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| Susan Bartlett, Ph.D.
High levels of depressive symptoms are common in persons with RA, with prevalence estimates ranging from 15%-45%. In the Johns Hopkins Arthritic Center, we have previously reported an estimated prevalence of depression of 30% in RA patients.1 While discussion continues about whether depressive symptoms precede or form in reaction to the diagnosis and reality of living with rheumatoid arthritis, several abstracts have focused on the causes and/or potential effects of depression on physical and psychological functioning.
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We evaluated depressive symptoms in RA patients and their relation to psychological and health outcomes. 77 patients completed rheumatology evaluations, measures of depression, social support, well-being, and quality of life (QOL) at baseline and 8 months later. Disease activity was not related to age, education, social support or QOL, but modestly related to gender (r =-.322) and depressive symptoms (r = .362; ps < .01). In contrast, depression scores were associated (ps < .01) with positive (r = -.532) and negative (r = .385) affect, lower social support (r = -.304) impaired QOL (rs from -.423 to -.611) and affect, symptoms, and physical functioning (PF) of the RA QOL (rs -.416 to -.542). At follow-up, similar relationships were observed. After controlling for baseline physical functioning, depressive symptoms were the best predictor of subsequent levels of functioning. We concluded that depressive symptoms are an important and independent contributor to poor health outcomes. | ||
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The goal of this investigation was to evaluate risk factors that potentially mediate the relationship between major depression and arthritis and other chronic illnesses. Using a nationally representative sample from the 1996 Health and Retirement Survey, the investigators assessed the standardized prevalence rates (PR) and attributable risk (AR) for major depression for chronic illnesses (including arthritis), functional limitations, instrumental ADL, sociodemographic factors and medical access. Results: Functional limitation accounted for the largest proportion of attributable risk (34%; CI 25 43%). Nearly two thirds (i.e., 64%) of adults with arthritis have functional limitations. Adults with arthritis also have the greatest AR for depression (AR 19%; CI 10-26%), relative to other chronic conditions including CVD, diabetes, lung disease, stroke, and obesity. The excess rates of major depression among people with arthritis are largely due to functional limitations. Thus, older persons with functional limitations due to arthritis are at elevated risk for major depression and should be routinely screened for depressive symptoms. Addressing the functional limitations experienced by older individuals with arthritis is important in managing depression; conversely, treating depression may also reduce functional limitations. | ||
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In addition to having higher rates of depression, patients with RA are also more likely to report hostile attitudes than persons in the general population. Because hostility and depression are both associated with early-onset cardiovascular disease, the goal of this study was to determine whether RA-specific risk factors were related with depressive symptoms and hostile attitudes and explore the relationship between these factors and markers of sub clinical atherosclerosis. Subjects were 143 women, who were at least 30 years of age and had been diagnosed with RA for at least two years. Depression and hostility were assessed using the CES-D and the Cook Medley Hostility Scale. Aortic and coronary calcium was assessed using electron beam computed tomography (EBT). Results: The highest levels of hostility and depression were seen in women with greater functional disability and poorer health perceptions. RA-risk factors associated with higher hostility and depression included smoking, being obese and having more joint disease (i.e., more joint tenderness and deformity). Women with the lowest levels of hostility and depression were those who reported regular rheumatology and use of NSAIDS > 1 month. Overall, women with higher depressive symptoms and hostility had greater evidence of aortic and coronary calcification using electron beam computed tomography), though the differences did not reach statistical significance. However, traditional biomarkers of both RA and CVD (ESR, CRP, fibrinogen, albumin, cholesterol and triglycerides) did not differ significantly by depression and hostility status. In summary, as in other populations, poor health habits may cluster (e.g., being overweight, smoking), resulting in increased psychological distress. Preliminary evidence suggests that, as in cardiovascular disease, psychological factors may be a role in the development of early atherosclerosis in patients with RA, though potential pathways remain unclear. | ||
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This study evaluated data from four ethnic groups (322 African American, 345 Asian Americans, 393 Caucasian Americans and 318 Hispanic) of patients participating in a clinical trial for treatment of knee OA. Depression status was assessed using the Patient Health Questionnaire 9 (PHQ-9), a self-administered instrument that has been shown to reliably identify depressive symptoms and grade symptom severity.ref 2 Pain was assessed with a 100-mm VAS and function was assessed using the WOMAC. Results: The prevalence of depression in the group was 14% and varied by race/ethnicity. Asian Americans and Caucasian Americans had the lowest rates of depression (i.e., 9% and 10%, respectively), while 18% of African Americans and 21% of Hispanics were classified as depressed. Among all groups, patients who were depressed reported greater pain and worse function. Even after adjusting for age, sex, OA medication use, pain and function, depressed patients were much more likely to rate their pain medications as significantly less effective. In summary, depression was prevalent among persons with OA, was highest in African Americans and Hispanics and associated with worse pain and functioning. The evaluation of pain medication effectiveness was influenced by depressive status, and varied by ethnic group. The investigators noted that prolonged reports of ineffective pain relief may be an important cue for providers to evaluate for depressive symptoms. In addition, the belief that pain medications are ineffective may influence adherence to medications. | ||
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Editorial Comments for all abstracts: Depression is an important co-morbidity to assess in arthritis patients. As functional limitations increase, so too does the likelihood of major depression, especially in older patients. Depression is twice as common in women as in men, with rates highest in the 25-44 year old age group (in both men and women).ref 3 Depression is associated with significant impairments in health, well-being and quality of life, and may contribute to the development or worsening of cardiovascular disease. Notably, arthritis patients who are depressed experience more pain and greater functional impairment, and are more likely to report their pain medications are less effective. Conversely, reports of prolonged, ineffective pain relief should cue providers to evaluate the presence of depressive symptoms. Finally, research in other chronic illnesses, such as cardiovascular disease, have shown that even low levels of depressive symptoms (i.e., well below what has been traditionally regarded as clinically significant) have recently been shown to have an important and negative effect on morbidity and mortality.ref 4 Effective treatments for depression exist and include psychotherapy, medications or their combination. Thus it is essential that clinicians identify and assess depressive symptoms in their patients with arthritis. | ||
| Center for Epidemiological Studies-Depression Scale | ||
The Center for Epidemiological Studies-Depression Scale (CES-D) is a 20-item scale that was developed by the National Institute of Mental Health to detect major or clinical depression in adolescents and adults.ref 5 The CES-D is a self-administered questionnaire that is widely used in research and clinical settings and takes less than 10 minutes to complete. Scores > 16 are suggestive of clinically significant levels of depressive symptoms. In persons with RA, scores > 19 are strongly suggestive of major depressive disorder.ref 6 (See a copy of the CES-D in PDF format). | ||
| :References | ||
| 1. Bartlett SJ, Piedmont RL, Bilderback A, Matsumoto A, Bathon JM. Spirituality, well-being and quality of life in persons with rheumatoid arthritis. Arthritis Care & Research 49(5), 2003.
2. Kroenke K, Spitzer RL, Williams JBW. The PHQ-9 - Validity of a brief depression severity measure. J Gen Intern Med 16(9):606-613, 2001. 3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders:DSM-IV. 4th ed. Washington, DC: Author, 1994. 4. Bush DE, Ziegelstein RC, Tayback M, Richter D, Stevens S, Zahalsky H et al. Even minimal symptoms of depression increase mortality risk after acute myocardial infarction. Am J Cardiol 88(4):337-341. 5. Radloff LS, Locke BZ. The community mental health assessment survey and the CES-D Scale. Community Surveys of Psychiatric Disorders. New Brunswick, NJ: Rutgers University Press, 1986. 6. Martens MP, Parker JC, Smarr KL, Hewett JE, Slaughter JR, Walker SE. Assessment of depression in rheumatoid arthritis: a modified version of the center for epidemiologic studies depression scale. Arthritis Rheum 49(4):549-555, 2003. | ||
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