from approximately 1 to 10 per 100,000, and prevalence rates generally range from 20 to 70 per 100,000 [ 2 ]. Many studies reported that the incidence rate of SLE in non-white people (compared with white people, the incidence of SLE has increased 5–9 times, and the prevalence has increased 2–3 times), and the incidence rate of SLE in some ethnic groups (such as Africa, Caribbean, and Southeast Asia) has increased [ 3 – 9 ]. In addition, females have a much higher incidence than males [ 10 ]. SLE generally manifests a female-to-male ratio ranging from 10–15:1 in adults [ 11 ]. The increased risks of SLE are related to exposure to crystalline silica, smoking, use of oral contraceptives and hormone replacement therapy, but negatively related to alcohol intake [ 12 ]. Furthermore, epigenetic modification mediates the influence of environment on immune response, resulting in inflammatory, autoimmune and multi-system diseases characterized by autoantibody production and tissue damage [ 13 – 15 ]. Patients with systemic lupus erythematosus have a greater impact on daily activities related to work, daily function, and living standards, which can seriously affect patients' psychological well-being and quality of life (QOL) [ 16 ]. A broad range of medications was used to treat SLE, including glucocorticoids, antimalarial agents, nonsteroidal antiinflammatory drugs (NSAIDs), immunosuppressive agents, and B cell–targeting biologics [ 17 ]. Hydroxychloroquine is the cornerstone of SLE treatment [ 17 ]. The choice of drugs mainly depends on the severity of the disease and the function of relevant organs [ 18 ]. Although drug treatment improves the overall survival rate, fatigue and psychosocial factors pose impacts on quality of life in a comprehensive manner [ 19 ]. Of note, various psychological interventions including person-centered counseling [ 20 , 21 ], group psychotherapy [ 22 ], stress-reduction program [ 23 ], cognitive behavioural therapy [ 24 ], acceptance and commitment therapy [ 25 ], and psychoanalytic psychotherapy have been proven separately to significantly improve pain or psychological outcomes, over and above that of usual medical interventions in SLE patients. However, no evidence on beneficial effect of person-centered counseling on the physical function or the pain improvment of SLE patients in the study by Maisiak et, al [ 20 ]. Furthermore, limited efficacy of web-based education and counselling in reducing fatigue and improving self-efficacy and satisfaction of care in chronic diseases [ 21 ]. A systematic review and meta-analysis published in 2012 compared the impact of psychological interventions on SLE patients; the authors found that compared with the control group, psychological interventions significantly reduced anxiety, depression, stress, and disease activity, whereas insignificant differences were observed in mental health, fatigue and physical function [ 26 ]. A systematic review based on 15 randomized controlled trials involving 846 participants suggested promising results for physical exercise and psychological interventions for improvement in fatigue, depression, pain and QOL for SLE [ 27 ]. Nevertheless, conventional meta-analyses only provided limited comparative effects of psychological intervention in SLE patients, evidence on the efficacy of different psychological approaches are warranted to guide the practice on the management of SLE. To our knowledge, accumulated evidence on the effects of psychological interventions on SLE was reported. Therefore, the main objective of this updated meta-analysis was to synthesize and analyze the effectiveness of psychological interventions on SLE patients, to improve their subjective experience and quality of life. Methods The meta-analysis was conducted under the guidance of the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) [ 28 ]. Data sources and searches We comprehensively searched the electronic databases, including Pubmed, Embase, Web of Science, and the Cochrane Library. All databases were searched from inception to December 12, 2022, with studies in English considered. Both medical subject headings (MeSH) and free-text terms were used for search terms. The following keywords and terms were used for the literature search: psychological interventions, cognitive behavioral therapy, psychodynamic therapy, counseling, behavior therapy, systemic lupus erythematosus, and SLE. Inclusion and exclusion criteria Inclusion criteria were as follows: 1) participants who have SLE; 2) participants > 18 years old; 3) psychological interventions were used; 4) reported changes in outcomes of psychological impact and disease activity in the intervention group and control group at the time of intervention and the end of the follow-up interval, including scores on fatigue physical function, pain, and depression, disease activity scores; 5) randomized controlled trials. Exclusion criteria included: 1) outcomes cannot be extracted or calculated; 2) observational studies, case reports, reviews, editorials, and animal studies; 3) non-English citations. Two independent researchers performed the literature search and study selection. Disagreements were resolved through discussion. Data extraction Two investigators independently screened the title and abstract of articles according to the inclusion criteria. They performed a full-text reading of the citations for the final judgment of inclusion. Moreover, the following information of each study included was extracted or calculated from the raw data provided in the articles included: first author's name, year of publication, number of participants, details on intervention and control, and scores of scales on fatigue, physical function, mental health, pain, depression, and disease activity. Risk of bias assessment The Cochrane Collaboration's tool for assessing the risk of bias in randomized trials was used to judge the risk for each included study [ 29 ]. Selection bias, performance bias, detection bias, attrition bias, and reporting bias were evaluated and defined as a low, high, or unclear risk of bias [ 29 ]. Statistical analysis The R Project for Statistical Computing Version 4.2.2 was used for statistical analyses on the study level. Pooled estimates of the standardized mean difference (SMD) of outcomes aforementioned in the psychological intervention and control groups, with their respective 95% confidence intervals (CIs), were calculated using the random effects model. We used the I 2 statistics to assess the heterogeneity between included studies. Insignificant, low, moderate, and high heterogeneity were identified as I 2 values of 0-%, 25-%, 50-%, and 75-%, respectively [ 30 ]. Egger's method was used to test publication bias statistically [ 31 ]. We conducted a sensitivity analysis to evaluate the robustness of the overall outcomes. Network meta-analysis (NMA) was performed in Stata (release 14, Stata- Corp LLC, TX, USA) using a frequentist, random-effects NMA model. Design-by-treatment interaction models assessed the inconsistency between direct and indirect treatment effects [ 32 , 33 ]. The surface under the cumulative ranking curves (SUCRA) was used to evaluate relative efficacy [ 34 ]. A SUCRA value of 100% indicates the intervention is the most effective in the network, while a value of 0% suggests it may be the least effective. The larger the SUCRA value, the better the rank of an intervention in the network. A p-value < 0.05 was considered to be statistically significant. Results Study selection and characteristics A total of 1330 citations were identified from the databases research. Sixty duplicates and 1245 studies were excluded through the first round of screening. After a full-text assessment for eligibility of the remaining 25 articles, seven randomized controlled clinical trials with 574 patients with SLE were identified for inclusion in this meta-analysis[ 21 , 23 , 35 – 39 ] ( Fig. 1 ) and the publication years of included trials ranged from 1996 to 2020. Psychological interventions mainly had patient education, relaxation, stress management or cognitive coping skills teaching, and therapeutic biofeedback; they were classified into three categories: psychoeducation/counseling intervention, supportive therapy, and cognitive behavioral treatment (CBT) (Table 1 ). Detailed information on the interventions and controls is shown in Table S1 . The network plots present direct comparisons of the various categories of psychological interventions; the size of the nodes is related to the number of participants involved in each treatment. The thickness of the lines is related to the number of studies connected to the network. The 2 interventions plus 1 control formed fatigue network of 3 nodes involving 4 network comparisons ( Supplementary Figs. 1 ). The 3 interventions and 1 control formed physical function network of 4 nodes involving 4 network comparisons ( Supplementary Figs. 2 ). Mental health network was formed by 3 interventions and 1 control with 4 nodes involving 3 network comparisons ( Supplementary Figs. 3 ). Pain network was formed by 2 interventions and 1 control with 3 nodes involving 3 network comparisons ( Supplementary Figs. 4 ). The 2 interventions plus 1 control formed the network for depression with 3 nodes involving 3 network comparisons ( Supplementary Figs. 5 ). Network for disease activity was formed by 3 interventions and 1 control with 4 nodes involving 3 network comparisons ( Supplementary Figs. 6 ). Most therapies were connected to the waiting list and standard of care. The risk of bias for each included study was rated moderate according to the Cochrane Tool (Table 2 ). Table 1 Study characteristics First Author Year Number of participants Age, mean ± SD Female, % Disease duration, mean ± SD Category of psychological interventions Outcomes reporter (Score on scales) Austin 1996 55 51.2 96 6.56 Psychoeducation/counselling intervention Fatigue, pain Dobkin 2002 133 42.5 ± 10.7 NR 10.9 ± 8.7 Supportive therapy Physical function, Mental health, Disease activity Greco 2004 59 48.7 ± 9.7 94 10.9 ± 7.0 CBT Fatigue, Physical function, pain, depression, Disease activity Karlson 2004 122 41.8 ± 18.2 98 NR Psychoeducation/counselling intervention Fatigue, Physical function, Mental health, Disease activity Navarrete-Navarrete 2010 45 42.0 ± 10.3 89 NR CBT Physical function, Mental health, pain, depression Conceicao 2019 80 42.4 ± 11.7 100 12.0 ± 8.0 Supportive therapy Depression Kankaya 2020 80 47.3 ± 10.8 95 NR Psychoeducation/counselling intervention Fatigue Table 2 Quality assessment of included studies Studies Random sequence generation Allocation concealment Blinding of participants and personnel Incomplete outcome data Selective reporting Other bias Austin1996 Unclear High High Low Low Unclear Dobkin2002 Unclear High High Low Low Unclear Greco2004 Low High High Low Low Unclear Karlson2004 Low High High Low Low Unclear Navarrete-Navarrete2010 Unclear High High Unclear Unclear Unclear Conceicao2019 Low High High Low Low Unclear Kankaya2020 Low High High Low Low Unclear Pooled analyses Fatigue scores Four included studies reported results on fatigue. The fatigue scores decreased significantly at the end of the follow-up in the psychological intervention group, compared to the control group [SMD: -0.48, (95% CI: -0.64, -0.04), z = -2.24, p = 0.0251; I 2 = 41%, p = 0.1669] (Fig. 2 ). The SUCRA indicated that regarding the fatigue outcome, psychoeducation/counseling is most likely the optimal psychological intervention ( Supplementary Fig. 7 ). Insignificant differences between different categories of interventions were detected (Table 3 ). Table 3 Comparative efficacy of psychological interventions for SLE in different parameters Fatigue scores Control -0.43 (-0.75,-0.11) -0.01 (-0.62,0.60) 0.43 (0.11,0.75) psychoeducation/counselling intervention 0.42 (-0.27,1.11) 0.01 (-0.60,0.62) -0.42 (-1.11,0.27) CBT Physical function Control 0.06 (-0.28,0.40) 0.48 (0.09,0.87) 0.32 (-0.04,0.68) -0.06 (-0.40,0.28) supportive therapy 0.42 (-0.10,0.94) 0.26 (-0.23,0.75) -0.48 (-0.87,-0.09) -0.42 (-0.94,0.10) cognitive behavioural treatment (CBT) -0.16 (-0.69,0.37) -0.32 (-0.68,0.04) -0.26 (-0.75,0.23) 0.16 (-0.37,0.69) psychoeducation/counselling intervention Mental health Control -0.21 (-0.55,0.14) 0.46 (0.10,0.82) 0.29 (-0.30,0.88) 0.21 (-0.14,0.55) supportive therapy 0.66 (0.17,1.16) 0.50 (-0.18,1.18) -0.46 (-0.82,-0.10) -0.66 (-1.16,-0.17) psychoeducation/counselling intervention -0.16 (-0.85,0.53) -0.29 (-0.88,0.30) -0.50 (-1.18,0.18) 0.16 (-0.53,0.85) CBT Pain Control 0.09 (-0.52, 0.70) 0.43 (-0.53, 1.40) -0.09 (-0.70, 0.52) psychoeducation/counselling intervention 0.34 (-0.80, 1.49) -0.43 (-1.40, 0.53) -0.34 (-1.49, 0.80) CBT Depression Control -0.20 (-0.59, 0.18) -1.60 (-2.11, -1.09) 0.20 (-0.18, 0.59) CBT -1.40 (-2.03, -0.76) * 1.60 (1.09, 2.11) 1.40 (0.76, 2.03) supportive therapy Disease activity Control 0 (-0.34, 0.34) -0.22 (-0.74, 0.29) 0.06 (-0.30, 0.41) 0 (-0.34, 0.34) supportive therapy -0.22 (-0.84, 0.39) 0.06 (-0.43, 0.55) 0.22 (-0.29, 0.74) 0.22 (-0.39, 0.84) CBT 0.28 (-0.34, 0.91) -0.06 (-0.41, 0.30) -0.06 (-0.55, 0.43) -0.28 (-0.91, 0.34) psychoeducation/counselling intervention Bold with *indicates P < 0.05. Values are presented by standardized mean differences with 95% confidence intervals. CBT, cognitive behavioral treatment. Physical function Results of physical function from 4 trials were pooled. Physical function scores improved significantly from the beginning to the end of the follow-up interval in the intervention in comparison to the control group [SMD: 0.27, (95% CI: 0.06, 0.49), z = 2.47, p = 0.0137; I 2 = 1%, p = 0.3892] (Fig. 3 ). The SUCRA indicated that CBT is most likely to be the best psychological intervention ( Supplementary Fig. 8 ). Insignificant differences between different categories of interventions were detected (Table 3 ). Mental health Outcomes on assessment of mental health were extracted from 3 studies. The SMD for mean change in mental health scores from the beginning to the end of the follow-up interval in the psychological intervention group and control group was 0.17 [(95% CI: -0.27, 0.60), z = 0.75, p = 0.4519; I 2 = 72%, p = 0.0274] (Fig. 4 ). The SUCRA indicated that psychoeducation/counseling is most likely to be the best psychological intervention to improve mental health ( Supplementary Fig. 9 ). Insignificant differences between different categories of interventions were detected (Table 3 ). Pain Three studies reported outcomes on pain scores. The SMD for mean change in pain scores from the beginning to the end of the follow-up interval in the psychological intervention group and control group was 0.26 [(95% CI: -0.16, 0.68), z = 1.23, p = 0.2200; I 2 = 0%, p = 0.3783] (Fig. 5 ). The SUCRA indicated that psychoeducation/counseling ranked higher than CBT concerning pain relief among SLE ( Supplementary Fig. 10 ). Insignificant differences between different categories of interventions were detected (Table 3 ). Depression Depression was evaluated in 3 studies. The SMD for mean change in depression scores from the beginning to the end of the follow-up interval in the psychological intervention and control groups was − 0.67 [(95% CI: -1.60, 0.26), z = -1. 42, p = 0.1570; I 2 = 89%, p < 0.0001] (Fig. 6 ). The SUCRA indicated that supportive therapy is most likely to be the best psychological intervention to relieve depression ( Supplementary Fig. 11 ). Supportive therapy performed better than CBT in depression relief (Table 3 ). Disease activity The SMD for mean change in disease activity scores in the psychological intervention group and control group in 3 studies was − 0.02 [(95% CI: -0.24, 0.20), z = -0.17, p = 0.8652; I 2 = 0%, p = 0.6718] (Fig. 7 ). The SUCRA indicated that CBT is most likely to be the best psychological intervention to improve disease activity ( Supplementary Fig. 12 ). Insignificant differences between different categories of interventions were detected (Table 3 ). Publication bias Egger's tests did not detect significant publication bias for all aspects of the analysis ( Supplementary Figs. 13–18 ). The respective p values were 0.9441, 0.1725, 0.7990, 0.7457, 0.5709, and 0.2324 for the pooled analysis of scores of scales on fatigue, physical function, mental health, pain, depression, and disease activity. Sensitivity Analysis No outlier was identified in all sensitivity analyses, indicating the pooled results' robustness. Discussion Summary and interpretation of findings Fatigue is one of the most common subjective symptoms of rheumatic diseases, especially in SLE, which severely affects patients' physical activity and quality of life. Unfortunately, the explicit contributory factors to fatigue in SLE are not well understood [ 21 ]. The results of this study manifested statistically significant improvement in fatigue alleviation in the psychological intervention group compared to the control group. SUCRA indicated that psychoeducation/counseling is most likely the optimal psychological intervention for fatigue relief and mental health improvement. Significant reduction in fatigue was found in SLE patients after education and telephone counselling in the study by Karlson et al., psychoeducation included efficacy enhancement, problem solving, and social support enhancement, which were regarded as a whole to be stronger than individual elements [ 37 ]. In addition, significant improvement in fatigue was observed in the web-based education and counselling group as compared to control group in Kankaya et al.’ study, educational materials used were developed on the basis of the self-management program for chronic diseases by Stanford University and guidelines about SLE patients management, the education topics included information about SLE, management of fever, fatigue and rest, exercise, the psychological effects of lupus and stress reduction, prevention, skin care and sun protection, nutrition, joint protection, gender and lupus, pregnancy, contraception and birth, and medications [ 21 ]. It is important to provide this approach for SLE patients in order to reduce the level of fatigue. In this study, physical function was significantly improved with the utility of psychological intervention in patients with SLE. Despite statistical insignificance, improvement in mental health, relief of depression, pain, and disease activity were also detected, and the results were consistent with previous studies [ 21 , 37 – 39 ]. A RCT in 122 SLE patients evaluating a theory-based educational intervention to improve patient self-efficacy and partner support to manage SLE, significantly higher scores for mental health status were observed in the intervention group compared with the control group [ 37 ]. In the study by Navarrete-Navarrete et al., 45 patients with lupus and high levels of daily stress were randomly assigned to a control group or a CBT group, which consisted of ten consecutive weekly sessions, they found significant reduction in the level of depression and anxiety and daily stress in the experimental group compared to the control group [ 38 ]. In a RCT by Conceicao et al., 80 female SLE patients were allocated into psychotherapy group and control group, compared to control group, treatment group was significantly lower in frequency of symptoms, anxiety, and depression [ 39 ]. In another RCT carried out by Kankaya et al., web-based education was performed for the first three months, and counselling and information updates were given for the next three months for the experimental group, significant improvement in fatigue and self-efficacy in the experimental group was observed at the end of the study [ 21 ]. In an earlier meta-analysis published in 2012, the comprehensive effects of included randomized controlled trials showed that compared with the control group, the anxiety, depression, stress, and disease activity of the intervention group were significantly reduced. The impact on mental health, fatigue, and physical function is in the expected direction, but no statistically significant difference has been observed [ 26 ]. CBT is favorable in improving physical function and relieving pain and disease activity. Current data support the hypothesis that psychological interventions positively affect physical function in the setting of SLE treatment based on the combination of the latest evidence. Strengths and limitations A NMA was performed to synthesize psychological outcomes of SLE based on the published clinical trials and to detect the efficacy of psychological interventions on the well-being of SLE adults. Data of this study originated from systematical processes regarding online databases search, citation screening, and data extraction. Both direct and indirect comparisons of different psychological modalities were performed to yield more precise results. Nevertheless, this NMA still have several limitations. In this meta-analysis, results displayed significant heterogeneity in the pooled analysis of change in physical function and depression in the psychological intervention group and control group; the possible reasons may be attributed to heterogeneity in patients' characteristics and instruments used to assess psychological outcomes, more details on the reasons for heterogeneity need to be furtherly investigated. Subgroup analysis was not carried out due to the limited baseline information extracted and the limited number of trials in each subgroup. Although efforts were made to contact the authors to obtain raw data, individual patient data were unavailable, and a meta-analysis of data combined at the study level may lead to an unavoidable risk of bias. In addition, the instruments used to measure physical and psychological functioning differed across the component studies, and the results in this study should be interpreted with caution. Implication for practice Systemic lupus erythematosus (SLE) is a chronic multi-system autoimmune disease that harms patients' mental health [ 40 ]. Targeting symptomatic treatment according to the type of neuropsychiatric presentation is challenging for therapists in diagnosis and treatment [ 41 , 42 ]. However, comprehensive care requires more than medication. Therefore, as a therapist who coordinates psychological care, the psychologist's role in improving the therapeutic efficacy of SLE patients is also critical [ 27 , 43 ]. Updated evidence on psychological treatments for patients with SLE are necessary to guide clinical practice. Findings of this study may provide for practitioners with information on the optimal choice of psychological methods to improve SLE patients’ physical and psychological well-being. Specific strategies should be formulated according to the patient's physical and psychological characteristics. Of note, the balance between the effects and costs of the different psychological interventions should be considered in the real-world setting. Conclusions Despite the limitations to current study, the findings of this study clearly highlight that psychological intervention serves as an effective modality for treating SLE besides the application of usual pharmacological care. It is recommended that similar well-designed randomized clinical trials with large sample sizes are warranted to strengthen the results. Declarations Acknowledgements Not applicable Author Contributions Conception and design: F.W.and M.Z.,Administrative support: F. W.,Provision of study materials or patients: Y.S.,Collection and assembly of data: Y.S.,Data analysis and interpretation: Y.S.,Manuscript writing: Y.S., M.Z. and F.W.,All authors reviewed the manuscript. Funding This study was supported by The Basic scientific Research Project of colleges and universities funded by Liaoning Province, China (No. LJKMZ20221183). Data availability The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request Ethics approval and consent to participate Not applicable. This paper constitutes a literature review and does not involve human subjects Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests References Gergianaki I, Bertsias G. Systemic Lupus Erythematosus in Primary Care: An Update and Practical Messages for the General Practitioner. Front Med (Lausanne). 2018;5:161. Pons-Estel GJ, Alarcón GS, Scofield L, Reinlib L, Cooper GS. Understanding the epidemiology and progression of systemic lupus erythematosus. Semin Arthritis Rheum. 2010;39(4):257-68. Williams EM, Bruner L, Adkins A, Vrana C, Logan A, Kamen D, et al. 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Combination of direct and indirect evidence in mixed treatment comparisons. Statistics in medicine. 2004;23(20):3105-24. White IR. Multivariate Random-effects Meta-regression: Updates to Mvmeta. The Stata Journal. 2011;11(2):255-70. Salanti G, Ades AE, Ioannidis JP. Graphical methods and numerical summaries for presenting results from multiple-treatment meta-analysis: an overview and tutorial. Journal of clinical epidemiology. 2011;64(2):163-71. Austin JS, Maisiak RS, Macrina DM, Heck LW. Health outcome improvements in patients with systemic lupus erythematosus using two telephone counseling interventions. Arthritis care & research. 1996;9(5):391-9. Dobkin PL, Da Costa D, Joseph L, Fortin PR, Edworthy S, Barr S, et al. Counterbalancing patient demands with evidence: Results from a pan-canadian randomized clinical trial of brief supportive-expressive group psychotherapy for women with systemic lupus erythematosus. Annals of Behavioral Medicine. 2002;24(2):88-99. Karlson EW, Liang MH, Eaton H, Huang J, Fitzgerald L, Rogers MP, et al. A randomized clinical trial of a psychoeducational intervention to improve outcomes in systemic lupus erythematosus. Arthritis and rheumatism. 2004;50(6):1832-41. Navarrete-Navarrete N, Peralta-Ramírez MI, Sabio-Sánchez JM, Coín MA, Robles-Ortega H, Hidalgo-Tenorio C, et al. Efficacy of cognitive behavioural therapy for the treatment of chronic stress in patients with lupus erythematosus: a randomized controlled trial. Psychotherapy and psychosomatics. 2010;79(2):107-15. Conceicao CTM, Meinao IM, Bombana JA, Sato EI. Psychoanalytic psychotherapy improves quality of life, depression, anxiety and coping in patients with systemic lupus erythematosus: a controlled randomized clinical trial. Advances in Rheumatology. 2019;59. Warchoł-Biedermann K, Mojs E, Sikorska D, Kotyla P, Teusz G, Samborski W. Psychological Implications to the Therapy of Systemic Lupus Erythematosus. International journal of environmental research and public health. 2022;19(23). Shi Y, Li M, Liu L, Wang Z, Wang Y, Zhao J, et al. Relationship between disease activity, organ damage and health-related quality of life in patients with systemic lupus erythematosus: A systemic review and meta-analysis. Autoimmunity Reviews. 2021;20(1):102691. Fanouriakis A, Kostopoulou M, Alunno A, Aringer M, Bajema I, Boletis JN, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Annals of the rheumatic diseases. 2019;78(6):736. Magro-Checa C, Zirkzee EJ, Huizinga TW, Steup-Beekman GM. Management of Neuropsychiatric Systemic Lupus Erythematosus: Current Approaches and Future Perspectives. Drugs. 2016;76(4):459-83. Additional Declarations No competing interests reported. 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Wang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3klEQVRIiWNgGAWjYLCCCiDmhzCZidRyBoglG0jWYnCAWC0Gx88efnGg5o7d5uOn0yQYKqwTG9jPHsCv5UxemsWBY8+St53J3SbBcCY9sYEnLwGvFrMDOWbGH9gOJ5vd4N0mwdh2OLFBgscAv5bzb8wMDvw7nGw8A6TlHzFabuQYPzjYdtjOQAKkpYEILfY33pgxHOw7nCBxJnezRcKxdOM2nhz8WiT7c4w/HPh22J6//ezGGx9qrGX72c/g1wIEbBJAIrEBxEwAcQmpBwLmDyAHEqFwFIyCUTAKRioAAGdsTBkaomRdAAAAAElFTkSuQmCC","orcid":"","institution":"The First Hospital of China Medical University","correspondingAuthor":true,"prefix":"","firstName":"Fang","middleName":"","lastName":"Wang","suffix":""},{"id":313929039,"identity":"db6993c7-2efa-4712-b3e3-c1dbb81e403d","order_by":2,"name":"Mengmeng Zhao","email":"","orcid":"","institution":"The First Hospital of China Medical University","correspondingAuthor":false,"prefix":"","firstName":"Mengmeng","middleName":"","lastName":"Zhao","suffix":""}],"badges":[],"createdAt":"2024-05-31 14:21:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4509580/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4509580/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":58599826,"identity":"e1473300-96d4-4101-98ad-8b4021e582a3","added_by":"auto","created_at":"2024-06-18 17:16:32","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":56435,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of the literature search\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-4509580/v1/57943201f1a5b9ac69484ad8.png"},{"id":58598670,"identity":"7510f860-afec-42d3-adb9-4e9d00dc3886","added_by":"auto","created_at":"2024-06-18 17:08:32","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":20967,"visible":true,"origin":"","legend":"\u003cp\u003eSMD for mean change in scores of scales on fatigue in the psychological intervention and control group\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-4509580/v1/55e80d6221c78f552f63f19b.png"},{"id":58599827,"identity":"1ce05a94-23c5-4156-adc8-95cd50a9d701","added_by":"auto","created_at":"2024-06-18 17:16:32","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":20959,"visible":true,"origin":"","legend":"\u003cp\u003eSMD for mean change in scores of scales on physical function in the psychological intervention and control group\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-4509580/v1/4f90d6d570c193d4a1e3db66.png"},{"id":58598676,"identity":"a2da38a3-179b-4126-8415-e230be5c0d27","added_by":"auto","created_at":"2024-06-18 17:08:32","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":19253,"visible":true,"origin":"","legend":"\u003cp\u003eSMD for mean change in scores of scales on mental health in the psychological intervention and control group\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-4509580/v1/a5a2746c03ad0a73c3da6824.png"},{"id":58598675,"identity":"8b172e9f-bddb-4bb7-a738-3ea4c266aaf8","added_by":"auto","created_at":"2024-06-18 17:08:32","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":89491,"visible":true,"origin":"","legend":"\u003cp\u003eSMD for mean change in scores of scales on pain in the psychological intervention and control group\u003c/p\u003e","description":"","filename":"floatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-4509580/v1/a49e17f1607bdea0e25f580a.png"},{"id":58598677,"identity":"75608e52-3bb2-463f-a956-4e9acec24287","added_by":"auto","created_at":"2024-06-18 17:08:32","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":19248,"visible":true,"origin":"","legend":"\u003cp\u003eSMD for mean change in scores of scales on depression in the psychological intervention and control group\u003c/p\u003e","description":"","filename":"Figure6.png","url":"https://assets-eu.researchsquare.com/files/rs-4509580/v1/341e2b7dd4f54352c5705856.png"},{"id":58598674,"identity":"10e9f57b-2afc-40da-b42e-110d2074265f","added_by":"auto","created_at":"2024-06-18 17:08:32","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":18852,"visible":true,"origin":"","legend":"\u003cp\u003eSMD for mean change in scores of scales on disease activity in the psychological intervention and control group\u003c/p\u003e","description":"","filename":"Figure7.png","url":"https://assets-eu.researchsquare.com/files/rs-4509580/v1/d4a59b7f6f673d145c54bdae.png"},{"id":67103840,"identity":"34009e62-f3ba-4785-a52e-8de812271c20","added_by":"auto","created_at":"2024-10-21 08:32:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1013406,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4509580/v1/5ed35e6a-a85d-45c1-b194-e52b8a92031f.pdf"},{"id":58598672,"identity":"0da33358-9204-48b4-94da-c805bb455b8b","added_by":"auto","created_at":"2024-06-18 17:08:32","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":31477,"visible":true,"origin":"","legend":"","description":"","filename":"PRISMA2020checklist.docx","url":"https://assets-eu.researchsquare.com/files/rs-4509580/v1/faa3b16725a95af6897d2fd7.docx"},{"id":58598678,"identity":"c8e773ac-4e1b-4903-bcb0-3f1e580b5f5f","added_by":"auto","created_at":"2024-06-18 17:08:32","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":857432,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterials.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4509580/v1/55518ec961748cd2679d0d40.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eEffects of psychological interventions for adults with systemic lupus erythematosus: a network meta-analysis\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSystemic lupus erythematosus (SLE) is a chronic autoimmune disease that manifests a wide range of organ involvement [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The clinical characteristics of lupus are usually challenging because this disease may be unpredictable, affects organs of different severity, and becomes complex due to organ damage and increased complications [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The estimated incidence rates of SLE worldwide range from approximately 1 to 10 per 100,000, and prevalence rates generally range from 20 to 70 per 100,000 [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Many studies reported that the incidence rate of SLE in non-white people (compared with white people, the incidence of SLE has increased 5\u0026ndash;9 times, and the prevalence has increased 2\u0026ndash;3 times), and the incidence rate of SLE in some ethnic groups (such as Africa, Caribbean, and Southeast Asia) has increased [\u003cspan additionalcitationids=\"CR4 CR5 CR6 CR7 CR8\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In addition, females have a much higher incidence than males [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. SLE generally manifests a female-to-male ratio ranging from 10\u0026ndash;15:1 in adults [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The increased risks of SLE are related to exposure to crystalline silica, smoking, use of oral contraceptives and hormone replacement therapy, but negatively related to alcohol intake [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Furthermore, epigenetic modification mediates the influence of environment on immune response, resulting in inflammatory, autoimmune and multi-system diseases characterized by autoantibody production and tissue damage [\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePatients with systemic lupus erythematosus have a greater impact on daily activities related to work, daily function, and living standards, which can seriously affect patients' psychological well-being and quality of life (QOL) [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. A broad range of medications was used to treat SLE, including glucocorticoids, antimalarial agents, nonsteroidal antiinflammatory drugs (NSAIDs), immunosuppressive agents, and B cell\u0026ndash;targeting biologics [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Hydroxychloroquine is the cornerstone of SLE treatment [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The choice of drugs mainly depends on the severity of the disease and the function of relevant organs [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Although drug treatment improves the overall survival rate, fatigue and psychosocial factors pose impacts on quality of life in a comprehensive manner [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Of note, various psychological interventions including person-centered counseling [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], group psychotherapy [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], stress-reduction program [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], cognitive behavioural therapy [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], acceptance and commitment therapy [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], and psychoanalytic psychotherapy have been proven separately to significantly improve pain or psychological outcomes, over and above that of usual medical interventions in SLE patients. However, no evidence on beneficial effect of person-centered counseling on the physical function or the pain improvment of SLE patients in the study by Maisiak et, al [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Furthermore, limited efficacy of web-based education and counselling in reducing fatigue and improving self-efficacy and satisfaction of care in chronic diseases [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. A systematic review and meta-analysis published in 2012 compared the impact of psychological interventions on SLE patients; the authors found that compared with the control group, psychological interventions significantly reduced anxiety, depression, stress, and disease activity, whereas insignificant differences were observed in mental health, fatigue and physical function [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. A systematic review based on 15 randomized controlled trials involving 846 participants suggested promising results for physical exercise and psychological interventions for improvement in fatigue, depression, pain and QOL for SLE [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Nevertheless, conventional meta-analyses only provided limited comparative effects of psychological intervention in SLE patients, evidence on the efficacy of different psychological approaches are warranted to guide the practice on the management of SLE.\u003c/p\u003e \u003cp\u003eTo our knowledge, accumulated evidence on the effects of psychological interventions on SLE was reported. Therefore, the main objective of this updated meta-analysis was to synthesize and analyze the effectiveness of psychological interventions on SLE patients, to improve their subjective experience and quality of life.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe meta-analysis was conducted under the guidance of the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData sources and searches\u003c/h2\u003e \u003cp\u003eWe comprehensively searched the electronic databases, including Pubmed, Embase, Web of Science, and the Cochrane Library. All databases were searched from inception to December 12, 2022, with studies in English considered. Both medical subject headings (MeSH) and free-text terms were used for search terms. The following keywords and terms were used for the literature search: psychological interventions, cognitive behavioral therapy, psychodynamic therapy, counseling, behavior therapy, systemic lupus erythematosus, and SLE.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eInclusion and exclusion criteria\u003c/h2\u003e \u003cp\u003eInclusion criteria were as follows: 1) participants who have SLE; 2) participants\u0026thinsp;\u0026gt;\u0026thinsp;18 years old; 3) psychological interventions were used; 4) reported changes in outcomes of psychological impact and disease activity in the intervention group and control group at the time of intervention and the end of the follow-up interval, including scores on fatigue physical function, pain, and depression, disease activity scores; 5) randomized controlled trials. Exclusion criteria included: 1) outcomes cannot be extracted or calculated; 2) observational studies, case reports, reviews, editorials, and animal studies; 3) non-English citations. Two independent researchers performed the literature search and study selection. Disagreements were resolved through discussion.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData extraction\u003c/h2\u003e \u003cp\u003e Two investigators independently screened the title and abstract of articles according to the inclusion criteria. They performed a full-text reading of the citations for the final judgment of inclusion. Moreover, the following information of each study included was extracted or calculated from the raw data provided in the articles included: first author's name, year of publication, number of participants, details on intervention and control, and scores of scales on fatigue, physical function, mental health, pain, depression, and disease activity.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eRisk of bias assessment\u003c/h2\u003e \u003cp\u003eThe Cochrane Collaboration's tool for assessing the risk of bias in randomized trials was used to judge the risk for each included study [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Selection bias, performance bias, detection bias, attrition bias, and reporting bias were evaluated and defined as a low, high, or unclear risk of bias [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eThe R Project for Statistical Computing Version 4.2.2 was used for statistical analyses on the study level. Pooled estimates of the standardized mean difference (SMD) of outcomes aforementioned in the psychological intervention and control groups, with their respective 95% confidence intervals (CIs), were calculated using the random effects model. We used the I\u003csup\u003e2\u003c/sup\u003e statistics to assess the heterogeneity between included studies. Insignificant, low, moderate, and high heterogeneity were identified as I\u003csup\u003e2\u003c/sup\u003e values of 0-%, 25-%, 50-%, and 75-%, respectively [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. \u003cem\u003eEgger's\u003c/em\u003e method was used to test publication bias statistically [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. We conducted a sensitivity analysis to evaluate the robustness of the overall outcomes. Network meta-analysis (NMA) was performed in Stata (release 14, Stata- Corp LLC, TX, USA) using a frequentist, random-effects NMA model. Design-by-treatment interaction models assessed the inconsistency between direct and indirect treatment effects [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. The surface under the cumulative ranking curves (SUCRA) was used to evaluate relative efficacy [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. A SUCRA value of 100% indicates the intervention is the most effective in the network, while a value of 0% suggests it may be the least effective. The larger the SUCRA value, the better the rank of an intervention in the network. A p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered to be statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eStudy selection and characteristics\u003c/h2\u003e \u003cp\u003eA total of 1330 citations were identified from the databases research. Sixty duplicates and 1245 studies were excluded through the first round of screening. After a full-text assessment for eligibility of the remaining 25 articles, seven randomized controlled clinical trials with 574 patients with SLE were identified for inclusion in this meta-analysis[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan additionalcitationids=\"CR36 CR37 CR38\" citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e] \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) and the publication years of included trials ranged from 1996 to 2020. Psychological interventions mainly had patient education, relaxation, stress management or cognitive coping skills teaching, and therapeutic biofeedback; they were classified into three categories: psychoeducation/counseling intervention, supportive therapy, and cognitive behavioral treatment (CBT) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Detailed information on the interventions and controls is shown in \u003cb\u003eTable \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e\u003c/b\u003e. The network plots present direct comparisons of the various categories of psychological interventions; the size of the nodes is related to the number of participants involved in each treatment. The thickness of the lines is related to the number of studies connected to the network. The 2 interventions plus 1 control formed fatigue network of 3 nodes involving 4 network comparisons (\u003cb\u003eSupplementary Figs.\u0026nbsp;1\u003c/b\u003e). The 3 interventions and 1 control formed physical function network of 4 nodes involving 4 network comparisons (\u003cb\u003eSupplementary Figs.\u0026nbsp;2\u003c/b\u003e). Mental health network was formed by 3 interventions and 1 control with 4 nodes involving 3 network comparisons (\u003cb\u003eSupplementary Figs.\u0026nbsp;3\u003c/b\u003e). Pain network was formed by 2 interventions and 1 control with 3 nodes involving 3 network comparisons (\u003cb\u003eSupplementary Figs.\u0026nbsp;4\u003c/b\u003e). The 2 interventions plus 1 control formed the network for depression with 3 nodes involving 3 network comparisons (\u003cb\u003eSupplementary Figs.\u0026nbsp;5\u003c/b\u003e). Network for disease activity was formed by 3 interventions and 1 control with 4 nodes involving 3 network comparisons (\u003cb\u003eSupplementary Figs.\u0026nbsp;6\u003c/b\u003e). Most therapies were connected to the waiting list and standard of care. The risk of bias for each included study was rated moderate according to the Cochrane Tool (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eStudy characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFirst Author\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYear\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNumber of participants\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAge, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFemale, %\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eDisease duration, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCategory of psychological interventions\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eOutcomes reporter (Score on scales)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAustin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1996\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e51.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePsychoeducation/counselling intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eFatigue, pain\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDobkin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e133\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e42.5\u0026thinsp;\u0026plusmn;\u0026thinsp;10.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10.9\u0026thinsp;\u0026plusmn;\u0026thinsp;8.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSupportive therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePhysical function, Mental health, Disease activity\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGreco\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e48.7\u0026thinsp;\u0026plusmn;\u0026thinsp;9.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10.9\u0026thinsp;\u0026plusmn;\u0026thinsp;7.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCBT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eFatigue, Physical function, pain, depression, Disease activity\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKarlson\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e122\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e41.8\u0026thinsp;\u0026plusmn;\u0026thinsp;18.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePsychoeducation/counselling intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eFatigue, Physical function, Mental health, Disease activity\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNavarrete-Navarrete\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2010\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e42.0\u0026thinsp;\u0026plusmn;\u0026thinsp;10.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCBT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePhysical function, Mental health, pain, depression\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConceicao\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e42.4\u0026thinsp;\u0026plusmn;\u0026thinsp;11.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12.0\u0026thinsp;\u0026plusmn;\u0026thinsp;8.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSupportive therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eDepression\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKankaya\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e47.3\u0026thinsp;\u0026plusmn;\u0026thinsp;10.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePsychoeducation/counselling intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eFatigue\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eQuality assessment of included studies\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudies\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRandom sequence generation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAllocation concealment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBlinding of participants and personnel\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIncomplete outcome data\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSelective reporting\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eOther bias\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAustin1996\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnclear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUnclear\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDobkin2002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnclear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUnclear\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGreco2004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUnclear\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKarlson2004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUnclear\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNavarrete-Navarrete2010\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnclear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUnclear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnclear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUnclear\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConceicao2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUnclear\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKankaya2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUnclear\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003ePooled analyses\u003c/h2\u003e \u003cdiv id=\"Sec11\" class=\"Section3\"\u003e \u003ch2\u003eFatigue scores\u003c/h2\u003e \u003cp\u003eFour included studies reported results on fatigue. The fatigue scores decreased significantly at the end of the follow-up in the psychological intervention group, compared to the control group [SMD: -0.48, (95% CI: -0.64, -0.04), z = -2.24, p\u0026thinsp;=\u0026thinsp;0.0251; I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;41%, p\u0026thinsp;=\u0026thinsp;0.1669] (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The SUCRA indicated that regarding the fatigue outcome, psychoeducation/counseling is most likely the optimal psychological intervention (\u003cb\u003eSupplementary Fig.\u0026nbsp;7\u003c/b\u003e). Insignificant differences between different categories of interventions were detected (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparative efficacy of psychological interventions for SLE in different parameters\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eFatigue scores\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.43 (-0.75,-0.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.01 (-0.62,0.60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0.43 (0.11,0.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003epsychoeducation/counselling intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.42 (-0.27,1.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0.01 (-0.60,0.62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.42 (-1.11,0.27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCBT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePhysical function\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.06 (-0.28,0.40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.48 (0.09,0.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.32 (-0.04,0.68)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e-0.06 (-0.40,0.28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003esupportive therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.42 (-0.10,0.94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.26 (-0.23,0.75)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e-0.48 (-0.87,-0.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.42 (-0.94,0.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecognitive behavioural treatment (CBT)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.16 (-0.69,0.37)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e-0.32 (-0.68,0.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.26 (-0.75,0.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.16 (-0.37,0.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003epsychoeducation/counselling intervention\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMental health\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.21 (-0.55,0.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.46 (0.10,0.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.29 (-0.30,0.88)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0.21 (-0.14,0.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003esupportive therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.66 (0.17,1.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.50 (-0.18,1.18)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e-0.46 (-0.82,-0.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.66 (-1.16,-0.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003epsychoeducation/counselling intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.16 (-0.85,0.53)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e-0.29 (-0.88,0.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.50 (-1.18,0.18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.16 (-0.53,0.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCBT\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePain\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.09 (-0.52, 0.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.43 (-0.53, 1.40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e-0.09 (-0.70, 0.52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003epsychoeducation/counselling intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.34 (-0.80, 1.49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e-0.43 (-1.40, 0.53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.34 (-1.49, 0.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCBT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDepression\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.20 (-0.59, 0.18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-1.60 (-2.11, -1.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0.20 (-0.18, 0.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCBT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-1.40 (-2.03, -0.76) *\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1.60 (1.09, 2.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.40 (0.76, 2.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003esupportive therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDisease activity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (-0.34, 0.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.22 (-0.74, 0.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.06 (-0.30, 0.41)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0 (-0.34, 0.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003esupportive therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.22 (-0.84, 0.39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.06 (-0.43, 0.55)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0.22 (-0.29, 0.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.22 (-0.39, 0.84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCBT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.28 (-0.34, 0.91)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e-0.06 (-0.41, 0.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.06 (-0.55, 0.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.28 (-0.91, 0.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003epsychoeducation/counselling intervention\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eBold with *indicates P\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Values are presented by standardized mean differences with 95% confidence intervals. CBT, cognitive behavioral treatment.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003ePhysical function\u003c/h2\u003e \u003cp\u003eResults of physical function from 4 trials were pooled. Physical function scores improved significantly from the beginning to the end of the follow-up interval in the intervention in comparison to the control group [SMD: 0.27, (95% CI: 0.06, 0.49), z\u0026thinsp;=\u0026thinsp;2.47, p\u0026thinsp;=\u0026thinsp;0.0137; I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;1%, p\u0026thinsp;=\u0026thinsp;0.3892] (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The SUCRA indicated that CBT is most likely to be the best psychological intervention (\u003cb\u003eSupplementary Fig.\u0026nbsp;8\u003c/b\u003e). Insignificant differences between different categories of interventions were detected (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eMental health\u003c/h2\u003e \u003cp\u003eOutcomes on assessment of mental health were extracted from 3 studies. The SMD for mean change in mental health scores from the beginning to the end of the follow-up interval in the psychological intervention group and control group was 0.17 [(95% CI: -0.27, 0.60), z\u0026thinsp;=\u0026thinsp;0.75, p\u0026thinsp;=\u0026thinsp;0.4519; I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;72%, p\u0026thinsp;=\u0026thinsp;0.0274] (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The SUCRA indicated that psychoeducation/counseling is most likely to be the best psychological intervention to improve mental health (\u003cb\u003eSupplementary Fig.\u0026nbsp;9\u003c/b\u003e). Insignificant differences between different categories of interventions were detected (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003ePain\u003c/h2\u003e \u003cp\u003eThree studies reported outcomes on pain scores. The SMD for mean change in pain scores from the beginning to the end of the follow-up interval in the psychological intervention group and control group was 0.26 [(95% CI: -0.16, 0.68), z\u0026thinsp;=\u0026thinsp;1.23, p\u0026thinsp;=\u0026thinsp;0.2200; I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0%, p\u0026thinsp;=\u0026thinsp;0.3783] (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). The SUCRA indicated that psychoeducation/counseling ranked higher than CBT concerning pain relief among SLE (\u003cb\u003eSupplementary Fig.\u0026nbsp;10\u003c/b\u003e). Insignificant differences between different categories of interventions were detected (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eDepression\u003c/h2\u003e \u003cp\u003eDepression was evaluated in 3 studies. The SMD for mean change in depression scores from the beginning to the end of the follow-up interval in the psychological intervention and control groups was \u0026minus;\u0026thinsp;0.67 [(95% CI: -1.60, 0.26), z = -1. 42, p\u0026thinsp;=\u0026thinsp;0.1570; I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;89%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001] (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e). The SUCRA indicated that supportive therapy is most likely to be the best psychological intervention to relieve depression (\u003cb\u003eSupplementary Fig.\u0026nbsp;11\u003c/b\u003e). Supportive therapy performed better than CBT in depression relief (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eDisease activity\u003c/h2\u003e \u003cp\u003eThe SMD for mean change in disease activity scores in the psychological intervention group and control group in 3 studies was \u0026minus;\u0026thinsp;0.02 [(95% CI: -0.24, 0.20), z = -0.17, p\u0026thinsp;=\u0026thinsp;0.8652; I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0%, p\u0026thinsp;=\u0026thinsp;0.6718] (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003e). The SUCRA indicated that CBT is most likely to be the best psychological intervention to improve disease activity (\u003cb\u003eSupplementary Fig.\u0026nbsp;12\u003c/b\u003e). Insignificant differences between different categories of interventions were detected (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003ePublication bias\u003c/h2\u003e \u003cp\u003eEgger's tests did not detect significant publication bias for all aspects of the analysis (\u003cb\u003eSupplementary Figs.\u0026nbsp;13\u0026ndash;18\u003c/b\u003e). The respective p values were 0.9441, 0.1725, 0.7990, 0.7457, 0.5709, and 0.2324 for the pooled analysis of scores of scales on fatigue, physical function, mental health, pain, depression, and disease activity.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eSensitivity Analysis\u003c/h2\u003e \u003cp\u003eNo outlier was identified in all sensitivity analyses, indicating the pooled results' robustness.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eSummary and interpretation of findings\u003c/h2\u003e \u003cp\u003eFatigue is one of the most common subjective symptoms of rheumatic diseases, especially in SLE, which severely affects patients' physical activity and quality of life. Unfortunately, the explicit contributory factors to fatigue in SLE are not well understood [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The results of this study manifested statistically significant improvement in fatigue alleviation in the psychological intervention group compared to the control group. SUCRA indicated that psychoeducation/counseling is most likely the optimal psychological intervention for fatigue relief and mental health improvement. Significant reduction in fatigue was found in SLE patients after education and telephone counselling in the study by Karlson et al., psychoeducation included efficacy enhancement, problem solving, and social support enhancement, which were regarded as a whole to be stronger than individual elements [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. In addition, significant improvement in fatigue was observed in the web-based education and counselling group as compared to control group in Kankaya et al.\u0026rsquo; study, educational materials used were developed on the basis of the self-management program for chronic diseases by Stanford University and guidelines about SLE patients management, the education topics included information about SLE, management of fever, fatigue and rest, exercise, the psychological effects of lupus and stress reduction, prevention, skin care and sun protection, nutrition, joint protection, gender and lupus, pregnancy, contraception and birth, and medications [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. It is important to provide this approach for SLE patients in order to reduce the level of fatigue.\u003c/p\u003e \u003cp\u003eIn this study, physical function was significantly improved with the utility of psychological intervention in patients with SLE. Despite statistical insignificance, improvement in mental health, relief of depression, pain, and disease activity were also detected, and the results were consistent with previous studies [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan additionalcitationids=\"CR38\" citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. A RCT in 122 SLE patients evaluating a theory-based educational intervention to improve patient self-efficacy and partner support to manage SLE, significantly higher scores for mental health status were observed in the intervention group compared with the control group [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. In the study by Navarrete-Navarrete et al., 45 patients with lupus and high levels of daily stress were randomly assigned to a control group or a CBT group, which consisted of ten consecutive weekly sessions, they found significant reduction in the level of depression and anxiety and daily stress in the experimental group compared to the control group [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. In a RCT by Conceicao et al., 80 female SLE patients were allocated into psychotherapy group and control group, compared to control group, treatment group was significantly lower in frequency of symptoms, anxiety, and depression [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. In another RCT carried out by Kankaya et al., web-based education was performed for the first three months, and counselling and information updates were given for the next three months for the experimental group, significant improvement in fatigue and self-efficacy in the experimental group was observed at the end of the study [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. In an earlier meta-analysis published in 2012, the comprehensive effects of included randomized controlled trials showed that compared with the control group, the anxiety, depression, stress, and disease activity of the intervention group were significantly reduced. The impact on mental health, fatigue, and physical function is in the expected direction, but no statistically significant difference has been observed [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCBT is favorable in improving physical function and relieving pain and disease activity. Current data support the hypothesis that psychological interventions positively affect physical function in the setting of SLE treatment based on the combination of the latest evidence.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eA NMA was performed to synthesize psychological outcomes of SLE based on the published clinical trials and to detect the efficacy of psychological interventions on the well-being of SLE adults. Data of this study originated from systematical processes regarding online databases search, citation screening, and data extraction. Both direct and indirect comparisons of different psychological modalities were performed to yield more precise results.\u003c/p\u003e \u003cp\u003eNevertheless, this NMA still have several limitations. In this meta-analysis, results displayed significant heterogeneity in the pooled analysis of change in physical function and depression in the psychological intervention group and control group; the possible reasons may be attributed to heterogeneity in patients' characteristics and instruments used to assess psychological outcomes, more details on the reasons for heterogeneity need to be furtherly investigated. Subgroup analysis was not carried out due to the limited baseline information extracted and the limited number of trials in each subgroup. Although efforts were made to contact the authors to obtain raw data, individual patient data were unavailable, and a meta-analysis of data combined at the study level may lead to an unavoidable risk of bias. In addition, the instruments used to measure physical and psychological functioning differed across the component studies, and the results in this study should be interpreted with caution.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eImplication for practice\u003c/h2\u003e \u003cp\u003eSystemic lupus erythematosus (SLE) is a chronic multi-system autoimmune disease that harms patients' mental health [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Targeting symptomatic treatment according to the type of neuropsychiatric presentation is challenging for therapists in diagnosis and treatment [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. However, comprehensive care requires more than medication. Therefore, as a therapist who coordinates psychological care, the psychologist's role in improving the therapeutic efficacy of SLE patients is also critical [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Updated evidence on psychological treatments for patients with SLE are necessary to guide clinical practice. Findings of this study may provide for practitioners with information on the optimal choice of psychological methods to improve SLE patients\u0026rsquo; physical and psychological well-being. Specific strategies should be formulated according to the patient's physical and psychological characteristics. Of note, the balance between the effects and costs of the different psychological interventions should be considered in the real-world setting.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eDespite the limitations to current study, the findings of this study clearly highlight that psychological intervention serves as an effective modality for treating SLE besides the application of usual pharmacological care. It is recommended that similar well-designed randomized clinical trials with large sample sizes are warranted to strengthen the results.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConception and design: F.W.and M.Z.,Administrative support: F. W.,Provision of study materials or patients: Y.S.,Collection and assembly of data: Y.S.,Data analysis and interpretation: Y.S.,Manuscript writing: Y.S., M.Z. and F.W.,All authors reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by The Basic scientific Research Project of colleges and universities funded by Liaoning Province, China (No. LJKMZ20221183).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. This paper constitutes a literature review and does not involve human subjects\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGergianaki I, Bertsias G. Systemic Lupus Erythematosus in Primary Care: An Update and Practical Messages for the General Practitioner. Front Med (Lausanne). 2018;5:161.\u003c/li\u003e\n\u003cli\u003ePons-Estel GJ, Alarc\u0026oacute;n GS, Scofield L, Reinlib L, Cooper GS. Understanding the epidemiology and progression of systemic lupus erythematosus. 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Arthritis and rheumatism. 2004;50(6):1832-41.\u003c/li\u003e\n\u003cli\u003eNavarrete-Navarrete N, Peralta-Ram\u0026iacute;rez MI, Sabio-S\u0026aacute;nchez JM, Co\u0026iacute;n MA, Robles-Ortega H, Hidalgo-Tenorio C, et al. Efficacy of cognitive behavioural therapy for the treatment of chronic stress in patients with lupus erythematosus: a randomized controlled trial. Psychotherapy and psychosomatics. 2010;79(2):107-15.\u003c/li\u003e\n\u003cli\u003eConceicao CTM, Meinao IM, Bombana JA, Sato EI. Psychoanalytic psychotherapy improves quality of life, depression, anxiety and coping in patients with systemic lupus erythematosus: a controlled randomized clinical trial. Advances in Rheumatology. 2019;59.\u003c/li\u003e\n\u003cli\u003eWarchoł-Biedermann K, Mojs E, Sikorska D, Kotyla P, Teusz G, Samborski W. Psychological Implications to the Therapy of Systemic Lupus Erythematosus. International journal of environmental research and public health. 2022;19(23).\u003c/li\u003e\n\u003cli\u003eShi Y, Li M, Liu L, Wang Z, Wang Y, Zhao J, et al. Relationship between disease activity, organ damage and health-related quality of life in patients with systemic lupus erythematosus: A systemic review and meta-analysis. Autoimmunity Reviews. 2021;20(1):102691.\u003c/li\u003e\n\u003cli\u003eFanouriakis A, Kostopoulou M, Alunno A, Aringer M, Bajema I, Boletis JN, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Annals of the rheumatic diseases. 2019;78(6):736.\u003c/li\u003e\n\u003cli\u003eMagro-Checa C, Zirkzee EJ, Huizinga TW, Steup-Beekman GM. Management of Neuropsychiatric Systemic Lupus Erythematosus: Current Approaches and Future Perspectives. Drugs. 2016;76(4):459-83.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"psychological interventions, systemic lupus erythematosus, effect, meta-analysis","lastPublishedDoi":"10.21203/rs.3.rs-4509580/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4509580/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePsychological interventions have been demonstrated to be effective in patients with systemic lupus erythematosus (SLE). However, limited evidence on the effects of different psychological interventions were provided by previous studies or traditional meta-analysis.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis updated meta-analysis aimed to synthesize and analyze the effectiveness of psychological interventions on SLE patients.PubMed, Embase, Web of Science, and the Cochrane Library were systematically searched. Inclusion criteria included 1) adults with SLE; 2) effects of psychological interventions were assessed; 3) outcomes of psychological impact and disease activity in the intervention group and control group were reported; 4) randomized controlled trials. We calculated standardized mean difference (SMD) of outcomes with the respective 95% confidence interval (CIs). Heterogeneity between enrolled studies was evaluated using the I2 statistics.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eSeven studies with 574 SLE patients were included in this meta-analysis. The SMDs for mean change in fatigue, physical function, mental health, pain, depression, and disease activity scores from the beginning to the end of the follow-up interval in the psychological intervention group and control group was \u0026minus;\u0026thinsp;0.48 [(95% CI: -0.64, -0.04), z=-2.24, p\u0026thinsp;=\u0026thinsp;0.0251; I2\u0026thinsp;=\u0026thinsp;41%, p\u0026thinsp;=\u0026thinsp;0.1669], 0.27 [(95% CI: 0.06, 0.49), z\u0026thinsp;=\u0026thinsp;2.47, p\u0026thinsp;=\u0026thinsp;0.0137; I2\u0026thinsp;=\u0026thinsp;1%, p\u0026thinsp;=\u0026thinsp;0.3892], 0.17 [(95% CI: -0.27, 0.60), z\u0026thinsp;=\u0026thinsp;0.75, p\u0026thinsp;=\u0026thinsp;0.4519; I2\u0026thinsp;=\u0026thinsp;72%, p\u0026thinsp;=\u0026thinsp;0.0274], 0.26 [(95% CI: -0.16, 0.68), z\u0026thinsp;=\u0026thinsp;1.23, p\u0026thinsp;=\u0026thinsp;0.2200; I2\u0026thinsp;=\u0026thinsp;0%, p\u0026thinsp;=\u0026thinsp;0.3783], -0.67 [(95% CI: -1.60, 0.26), z=-1. 42, p\u0026thinsp;=\u0026thinsp;0.1570; I2\u0026thinsp;=\u0026thinsp;89%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001], and \u0026minus;\u0026thinsp;0.02 [(95% CI: -0.24, 0.20), z=-0.17, p\u0026thinsp;=\u0026thinsp;0.8652; I2\u0026thinsp;=\u0026thinsp;0%, p\u0026thinsp;=\u0026thinsp;0.6718].\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThis meta-analysis indicates that psychological intervention effectively improves fatigue and physical function in patients with SLE.\u003c/p\u003e","manuscriptTitle":"Effects of psychological interventions for adults with systemic lupus erythematosus: a network meta-analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-18 17:08:27","doi":"10.21203/rs.3.rs-4509580/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"95ef2a0d-9967-4b23-823b-cf79f51ee009","owner":[],"postedDate":"June 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-10-21T08:24:32+00:00","versionOfRecord":[],"versionCreatedAt":"2024-06-18 17:08:27","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4509580","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4509580","identity":"rs-4509580","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}