Osteoarthritis, sometimes called degenerative joint disease, mostly affects the cartilage, the slippery tissue that covers the ends of bones in a joint. Healthy cartilage allows bones to glide smoothly over one another and absorbs energy from the shock of physical movement. In osteoarthritis, the surface layer of cartilage breaks down and wears away, causing pain, swelling, and loss of movement in the joint. Small growths called bone spurs also may grow on the edges of the joint, and small pieces of bone or cartilage can break off and float inside the space around the joint, causing more pain and damage.[1,23]

Osteoarthritis most often occurs in the knees, hips, lower back, neck, ends of fingers, and thumbs. Management of osteoarthritis focuses on decreasing pain and improving joint movement, which may involve multiple approaches, including exercise, rest, joint care, pain and stress management techniques, weight control, dietary changes, medications, surgery, and treatments such as nutritional supplements and acupuncture.[2,23] Self-management programs have been shown to help people understand and cope with the disease.[4,5,12,18,19]

Osteoarthritis affects only a person's joints. In contrast, other types of arthritis may have more general effects. For example, in addition to causing inflammation and affecting other parts of the body such as internal organs, rheumatoid arthritis may make people feel tired and feverish.[23]

Interview #1:

'Managing Osteoarthritis'

John H. Klippel, MD, is medical director of the Arthritis Foundation, serving as the organization's principal medical liaison for activities related to biomedical research, professional education, and medical affairs. Dr. Klippel has more than 25 years of experience in rheumatology and biomedical research related to arthritis. Before joining the Arthritis Foundation, he was clinical director of the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) at the National Institutes of Health and previously was a senior investigator in the Arthritis and Rheumatism Branch at NIAMS.

Q: What are the risk factors for osteoarthritis?

A: One of the risk factors for osteoarthritis is age. Another risk factor, particularly for hip and knee osteoarthritis, is being overweight. Injury to a joint or a lack of medical attention to an injury also increases the risk of osteoarthritis.

Q: If age is a risk factor, does that mean that osteoarthritis is an inevitable part of aging?

A: No. It's a misconception that everyone gets osteoarthritis. Joint problems are not necessarily a part of growing old.

Q: What are some of the goals in managing osteoarthritis?

A: One goal is to reduce pain. The second goal is to prevent osteoarthritis from interfering with daily life so that the person is able to do what is important to him or her. The third goal is to prevent progression of the disease and to prevent it from becoming chronic.

Q: What health care professionals might be involved in helping a person with osteoarthritis to manage the disease?

A: In most instances, the key health care provider, and the original point of contact, is the primary care physician. Sometimes, a rheumatologist -- a specialist in the care of patients with arthritis -- will confirm the diagnosis and coordinate the care. The rheumatologist also can offer management advice about issues like medications, the use of physical therapy, and the need for surgical intervention. Occasionally, with advanced osteoarthritis in which there is a lot of joint destruction, surgeons play an important role in either correcting the alignment abnormalities of the joint that contribute to osteoarthritis or doing a total joint replacement. In addition, the team might include a nurse or nurse practitioner who offers educational advice or helps with coordinating care; a pharmacist who addresses questions about medications or alternative therapies; a physical therapist who helps with muscle strengthening, suggests exercises, or offers advice about protecting the joint; and an occupational therapist who looks at the ways in which the arthritis is affecting the patient's life and the modifications that can be made to make life easier.

Q: Does osteoarthritis have any effects that might require counseling?

A: Yes. Because of the disease's impact on daily living, people with osteoarthritis may develop various degrees of depression. In these instances a counselor can help the patient deal with the depression. Counselors can also help patients to understand that they are in control -- that the decisions they make in their own care and how they approach their arthritis are very important in determining the outcome.

Q: How can the patient be an effective member of the health care team?

A: First, the patient must be a good communicator. It is critical that people with osteoarthritis be able to describe what they are experiencing and how the osteoarthritis affects their lives. The professionals need to help patients feel comfortable enough to share their experience with members of the health care team. The patient also needs to understand that he or she is really in control. To gain control, the patient must learn self-care strategies and actively participate in managing the arthritis rather than just following directions from the health care team.

For many people, osteoarthritis is a chronic condition that they will live with for the rest of their lives, so trying to monitor whether things are improving, staying the same, or worsening on a regular basis is very important. In addition, we see a lot of new medication developments and new surgical and therapy techniques, so it is important to ask on a regular basis whether these new developments might make a difference to the patient.

Q: Can you give some examples of these new developments?

A: Within the past two years, new and safer drugs, such as the COX-2 inhibitors, have been developed to treat both the pain and the inflammation that one sees in osteoarthritis. In addition, in the past two years, we have seen the introduction of a new approach whereby a material called a viscosupplement is actually injected into people with osteoarthritis of the knee. These approaches can help relieve pain and potentially prevent the progression of the disease. Patients and their health care providers need to think about these new developments and then ask whether they might have some benefit.

Q: There are a lot of dietary supplements and other non-traditional approaches on the market. How would a patient know what is important, what works, what doesn't work, and what to ask about?

A: The Arthritis Foundation has taken a very active role in this. For example, the Foundation published the Arthritis Foundation's Guide to Alternative Therapies,[13] which is a tool to educate people with arthritis, as well as health care providers, about non-traditional approaches to managing arthritis. We are strong believers in the need to educate both the public and the professional community about these approaches because they are commonly used by patients. It's also very important for people who are using alternative approaches to communicate with their doctors so that the doctor is aware that the patient is using these approaches.

Interview #2:

'Putting the Patient in Charge: A Short Course in Self-Management'

Kate Lorig, RN, DrPH, is an associate professor at the Stanford University School of Medicine and director of the Stanford Patient Education Research Center. She and her colleagues developed the Arthritis Self-Help Course, which is offered by Arthritis Foundation chapters nationwide. The course has been replicated in Canada, Great Britain, Australia, and other countries and has been used as a model for programs to teach self-management of other chronic diseases. Dr. Lorig also is co-author of The Arthritis Helpbook, a companion to the Arthritis Self-Help Course.

Q: Why is the patient's behavior so important in managing chronic conditions like osteoarthritis?

A: No medications or medical interventions can cure or stop the progress of osteoarthritis, although medications can ease the pain to some extent. Medical management is of limited value until one gets to the point of needing joint replacement. Therefore, if one wants to have the best quality of life in the face of this disease, then one needs to self-manage. Even with joint replacement, self-management is very important because the success of the surgery depends very much on how much the patient cooperates in exercising to strengthen muscles before and after the operation.

Q: How do you define self-management?

A: Self-management is using the knowledge and skills to deal with the disease in three domains on a day-to-day basis. The first domain is medical management, which deals with questions such as "When do I take medication?"; "When don't I take medication?"; "How do I know if this medication is right?"; "Should I have joint replacement surgery?"; "Should I not have joint replacement surgery?"; and "How do I make those decisions?" The second domain of self-management is dealing with roles and functions in life, so the person can continue with activities that are important to him or her -- cooking, knitting, hiking, playing with grandchildren, shopping in the mall, woodworking, or whatever is meaningful. The third domain of self-management is learning skills to deal with the emotional changes -- fear, anxiety, depression, frustration -- that come with all chronic illnesses.

Q: What are the components of self-management?

A: First, the person needs to understand what the disease is and to work in partnership with the health care provider so that the patient can help make decisions. The person also needs to understand how to exercise and how to change an exercise regime based on the trends and tempo of the disease. Self-management also involves learning cognitive self-management strategies. Worrying and fretting often serves to increase pain -- not just in osteoarthritis but in all diseases. That worrying and fretting as well as depression and anxiety ends up causing more pain, so it is important to learn strategies to reduce this anxiety and worry.

Q: If the person with arthritis becomes adept at self-management, then what role does the health care professional play?

A: Self-management doesn't mean the person is managing the disease all alone. It involves becoming a partner with health care providers so that the patient asks the questions and the patient and health care provider make decisions together. The provider only sees the patient at set points in time. You can have exactly the same symptoms at three points in time, yet at one point your symptoms may be getting worse, at another point they may be staying about the same, and at a third point they may be getting better. If you don't report which point you are at, the physician may think your disease is static, when in fact your disease isn't static at all. Therefore, being an accurate reporter and observer of the disease in your body is very important because there is no other way -- especially with osteoarthritis -- that the physician can understand the course of the disease. No lab tests or x-rays can show that.

Q: What other advice can you offer to people with osteoarthritis to help them work effectively with their physicians and other health professionals?

A: Communicating well and reporting accurately are most important. People also need to understand that the options for medical treatment for osteoarthritis are very limited -- that outside of joint replacement there is very little a physician can do for osteoarthritis. Sometimes people expect that the doctor is going to make it all well when, in fact, that just doesn't happen with osteoarthritis. People also need to understand their medications. We usually think of drugs as things that will help us get better, but sometimes they are meant to stop us from getting worse or to help us get worse more slowly. Sometimes patients think a drug isn't working because they don't see an effect.

Q: Does the health care professional's role increase and the patient's role decrease as the disease progresses?

A: It's just the opposite. In the early stages of the disease, it is up to the health care professional to educate the patient -- to help the patient understand the disease and to choose the best treatment from among the limited treatments that are available. Once that is done, there is not much more the health professional can do short of joint replacement surgery, so the patient's role becomes ever more important in managing the disease. But it's important to remember that arthritis pain changes over time; complications develop when people get new diseases that affect their ability to manage their arthritis. People need to maintain ongoing partnerships with their health care providers over time to make sure they are making course corrections in their medical management as well.

Q: What evidence is there that self-management is effective?

A: About 150 studies have been conducted on the subject. To sum up the results of these studies, we can say that people who actively self-manage have between 20 and 30 percent less pain, they end up being more physically active, and they are able to slow their decline and disability.

Weighing Alternatives: Doctor-Patient Communication Key:

Two out of three people with arthritis turn to complementary or alternative approaches to manage the pain and other symptoms of their disease, and nearly one in four say they have used three or more alternative therapies, report researchers at the Indiana University School of Medicine and the Regenstrief Institute for Health Care. Those with osteoarthritis and those with severe pain are more likely than others to use alternative therapies.[24]

Some of these approaches are gaining interest and serious consideration in the medical and research communities.

For example, in the fall of 1999, Belgian researchers released evidence at the American College of Rheumatology's annual scientific meeting that a daily dose of the dietary supplement glucosamine sulfate -- a widely used, over-the-counter dietary supplement made from shellfish --decreases the progression of knee osteoarthritis. Furthermore, studies recently funded by the National Institutes of Health will examine the effectiveness of glucosamine sulfate and another supplement, chondroitin sulfate, as well as the effectiveness of acupuncture in alleviating the effects of knee osteoarthritis.

The Indiana University study found that despite the common use of alternative approaches, more than half of arthritis sufferers using these approaches do not tell their physicians -- an issue of concern to some in the medical community. According to the patients, the physician did not ask or the patient forgot to tell their physician.[24]

Another study sponsored by the Arthritis Foundation's magazine, Arthritis Today, found that those who use alternative therapies don't tell their doctors because they believe the doctor does not know enough to advise them, there is no reason to tell, or they are afraid the doctor will not approve.[14]

Leigh Callahan, PhD, associate director of the Thurston Arthritis Research Center at the University of North Carolina at Chapel Hill, served as lead researcher for the Arthritis Today survey. "The population in general is turning more often to alternative therapies," she says. "Arthritis is a prime disease for alternative therapy use because it's a chronic disease without a cure and because the disease is controlled through pain management."

Many people with arthritis take physician-prescribed medications while using alternative therapies, but harmful interactions can occur. Therefore, Callahan notes, "It's important for the physician to have an understanding of all of the strategies the patients are using to manage their condition."

Complementing the Arthritis Today consumer study, the Research Center found that nearly half of respondents to its survey of physicians believe that some alternative therapies are effective and recommend them, while more than a third believe they are effective but do not recommend them.

Twelve percent of the physicians said they initiate discussion of alternative therapies with the intention of recommending some, 27 percent initiate discussion with patients but do not necessarily recommend alternative therapies, and 59 percent discuss alternative therapies if the patient initiates the discussion. Women physicians were more likely than men to have favorable attitudes toward alternative therapies and to initiate discussion about them.

"Some patients want to be equal partners in the care process. Others really want to take the lead. Still others want to have the physician direct the care," Callahan explains. "The difficulty is finding a match between the patient's and the physician's style. Ideally, physicians would be able to assess a patient to determine what type of partnership or relationship the patient wants and then adapt the communication approach based on the patient's needs."

Management Must Go Beyond Drugs:

The past couple of years have seen the introduction of COX-2 inhibitors, a new drug class that offers the pain-relieving benefits of non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, yet are far less likely to cause potentially life-threatening gastrointestinal ulcers.[11,15] The new drugs, marketed as Celebrex and Vioxx, received Food and Drug Administration approval in 1998 and 1999. Doctors often prescribe NSAIDs as a second line of defense for osteoarthritis pain treatment, generally when the milder analgesics like Tylenol don't work.

Despite the introduction of the COX-2 inhibitors, many in the arthritis medical community believe that behavioral and other nonmedicinal approaches are as important -- if not more important -- than prescribing drugs in the long-term management of osteoarthritis.[7,10,26]

"Management of the patient with osteoarthritis should be comprehensive," writes Kenneth D. Brandt, MD, director of the Indiana University Multipurpose Arthritis and Musculoskeletal Diseases Center. "Indeed, analgesics and non-steroidal anti-inflammatory drugs should not be used as a sole, or even primary, therapy but as adjuncts to nonmedicinal aspects of the treatment program."[7]

Research indicates that pain and disability are highly influenced by the psychological state of the patient. A number of strategies help patients exercise control over their mental state, outlook, and attitudes to alter the condition of their body. For example, among the strategies used in the Arthritis Self-Help program and other programs are relaxation and meditation training, guided imagery, cognitive reappraisal of events, anger management, stress management, biofeedback, and pacing of activities. These strategies are part of a repertoire of techniques and activities that patients can develop to become effective self-managers of chronic diseases such as osteoarthritis.[8]

Experts like Brandt recommend that osteoarthritis management programs sample from a range of behavioral and biomechanical approaches: education about joint protection, weight loss counseling for obese people, development of pain-coping skills, enhancement of social support, application of heat or cold to painful joints, exercise and muscle strengthening, and use of a cane or a walker. Development of pain-coping skills is especially important, given that pain is the most pressing concern for many people with arthritis, bringing with it depression, psychological stress, sleep disturbance, and reduced function.[6]

Exercise and Osteoarthritis: Just Do It:

Two decades ago, the suggestion that a person with osteoarthritis go to the gym to lift weights or head outdoors for a vigorous daily walk would have raised eyebrows. Today, thanks to a growing body of empirical evidence [9,19,21,26] and to the persistence of exercise advocates like Marian Minor, PT, PhD, physical activity has become a recommended item on the osteoarthritis management menu.

Minor, who is associate professor of physical therapy at the University of Missouri-Columbia and a researcher with the federally funded Missouri Arthritis Research and Training Center, has championed the idea that exercise can safely and effectively alleviate the pain and disability associated with osteoarthritis.

"In general, our population doesn't get adequate exercise for health. That becomes worse as people get older, retire, and give up some of their daily work and recreational activities," Minor explains. "When people have arthritis, they very often limit what they do, so it compounds the problem of inactivity. We now know from the research that exercise improves health but doesn't make arthritis worse."

People with osteoarthritis benefit from two types of exercise. Regular physical, aerobic activity such as walking, swimming, gardening, or raking leaves promotes overall health and reduces the risk of obesity, diabetes, heart disease, and other chronic conditions. Therapeutic or rehabilitation exercise reduces arthritis pain, stiffness, and weakness of specific joints and prevents unnecessary disability.

Despite its benefits, many people with arthritis face barriers to exercise. Pain, fear of causing pain, fear of damaging joints, low self-expectations, and lack of self-confidence all contribute. Moreover, many health care professionals in the past have not promoted exercise as part of arthritis management.

Minor firmly believes that collaboration among health professionals and with the patient is key to successful arthritis management and exercise management. "The patient should decide what he or she is going to do and how he or she is going do it. The professionals should be consultants to the patient. They can provide information, they can provide encouragement, and they can provide support and answer questions, but when we're talking about lifelong exercise, each individual must choose activities and places and times that are reasonable for him or herself."

For Better or Worse: Supporting Spouses' Needs:

On their wedding days, most couples vow to stand by one another "in sickness and in health, for better or for worse," although no marriage manual exists to instruct couples how to deal with the effects of chronic illnesses like arthritis. In recent years, however, behavioral scientists have begun to explore the ways in which chronic disease affects marriage, as well as couples' needs and coping skills when faced with arthritis.[16]

For example, researchers at the Thurston Arthritis Research Center at the University of North Carolina (UNC) at Chapel Hill are looking at social support and psychological adjustment in couples in which one spouse has osteoarthritis or rheumatoid arthritis.

"Epidemiological studies have shown that people who have better social support live longer, healthier, and happier lives," explains Robert DeVellis, PhD, the study's principal investigator and research professor of health behavior at UNC. The researchers are examining social support skills such as "empathic accuracy," the ability of one spouse to "read" the other spouse's thoughts or feelings, and "awareness of feelings," the ability to recognize the presence of feelings in oneself. The volunteers' ages ranged from the middle 40s to the late 80s, and some of the couples had been married for more than 50 years.

To measure empathic accuracy, the researchers asked each couple to discuss a selected topic while being videotaped. The couples were then separated, and each spouse independently reviewed a copy of the videotape and identified time points when he or she was thinking or feeling something not expressed verbally. Later, the researchers asked the other person to identify what his or her spouse thought or felt at the identified time points, and the researchers derived an empathic accuracy score.

"What we found was really quite dramatic," DeVellis says of the preliminary study results. "For the women who had arthritis, the best single predictor of psychological adjustment was their husbands' empathic accuracy skill. In other words, wives whose husbands were good at understanding their thoughts and feelings were better adjusted psychologically."

The relationship of empathic accuracy to psychological adjustment was not "symmetrical," however, DeVellis points out. "Men did not seem to benefit from their wives having higher levels of empathic accuracy. Their psychological adjustment seemed to have more to do with attributes of themselves than attributes of their spouses. The men who were more attentive to and better able to regulate their own moods had better psychological adjustment three months later."

Steps to Collaborative Management of Chronic Conditions:

Once a chronic condition has been identified, patients do best if there is on-going commitment by patients, their families, and their health care providers to work together over time. There is strong evidence that the following simple steps taken by providers and patients can significantly improve health and well-being.

1. Define the problem jointly: Providers often define problems in terms of medical diagnoses and treatments, while patients define them in terms of the impact that symptoms have on their lives. Patients are more likely to benefit when these two perspectives are harmonized in a shared definition of the problem.

2. Develop a common action plan: Managing chronic conditions is more successful when providers and patients focus on a few specific concerns, identify realistic goals, and commit to a joint plan of action in which the responsibilities of both parties are clear.

3. Explore possible programs and services: Many chronic conditions are better managed when patients are referred by providers to special support services or behavior change programs tailored to their priorities, needs, and preferences.

4. Track progress and anticipate course corrections: Scheduled, on-going communication between providers and patients is critical to tracking progress in achieving goals, identifying potential barriers and complications, and making needed adjustments in the joint plan of action.

For more information on the Health Behavior Change in Managed Care Project, visit our Web site www.cfah.org.

The Research:

1. Arthritis Foundation. (1998). Arthritis types and prevalence. http://www.arthritis.org/resource/fs/arthritis.asp.

2. Arthritis Foundation. (1998). Osteoarthritis fact sheet. http://www.arthritis.org/resource/fs/osteoarthritis.asp.

3. Arthritis Foundation, Association of State and Territorial Health Officials, and Centers for Disease Control and Prevention. (1999). National Arthritis Action Plan: A Public Health Strategy.

4. Barlow JH, Turner AP & Wright CC. (1998). Long-term outcomes of an arthritis self-management programme. British Journal of Rheumatology, 37(12):1315-9.

5. Barlow JH, Williams B & Wright CC. (1999). Instilling the strength to fight the pain and get on with life: Learning to become an arthritis self-manager through an adult education programme. Health Education Research, 14(4):533-44.

6. Bradley LA & Alberts KR. (1999). Psychological and behavioral approaches to pain management for patients with rheumatic disease. Rheumatic Disease Clinics of North America, 25(1):215-32.

7. Brandt KD. (1998). The importance of nonpharmacologic approaches in management of osteoarthritis. The American Journal of Medicine, 105(1B):39S-43S.

8. Broderick, JE. (2000). Mind-body medicine in rheumatologic disease. Rheumatic Disease Clinics of North America, 26(1), 161-76, xi.

9. Ettinger WH, Burns R, Messier SP, Applegate W, et al. (1997). A randomized trial comparing aerobic exercise and resistance exercise with a health education program in older adults with knee osteoarthritis: The Fitness Arthritis and Seniors Trial (FAST). Journal of the American Medical Association, 277(1):25-31.

10. Felson DT. (1998). Nonmedicinal therapies for osteoarthritis. Bulletin on the Rheumatic Diseases. 47(2):5-7.

11. Hawkey C, Laine L, Simon T, Beaulieu A, et al. (2000). Comparison of the effect of rofecoxib (a cyclooxygenase 2 inhibitor), ibuprofen, and placebo on the gastroduodenal mucosa of patients with osteoarthritis: A randomized, double-blind, placebo-controlled trial. Arthritis and Rheumatism, 43(2):370-7.

12. Holman HR & Lorig KR. (1997). Overcoming barriers to successful aging: Self-management of osteoarthritis. Western Journal of Medicine, 167(4):265-8.

13. Horstman J. (1999). The Arthritis Foundation's Guide to Alternative Therapies. Atlanta, GA: The Arthritis Foundation.

14. Horstman J. (1999). The dangerous divide: Why doctors aren't asking and you aren't telling. Arthritis Today, 13(6), 34-41.

15. Keefe FJ, Caldwell DS, Baucom D, Salley A, et al. (1996). Spouse-assisted coping skills training in the management of osteoarthritic knee pain. Arthritis Care and Research, 9(4):279-91.

16. Keefe FJ, Caldwell DS, Baucom D, Salley A, et al. (1999). Spouse-assisted coping skills training in the management of knee pain in osteoarthritis: Long-term followup results. Arthritis Care and Research, 12(2):101-11.

17. Laine L, Harper S, Simon T, Bath R, et al. (1999). A randomized trial comparing the effect of rofecoxib, a cyclooxygenase 2-specific inhibitor, with that of ibuprofen on the gastroduodenal mucosa of patients with osteoarthritis. Gastroenterology, 117(4):776-83.

18. Lorig KR, Sobel DS, Stewart AL, Brown BW Jr, et al. (1999). Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization: A randomized trial. Medical Care, 37(1):5-14.

19. Mazzuca SA, Brandt KD, Katz BP, Hanna MP & Melfi CA. (1999). Reduced utilization and cost of primary care clinic visits resulting from self-care education for patients with osteoarthritis of the knee. Arthritis and Rheumatism, 42(6):1267-73.

20. Minor MA. (1996). Arthritis and exercise: The times they are a-changin'. Arthritis Care and Research, 9(2):79-81.

21. Minor MA. (1999). Exercise in the treatment of osteoarthritis. Rheumatic Disease Clinics of North America, 25(2):397-415.

22. National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention. (1999). Targeting arthritis: The nation's leading cause of disability, At-a-Glance 1999. http://www.cdc.gov/nccdphp/art-aag.htm.

23. National Institute of Arthritis and Musculoskeletal and Skin Diseases. Handout on health: Osteoarthritis. http://www.nih.gov/niams/healthinfo/osteoarthritis/osteohandout_breaks.html.

24. Rao JK, Mihaliak K, Kroenke K, Bradley J, et al. (1999). Use of complementary therapies for arthritis among patients of rheumatologists. Annals of Internal Medicine, 131(6):409-16.

25. van Baar ME, Assendelft WJ, Dekker J, Oostendorp RA & Bijlsma JW. (1999). Effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee: A systematic review of randomized clinical trials. Arthritis and Rheumatism, 42(7):1361-9.

26. van Baar ME, Dekker J, Oostendorp RA, Bijl D, et al. (1998). The effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee: A randomized clinical trial. The Journal of Rheumatology, 25(12):2432-9.

27. Zeb S and Edwards NL. (1998). Osteoarthritis: Nonpharmacologic therapy. Clinical Reviews, Summer:14-7.

Facts of Life is prepared with assistance from:

Academy of Behavioral Medicine Research
Academy of Psychosomatic Medicine
American Academy of Nursing
American College of Neuropsychopharmacology
American Psychiatric Association
American Psychological Association
American Psychological Association-Division 38
American Psychosomatic Society
American Society of Psychiatric Oncology
American Sociological Association
Association for Applied Psychophysiology and Biofeedback
College on Problems of Drug Dependence
Institute for the Advancement of Social Work Research
International Psycho-Oncology Society
International Society for Traumatic Stress Studies
Society of Behavioral Medicine
Society for Developmental and Behavioral Pediatrics
Society for Public Health Education
Society for Research on Nicotine and Tobacco

The Center for the Advancement of Health, a nonprofit organization, promotes the science underlying the relationship between mental and physical states that influence health and illness, and works to turn that knowledge into practical health care solutions. The Center was founded by the John D. and Catherine T. MacArthur Foundation and the Nathan Cummings Foundation, which continue to provide core funding. Funding for this series was provided by the Robert Wood Johnson Foundation.

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