The relationship between disease activity and depression in patients with Behcet disease and rheumatoid arthritis

Psychiatric Symptoms and Cognitive Disorders in Behçet's Disease: A Single-Center, Cross-Sectional Study

BACKGROUND

Behçet's disease (BD) is a rare form of vasculitis involving both veins and arteries of all calibers. Psychological symptoms and cognitive impairment appear to be frequent, but few data are available.

METHODS

All consecutive patients in our center fulfilling the 2013 BD criteria underwent a psychometric evaluation with auto- (SCL-90-R and Modified Fatigue Index) and hetero-questionnaires (MINI). A standardized test battery assessed cognitive dysfunction. Data were correlated with BD activity as well as quality of life (SF-36).

RESULTS

We included 20 consecutive patients (16 men, four women) with a median [IQR] age of 38 (30.0-45.5) and a median disease duration of 7 years (1.8-11.0). Five patients had an abnormal brain MRI. The SCL-90-R questionnaire highlighted eight psychopathological profiles (42.1%) that correlated with altered quality of life and more severe fatigue. The most frequent symptoms were anxiety (9/19, 47.4%), somatization (8/19, 42.1%) and phobia (5/19, 26.3%). Psychopathological symptoms appeared to be more severe, but not more frequent, in neuro-Behçet's patients. Based on standardized cognitive evaluation, nine patients had cognitive impairment defined by three or more altered tests. Notably, 6/9 patients did not have any complaint of memory loss and were thus considered ansognostic.

CONCLUSION

Cognitive involvement was significantly associated with BD activity score (BSAS) but not with brain MRI abnormalities.

The Link Between Autonomic Nervous System and Rheumatoid Arthritis: From Bench to Bedside

Neuronal stimulation is an emerging field of research focused on the management and treatment of various diseases through the reestablishment of physiological homeostasis. Electrical vagus nerve stimulation has recently been proposed as a revolutionary therapeutic option for rheumatoid arthritis (RA) in combination with or even as a replacement for conventional and biological drugs. In the past few years, disruption of the autonomic system has been linked to RA onset and activity. Novel research on the link between the autonomic nervous system and the immune system (immune-autonomics) has paved the way for the development of innovative RA management strategies. Clinical evidence supports this approach. Cardiovascular involvement, in terms of reduced baroreflex sensitivity and heart rate variability-derived indices, and mood disorders, common comorbidities in patients with RA, have been linked to autonomic nervous system dysfunction, which in turn is influenced by increased levels of circulating pro-inflammatory cytokines. This narrative review provides an overview of the autonomic nervous system and RA connection, discussing most of the common cardiac and mental health-related RA comorbidities and their potential relationships to systemic and joint inflammation.

Association of lifestyle elements with self-rated wellness and health status in patients with Behcet's disease

Background

Assessment of the association of various lifestyle factors and wellness and health status in patients with Behcet’s disease was the main goal of this study.

Methods

Demographic information, body mass index, smoking habit, mood status, sleep quality, physical activity levels, nutritional data, symptoms, signs, laboratory findings and patient reported outcome (self-rated wellness and health) in 52 patients with Behcet’s disease were collected in this cross-sectional study. A multivariable linear regression model was used to assess the association of self-rated wellness and health status and lifestyle factors, adjusted for age, sex, BMI, major symptoms and signs, as well as laboratory findings.

Results

Female to male ratio was 21/31, and the mean age of participants was 44 years. Mean self-rated wellness and health score was 14.6 out of 20. Oral and genital aphthous, ocular involvement, pathergy, and skin involvement were observed in 100, 52, 92, 36.5, and 9.5% of patients, respectively. The mean values of sleep, mood and nutrition quality scores were 17.7 (out of 70), 13.8 (out of 35), and 9 (out of 21), respectively. Univariable regression analysis showed a significant association between sleep quality, mood status, and disease duration, with patients’ status in terms of self-rated wellness and health. In multivariable linear regression, sleep quality was the only significant predictive variable associated with self-rated wellness and health.

Conclusion

Sleep quality was the most important factor associated with low self-rated wellness and health status in patients with Behcet’s disease.

Systemic vasculitis and patient-reported outcomes: how the assessment of patient preferences and perspectives could improve outcomes

The systemic vasculitides are a group of multisystem diseases, which can be life and organ threatening. High-dose immunosuppressants are required to control inflammation in vital organs, such as the kidneys, lungs, skin, joints, and eyes. Patients report a range of impacts on their health-related quality of life due to symptoms, irreversible damage, and the adverse effects of medications. The measurement of patient perspectives within clinical studies in vasculitis is essential to capture outcomes of greatest importance to patients. Validated generic, disease-specific and symptom-specific patient-reported outcomes available for use in patients with systemic vasculitis are reviewed here.

Effects of Conventional and Biological Drugs Used for the Treatment of Rheumatoid Arthritis on the Quality of Life and Depression

Objective

This study aims to investigate the effects of conventional and biological drugs used for the treatment of rheumatoid arthritis (RA) on patients' quality of life, depression, and anxiety.

Materials and Methods

A total of 80 patients with a diagnosis of RA based on the American College of Rheumatology/Annual European Congress of Rheumatology (ACR/EULAR) 2010 diagnostic criteria were included in the study. Patients were classified into two groups as follows: patients using conventional disease-modifying agents (csDMARDs) alone (Group 1, n=40) and patients using biological disease-modifying agents (bDMARDs) and a csDMARD combination (Group 2, n=40). Demographical patient data were collected. The levels of rheumatoid factor (RF) and anti-cyclic citrullinated peptide (anti-CCP) were measured in both groups. All patients completed the Disease Activity Score (DAS28), Health Assessment Questionnaire (HAQ), Short Form-36 (SF-36), Beck Depression Scale (BDS), and Hospital Anxiety Depression Scale (HADS).

Results

There was no significant difference between the two groups of patients regarding their demographical characteristics, autoantibody positivity, or DAS scores (p>0.05). HAQ scores and all parameters and summary scores of the SF-36, BDS, and HADS scores were not significantly different between the two groups (p>0.05).

Conclusion

Results of the present study showed that csDMARDs and bDMARDs, which required a more invasive administration and were associated with serious side effects, were not superior to each other in terms of their effects on patients' quality of life. csDMARD and bDMARD were also not superior to each other regarding their effects on anxiety and depression among patients with RA.

The influence of oral health and psycho-social well-being on clinical outcomes in Behçet's disease

This study was designed to investigate the association of oral ulceration and oral health factors, together with psycho-social well-being in Behçet's disease (BD), and to clarify the importance of psycho-social support of patients in the overall management of BD. The study comprised of a cohort of 146 BD patients (mean age ± SD = 39.65 ± 13.20) and 20 recurrent aphthous stomatitis (RAS) patients (mean age ± SD = 42.32 ± 11.32). Oral ulcer severity score (OUSS), Behçet's disease current activities form (BDCAF), hospital anxiety and depression scale (HADS), and the work and social adjustment scale (WSAS) were investigated. Oral health risk factors were also included. The analysis of variance, regression, and factor analysis were used to scrutinise the data. Almost 73% of patients were at high caries risk in BD and RAS groups. Thirty-nine percent of BD and forty percent of RAS had a score of BPE3 (probing depth 3.5-5.5 mm). Regression analysis revealed that OUSS and WSAS had a positive impact to increase the BDCAF score in BD patients (β = 0.395, P = 0.001; β = 0.240, P = 0.019), respectively. Dental health, periodontal health, anxiety, depression, and WSAS variables had strong loadings by factor analysis based on gender and at the time of present and absent of oral ulceration. The main oral ulcer characteristics that had significant influences on the total of oral health quality of life by 68.6% were: size, duration, ulcer-free period, and pain. The results highlighted the significant influence of oral ulceration, patients' oral health, diet, and psycho-social well-being as multi-factorial causes on increasing disease activity in BD patients.

Quality of life impairment in Behçet's disease and relationship with disease activity: a prospective study

Our aim was to prospectively investigate the impact of Behçet's disease (BD), disease activity, and clinical and demographic characteristics on different aspects of quality of life (QoL) measured by the short-form (SF)-36 QoL scale. We administered the SF-36 to 37 consecutive BD patients in different moments of disease activity, and to 23 healthy controls (HC). The eight subcategories of the SF-36 underwent statistical analysis for identifying differences and correlations. Compared to HC, BD patients showed significantly lower mean scores in all SF-36 QoL subscales except mental health and role-emotional. Females showed a poorer QoL compared to males. Disease activity evaluated by the BD Current Activity Form inversely correlated with physical functioning (ρ = -0.68, p < 0.0001), bodily pain (ρ = -0.68, p < 0.0001), role-physical (ρ = -0.64, p < 0.0001), vitality (ρ = -0.64, p < 0.0001), general health (ρ = -0.64, p < 0.0001), social functioning (ρ = -0.50, p = 0.0002), mental health (ρ = -0.48, p = 0.0004), and role-emotional (ρ = -0.40, p = 0.003). Mucosal, central nervous system (CNS), musculoskeletal and ocular manifestations were the main factors that negatively affected QoL in BD. For ocular disease, physical functioning was significantly impaired in patients with panuveitis compared to other ocular manifestations (p = 0.0002). Best-corrected visual acuity was inversely correlated with social functioning (ρ = -0.53, p < 0.0001), role-physical (ρ = -0.48, p < 0.0001), bodily pain (ρ = -0.46, p = 0.02), and mental health (ρ = -0.43, p < 0.0001). Patients with BD have a poorer QoL compared to HC, particularly for women, while the decline of QoL is closely related to the overall disease activity of BD. Single organ involvements may affect independently specific SF-36 subscales, especially mucosal, CNS, musculoskeletal, and ocular manifestations.

Healthcare burden of depression in adults with arthritis

INTRODUCTION

Arthritis and depression are two of the top disabling conditions. When arthritis and depression exist in the same individual, they can interact with each other negatively and pose a significant healthcare burden on the patients, their families, payers, healthcare systems, and society as a whole. Areas covered: The primary objective of this review is to summarize, identify knowledge gaps and discuss the challenges in estimating the healthcare burden of depression among individuals with arthritis. Electronic literature searches were performed on PubMed, Embase, EBSCOhost, Scopus, the Cochrane Library, and Google Scholar to identify relevant studies. Expert Commentary: Our review revealed that the prevalence of depression varied depending on the definition of depression, type of arthritis, tools and threshold points used to identify depression, and the country of residence. Depression exacerbated arthritis-related complications as well as pain and was associated with poor health-related quality of life, disability, mortality, and high financial burden. There were significant knowledge gaps in estimates of incident depression rates, depression attributable disability, and healthcare utilization, direct and indirect healthcare costs among individuals with arthritis.

Evidence-based Recommendations for the Management of Comorbidities in Rheumatoid Arthritis, Psoriasis, and Psoriatic Arthritis: Expert Opinion of the Canadian Dermatology-Rheumatology Comorbidity Initiative

Objective.

Comorbidities such as cardiovascular diseases (CVD), cancer, osteoporosis, and depression are often underrecognized in patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA), or psoriasis (PsO). Recommendations may improve identification and treatment of comorbidities. The Canadian Dermatology-Rheumatology Comorbidity Initiative reviewed the literature to develop practical evidence-based recommendations for management of comorbidities in patients with RA, PsA, and PsO.

Methods.

Eight main topics regarding comorbidities in RA, PsA, and PsO were developed. MEDLINE, EMBASE, and the Cochrane Library (1960–12/2012), together with abstracts from major rheumatology and dermatology congresses (2010–2012), were searched for relevant publications. Selected articles were analyzed and metaanalyses performed whenever possible. A meeting including rheumatologists, dermatologists, trainees/fellows, and invited experts was held to develop consensus-based recommendations using a Delphi process with prespecified cutoff agreement. Level of agreement was measured using a 10-point Likert scale (1 = no agreement, 10 = full agreement) and the potential effect of recommendations on daily clinical practice was considered. Grade of recommendation (ranging from A to D) was determined according to the Oxford Centre for Evidence-Based Medicine evidence levels.

Results.

A total of 17,575 articles were identified, of which 407 were reviewed. Recommendations were synthesized into 19 final recommendations ranging mainly from grade C to D, and relating to a large spectrum of comorbidities observed in clinical practice: CVD, obesity, osteoporosis, depression, infections, and cancer. Level of agreement ranged from 80.9% to 95.8%.

Conclusion.

These practical evidence-based recommendations can guide management of comorbidities in patients with RA, PsA, and PsO and optimize outcomes.

Epidemiology and management of neuropsychiatric disorders in Behçet's syndrome

Behçet's syndrome (BS) is a systemic, chronic, relapsing vasculitis, typically characterized by recurrent orogenital ulcers, ocular inflammation and skin manifestations; articular, vascular, gastroenteric and neurological involvement may also occur. Besides the other clinical features of BS, it seems relatively frequent that patients with BS develop a neurobehavioural syndrome, characterized by euphoria, bipolar disorders and paranoid attitudes, loss of insight/disinhibition, and indifference to their disease, defined as 'neuro-psycho-BS'. To date, the pathogenetic mechanism underlying neuro-psycho-BS has not been determined. It may be secondary to organic neurological involvement, or it may be related to poor quality of life and the relapsing course of the disease. Another engaging theory suggests that it could be related to the frequent observation of psychiatric symptoms during relapses or, in some cases, in the phases preceding reactivation of the disease; these elements suggest that psychiatric disorders in BS could represent a crucial element, whether a psychiatric subset or a distinct clinical feature of the disease. Moreover, it has been reported that cognitive impairment in BS can be seen with or without central nervous system involvement. Globally, psychiatric symptoms have been described as being multifaceted, ranging from anxiety disorders to depressive-bipolar disorders or to psychotic ones. In addition, some psychological characteristics of BS patients seem to predispose them to maladaptive stress management, which may lead to stress-related disorders, including anxiety and depression. Therefore, the aims of this review are to explore the epidemiology of neuro-psycho-BS by evaluating the relationship between the stress system and the multifaceted psychiatric manifestations in BS, and to summarize the therapeutic strategy used.

The impact of personality on quality of life and disease activity in patients with Behcet's disease: a pilot study

BACKGROUND

The aim of this study was to examine the personality characteristics of patients with Behcet's Disease (BD) using the Temperament and Character Inventory (TCI) compared with healthy control subjects and to investigate the relationship between the temperament and character properties and quality of life, disease activity, depression and anxiety in Behcet's patients.

METHODS

A total of 46 BD patients and 40 healthy subjects were included in the study. All patients and controls were determined using the TCI, Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders Clinical Version for Axis I disorders (SCID-CV), Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Quality of life (QOL) Instrument for Skin Disorders and Behcet Disease Current Activity Form (BDCAF).

RESULTS

BD patients demonstrated significantly lower Reward Dependence than healthy controls. Among the subscales; Explarotory Excitability, Shyness with Strangers, Attachment, Spiritual Acceptance were lower and Self-Acceptance was higher in patients compared to control subjects. Decreased quality of life and increased disease activity of the patients were correlated with increased anxiety and depression. Responsibility, Self-Forgetfulness and Transpersonal Identification were associated with quality of life while Responsibility was the major factor effecting QOL. Disease activity was not found related with TCI properties.

CONCLUSION

Temperament and Character traits of BD patients were different from healthy group that might be due to many factors like genetics, biological or socio-cultural differences. BD patients were demonstrated as materialistic, self-contained, self-confident, cold, detached, and reserved although they are not shy. Considering the different personality traits of BD patients in psychotherapeutic approaches, may have a positive impact on QOL and comorbid major depressive disorder.

Outcome measures used in clinical trials for Behçet syndrome: a systematic review

Behçet syndrome (BS) is a multisystem vasculitis that is most active during young adulthood, causing serious disability and significant impairment in quality of life. Differences in the disease course, severity, and organ involvement between patients, depending on the age at presentation and sex, makes it impossible to determine a single management strategy. The diversity and variability in the outcome measures used in clinical trials in BS makes it difficult to compare the results or inform physicians about the best management strategy for individual patients. There is a large unmet need to determine or develop validated outcome measures for use in clinical trials in BS that are acceptable to researchers and regulatory agencies. We conducted a systematic review to describe the outcomes and outcome measures that have been used in clinical trials in BS. This review revealed the diversity and variability in the outcomes and outcome measures and the lack of standard definitions for most outcomes and rarity of validated outcome tools for disease assessment in BS. This systematic literature review will identify domains and candidate instruments for use in a Delphi exercise, the next step in the development of a core set of outcome measures that are properly validated and widely accepted by the collaboration of researchers from many different regions of the world and from different specialties, including rheumatology, ophthalmology, dermatology, gastroenterology, and neurology.

Depressão e qualidade de vida em indivíduos com artrite reumatoide e indivíduos com saúde estável: um estudo comparativo

O objetivo deste estudo foi verificar a ocorrência de depressão e alterações da qualidade de vida (QV) em indivíduos com artrite reumatoide (AR).Participaram da pesquisa 60 indivíduos, divididos em 2 grupos com 30 cada, sendo o Grupo Teste composto por indivíduos com AR e o Grupo Controle composto por indivíduos com saúde estável. A QV foi avaliada pelo Medical Outcomes Study 36-Item Short-Form Healthy Survey (SF-36) e a depressão, pela Escala de Depressão de Beck (BDS). Para estabelecer comparações entre os grupos quanto aos escores de cada domínio do SF-36, utilizamos o teste de Mann-Whitney e, para os dados do "estado de saúde em geral" do SF-36, o teste do χ². Para comparar os grupos quanto ao escore total de depressão e quanto aos escores de cada categoria de depressão, empregamos respectivamente os testes Wilcoxon-Mann-Whitney (WMW) e χ². Para as variáveis "estado de saúde" em geral do SF-36 e classificação da depressão, calculou-se a Odds Ratio bruta e ajustada por meio de modelagem de regressão logística. O nível de significância foi estabelecido em 5%. Os resultados mostraram que houve diferenças entre os grupos nos oito domínios do SF-36, indicando queindivíduos com AR apresentam menores índices de QV e autoavaliação em saúde (ORajustada=14,38) e que 63,33% dos participantes com AR apresentam algum grau de depressão. Concluímos que a AR causa um impacto negativo na QV e que a depressão poder ser considerada um sintoma associado à diminuição da capacidade funcional decorrente da doença.

Anxiety, depression and suicidal ideation in patients with rheumatoid arthritis in use of methotrexate, hydroxychloroquine, leflunomide and biological drugs

OBJECTIVE

This paper aims to investigate the prevalence of anxiety, depression and suicidal ideation in patients with rheumatoid arthritis taking different drugs to control the disease.

METHODS

The study included 105 patients with rheumatoid arthritis who were treated with methotrexate, leflunomide, hydroxychloroquine and biological drugs. All patients were assessed using the Mini International Neuropsychiatric Interview, the Beck Scale for Suicide Ideation and the Hospital Anxiety and Depression Scale.

RESULTS

Difference was statistically significant (p < 0.001) for both depression and anxiety as to suicidal ideation among groups of patients according to the medication used. Furthermore, the value reached by those patients taking biological drugs was alarming with higher scores for all measures, including suicide ideation. The patients using methotrexate and leflunomide reported lower scores on suicidal ideation than those using hydroxychloroquine and biological drugs. Patients using leflunomide showed less mental health impairment than other groups.

CONCLUSION

Greater scores for depression, as a comorbidity of rheumatoid arthritis, increase the rate of suicidal ideation and depression also can worsen general pain, hardships, treatment denial, and prognosis, as well as cause a faster reduction in quality of life. Patients taking biologic DMARDs (drugs known as disease-modifying drugs) had the highest rates of depression, anxiety and suicidal ideation among all patients studied. The current analysis showed that psychiatric aspects such as depression, anxiety and even suicide ideation, may differ between groups of patients with arthritis according to the drug used, serving as an alert to the importance of considering also this factors in therapeutic decisions.

Sexual dysfunction and depression in premenopausal women with mucocutaneous Behçet's disease

AIM

The aim of this study was to investigate depression and sexual dysfunction in female patients with mucocutaneous Behçet's disease (BD).

METHODS

Twenty-five consecutive, sexually active premenopausal female patients with mucocutaneous BD (mean age: 34.76 ± 4.61 SD years) followed at a rheumatology outpatient clinic were enrolled into the study. The control group consisted of 27 age-matched (mean age: 37.0 ± 4.6 SD years), sexually active, healthy volunteers. The Female Sexual Function Index (FSFI) and Beck Depression Inventory (BDI) were used for sexual and psychiatric assessment.

RESULTS

Depression was found in four of 27 (14.8%) in the control group and eight of 25 (32%) in the BD group (P = 0.01). The median total FSFI score for patients with BD was 21.85 (interquartile range [IQR]: 18.25-27.9) and for healthy controls, 27 (IQR 21.5-29.3; P = 0.03). Female sexual dysfunction was diagnosed in 14 of 25 (56%) in the BD group and in 11 of 27 (41%) in the control group (P = 0.27). The pain domain was significantly higher in the BD group at 5.6 (4.4-6.0) than in the control group at 4.4 (3.2-5.5; P = 0.03). None of the other domains (desire, arousal, lubrication, orgasm and satisfaction) of the BD and control groups were different. There were no statistically significant differences between the FSFI, BDI scores and presence of genital ulceration in the BD patients.

CONCLUSION

Depression and FSD were more common in the patients with BD than in the healthy subjects. This might have been a result of the depressive effect of chronic disease as well as BD and low androgen levels.

The prevalence of fibromyalgia in patients with Behçet's disease and its relation with disease activity

Behçet's disease (BD) is a chronic disorder characterized by mucocutaneous and multisystem manifestations. Fibromyalgia (FM) is characterized by widespread musculoskeletal pain and may be present concomitantly with several rheumatic diseases. Our aims were to investigate the prevalence of FM in patients with BD and to evaluate the possible relation of FM presence with BD disease activity. A total of 104 Behcet patients were included in this study. Age, sex, disease durations and the BD Current Activity Form (BDCAF) scores as disease activity evaluation were recorded. Presence of FM and the Fibromyalgia Impact Questionnaire (FIQ) scores was investigated. Also, ESR and CRP concentrations were determined in all patients. Mann-Whitney U test and Pearson's correlation tests were used for the statistical analysis. There were 60 female and 40 male patients with an age range of 19-51 years. Eighteen of 100 BD patients were diagnosed as FM. Although ages, disease duration and laboratory parameters did not differ between BD patients with and without FM, BD patients with FM were more frequently female (p < 0.000). The presence of FM did not differ significantly between patients with and without systemic manifestations. Also, oral-genital ulcers, erythema nodosum, thrombophlebitis, pustular lesions and doctor's impression of disease activity scores were not found to be different in BD patients with or without FM. However, there were significant differences in fatigue, headache, arthralgia and patient impression of disease activity (today and last 28 days) between these groups (p < 0.000; p < 0.01; p < 0.01; p = 0.021 and p = 0.027, respectively). Also, there were significant correlations between BDCAF and FIQ items that refer pain and fatigue (p < 0.01). FM is a common and important clinical problem that may represent an additional factor that worsens pain and physical limitations in patients with BD. The higher prevalence of FM in patients with BD seems to be affected by BD itself, rather than its severity.

Behçet's disease

Questions from patients about analgesic pharmacotherapy and responses from authors are presented to help educate patients and make them more effective self-advocates. The topic addressed in this issue is Behçet's disease (BD), a chronic inflammatory, vascular, and/or autoimmune disease affecting the entire body, and discussion of symptoms, course of disease, treatments, prognosis, and quality of life.

How should morning function in rheumatoid arthritis be assessed? Bibliographic study of current assessment

In patients with rheumatoid arthritis (RA), symptoms of joint stiffness and pain may be most severe in the morning, resulting in impaired ability to carry out normal morning functions. Although morning stiffness was included in the criteria for classification and remission of RA, defined by the American College of Rheumatology (ACR) in 1987, the approach to assessment of this circadian symptom has not been standardized, and other circadian aspects of the disease (i.e. pain, functional ability) were not included. A bibliographic study of papers published in English in the period January 2007 to January 2010 and reporting morning stiffness, pain or function was undertaken to investigate methods of assessing circadian aspects of RA. A total of 73 studies were identified using Medline, including 62 clinical trials. Full papers were obtained for 52 reports of clinical studies (84%), most of which (44/52, 85%) assessed duration of morning stiffness. Only two studies (4%) specified that severity of morning stiffness was assessed, only three (6%) assessed pain in the morning, and none assessed morning functional ability. These findings suggest the need for consistent reporting of a measure to reflect the impaired morning function, arising from joint stiffness and pain that is commonly experienced by patients.