Risk factors, including different biologics, associated with depression and anxiety in patients with rheumatoid arthritis: a cross-sectional observational study

A qualitative survey on factors affecting depression and anxiety in patients with rheumatoid arthritis: a cross-sectional study in Syria

Depression and anxiety often coexist with rheumatoid arthritis (RA) and affect the course of the disease. These mental health conditions can be overlooked or underdiagnosed in people with RA. There is conflicting evidence in previous studies regarding this topic, indicating that further research is necessary to provide a thorough understanding of the relationship between anxiety, depression, and RA. This study aims to determine the factors correlated with depression and anxiety symptoms in RA patients by evaluating disease activity at the same time. This cross-sectional study was conducted at four outpatient rehabilitation centers in four Syrian provinces: Damascus, Homs, Hama, and Latakia. The study included RA patients who attended the RA department of rehabilitation centers from January 1 to June 31, 2023. RA patients who presented at a rheumatology clinic were selected consecutively. RA patients were included in the study in accordance with the ACR/EULAR classification criteria, disease activity was assessed by disease activity score based on the 28-joint count (DAS28), and patients with DAS28 > 2.6 were considered to have active RA. The demographic data, as well as disease duration, educational status, Disease Activity Score with 28-joint counts (DAS28), health assessment questionnaire (HAQ) score, and the hospital anxiety and depression scale (HADS), were the parameters used in the analysis. Two hundred and twelve patients (female, 75%) with a mean age of 49.3 ± 13.1 years and a mean disease duration of 8.3 ± 6.9 years were studied. Depression was diagnosed in 79 (37.3%) patients and anxiety in 36 (16.9%) patients. Patients with depression and/or anxiety had higher HAQ and DAS28 scores compared to other RA patients. Blue-collar workers exhibited a higher prevalence of anxiety, whereas females, housewives, and individuals with lower educational attainment demonstrated a higher prevalence of depression. The current study found high rates of anxiety and depression in RA patients, highlighting the significant burden of these mental health conditions compared to the general population. It is essential for healthcare providers not to overlook the importance of psychiatric evaluations, mental health assessments, and physical examinations of RA patients.

Rheumatoid Arthritis and Risk of Depression in South Korea

Importance

Depression is among the most common comorbidities in rheumatoid arthritis (RA). There is a lack of data regarding the association of RA seropositivity and biologic agents with depression risk among individuals with RA.

Objective

To investigate the risk of depression following RA diagnosis among patients in South Korea.

Design, Setting, and Participants

This retrospective cohort study included 38 487 patients with RA and a comparison group of 192 435 individuals matched 1:5 for age, sex, and index date. Data were from the Korean National Health Insurance Service database. Participants were enrolled from 2010 to 2017 and were followed up until 2019. Participants who had previously been diagnosed with depression or were diagnosed with depression within 1 year after the index date were excluded. Statistical analysis was performed in May 2023.

Exposures

Seropositive RA (SPRA) was defined with the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) codes M05 and enrollment in the Korean Rare and Intractable Diseases program. Seronegative RA (SNRA) was defined with ICD-10 codes M06 (excluding M06.1 and M06.4) and a prescription of any disease-modifying antirheumatic drugs (DMARDs) for 270 days or more.

Main Outcomes and Measures

Newly diagnosed depression (ICD-10 codes F32 or F33).

Results

The mean (SD) age of the total study population was 54.6 (12.1) years, and 163 926 individuals (71.0%) were female. During a median (IQR) follow-up of 4.1 (2.4-6.2) years, 27 063 participants (20 641 controls and 6422 with RA) developed depression. Participants with RA had a 1.66-fold higher risk of depression compared with controls (adjusted hazard ratio [aHR], 1.66 [95% CI, 1.61-1.71]). The SPRA group (aHR, 1.64 [95% CI, 1.58-1.69]) and the SNRA group (aHR, 1.73 [95% CI, 1.65-1.81]) were associated with an increased risk of depression compared with controls. Patients with RA who used biologic or targeted synthetic DMARDs (aHR, 1.33 [95% CI, 1.20-1.47]) had a lower risk of depression compared with patients with RA who did not use these medications (aHR, 1.69 [95% CI, 1.64-1.74]).

Conclusions and Relevance

This nationwide cohort study found that both SPRA and SNRA were associated with a significantly higher risk of depression. These results suggest the importance of early screening and intervention for mental health in patients with RA.

Prevalence, Severity, and Measures of Anxiety in Rheumatoid Arthritis: A Systematic Review

OBJECTIVE

Many studies have reported high rates of anxiety in adults with rheumatoid arthritis (RA). The aim of this systematic review was to examine those findings and determine the overall prevalence, severity, and commonly used measures of anxiety in individuals with RA.

METHODS

Six databases were searched from January 2000 without restrictions on language/location, study design, or gray literature. All identified studies that examined anxiety prevalence and severity in adults with RA, as assessed with clinical diagnostic interview and/or standardized self-report measures, were considered for inclusion. Quality assessment of included studies was conducted using a modified Newcastle-Ottawa Evaluation Scale, and the findings were synthesized via a narrative approach.

RESULTS

Across the 47 studies (n = 11,085 participants), the sample size ranged from 60 to 1,321 participants with seven studies including healthy controls or groups with other health conditions. The studies were conducted across 23 countries, and anxiety prevalence ranged from 2.4% to 77%, predominantly determined with standardized self-report measures, of which Hospital Anxiety and Depression scale was used most frequently; only eight studies used a clinical diagnostic interview to confirm a specific anxiety diagnosis. Notable associations with anxiety in RA were physical disability, pain, disease activity, depression, and quality of life.

CONCLUSION

The reported prevalence of anxiety in RA varied widely potentially because of use of different self-report measures and cutoff points. Such cutoff points will need to be standardized to clinical thresholds to inform appropriate interventions for anxiety comorbidity in RA.

Evaluation of Depression and Anxiety in Rheumatoid Arthritis Patients During COVID-19 Pandemic

Background

Rheumatoid arthritis (RA) disease activity, associated comorbidities, and therapy-related side effects impair the physical, social, and emotional dimensions of the patient's health. Presently, the ongoing COVID-19 pandemic has been associated with a broad range of psychosocial disorders in various populations. Patients with RA are especially vulnerable to such effects.

Objectives

Detect the prevalence of recent COVID-19 infection among patients with RA, assess depression and anxiety in these patients and their associated factors during the COVID-19 pandemic and their potential relation to disease activity.

Design and Methods

This is a cross-sectional study conducted on 120 adult Egyptian patients diagnosed with RA during the COVID-19 pandemic. The prevalence of recent COVID-19 infection among the patients was evaluated. The patients underwent psychological assessment using the Hamilton Depression Rating Scale (Ham-D) and the Hamilton Anxiety Rating Scale (Ham-A) to measure levels of depression and anxiety levels. The RA disease activity was assessed using Disease Activity Score (DAS) Das-28-ESR.

Results

This study encompasses a total of 120 RA patients. The prevalence of patients with a recent history of COVID-19 infection was 40.8%. Both groups exhibited significantly elevated mean scores on the Das-28-ESR scale and also scored higher on measures of depression and anxiety. Interestingly, the COVID-19 group exhibited a higher percentage of unmarried individuals, had educational attainment below the university level, and were unemployed. Patients with recent COVID-19 had significantly lower numbers of children, higher disease duration, higher Das-28-ESR scores, and elevated depression and anxiety scores. The statistical analysis revealed that the COVID-19 infection and disease duration were significant predictors of depression and anxiety. The results also exhibited that the depression score was positively correlated with age and DAS scores.

Conclusions

It was observed that patients diagnosed with RA revealed a higher prevalence of COVID-19 infection. The occurrence of depression and anxiety was observed to be widespread among patients diagnosed with RA and, more significantly, prevalent in RA patients who had a recent COVID-19 and had a higher level of disease activity. The occurrence of COVID-19 and disease duration were identified as factors that can anticipate the development of depression and anxiety.

Anxiety and depression in rheumatoid arthritis patients: prevalence, risk factors and consistency between the Hospital Anxiety and Depression Scale and Zung's Self-rating Anxiety Scale/Depression Scale

Objectives

The aim was to explore the prevalence and independent risk factors for anxiety and depression in RA patients and to assess the consistency between the hospital anxiety and depression scale (HADS) and Zung's self-rating anxiety scale/depression scale (SAS/SDS).

Methods

In total, 160 RA patients and 60 healthy controls (HCs) were enrolled consecutively, and HADS and SAS/SDS were completed.

Results

The HADS-defined anxiety rate, HADS-defined depression rate, SAS-defined anxiety rate and SDS-defined depression rate were 36.9, 36.3, 29.4 and 29.4%, respectively, in RA patients, all of which were much higher in RA patients than in HCs (all P < 0.001). A relatively high consistency was observed between HADS-defined anxiety and SAS-defined anxiety (κ = 0.551, P < 0.001) and between HADS-defined depression and SDS-defined depression (κ = 0.563, P < 0.001) in RA patients. Interestingly, screened by multivariate logistic regression analyses, single/divorced/widowed marital status, swollen joint count, disease duration, ESR, physician's global assessment (PhGA) and DAS28 were independently correlated with HADS-defined or SAS-defined anxiety risk in RA patients; meanwhile, female biological sex, single/divorced/widowed marital status, rural location, disease duration, PhGA and DAS28 were independently associated with HADS-defined or SDS-defined depression risk in RA patients.

Conclusion

Anxiety and depression are highly prevalent in RA patients and are independently correlated with single/divorced/widowed marital status and higher disease activity. In addition, the HADS presents a high consistency with the SAS/SDS with many fewer questions, which might be more suitable for long-term assessment of RA.

Determinants of Depressive Symptoms Among Patients with Rheumatoid Arthritis in China: A Structural Equation Model

Background

This study aimed to examine how personality traits, social support and clinical features including pain, disease activity, functional status, sleep quality, and fatigue influence on depressive symptoms in Chinese rheumatoid arthritis (RA) patients.

Methods

This study was conducted from November, 2022 to June, 2023 among Chinese RA patients. Pain, disease activity, functional status, sleep quality, fatigue, social support, personality traits, and depressive symptoms were assessed. The following relationships among three hypotheses were analyzed by structural equation model (SEM): H1: clinical features have a direct effect on depressive symptoms; H2: personality traits might work as a mediator between clinical features and depression; H3: social support is related to depressive symptoms, being a direct effect or an indirect effect through clinical features or personality traits.

Results

The final model including 326 RA patients presented a good fit (χ2=103, χ2/df=1.69; GFI=0.96; AGFI=0.93; CFI=0.97; TLI=0.96; RMSEA=0.046). Clinical features had a total effect of 0.59 on depressive symptoms, of which β=0.33 (P=0.013) was an indirect effect through personality traits, indicating a mediating influence between this relationship; moreover, there was a significant direct association between clinical features and depressive symptoms (β=0.26; P=0.022). Personality traits (β=-0.65; P<0.001) had a much stronger relation with depressive symptoms than with clinical features. Social support had a total effect of 0.81 on personality traits, being a direct effect of β=0.52 (P<0.001) and an indirect effect of β=0.29 (P<0.001) through clinical features. The final proposed model explained 77% of the variance of depressive symptoms.

Conclusion

Personality traits had a considerable influence upon depressive symptoms, while social support seemed to have a major effect on personality traits. It is necessary to apply comprehensive assessment and interventions of patients' personality traits, clinical features, as well as social support, which could optimize their mental health.

Relationship between perceived stress, stress coping strategies, and clinical status in patients with rheumatoid arthritis

Coping with a chronic disease such as rheumatoid arthritis (RA) involves significant changes in life and promotes stressful situations. The inability to cope with stress can contribute to the lack of effectiveness of therapy. The aim of this study was to evaluate the relationship between perceived stress, coping strategies, and the clinical status of RA patients determined by C-reactive protein (CRP) and Disease Activity Score (DAS28). 165 subjects were studied, 84 of them had RA and the rest were controls. Standardised questionnaires were used: the Inventory for the Measurement of Coping Strategies (Mini-COPE) and the Perceived Stress Scale (PSS-10). A self-administered questionnaire was used to collect sociodemographic data. The blood levels of protein CRP and cortisol were determined. DAS28 was obtained from medical records. The study was cross-sectional. The mean severity of perceived stress PSS-10 was not significantly different between the control and study groups. RA patients most often used coping strategies such as active coping, planning, and acceptance. Compared to the control group, they used the strategy of turning to religion significantly more often (1.8 vs 1.4; p = 0.012). Women with RA who had higher cortisol levels were more likely to use positive reevaluation, seeking emotional support and instrumental support, as well as the denial strategy. In men with RA, high stress was associated with twice as high CRP levels compared to patients with low stress (p = 0.038). As the levels of CRP protein levels (p = 0.009) and the DAS28 index (p = 0.005) increased, patients were more likely to use a denial strategy.

Effect of type of disease-modifying antirheumatic drugs on depression and anxiety of patients with rheumatoid arthritis in Saudi Arabia: a cross-sectional study

Background

Rheumatoid arthritis (RA) can cause depression and anxiety. This study evaluated the factors associated with depression and anxiety in patients with RA and examined the effect of conventional and biologic disease-modifying antirheumatic drugs (DMARDs).

Methods

This cross-sectional study was conducted in a regional hospital in Riyadh between March and November 2022 and included 213 patients with RA. Depression and anxiety were measured using the Hospital Anxiety and Depression Scale (HADS) and data about patients' DMARDs use was obtained from the hospital's medical records.

Results

Based on the HADS scores, 35 (16.4%) and 49 (23%) patients with RA had depression and anxiety, respectively. There was a significant association between the level of depression and anxiety and the use of leflunomide and tocilizumab among patients with RA (p = 0.006 and p = 0.009, respectively). Patients with RA who took leflunomide had significantly higher scores for anxiety (β = 0.158, value of p = 0.037) when compared to patients who did not take leflunomide. Patients with RA who took etanercept showed a significantly lower depression score even after adjusting for confounders, including sociodemographic, clinical, and lifestyle factors (β = -0.189, p = 0.043).

Conclusion

The present study highlighted the prevalence of psychiatric disorders among patients with RA and the level of depression and anxiety may differ between patients with RA depending on the type of DMARDs used. We recommend patients with RA be screened regularly for depression and anxiety to avoid further extra-articular systemic complications associated with RA.

Eating attitude in patients with rheumatoid arthritis: The relationship between pain, body mass index, disease activity, functional status, depression, anxiety and quality of life

PURPOSE

The aim of this study is to evaluate the relationship between eating attitude and pain, body mass index, disease activity, functional status, depression, anxiety and quality of life in patients with rheumatoid arthritis (RA).

DESIGN AND METHODS

This descriptive and cross-sectional study was conducted with 111 RA patients between January 2021 and May 2021.

FINDINGS

The Eating Attitudes Test scores of the participants had a positive significant relationship with their Visual Analog Scale scores (r = 0.257), Health Assessment Questionnaire scores (r = 0.221), Beck Anxiety Inventory scores (r = 0.287), Beck Depression Inventory scores (p = 0.224), and Rheumatoid Arthritis Quality of Life Scale scores (r = 0.298) (p < 0.05). This study showed that when the eating attitudes of the RA patients were negative, their anxiety and depression levels increased, and their quality of life was negatively affected.

PRACTICE IMPLICATIONS

In the positive management of depression and anxiety, by creating treatment guidelines, the moderation of the eating attitudes of patients and increasing their quality of life levels should be ensured.

Assessment of Bidirectional Relationships between Mental Illness and Rheumatoid Arthritis: A Two-Sample Mendelian Randomization Study

A correlation between mental illness and systemic rheumatoid arthritis (RA) has been observed in several prior investigations. However, little is known about the causative relationship between them. The present study aimed to systematically investigate the potential association between genetically determined mental illness and RA. Two-sample bidirectional Mendelian randomization (MR) analysis was performed using publicly released genome-wide association studies (GWAS). We selected independent genetic variants associated with four mental illnesses (bipolar disorder, broad depression, major depression, and anxiety) as instrumental variables. The inverse variance weighted (IVW) method was used as the primary analysis to assess the causal relationship between mental illness and RA. Results of the IVW analysis suggested that genetic predisposition to bipolar disorder was associated with a decreased risk of RA (odds ratio [OR] = 0.825, 95% CI = 0.716 to 0.95, p = 0.007). Furthermore, we did not find a significant causal effect of RA on bipolar disorder in the reverse MR analysis (p > 0.05). In addition, our study found no evidence of a bidirectional causal relationship between genetically predicted broad depression, major depression, anxiety, and RA (p > 0.05). The genetically proxied bipolar disorder population has a lower RA risk, which may indicate that there is a hidden mechanism for inhibiting the pathogenesis of RA in bipolar disorder. However, results do not support a causal connection between depression, anxiety, and RA.

Research progress on rheumatoid arthritis-associated depression

Depression is an independent mood disorder and one of the most common comorbidities of rheumatoid arthritis (RA). Growing evidence suggests that there is two-way regulation between RA and depression, resulting in a vicious cycle of RA, depression, poor outcomes, and disease burden. The rising prevalence of RA-associated depression warrants a re-examination of the relationships between them. Here we provide an overview of the etiology and pathological mechanisms of RA-associated depression, and recent advances in treatment with biologics, which will facilitate the development of new and effective prevention and treatment strategies.

Increased Serum Levels of Brain-Derived Neurotrophic Factor Contribute to Inflammatory Responses in Patients with Rheumatoid Arthritis

The aim of this study is to investigate the role of brain-derived neurotrophic factor (BDNF) in the inflammatory responses in patients with rheumatoid arthritis (RA). Serum levels of BDNF and the precursor form of BDNF (proBDNF) from 625 RA patients and 40 controls were analyzed using enzyme-linked immunosorbent assay. Effects of BDNF on the mitogen-activated protein kinase pathway were analyzed by Western blotting. Microarray analysis was conducted to search BDNF regulated gene expression in Jurkat cells, and the differentially expressed genes were validated using T cells from patients with RA and controls. Serum BDNF levels were significantly elevated in patients with RA compared with the controls. Low serum BDNF levels were found in RA patients with anxiety or receiving biologics treatment. BDNF (20 ng/mL) enhanced the phosphorylation of ERK, JNK, and c-Jun, but suppressed the phosphorylation of p38, whereas BDNF (200 ng/mL) enhanced the phosphorylation of ERK and p38. After validation, the expression of CAMK2A, MASP2, GNG13, and MUC5AC, regulated by BDNF and one of its receptors, NGFR, was increased in RA T cells. BDNF increased the IL-2, IL-17, and IFN-γ expression in Jurkat cells and IL-2 and IFN-γ secretion in activated peripheral blood mononuclear cells.

Modestly Elevated Serum Procalcitonin Levels in Patients with Rheumatoid Arthritis Free of Active Infection

Background and objectives: To investigate the serum procalcitonin (PCT) levels among patients with rheumatoid arthritis (RA) without active infection compared with healthy controls and to understand the relationship of PCT with RA disease activity, and treatment received by patients. Materials and Methods: Patients aged 20 years and above with clinician-confirmed diagnosis of RA and healthy volunteers were included during regular outpatient visits, and those with active infection symptoms and signs were excluded. RA disease activity was measured using the Disease Activity Score-28 for Rheumatoid Arthritis with erythrocyte sedimentation rate (DAS28-ESR). Medications received by the patients were also recorded. Results: A total of 623 patients with RA and 87 healthy subjects were recruited in this study. The mean PCT were significantly higher in patients with RA (6.90 ± 11.81 × 10⁻³ ng/mL) compared with healthy controls (1.70 ± 6.12 × 10⁻³ ng/mL) (p < 0.001) and the difference remained statistically significant after adjusting for age and sex. In addition, multiple linear regression analysis showed that a lower rank-transformed PCT serum level was significantly correlated with the use of biologics (p = 0.017) and a high DAS28-ESR score (p = 0.028) in patients with RA. Conclusion: Patients with RA have a significantly higher serum PCT levels compared with healthy controls. The use of biologics and an active RA disease activity were associated with a lower level of PCT in patients with RA. Further investigation is required to determine the optimal cutoff value of PCT among patients with RA and its association with disease activity and biologic usage.

Brain TNF drives post-inflammation depression-like behavior and persistent pain in experimental arthritis

Patients with rheumatoid arthritis experience chronic pain, depression and fatigue, even when inflammation of the joints is well controlled. To study the relationship between arthritis, depression, and sustained pain when articular inflammation is no longer observed, we tested the hypothesis that brain TNF drives post-inflammation depression-like behavior and persistent pain in experimental arthritis. The murine model of antigen-induced arthritis (AIA) was used to evaluate the effects of knee inflammation on sustained pain and depression-like behavior. We measured joint pain using an automated dynamic plantar algesiometer and depression-like behavior with the tail suspension test. Cytokines were measured by Luminex assay and ELISA. TNF in the brain was blocked by intracerebroventricular injection of anti-TNF antibodies. Histological damage and elevated levels of cytokines were observed in the knee 24 h after antigen treatment, but not at 13 days. Reduced pain thresholds were seen 24 h and 13 days after treatment. Depression-like behavior was observed on day 13. Treatment with the antidepressant imipramine reduced both depression-like behavior and persistent pain. However, blocking joint pain with the analgesic dipyrone did not alter depression-like behavior. Elevated levels of TNF, CCL2, and CXCL-1 were observed in the hippocampus 24 h after treatment, with TNF remaining elevated at day 13. Intracerebroventricular infusion of an anti-TNF antibody blocked depression-like behavior and reduced persistent pain. We have demonstrated that depression-like behavior and pain is sustained in AIA mice after the resolution of inflammation. These changes are associated with elevated levels of TNF in the hippocampus and are dependent upon brain TNF. The findings reveal an important mechanistic link between the expression of chronic pain and depression in experimental arthritis. Furthermore, they suggest treating depression in rheumatoid arthritis may positively impact other debilitating features of this condition.

Multidimensional Health Assessment Questionnaire as an Effective Tool to Screen for Depression in Routine Rheumatology Care

OBJECTIVE

To analyze the use of the Multidimensional Health Assessment Questionnaire (MDHAQ) to screen for depression, as compared to 2 reference standards, the Patient Health Questionnaire 9 (PHQ-9) and the Hospital Anxiety and Depression Scale depression domain (HADS-D).

METHODS

Patients from Barcelona with a primary diagnosis of rheumatoid arthritis (RA) or spondyloarthritis (SpA) completed the MDHAQ, the PHQ-9 (depression ≥10), and the HADS-D (depression ≥8) measures. The MDHAQ includes 2 depression items, 1 in the patient-friendly HAQ, scored in a 4-point format from 0 to 3.3, and a yes/no item on a 60-symptom checklist. Percentage agreement and kappa statistics quantified the agreement between 6 screening criteria: yes on the 60-symptom checklist, a score of ≥1.1, a score of ≥2.2 on a 4-point scale, and either a response of yes on the 60-symptom checklist or scores of ≥2.2, PHQ-9 ≥10, and HADS-D ≥8.

RESULTS

Depression screening was positive according to 6 criteria in 19.6-32.4% of 102 patients with RA, and 27.9-44.8% of 68 with SpA (total = 170). All MDHAQ scores, including depression items, were higher in patients with SpA compared to patients with RA, and within each diagnostic group in patients who met PHQ-9 ≥10 and HADS-D ≥8 depression screening criteria. The highest percentage agreement between an MDHAQ screening criterion versus PHQ-9 ≥10 was 83.3% for either an answer of yes on the 60-symptom checklist or a score of ≥2.2 on a 4-point scale, which we have termed MDHAQ-Dep. The agreement of MDHAQ-Dep versus HADS-D ≥8 was 81.7%, similar to the agreement of PHQ-9 ≥10 versus HADS-D ≥8, which was 82.2%. Kappa measures of agreement were 0.63 for MDHAQ-Dep versus PHQ-9 ≥10, 0.60 for MDHAQ-Dep versus HADS-D ≥8, and 0.62 for PHQ-9 ≥10 versus HADS-D ≥8.

CONCLUSION

A positive MDHAQ-Dep response (either an answer of yes on a 60-symptom checklist or a score of ≥2.2 on a 4-point scale) yielded similar results to PHQ-9 ≥10 or HADS-D ≥8 to screen for depression in these RA and SpA patients.