Depression in rheumatoid arthritis: a systematic review of the literature with meta-analysis

Longitudinal effects of affective distress on disease outcomes in rheumatoid arthritis: a meta-analysis and systematic review

Patients with rheumatoid arthritis have higher rates of mental health conditions compared to the general population. It is believed that affective distress and rheumatoid arthritis have a bi-directional relationship. This review will examine the associations between affective distress and rheumatoid arthritis outcomes over time. Several disease outcomes are included covering disease activity, function, and disability to provide a broad picture of the various ways patients are impacted. A quality assessment was also conducted. There were 71 studies included in the review. Three measures (disease activity, disability, and mortality) had enough data to complete meta-analyses of odds ratios or hazard ratios. The outcomes included were disease activity, tender joint count, swollen joints, pain, physician global assessment, patient global assessment, physical disability, acute phase reactants, stiffness, fatigue, work disability, and mortality. Numerous measures were included for most of the outcomes due to the variability across studies of measures used. Patients with affective distress had lower rates of remission according to the DAS-28, greater disability, and higher mortality. All of the outcomes covered had studies with mixed results, but swollen joint count, tender joint count, patient global assessment, and physician global assessment had the strongest evidence that they were associated with mental health longitudinally. The relationships between affective distress and disease outcomes are complex and vary depending on the measures. Overall, the effects fade over time. It is important for clinicians to be aware of the differing manifestations of the relationship between affective distress and rheumatoid arthritis outcomes.

Omics approaches open new horizons in major depressive disorder: from biomarkers to precision medicine

Major depressive disorder (MDD) is a recurrent episodic mood disorder that represents the third leading cause of disability worldwide. In MDD, several factors can simultaneously contribute to its development, which complicates its diagnosis. According to practical guidelines, antidepressants are the first-line treatment for moderate to severe major depressive episodes. Traditional treatment strategies often follow a one-size-fits-all approach, resulting in suboptimal outcomes for many patients who fail to experience a response or recovery and develop the so-called "therapy-resistant depression". The high biological and clinical inter-variability within patients and the lack of robust biomarkers hinder the finding of specific therapeutic targets, contributing to the high treatment failure rates. In this frame, precision medicine, a paradigm that tailors medical interventions to individual characteristics, would help allocate the most adequate and effective treatment for each patient while minimizing its side effects. In particular, multi-omic studies may unveil the intricate interplays between genetic predispositions and exposure to environmental factors through the study of epigenomics, transcriptomics, proteomics, metabolomics, gut microbiomics, and immunomics. The integration of the flow of multi-omic information into molecular pathways may produce better outcomes than the current psychopharmacological approach, which targets singular molecular factors mainly related to the monoamine systems, disregarding the complex network of our organism. The concept of system biomedicine involves the integration and analysis of enormous datasets generated with different technologies, creating a "patient fingerprint", which defines the underlying biological mechanisms of every patient. This review, centered on precision medicine, explores the integration of multi-omic approaches as clinical tools for prediction in MDD at a single-patient level. It investigates how combining the existing technologies used for diagnostic, stratification, prognostic, and treatment-response biomarkers discovery with artificial intelligence can improve the assessment and treatment of MDD.

Cognitive dysfunction, depression and serum level of brain-derived neurotrophic factor (BDNF) in Egyptian patients with rheumatoid arthritis

AIM OF THE WORK

To evaluate serum brain-derived neurotrophic factor (BDNF) in Egyptian patients with rheumatoid arthritis (RA) and its relation with cognitive dysfunction.

PATIENTS AND METHODS

The study was carried out on 60 RA patients; 30 were active (group A) and 30 were non active (group B); and 30 controls (group C). RA disease activity was assessed via DAS28 tool, cognitive function via The Montreal Cognitive Assessment and depression via the PHQ depression scale. Serum BDNF levels were measured.

RESULTS

The mean age in group A was 37.8 (±9.37) years with 83.3% females, in group B was 39.97 (±8.04) years with 86.7% females and in group C was 33.17 (±3.6) years with 93.3% females. Abnormal cognitive functions test was detected in 66.7% of group A, 66.7% of group B, and in 23.3% of group C. There was a statistically significant difference in BDNF serum level between both groups of patients (1.58±0.9ng/ml for group A, 1.81±1.17ng/ml for group B) compared with the control group (3.01±1.25ng/ml, p<0.001). There was no statistically significant difference between BDNF and both disease duration and cognitive function, also no statistically significant difference regarding cognitive function, depression, and BNDF levels in patients with and without fibromyalgia. At a cut-off value of <2ng/ml, BDNF detected RA patients with cognitive dysfunction with a sensitivity of 80%, specificity of 96.67%.

CONCLUSION

BDNF can be a potential biomarker of cognitive dysfunction in 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.

Diversity of purposes of use, time spent online, and depression among older Chinese Internet users

Objectives: Previous studies on the associations between Internet use and older people's depression have mostly focused on single types of online activities, especially online social engagement. The current study investigated the diversity of purposes of Internet use and its interaction with the time spent online in shaping older Chinese Internet users' depression.

Method: A sample of 974 Internet users aged 60 and above was adopted from the 2020 China Family Panel Studies wave. We adopted a latent class analysis (LCA) to explore the diverse purposes of internet usage.

Results: The participants were classified into three distinct types: socializers, basic users, and maximizers. Basic users and maximizers use the Internet for various purposes, despite different intensities; socializers use the Internet only to keep connected with families and friends. Compared with basic users and maximizers, a longer time spent online among socializers was significantly associated with a higher level of depression.

Conclusion: This study calls for a closer examination of online profiles among older Internet users; more attention should be paid to the potential harms of excessive Internet use for social reasons only among older adults. Practitioners should enhance older Internet users' digital literacy to maximize the wide-range benefits of Internet use and reduce potential health inequality.

The Association Between Endometriosis Treatments and Depression and/or Anxiety in a Population-Based Pathologically Confirmed Cohort of People with Endometriosis

Objective

Endometriosis patients have a high rate of co-occurring anxiety and depression. There is currently no literature investigating how this may affect endometriosis treatment and outcomes. This study examines the prevalence of depression and anxiety in a pathologically confirmed population-based endometriosis cohort and examines how endometriosis treatments and outcomes differ by the presence of co-occurring depression and/or anxiety.

Methods

This retrospective cohort study using population-based administrative data sets included pathologically confirmed endometriosis patients identified from the complete pathology records of Vancouver Coastal Health Authority (British Columbia, Canada) between 2000 and 2008. These data were linked with population-based health data for follow-up to 2017. Bivariate analyses assessed differences between patients with depression and/or anxiety and those without. Odds ratios (ORs) were calculated to assess the odds of binary postsurgical outcomes.

Results

Our final cohort consisted of 3815 patients. There were 603 patients (15.8%) with depression and/or anxiety. They were more likely to visit a physician for pelvic pain, more likely to take some hormonal medications, and more likely to fill prescription-level analgesics, including opioids both before and after surgery. They also had a significantly higher risk of reoperation for their endometriosis than people without co-occurring depression and/or anxiety (OR 1.32, 95% confidence interval [CI]: 1.07-1.61).

Conclusion

Endometriosis patients with co-occurring depression and/or anxiety used more health services for pain, including prescription-level analgesics, and were more likely to have an endometriosis reoperation. We recommend that future study should aim to better understand the direction of this association between depression and/or anxiety and increased health services use.

Estimation of life expectancy and healthcare cost in rheumatoid arthritis patients with and without depression: a population-based retrospective cohort study

Purpose

This study aimed to estimate the lifetime healthcare costs and loss of life expectancy (loss-of-LE) among patients with incident rheumatoid arthritis (RA) with and without depression.

Methods

This 18 years longitudinal cohort study used data from Taiwan's National Health Insurance Research Database. In total, 43,311 patients with RA were included. Among them, 1,663 patients had depressive disorders in the year preceding the RA diagnosis. The survival function for patients with RA with or without depression was estimated and extrapolated over a lifetime using the rolling extrapolation algorithm. The loss-of-LE was calculated by comparing the sex, age, and calendar year-matched referents from vital statistics. The average monthly cost was calculated as the sum of the monthly costs for all patients divided by the number of surviving patients. Lifetime healthcare costs were estimated by multiplying the monthly average cost by the monthly survival probability.

Results

The loss-of-LE for RA patients with and without depression was 5.60 years and 4.76 years, respectively. The lifetime costs of RA patients with and without depression were USD$ 90,346 and USD$ 92,239, respectively. However, the annual healthcare costs were USD$ 4,123 for RA patients with depression and USD$ 3,812 for RA patients without depression. Regardless of sex or age, RA patients with depression had higher annual healthcare costs than those without depression.

Conclusion

Patients with RA and depression have a high loss-of-LE and high annual healthcare costs. Whether treating depression prolongs life expectancy and reduces healthcare costs warrants further investigation.

Depression among rheumatoid arthritis patients and barriers to seeking professional help: An observational study

Background

A few studies have reported the association of rheumatoid arthritis (RA) with emotional changes including anxiety and depression. There is a paucity of Indian studies in this area.

Aim

To assess depression and its correlates in diagnosed cases of RA.

Materials and Methods

This was a cross-sectional and hospital-based study. A total of 70 patients with RA fulfilled the inclusion and exclusion criteria. Their demographic characteristics were recorded. They were individually assessed with the Clinical Disease Activity Index, Numerical Pain Rating Scale, Barriers to Access Care Evaluation, and Beck Depression Inventory. Statistical analysis was undertaken with SPSS.

Results

In the patients with RA the prevalence of depression was 44.2%. Analysis revealed that there was a significant positive correlation between depression with the severity of RA. Barriers to help-seeking were mainly attitudinal rather than stigma-related or instrumental barriers.

Conclusion

In the RA patients, the prevalence of depression was 44.2%. Clinical disease activity and the pain index were higher in patients with depression.

Stress circuitry: mechanisms behind nervous and immune system communication that influence behavior

Inflammatory processes are increased by stress and contribute to the pathology of mood disorders. Stress is thought to primarily induce inflammation through peripheral and central noradrenergic neurotransmission. In healthy individuals, these pro-inflammatory effects are countered by glucocorticoid signaling, which is also activated by stress. In chronically stressed individuals, the anti-inflammatory effects of glucocorticoids are impaired, allowing pro-inflammatory effects to go unchecked. Mechanisms underlying this glucocorticoid resistance are well understood, but the precise circuits and molecular mechanisms by which stress increases inflammation are not as well known. In this narrative review, we summarize the mechanisms by which chronic stress increases inflammation and contributes to the onset and development of stress-related mood disorders. We focus on the neural substrates and molecular mechanisms, especially those regulated by noradrenergic signaling, that increase inflammatory processes in stressed individuals. We also discuss key knowledge gaps in our understanding of the communication between nervous and immune systems during stress and considerations for future therapeutic strategies. Here we highlight the mechanisms by which noradrenergic signaling contributes to inflammatory processes during stress and how this inflammation can contribute to the pathology of stress-related mood disorders. Understanding the mechanisms underlying crosstalk between the nervous and immune systems may lead to novel therapeutic strategies for mood disorders and/or provide important considerations for treating immune-related diseases in individuals suffering from stress-related disorders.

Effect of Leflunomide-Metal Complexes on ROS, TNF, and Brain Indolamines in Comparison with Anti-Depressants as Adjunct Therapy in Rheumatoid Arthritic Model

Leflunomide is an isoxazole immunomodulating drug used to treat rheumatoid arthritis (RA). It is adopted as a metal-containing molecule to proceed with saturated salts of essential and detected metals; it amends the pharmacokinetic and pharmacodynamics activity of leflunomide to provide [M(Lef)4]X2-type complexes. Earlier it has been reported that after forming complexes with metals, leflunomide anti-arthritic activity was significantly altered in an acute arthritic model. In the present study, we evaluated the possible modification in anti-arthritic activities of leflunomide-metal complexes (Mg+2, Ca+2, Fe+2, Zn+2) with and without an anti-depressant drug, i.e., fluoxetine (10 mg/kg) in a chronic AIA model. Rats (n = 5) were administered with 0.1 mL of CFA into the right hind paw while treated groups received leflunomide and its metal complexes orally (3.2 mg/kg) for 24 days. On the final day of experiment, rats were sacrificed; a specific rat immunoassay ELISA kit was used to assess TNF-α in serum samples and read at 450 nm; a tissue sample of a paw was homogenized in a phosphate buffer using DCFH-DA dye for binding to assess ROS. A rat's brain sample was homogenized and evaluated for tryptophan, serotonin (5-HT), and HIAA by RP-HPLC with EC detector. The overall TNF production was altered in treated rats. In addition, a decreased ROS was observed in all categories, except lef+Mg+2 group. Moreover, depletion in the brain indolamine levels were found in treated groups; an upraised level of these indolamines was observed when fluoxetine was added. It is concluded that metals affect leflunomide activity on complexation and simultaneous administration of fluoxetine cope up with the depression in arthritic-induced rats.

Integrating PROMIS Measures in a Treat-to-Target Approach to Standardize Patient-Centered Treatment of Rheumatoid Arthritis

OBJECTIVE

To evaluate the effect of a patient-centered rheumatoid arthritis (RA) treat-to-target (T2T) disease management approach on patient outcomes and patient satisfaction with care.

METHODS

In this longitudinal, observational pilot study, rheumatologists implemented a modified T2T approach that integrated Patient Reported Outcomes Measurement Information System (PROMIS) measures for depression, fatigue, pain interference, physical function, and social function into RA care. Study participants selected 1 PROMIS domain to target treatment and completed quarterly follow-up assessments. Participants were classified as improved if their Clinical Disease Activity Index (CDAI) changed by > 5 points. Change in PROMIS t scores was examined for the group with improved CDAI, and then compared to those with unchanged or worsened CDAI. Satisfaction with care was assessed using multiple measures, including the Functional Assessment of Chronic Illness Therapy-Treatment Satisfaction-Patient Satisfaction Scale.

RESULTS

The analytical sample (n = 119, median age 57 years, 90.8% female) was split between those with CDAI > 10 (n = 63) and CDAI ≤ 10 (n = 53). At 1 year, there was improvement in CDAI by > 5 points in 66% and 13% of individuals with baseline CDAI > 10 and baseline CDAI ≤ 10, respectively. Across all participants, improvement in CDAI by > 5 points correlated with improvements in the 5 PROMIS domains. Satisfaction with RA treatment also increased.

CONCLUSION

The integration of PROMIS measures into the T2T approach for RA care was associated with improvements in disease activity, and improvement in disease activity was associated with improvements in PROMIS measures.

Effects of a community-based chronic disease self-management programme on chronic disease patients in Singapore

OBJECTIVE

The Chronic Disease Self-Management Programme (CDSMP) is a small-group intervention attended by people with chronic diseases and aims to promote self-efficacy and improve health. We adopted this programme to improve population health in the Western region of Singapore. This study aimed to evaluate the association of the CDSMP with various health outcomes for people with chronic disease living in the community.

METHODS

Validated instruments were used to measure various health outcomes. Participants completed baseline questionnaires before the programme. Post-intervention questionnaires were administered 6 months after programme. Primary outcome measures include self-efficacy and self-rated health status while secondary outcomes include several other self-management behaviours and healthcare utilisation.

RESULTS

461 participants attended the baseline questionnaire and 265 participants returned for the post-intervention questionnaire from November 2014 to August 2020. Post intervention, participants had statistically significant improvement in self-efficacy, self-rated health score, self-management behaviours and symptoms. The proportion of participants with depression and medication adherence also improved. There were no statistically significant changes in cognitive symptom management and healthcare utilisation.

CONCLUSION

CDSMP in the community can improve health outcomes and should be standard care for people with chronic disease. It can be an effective way for sustainable chronic disease management in Singapore.

Effects of Aquatic Exercises for Women with Rheumatoid Arthritis: A 12-Week Intervention in a Quasi-Experimental Study with Pain as a Mediator of Depression

BACKGROUND

Rheumatoid arthritis (RA) is characterized by low physical fitness, pain, and depression. The present study aimed to examine the effects of a supervised aquatic exercise program on physical fitness, depression, and pain in women with RA and determine whether decreases in pain mediate depression.

METHODS

Forty-three women with RA, divided into an experimental group (EG; n = 21) and a control group (CG; n = 23), participated in a 12-week exercise program. Treatment effects were calculated via standardized difference or effect size (ES) using ANCOVA adjusted for baseline values (ES, 95% confidence interval (CI)). A simple panel of mediation was executed to determine whether changes in pain mediated improvements in depression after controlling for confounding variables, such as age, physical activity, and body mass index (BMI).

RESULTS

The aquatic exercise program had trivial and small effects on physical fitness, large effects on pain, and moderate effects on depression. The mediation model confirmed the indirect effect of pain on the decrease of depression in the participants of the aquatic exercise program.

CONCLUSIONS

Participants with RA in the aquatic exercise program experienced improvements in physical fitness, depression, and joint pain. Moreover, the improvements in joint pain mediated improvements in depression.

Weapons of stress reduction: (R,S)-ketamine and its metabolites as prophylactics for the prevention of stress-induced psychiatric disorders

Exposure to stress is one of the greatest contributing factors to developing a psychiatric disorder, particularly in susceptible populations. Enhancing resilience to stress could be a powerful intervention to reduce the incidence of psychiatric disease and reveal insight into the pathophysiology of psychiatric disorders. (R,S)-ketamine and its metabolites have recently been shown to exert protective effects when administered before or after a variety of stressors and may be effective, tractable prophylactic compounds against psychiatric disease. Drug dosing, sex, age, and strain in preclinical rodent studies, significantly influence the prophylactic effects of (R,S)-ketamine and related compounds. Due to the broad neurobiological actions of (R,S)-ketamine, a variety of mechanisms have been proposed to contribute to the resilience-enhancing effects of this drug, including altering various transcription factors across the genome, enhancing inhibitory connections from the prefrontal cortex, and increasing synaptic plasticity in the hippocampus. Promisingly, select data have shown that (R,S)-ketamine may be an effective prophylactic against psychiatric disorders, such as postpartum depression (PPD). Overall, this review will highlight a brief history of the prophylactic effects of (R,S)-ketamine, the potential mechanisms underlying its protective actions, and possible future directions for translating prophylactic compounds to the clinic. This article is part of the Special Issue on 'Ketamine and its Metabolites'.

Depression in Saudi Patients with Rheumatoid Arthritis

Purpose

Depression is the most common psychiatric disorder associated with rheumatoid arthritis (RA). However, little is known about its prevalence and risk factors among Saudi patients, specifically. Therefore, this study sought to determine the prevalence and predictors of depression in patients with RA in Saudi Arabia.

Patients and Methods

A cross-sectional study was conducted with patients registered at the Saudi Charitable Association for Rheumatic Diseases. Inclusion criteria were that the patients either met the American College of Rheumatology 1987 revised criteria for the classification of RA or the 2010 RA classification criteria. Demographic data and clinical variables were collected, and Beck's 21-item Depression Inventory was used to assess for depression.

Results

Of the 210 participants with RA, 171 were women (81.4%), and 39 were men (18.6%). The prevalence of depression was 68%. There were significant relationships between age, gender, marital status, and having depression. Rheumatoid factor (RF) was positive in 144 participants (68.6%), which positively correlated with the risk of having depression (P value < 0.001). Moreover, depression severity correlated with age, gender, marital status, RF positivity, and prolonged disease duration.

Conclusion

Based on the results, depression is highly prevalent in Saudi patients with RA, especially those with positive RF and those who are female, middle-aged, and divorced. Early detection and treatment of depression in patients with RA is highly recommended to improve their quality of life and avoid unfavorable effects on RA clinical progression.

Association of systemic inflammatory biomarkers with depression risk: Results from National Health and Nutrition Examination Survey 2005-2018 analyses

BACKGROUND/AIM

Depression has become a multiple disease worldwide, and is closely related to the systemic inflammatory response.

METHODS

Based on the data of the National Health and Nutrition Examination Survey (NHANES), this study included 2,514 depressive and 26,487 non-depressive adults. The systemic immune-inflammation index (SII) and systemic inflammation response index (SIRI) were used to quantify systemic inflammation. The multivariate logistic regression and inverse probability weighting methods were used to analyze the effect size of SII and SIRI on the risk of depression.

RESULTS

After adjusting for all confounders, the above associations of SII and SIRI with depression risk remained significant (SII, OR = 1.02, 95% CI = 1.01 to 1.02, p = 0.001; SIRI, OR = 1.06, 95% CI = 1.01 to 1.10, p = 0.016). Each 100-unit increase in SII was associated with a 2% increase in the risk of depression, while each one-unit increase in SIRI was associated with a 6% increase in the risk of depression.

CONCLUSION

Systemic inflammatory biomarkers (SII and SIRI) significantly affected the risk of depression. SII or SIRI can serve as a biomarker of anti-inflammation treatment for depression.

Potential diagnostic markers and therapeutic targets for rheumatoid arthritis with comorbid depression based on bioinformatics analysis

Background

Rheumatoid arthritis (RA) and depression are prevalent diseases that have a negative impact on the quality of life and place a significant economic burden on society. There is increasing evidence that the two diseases are closely related, which could make the disease outcomes worse. In this study, we aimed to identify diagnostic markers and analyzed the therapeutic potential of key genes.

Methods

We assessed the differentially expressed genes (DEGs) specific for RA and Major depressive disorder (MDD) and used weighted gene co-expression network analysis (WGCNA) to identify co-expressed gene modules by obtaining the Gene expression profile data from Gene Expression Omnibus (GEO) database. By using the STRING database, a protein-protein interaction (PPI) network constructed and identified key genes. We also employed two types of machine learning techniques to derive diagnostic markers, which were assessed for their association with immune cells and potential therapeutic effects. Molecular docking and in vitro experiments were used to validate these analytical results.

Results

In total, 48 DEGs were identified in RA with comorbid MDD. The PPI network was combined with WGCNA to identify 26 key genes of RA with comorbid MDD. Machine learning-based methods indicated that RA combined with MDD is likely related to six diagnostic markers: AURKA, BTN3A2, CXCL10, ERAP2, MARCO, and PLA2G7. CXCL10 and MARCO are closely associated with diverse immune cells in RA. However, apart from PLA2G7, the expression levels of the other five genes were associated with the composition of the majority of immune cells in MDD. Molecular docking and in vitro studies have revealed that Aucubin (AU) exerts the therapeutic effect through the downregulation of CXCL10 and BTN3A2 gene expression in PC12 cells.

Conclusion

Our study indicates that six diagnostic markers were the basis of the comorbidity mechanism of RA and MDD and may also be potential therapeutic targets. Further mechanistic studies of the pathogenesis and treatment of RA and MDD may be able to identify new targets using these shared pathways.

Associations between psoriatic arthritis and mental health among patients with psoriasis: A replication and extension study using the British Association of Dermatologists Biologics and Immunomodulators Register (BADBIR)

Background

Despite some evidence that psoriatic arthritis (PsA) may increase psychological burden in psoriasis, the mental health of this subpopulation is under-investigated.

Objectives

To investigate whether PsA is associated with higher depression and anxiety in moderate-to-severe psoriasis; explore whether pain mediates these associations; and estimate the prevalence of undiagnosed and untreated depression.

Methods

Baseline data from British Association of Dermatologists Biologic and Immunomodulators Register (BADBIR) participants completing the Hospital Anxiety and Depression Scale (HADS) were analysed.

Results

707 patients (n = 540 with psoriasis only; n = 167 with PsA) were included. Depression prevalence was higher in patients with than without PsA, when a HADS-depression subscale cut-off ≥8 was used (33% vs. 23%, adjusted Odds Ratio [OR] (95% Confidence Intervals [CI]) = 1.64 (1.09-2.45)), but did not differ using the HADS cut-off ≥ 11. Anxiety prevalence was higher among PsA patients, regardless of HADS cut-off (cut-off ≥11: adjusted OR (95% CI) = 1.62 (1.07-2.45)). Pain fully mediated the effect of PsA on depression and anxiety in psoriasis. 53.6% of participants identified as depressed did not have a known psychiatric disorder; two thirds of depressed participants were not treated.

Conclusions

PsA comorbidity in psoriasis is associated with higher anxiety; its association with depression appears to be robust when milder depressive syndromes are included, but less consistent for higher-threshold depression definitions. Depression remains unrecognized and untreated in over half of moderately-to-severe psoriasis patients. Routine depression and anxiety screening is recommended in psoriasis and PsA. PsA comorbidity may increase depression and anxiety in psoriasis through pain experience.

Associations of rheumatoid arthritis and rheumatoid factor with mental health, sleep and cognition characteristics in the UK Biobank

While previous rheumatoid arthritis (RA) studies have focussed on cardiometabolic and lifestyle factors, less research has focussed on psychological variables including mood and cognitive health, and sleep. Cross-sectional analyses tested for associations between RA and RF+ (positive rheumatoid factor) vs. mental health (depression, anxiety, neuroticism), sleep variables and cognition scores in UK Biobank (total n = 484,064). Those RF+ were more likely to report longer sleep duration (β = 0.01, SE = 0.004, p < 0.01) and less likely to get up in the morning easily (OR 0.95, 95% CI 0.92-0.99, p = 0.01). Those reporting RA were more likely to score higher for neuroticism (β = 0.05, SE = 0.01, p < 0.001), to nap during the day (OR 1.10, 95% CI 1.06-1.14, p < 0.001), have insomnia (OR 1.28, 95% CI 1.22-1.35, p < 0.001), have slower reaction times (β = 0.02, SE = 0.008, p < 0.005) and score less for fluid intelligence (β = - 0.03, SE = 0.01, p < 0.05) and less likely to get up easily (OR 0.61, 95% CI 0.58-0.64, p < 0.001). The current study suggests that prevalent RA, and RF+ status are associated with differences in mental health, sleep, and cognition, highlighting the importance of addressing these aspects in clinical settings and future research.

Nutrient deficiency profiles and depression: A latent class analysis study of American population

BACKGROUND

Research into the effects of nutrition on depression is often performed by examining the effects of singular nutrients and dietary styles (e.g.: vegan, Mediterranean). The present study is the first one to establish the effects of patterns of nutritional deficiency within the American population and examines their effects on depression.

METHODS

Data was drawn from National Health and Nutrition Examination Survey (NHANES). Latent class analysis was performed to identify homogeneous groups of nutrient deficiency. A 3-step analysis was performed to establish class-dependant differences in depression severity. BCH analysis revealed unique predictors of depression dependant on most probable class.

RESULTS

Analysis revealed 4 classes of nutrient deficiency. Magnesium and dietary fibre were the least endorsed. 'Nutrient deprived' individuals showed the highest depression severity (Mean = 4.137, SD = 0.337). Profiles were predicted by different socioeconomic and anthropogenic predictors with meeting minimum calories showing the strongest odds of not being nutrient deprived (OR between 5.44 and 11.11). Overall, age (β = -0.115, p ≤ 0.01) and income (β = -0.147, p ≤ 0.01) were the strongest protecting factors while being female (β = 0.128, p ≤ 0.01) and arthritis (β = 0.130, p ≤ 0.01) were the strongest risk factors.

LIMITATIONS

The study involved binary variables based on minimum daily intakes and did not account for positive effects of exceeding minimum recommended doses.

CONCLUSIONS

The study supports the notion of a negative relationship between good nutrition and depression. Finding unique risk factors for depression symptoms supports the utility of nutrient deficiency profiling.

Associations between existing and newly diagnosed chronic health conditions and change in subjective life expectancy: Results from a panel study

Background

Subjective life expectancy (SLE) is a vital predictor of mortality, health and retirement. Nevertheless, we have sparse knowledge about what drives changes in SLE. Having a chronic health condition (CHC) is probably associated with a change SLE. However, how CHCs are associated with changes in SLE may depend on whether the CHC was newly diagnosed and the type of CHC.

Aim

We hypothesize that newly diagnosed CHCs will be strongly negatively associated with changes in SLE than existing CHCs. As CHCs vary in their presentation and prognosis, we differentiate associations between five CHCs - arthritis, cardiovascular diseases, sleep disorders, psychological disorders and life-threatening conditions - and changes in SLE.

Method

Data from two waves of a Dutch pension panel survey, collected 3 years apart in 2015 and 2018, were used. The analytical sample included 4824 older workers between the ages of 60-65 years at wave 1. Data were analysed longitudinally using a conditional change ordered logistic regression model.

Results

In general, newly diagnosed CHCs were strongly negatively associated with changes in SLE, relative to having no CHCs. Existing CHCs were also negatively associated with changes in SLE, but to a weaker strength. Interestingly, associations between CHCs and the change in SLE differed based on the CHC in question.

Conclusion

Newly diagnosed life-threatening conditions, psychological disorders and cardiovascular diseases are strongly negatively associated with changes in SLE. These results provide insight into the differences in how older workers with CHCs experience late career work and how these experiences influence their SLE.

Patterns of change and factors associated with IADL function decline in community-dwelling older adults with arthritis

Arthritis is a major cause of functional decline, which affects the quality of life (QoL) of older adults. This study analyzed instrumental activities of daily living (IADL) patterns in older adults with arthritis and the risk factors of functional decline. Data from the Korean Longitudinal Study of Aging (KLoSA), in which the participants were community-dwelling older adults aged ≥ 65 years and conducted every two years, were used to examine patterns in IADL performance between 2006 and 2016. The participants comprised 1,822 older adults, divided into an arthritis group and a non-arthritis group. A Generalized Estimating Equations (GEE) model and Kaplan–Meier analysis was used for the data analysis. The arthritis groups showed a statistically significant decrease in IADL function in 2012 (β = 1.283, p = 0.026), 2014 (β = 1.323, p = 0.028), and 2016 (β = 1.484, p = 0.014). The GEE model identified psychological conditions (depressive symptoms, cognitive function) and number of chronic diseases in the arthritis group as risk factors for increased IADL dependence. Healthcare providers should develop strategies to manage long-term functional decline, including programs to manage and prevent chronic diseases, cognitive function decline, and keep depressive symptoms under control, beginning within six years of arthritis diagnosis.

Barriers and facilitators to physical activity in people with an inflammatory joint disease: a mixed methods study

Background

Physical activity has been shown to be of great benefit to people with an inflammatory joint disease (IJD), however people with an IJD have been shown to be very inactive compared to the general population. The aims of this study were to explore 1) whether the transition from a National Health Service (NHS)-run exercise programme into exercising in the community could be achieved successfully; and 2) the barriers and facilitators during the transition period.

Methods

This study adopted a complementary mixed-methods study design including a qualitative approach using focus groups and a prospective cohort study. Descriptive statistics were used to summarise the cohort study data. All variables were assessed for normality of distribution using the Sharpiro-Wilk test. Paired t-tests or Wilcoxon tests were undertaken for two consecutive assessment timepoints; one-way repeated measures ANOVAs or Friedman’s tests for three consecutive assessment timepoints. Micro-interlocutor analysis was used to analyse the focus group data. Areas of congruence and incongruence were explored by confirming the statistical results against the qualitative results. The adapted ecological model of the determinants of physical activity was then used as a framework to describe the findings.

Results

A successful transition was defined as still exercising in the community 6-months post discharge from the NHS-run Inflammatory Arthritis Exercise Programme. This was self-reported to be 90% of the cohort. An individual barrier to physical activity in people with an IJD was found to be the unpredictable nature of their condition. Other barriers and facilitators found were similar to those found in the general population such as recreation facilities, locations, transportation and cost. Other facilitators were similar to those found in people living with other chronic long-term conditions such as the importance of peer support.

Conclusions

90% of the cohort data were defined as a successful transition. People with an IJD have similar barriers and facilitators to exercise as the general population and those living with other chronic long-term conditions. A barrier which appears to be unique to this population group is that of the unpredictable nature of their condition which needs to be considered whenever tailoring any intervention.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05847-z.

New Insights into the Pivotal Role of the Amygdala in Inflammation-Related Depression and Anxiety Disorder

Depression and anxiety disorders are the two most prevalent psychiatric diseases that affect hundreds of millions of individuals worldwide. Understanding the etiology and related mechanisms is of great importance and might yield new therapeutic strategies to treat these diseases effectively. During the past decades, a growing number of studies have pointed out the importance of the stress-induced inflammatory response in the amygdala, a kernel region for processing emotional stimuli, as a potentially critical contributor to the pathophysiology of depression and anxiety disorders. In this review, we first summarized the recent progress from both animal and human studies toward understanding the causal link between stress-induced inflammation and depression and anxiety disorders, with particular emphasis on findings showing the effect of inflammation on the functional changes in neurons in the amygdala, at levels ranging from molecular signaling, cellular function, synaptic plasticity, and the neural circuit to behavior, as well as their contributions to the pathology of inflammation-related depression and anxiety disorders. Finally, we concluded by discussing some of the difficulties surrounding the current research and propose some issues worth future study in this field.

Perceived Cognitive Function in People With Systemic Sclerosis: Associations With Symptoms and Daily Life Functioning

OBJECTIVE

Perceived cognitive dysfunction is prevalent in patients with systemic sclerosis (SSc) but not well understood. This study aimed to examine potential factors associated with perceived cognitive function and to investigate the contributions of perceived cognitive function and symptoms to functional measures.

METHODS

A cross-sectional survey was conducted among patients with SSc (n = 106). Participants were mainly female (84%) and White (82%). Perceived cognitive function, symptoms, and functional measures were assessed with Patient-Reported Outcomes Measurement Information System (PROMIS) measures. A multivariable regression was conducted to identify factors associated with perceived cognition. Hierarchical linear regressions examined the unique contributions of perceived cognitive function and symptoms to social participation and physical function.

RESULTS

Fifty-nine (56%) patients with SSc perceived mild-to-severe cognitive dysfunction. Being on work disability and having more fatigue were both significantly associated with perceived cognitive dysfunction. When examining the contributions of cognition and other symptoms to functional measures, self-reported cognition became nonsignificant after fatigue and pain were entered into the regression model.

CONCLUSION

Being on work disability and having more fatigue were most highly associated with perceived cognitive dysfunction in patients with SSc. Unlike fatigue and pain, perceived cognitive function was not independently associated with functional measures. Nonetheless, future research should disentangle cognitive function and other symptoms, as well as their effects on daily activities, in SSc.

Morus mesozygia leaf extract ameliorates behavioral deficits, oxidative stress and inflammation in Complete Freund's adjuvant-induced arthritis in rats

ETHNOPHARMACOLOGICAL RELEVANCE

Morus mesozygia Stapf (Moraceae), otherwise referred to as African mulberry, is utilized domestically as a remedy for a variety of inflammatory disorders including rheumatism.

AIM

The anti-arthritic effect of the ethylacetate fraction of M. mesozygia leaf extract (EAFMm) was assessed on complete Freund's adjuvant (CFA)-induced arthritis in male Wistar rats.

METHOD

Groups of male Wistar rats were injected with CFA (0.2 mL; 10 mg/mL) in the plantar surface of their right hind paws and treated orally with EAFMm (50 and 100 mg/kg) or its vehicle daily for 28 days. The effect on joint inflammation and mechanical nociception threshold, behavioral deficits (spontaneous motor activity in the open field test and depressive-like symptoms in the forced swim test) was evaluated. The levels and activities of the biomarkers of oxidative-nitrosative stress (reduced glutathione, superoxide dismutase, nitrite, and malondialdehyde) and inflammatory markers [TNF-α, IL-6, COX-2, NFκB and myeloperoxidase] were also analysed.

RESULTS

The EAFMm at the doses of 50 and 100 mg/kg produced a dose dependent reduction in joint inflammation and mechanical hyperalgesia, and as well improved behavioral deficits like spontaneous motor activity and depressive-like behavior. The EAFMm also significantly reduced oxido-nitrosative stress response in the joint and brain tissues. It also decreased TNF-α, interleukin-6 levels and myeloperoxidase enzyme activities in joints and brain tissues of rats. Furthermore, EAFMm attenuated the activity of NFκB and reduced the cyclooxygenase -2 protein expression level in joint tissues.

CONCLUSION

The ethylacetate fraction of Morus mesozygia leaf extract demonstrated anti-arthritic activity and ameliorated co-morbid depressive-like behavior via inhibition of oxidative stress and inflammation in a rat model of arthritis.

Multi-strain Probiotic Formulation Reverses Maternal Separation and Chronic Unpredictable Mild Stress-Generated Anxiety- and Depression-like Phenotypes by Modulating Gut Microbiome-Brain Activity in Rats

Depression is a debilitating mental disorder that affects >322 million people worldwide. Despite the availability of several antidepressant agents, many patients remain treatment refractory. A growing literature study has indicated the role of gut microbiota in neuropsychiatric disorders. Herein, we examined the psychobiotic-like activity of multi-strain probiotic formulation in maternal separation (MS) and chronic unpredictable mild stress (CUMS) models of anxiety- and depression-like phenotypes in Sprague-Dawley rats. Early- and late-life stress was employed in both male and female rats by exposing them to MS and CUMS. The multi-strain probiotic formulation (Cognisol) containing Bacillus coagulans Unique IS-2, Lactobacillus plantarum UBLP-40, Lactobacillus rhamnosus UBLR-58, Bifidobacterium lactis UBBLa-70, Bifidobacterium breve UBBr-01, and Bifidobacterium infantis UBBI-01 at a total strength of 10 billion cfu along with l-glutamine was administered for 6 weeks via drinking water. Neurobehavioral assessment was done using the forced swim test (FST), sucrose preference test (SPT), elevated plus maze (EPM), and open field test (OFT). Animals were sacrificed after behavioral assessment, and blood, brain, and intestine samples were collected to analyze the levels of cytokines, metabolites, and neurotransmitters and histology. Animals exposed to stress showed increased passivity, consumed less sucrose solution, and minimally explored the open arms in the FST, SPT, and EPM, respectively. Administration of multi-strain probiotics along with l-glutamine for 6 weeks ameliorated the behavioral abnormalities. The locomotor activity of animals in the OFT and their body weight remained unchanged across the groups. Cognisol treatment reversed the decreased BDNF and serotonin levels and increased CRP, TNF-α, and dopamine levels in the hippocampus and/or frontal cortex. Administration of Cognisol also restored the plasma levels of l-tryptophan, l-kynurenine, kynurenic-acid, and 3-hydroxyanthranilic acid; the Firmicutes-to-Bacteroides ratio; the levels of acetate, propionate, and butyrate in fecal samples; the villi/crypt ratio; and the goblet cell count, which manifested in the restoration of intestinal functions. We suggest that the multi-strain probiotic and glutamine formulation (Cognisol) ameliorated the MS + UCMS-generated anxiety- and depression-like phenotypes by reshaping the gut microbiome-brain activity in both sexes.

An Overview on Causes of Nonadherence in the Treatment of Rheumatoid Arthritis: Its Effect on Mortality and Ways to Improve Adherence

Rheumatoid arthritis is one of the most prevalent musculoskeletal disorders that, when insufficiently treated, results in detrimental sequelae including joint damage and reduced quality of life. Poor patient adherence to medication is a significant blockade to effective management. The purpose of this review is to highlight and discuss the factors responsible for defiance of antirheumatic medication and ways to overcome these barriers. Education level, health literacy, cohabitation status, multi-morbidities, complicated drug regimen, intermittent co-payments, prescribed regimen adverse effects, and cognitive impairment are a few among many common barrier factors leading to poorer outcomes in rheumatoid arthritis. While there is an abundance of inhibitory factors leading to worsening disease progression, they each can be easily dealt with an effective approach at the beginning or during the treatment course to ensure a better outcome.

Targeting the Adaptive Immune System in Depression: Focus on T Helper 17 Cells

There is a vital need to understand mechanisms contributing to susceptibility to depression to improve treatments for the 11% of Americans who currently suffer from this debilitating disease. The adaptive immune system, comprising T and B cells, has emerged as a potential contributor to depression, as demonstrated in the context of lymphopenic mice. Overall, patients with depression have reduced circulating T and regulatory B cells, "immunosuppressed" T cells, and alterations in the relative abundance of T cell subtypes. T helper (Th) cells have the capacity to differentiate to various lineages depending on the cytokine environment, antigen stimulation, and costimulation. Regulatory T cells are decreased, and the Th1/Th2 ratio and the Th17 cells are increased in patients with depression. Evidence for changes in each Th lineage has been reported to some extent in patients with depression. However, the evidence is strongest for the association of depression with changes in Th17 cells. Th17 cells produce the inflammatory cytokine interleukin (IL)-17A, and the discovery of Th17 cell involvement in depression evolved from the well established link that IL-6, which is required for Th17 cell differentiation, contributes to the onset, and possibly maintenance, of depression. One intriguing action of Th17 cells is their participation in the gut-brain axis to mediate stress responses. Although the mechanisms of action of Th17 cells in depression remain unclear, neutralization of IL-17A by anti-IL-17A antibodies, blocking stress-induced production, or release of gut Th17 cells represent feasible therapeutic approaches and might provide a new avenue to improve depression symptoms. SIGNIFICANCE STATEMENT: Th17 cells appear as a promising therapeutic target for depression, for which efficacious therapeutic options are limited. The use of neutralizing antibodies targeting Th17 cells has provided encouraging results in depressed patients with comorbid autoimmune diseases.

Experimental Arthritis Inhibits Adult Hippocampal Neurogenesis in Mice

Background: Adult-born neurons of the hippocampal dentate gyrus play a role in specific forms of learning, and disturbed neurogenesis seems to contribute to the development of neuropsychiatric disorders, such as major depression. Neuroinflammation inhibits adult neurogenesis, but the effect of peripheral inflammation on this form of neuroplasticity is ambiguous. Objective: Our aim was to investigate the influence of acute and chronic experimental arthritis on adult hippocampal neurogenesis and to elucidate putative regulatory mechanisms. Methods: Arthritis was triggered by subcutaneous injection of complete Freund’s adjuvant (CFA) into the hind paws of adult male mice. The animals were killed either seven days (acute inflammation) or 21 days (chronic inflammation) after the CFA injection. Behavioral tests were used to demonstrate arthritis-related hypersensitivity to painful stimuli. We used in vivo bioluminescence imaging to verify local inflammation. The systemic inflammatory response was assessed by complete blood cell counts and by measurement of the cytokine/chemokine concentrations of TNF-α, IL-1α, IL-4, IL-6, IL-10, KC and MIP-2 in the inflamed hind limbs, peripheral blood and hippocampus to characterize the inflammatory responses in the periphery and in the brain. In the hippocampal dentate gyrus, the total number of newborn neurons was determined with quantitative immunohistochemistry visualizing BrdU- and doublecortin-positive cells. Microglial activation in the dentate gyrus was determined by quantifying the density of Iba1- and CD68-positive cells. Results: Both acute and chronic arthritis resulted in paw edema, mechanical and thermal hyperalgesia. We found phagocytic infiltration and increased levels of TNF-α, IL-4, IL-6, KC and MIP-2 in the inflamed hind paws. Circulating neutrophil granulocytes and IL-6 levels increased in the blood solely during the acute phase. In the dentate gyrus, chronic arthritis reduced the number of doublecortin-positive cells, and we found increased density of CD68-positive macrophages/microglia in both the acute and chronic phases. Cytokine levels, however, were not altered in the hippocampus. Conclusions: Our data suggest that acute peripheral inflammation initiates a cascade of molecular and cellular changes that eventually leads to reduced adult hippocampal neurogenesis, which was detectable only in the chronic inflammatory phase.

Association between depression, anxiety, chronic pain, or opioid use and tumor necrosis factor inhibitor persistence in inflammatory arthritis

INTRODUCTION

Depression, anxiety, and chronic pain are common comorbidities in patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA), and ankylosing spondylitis (AS) and may substantially impact patient outcomes. We aimed to determine whether these comorbidities were associated with earlier TNF-inhibitor (TNFi) discontinuation.

METHODS

This retrospective cohort study using Optum's de-identified Clinformatics® Data Mart Database 2000-2014 identified patients with RA, PsA, and AS initiating a first TNFi. Depression/anxiety, chronic pain, and opioid use were identified using diagnosis codes and prescription fill data. Cox proportional hazards models were used to compare time to medication discontinuation in patients with or without each of these risk factors and to assess the additive effect of having multiple risk factors.

RESULTS

Among 33,744 patients initiating a TNFi (23,888 RA, 6443 PsA, 3413 AS), depression/anxiety, chronic pain, and opioid use were common, with ≥ 1 risk factor in 48.1%, 42.5%, and 55.4% of patients with RA, PsA, and AS respectively. Each risk factor individually was associated with a 5-7-month lower median treatment persistence in each disease (all p < 0.001). Presence of multiple risk factors had an additive effect on time to discontinuation with HR (95% CI) 1.19 (1.14-1.24), 1.41 (1.33-1.49), and 1.47 (1.43-1.73) for 1, 2, or 3 risk factors respectively in RA. Findings were similar in PsA and AS.

CONCLUSIONS

Depression, anxiety, chronic pain, and opioid use are common in inflammatory arthritis and associated with earlier TNFi discontinuation. Recognizing and managing these risk factors may improve treatment persistence, patient outcomes, and cost of care. Key Points • Depression, anxiety, chronic pain, and opioid use are common in patients with inflammatory arthritis. • In patients initiating treatment with a TNF-inhibitor, depression, anxiety, chronic pain, or recent opioid use are associated with sooner discontinuation of TNFi therapy. • Patients with multiple of these risk factors are even more likely to discontinue therapy sooner.

MicroRNA-Messenger RNA Regulatory Network Mediates Disrupted TH17 Cell Differentiation in Depression

Accumulating evidence indicates an important role for microRNA (miRNA)-messenger RNA (mRNA) regulatory networks in human depression. However, the mechanisms by which these networks act are complex and remain poorly understood. We used data mining to identify differentially expressed miRNAs from GSE81152 and GSE152267 datasets, and differentially expressed mRNAs were identified from the Netherlands Study of Depression and Anxiety, the GlaxoSmithKline-High-Throughput Disease-specific target Identification Program, and the Janssen-Brain Resource Company study. We constructed a miRNA-mRNA regulatory network based on differentially expressed mRNAs that intersected with target genes of differentially expressed miRNAs, and then performed bioinformatics analysis of the network. The key candidate genes were assessed in the prefrontal cortex of chronic social defeat stress (CSDS) depression mice by quantitative real-time polymerase chain reaction (qRT-PCR). Three differentially expressed miRNAs were commonly identified across the two datasets, and 119 intersecting differentially expressed mRNAs were identified. A miRNA-mRNA regulatory network including these three key differentially expressed miRNAs and 119 intersecting differentially expressed mRNAs was constructed. Functional analysis of the intersecting differentially expressed mRNAs revealed that an abnormal inflammatory response characterized by disturbed T-helper cell 17 (Th17) differentiation was the primary altered biological function. qRT-PCR validated the decreased expression of Th17 cell differentiation-related genes, including interleukin (IL)17A, IL21, IL22, and IL1β, and the increased expression of retinoic acid receptor-related orphan receptor gamma-t (RORγt) in CSDS mice, which showed significant depressive- and anxiety-like behaviors. This study indicates that an abnormal inflammatory response characterized by disturbed Th17 cell differentiation is the primary altered biological process in major depressive disorder. Our findings indicate possible biomarkers and treatment targets and provide novel clues to understand the pathogenesis of major depressive disorder.

Exploring the relationship between depression and different multimorbidity patterns among older people covered by long-term care insurance in Shanghai, China

BACKGROUND

Depression is common in patients with multimorbidity, but little is known about the relationship between depression and multimorbidity. The purpose of our research was to investigate multimorbidity patterns and their association with depression in a sample of older people covered by long-term care insurance in Shanghai, China.

METHOD

This was a population-based cross-sectional study, with 1871 participants aged ≥60 years old who are covered by Shanghai long-term care insurance. Multimorbidity was defined as the presence of two or more chronic diseases at the same time. We collected information on chronic conditions using a self-reported medical history, and we used the 30-item Geriatric Depression Scale (GDS-30) to evaluate depressive symptoms. Patterns of multimorbidity were identified with exploratory factor analysis, using oblimin rotation. Logistic regression was used to estimate the relationship between multimorbidity patterns and depressive symptoms.

RESULTS

Among the participants, the prevalence of multimorbidity was 64.7%, and the prevalence of depression was 64.6%. Hypertension, cardiovascular disease, cerebrovascular disease (CVD), and cataracts showed strong associations with depression when co-occurring with other conditions. Three patterns of multimorbidity were identified: a musculoskeletal pattern, cardiometabolic pattern, and degenerative disease pattern. Among these, the cardiometabolic (adjusted odds ratio (AOR) 1.223; 95% confidence interval (CI) 1.102, 1.357) and degenerative disease (AOR 1.185; 95% CI 1.071, 1.311) patterns were associated with a higher risk of depressive symptoms.

CONCLUSION

Two of three multimorbidity patterns were found to be associated with depression. Physical and psychological dimensions require greater attention in the care of older adults who are covered by long-term care insurance.

Association of lifestyle and disease characteristics with self-rated wellness/health score in patients with rheumatoid arthritis

Objective

To study the relationship of self-rated wellness/health and lifestyle in patients with rheumatoid arthritis.

Methods

Self-rated wellness/health, demographics, smoking, mood, sleep, physical activity, diet, symptoms/signs, body mass index and laboratory findings in 142 patients with rheumatoid arthritis were collected in the current cross-sectional study. Multivariable generalized additive model (GAM) was employed to study the association of self-rated wellness/health score and lifestyle factors.

Results

Female/male ratio was 116/26 and the mean (SD) age of sample was 52 (13) years. Mean (SD) self-rated wellness/health score out of 10 was 7.2 (1.63). Mean (SD) number of tender joints and swollen joints were 4.42 (4.55) and 4.00 (4.26), respectively. The mean sleep score was 29.5 out of 70. Patients went to bed more than one hour earlier during the weekdays compared to weekends (22:45 vs. 23:52 PM, respectively, p < 0.0001). They also woke up more than one hour earlier during the weekdays compared to the weekends (6:08 vs. 7:20 AM, respectively, p < 0.0001). Their nap duration during weekdays was about half an hour shorter than the nap duration on weekends (19.75 vs. 48.02 minutes, respectively, p < 0.0001). The mean mood and diet scores were 18.5/35 and 22.5/42, respectively. By backward elimination in multivariable regression model (GAM), disease duration, mood, sleep quality, weekdays sleep characteristics (sleep duration, time to go to bed, wake-up time, time to fall asleep and nap duration), and sleep duration on weekends remained in the final model (R² = 0.225, p = 0.01). Sleep quality, nap duration on weekdays, night sleep duration on weekends and mood status were the significant variables associated with self-rated wellness/health score.

Conclusion

In patients with rheumatoid arthritis, the low self-rated wellness/health score was associated with the low sleep quality, long sleep duration on weekends, and long nap duration on weekdays.

Arthritis status changes and depressive symptoms among middle-aged and older Koreans: Analysis of data from the Korean Longitudinal Study of Aging survey

OBJECTIVE

Arthritis can negatively affect physical and mental health, especially among middle-aged and older people. This study investigated the longitudinal association between changes in arthritis status and depressive symptoms among Korean adults aged ≥45 years.

METHODS

We analyzed data from the Korean Longitudinal Study of Aging 2008-2018, using a generalized estimating equation model to investigate associations between arthritis status change and depressive symptoms, which were assessed using five categories according to measurements based on the Center for Epidemiological Studies Depression Scale (CES-D-10).

RESULTS

Both men and women whose arthritis status changed to "worse" or remained "same" scored higher for depressive symptoms than those who reported "no symptoms of arthritis" (men, worse = β: 1.07, P ≤ .001, same = β: 0.25 P = .031; women, worse = β: 0.99, P ≤ .001, same = β: 0.13, P = .049). Conversely, men with a "better" arthritis status (β: -0.71, P ≤ .001) and women with a "recovered" arthritis status (β: -0.56, P = .031) scored lower for depressive symptoms than those who reported "no symptoms of arthritis."

CONCLUSIONS

Arthritis status changes are associated with depressive symptoms in middle-aged and older Koreans. Therefore, mental health evaluation and management interventions are recommended for patients with arthritis and changes in disease status.

Development of the Rheumatoid Arthritis Distress Scale (RADS): a new tool to identify disease-specific distress in patients with Rheumatoid Arthritis

Background

Patients with Rheumatoid Arthritis (RA) may experience psychological distress (depression, anxiety) in addition to their physical symptoms. People with RA may also experience disease-specific distress (DSD), related to the specific burden of living with their life-long condition. DSD is a patient reported outcome in several long-term conditions, including type 1 and 2 diabetes. The aims of this study were to determine whether DSD is experienced by people with RA, and if so, develop a Patient Reported Outcome Measure (PROM) to assess for DSD in people with RA.

Methods

A five-phased qualitative study was conducted which consisted of a secondary data analysis of 61 interviews of people with rheumatological disease (Phase 1), validation of findings via a Patient and Public Involvement (PPI) group of people with RA (n = 4) (Phase 2), item generation for a PROM (Phase 3) and establishing face and content validity of the PROM via PPI group (n = 4) and individual cognitive interviews (n = 9) of people with RA respectively (Phase 4 and 5). The final PROM was presented at a Patient Education Evening for patients with long-term rheumatological conditions, including RA, and carers.

Results

Five themes of rheumatological disease distress emerged from Phase 1, which were validated in the Phase 2 PPI group. After Phases 3–5, the Rheumatoid Arthritis Distress Scale (RADS) was formed of 39 items and 3 supplementary questions. Overall participants reported the content of the RADS to be clear and relevant, and that DSD is a valid concept in RA, distinct from other entities like clinical depression or anxiety.

Conclusions

DSD appears to be an important concept in RA. The 39-item RADS demonstrates acceptable face and content validity in this patient group. Further psychometric testing is needed. The RADS may be a useful tool for healthcare professionals to identify RA distress.

Factors associated with anxiety and depression in rheumatoid arthritis patients: a cross-sectional study

BACKGROUND

The management of anxiety and depression symptoms in rheumatoid arthritis (RA) patients is vital. Previous study findings on this topic are conflicting, and the topic remains to be thoroughly investigated. This study aimed to clarify the association of RA disease activity with anxiety and depression symptoms after controlling for physical disability, pain, and medication.

METHODS

We conducted a cross-sectional study of RA patients from the XXX Rheumatoid Arthritis Management Alliance cohort. We assessed patients using the Disease Activity Score (DAS28), Health Assessment Questionnaire Disability Index (HAQ-DI), and Hospital Anxiety and Depression Scale (HADS). Anxiety and depression symptoms were defined by a HADS score ≥ 8. We analyzed the data using multivariable logistic regression analyses.

RESULTS

Of 517 participants, 17.6% had anxiety symptoms and 27.7% had depression symptoms. The multivariable logistic regression analysis demonstrated that DAS28 was not independently associated with anxiety symptoms (odds ratio [OR] [95% confidence interval; CI] 0.93 [0.48-1.78]; p = 0.82) and depression symptoms (OR [95% CI] 1.45 [0.81-2.61]; p = 0.22). However, DAS28 patient global assessment (PtGA) severity was associated with anxiety symptoms (OR [95% CI] 1.15 [1.02-1.29]; p = 0.03) and depression symptoms (OR [95% CI] 1.21 [1.09-1.35]; p < 0.01). Additionally, HAQ-DI scores ≤ 0.5 were associated with anxiety symptoms (OR [95% CI] 3.51 [1.85-6.64]; p < 0.01) and depression symptoms (OR [95% CI] 2.65 [1.56-4.50]; p < 0.01). Patients using steroids were more likely to have depression than those not using steroids (OR [95% CI] 1.66 [1.03-2.67]; p = 0.04).

CONCLUSIONS

No association was found between RA disease activity and anxiety and depression symptoms in the multivariable logistic regression analysis. Patients with high PtGA scores or HAQ-DI scores ≤ 0.5 were more likely to experience anxiety and depression symptoms, irrespective of disease activity remission status. Rather than focusing solely on controlling disease activity, treatment should focus on improving or preserving physical function and the patient's overall sense of well-being.

Patient-Reported Outcome Measures in Takayasu Arteritis: A Systematic Review and Meta-Analysis

INTRODUCTION

We conducted a systematic review of patient-reported outcome measures (PROMs) regarding quality of life, disability, mood abnormalities (anxiety, depression), fatigue, illness perceptions and fibromyalgia in Takayasu arteritis (TAK). Wherever available, comparisons with healthy controls, disease controls or longitudinal changes in PROMs were noted.

METHODS

MEDLINE, EMBASE, Scopus, Web of Science and Pubmed Central databases, major recent international rheumatology conference abstracts, clinical trial databases and the Cochrane library were searched for relevant articles. Wherever possible, outcome measures across studies were pooled using the restricted maximum likelihood model. Inter-group differences were pooled and compared using standardized mean differences (SMD) with 95% confidence intervals (95% CI). Heterogeneity was assessed using the I2 statistic. Quality of randomized controlled trials was assessed using the Cochrane risk of bias tool. For cross-sectional and cohort studies, the Joana Briggs Institute checklist and Newcastle-Ottawa scale were used, respectively. GRADE methodology was used to determine the certainty of evidence for outcomes.

RESULTS

Twenty-one studies (all but one observational) involving 1311 patients with TAK and 308 healthy controls were identified. Ten studies (559 TAK patients, 182 healthy controls were synthesized in a meta-analysis. Patients with TAK had worse quality of life (pooled SMD - 6.66, 95% CI - 10.08 to - 3.23 for individual domains; - 0.64, 95% CI - 1.19 to - 0.09 for pooled physical and mental component scores of 36-item Short Form Survey), depression (SMD 0.26, 95% 0.05-0.47) and anxiety (SMD 0.34, 95% CI - 0.06 to 0.75) scores and higher disability (SMD 0.64, 95% CI 0.43-0.84) than healthy controls. Patients with active TAK had worse quality of life, depression and work impairment when compared with those with inactive disease. Included studies were of moderate to high quality. Certainty of evidence for individual outcomes was low to very low.

CONCLUSION

Literature on PROMs in TAK, albeit sparse, appears to indicate worse scores in patients with TAK compared to healthy individuals. These results, however, require cautious interpretation. Development of a TAK-specific PROM is an important focus of the research agenda.

Hope, Optimism, and Clinical Pain: A Meta-Analysis

BACKGROUND

Generalized expectancies have been theorized to play key roles in pain-related outcomes, but the empirical findings have been mixed.

PURPOSE

The primary aim of this meta-analysis was to quantify the relationships between two of the most researched positive generalized expectancies (i.e., hope and optimism) and pain-related outcomes (i.e., pain severity, physical functioning, and psychological dysfunction) for those experiencing clinical pain.

METHODS

A total of 96 studies and 31,780 participants with a broad array of pain diagnoses were included in analyses, using random-effects models.

RESULTS

Both hope and optimism had negative correlations with pain severity (hope: r = -.168, p < .001; optimism: r = -.157, p < .001), positive correlations with physical functioning (hope: r = .199, p < .001; optimism: r = .175, p < .001), and negative correlations with psychological dysfunction (hope: r = -.349, p = .001; optimism: r = -.430, p <.001).

CONCLUSION

The current findings suggest that hope and optimism are similarly associated with adaptive pain-related outcomes. Future research should examine the efficacy of interventions on hope and optimism in ameliorating the experience of clinical pain.

A Systematic Review of Depression and Anxiety in Adults with Pyoderma Gangrenosum

OBJECTIVE

To synthesize the available evidence on the prevalence and odds for anxiety and depression in adults with pyoderma gangrenosum (PG).

DATA SOURCES

Observational studies examining anxiety and depression in adults with PG were systematically searched using the MEDLINE, EMBASE, PsycINFO, and CINAHL databases from the inception of each database to March 11, 2020.

STUDY SELECTION

Two authors independently screened references based on predetermined eligibility criteria.

DATA EXTRACTION

Of the 244 articles identified, three met the eligibility criteria. Relevant data were extracted from included studies, and methodological quality was evaluated independently by two authors using the modified Newcastle-Ottawa Scale.

DATA SYNTHESIS

Three observational studies comprising 183 participants with PG met the inclusion criteria. Estimated rates of depression in adults with PG ranged from 10% to 23%. None of the studies measured rates of anxiety.

CONCLUSIONS

The current systematic review suggests that depression is a common psychological comorbidity in adults with PG. Additional research is required to further assess the psychological comorbidities in this population.

Pain and Anxiety due to the COVID-19 Pandemic: A Survey of Patients With Delayed Elective Hip and Knee Arthroplasty

Background

The COVID-19 pandemic led to cancelation of all elective surgeries for a time period in the vast majority of the United States. We compiled a questionnaire to determine the physical and mental toll of this delay on elective total joint arthroplasty patients.

Methods

All patients whose primary or revision total hip or knee arthroplasty was canceled because of the COVID-19 pandemic at a large academic-private practice were identified. An 11-question survey was administered to these patients via email. All data were deidentified and stored in a REDCAP database.

Results

Of 367 total patients identified, 113 responded to the survey. Seventy-seven percent of patients had their surgery postponed at least 5 weeks, and 20% were delayed longer than 12 weeks. Forty-one percent of patients reported an average visual analog scale pain score greater than 7.5. Forty percent of respondents experienced increased anxiety during the delay. Thirty-four percent of patients felt their surgery was not elective. Sixteen percent experienced a fall during the delay, and 1 patient sustained a hip fracture. Level of pain reported was significantly associated with negative emotions, negative effects of delay, and whether patients felt their surgery was indeed elective. Seventy-six percent reported trust in their surgeon's judgment regarding appropriate timing of surgery. Communication was listed as the number one way in which patients felt their surgeon could have improved during this time.

Conclusion

Surgical delay due to the COVID-19 pandemic resulted in increased pain and anxiety for many total joint arthroplasty patients. While most patients maintained trust in their surgeon during the delay, methods to improve communication may benefit the patient experience in future delays.

Level of Evidence

Level II.

A Narrative Review of the Assessment of Depression in Chronic Pain

OBJECTIVES

This narrative review sought to explore the main critical issues in the assessment of depression in chronic pain and to identify self-report tools that can be reliably used for measuring it.

DESIGN

Narrative review of the literature.

METHODS

Articles were obtained through a search of three databases and a hand search of the references of full-text papers. Key results within the retrieved articles were summarized and integrated to address the review objectives.

RESULTS

Criterion contamination, different ways to define and evaluate pain and depression across studies, variability in chronic pain samples and settings, pitfalls of diagnostic systems and self-reports, and reluctance to address (or difficulty of recognizing) depression in patients and healthcare providers emerged as main critical issues. The Beck Depression Inventory seems to be the more accurate tool to evaluate depression in chronic pain patients, while other instruments such as the Patient Health Questionnaire could be recommended for a rapid screening.

CONCLUSIONS

Assessment of depression comorbidity in chronic pain represents a challenge in both research and clinical practice; the choice and use of tests, as well as the score interpretation, require clinical reasoning.

NURSING PRACTICE IMPLICATIONS

Nurses play an important role in screening for depression. Cognitive contents of depression should be carefully evaluated since somatic symptoms may be confusing in the chronic pain context. Some self-reports may be useful for rapid screening. It is also advisable to consider other relevant patient information in evaluating depression.

Increased risk of mental health disorders in patients with RA during the COVID-19 pandemic: a possible surge and solutions

Depression is a common co-morbidity among rheumatoid arthritis (RA) patients, which may translate into difficulty performing activities of daily living. COVID-19 is an unprecedented disaster that has disrupted lives worldwide and led to a rise in the incidence of mental health disorders. Given the widespread economic devastation due to COVID-19, many RA patients, already susceptible to mental illness, maybe at an increased risk of inaccessibility to medical care, accentuated stress, and consequent worsening of existent mental health disorders, or the onset of new mental health disorders such as anxiety, post-traumatic stress disorder, or depression. The objective of this review is to assess if there is an increased risk of mental health disorders in patients with RA during the COVID-19 pandemic. Telemedicine has bridged the transition to remote chronic care in the pandemic period, though certain accessibility and technological challenges are to be addressed. Decreased access to care amid lockdowns and a proposed triggering of disease activity in patients with autoimmune disorders may potentially herald a massive spike in incidence or flares of patients diagnosed with RA in the coming months. Such a deluge of cases may be potentially devastating to an overburdened healthcare system. Rheumatologists may need to prepare for this eventuality and explore techniques to provide adequate care during these challenging times. The authors found that there is a significant association between the adverse impact on the mental health of RA patients and the COVID-19 pandemic. However, more research is needed to highlight individual risk factors.

2018 Chinese Guidelines for the Diagnosis and Treatment of Rheumatoid Arthritis

A multidisciplinary guideline development group was established to formulate this evidence-based diagnosis and treatment guidelines for rheumatoid arthritis (RA) in China. The grading of recommendations, assessment, development, and evaluation (GRADE) system was used to rate the quality of the evidence and the strength of recommendations, which were derived from research articles and guided by the analysis of the benefits and harms as well as patients' values and preferences. A total of 10 recommendations for the diagnosis and treatment of RA were developed. This new guideline covered the classification criteria, disease activity assessment and monitoring, and the role of disease modifying antirheumatic drugs (DMARDs), biologics, small molecule synthetic targeting drugs, and glucocorticoids in the treat-to-target approach of RA. This guideline is intended to serve as a tool for clinicians and patients to implement decision-making strategies and improve the practices of RA management in China.

Emotion Regulation, Physical Diseases, and Borderline Personality Disorders: Conceptual and Clinical Considerations

This perspective paper aims at discussing theoretical principles that could explain how emotion regulation and physical diseases mutually influence each other in the context of borderline personality disorder (BPD). Furthermore, this paper discusses the clinical implications of the functional relationships between emotion regulation, BPD and medical conditions considering dialectical behavior therapy (DBT) as a well-validated therapeutic intervention, which encompasses these issues. The inflexible use of maladaptive emotion regulation strategies (e.g., suppression, experiential avoidance, and rumination) might directly increase the probability of developing physical diseases through a physiological pathway, or indirectly through a behavioral pathway. Some metabolic and chronic medical conditions could significantly impact emotional functioning through biological alterations involved in emotion regulation. Several empirical studies have shown high co-occurrence rates between BPD and several chronic physical diseases, especially ones linked to emotion-based maladaptive behaviors. DBT addresses physical diseases reported by individuals with BPD reducing problematic behaviors functionally associated to emotion dysregulation and identifying physical health as a goal for Building a Life Worth Living.

Effectiveness of an Interpersonal Psychotherapy (IPT) Group Depression Treatment for Head Start Mothers: A Cluster-Randomized Controlled Trial

BACKGROUND

Maternal depression is known to be a serious problem with higher rates among poor and racial/ethnic minority mothers that can have numerous negative impacts on their children. These mothers have less access to effective care and may be wary of traditional mental health care because of the stigma. The purpose of this study was to test whether an adaptation of an Interpersonal Psychotherapy group for perinatal depression could be effective in reducing depressive symptoms of mothers whose children were enrolled in Head Start.

METHODS

Forty-nine mothers, randomized by site, were recruited into the intervention group, 70 into the control group. They were measured on depressive symptoms, parenting stress, parenting behavior, and parent child interaction at intake, at end of the group, and 6 months following.

RESULTS

The intervention group was lower in depressive symptoms at the end of treatment with a further decrease 6 months post intervention. There was no change in the control group. The intervention group also improved in parenting stress.

LIMITATIONS

The sample size for the intervention group was smaller than desired.

CONCLUSIONS

This study supports the effectiveness of this 12 session IPT group which was highly effective for a population of Head Start mothers. It is a strategy that can be adapted to other settings that serve low income mothers.

Secular changes in the progression of clinical markers and patient-reported outcomes in early rheumatoid arthritis

Objectives

To examine secular trends in the progression of clinical and patient-reported outcomes in early RA.

Methods

A total of 2701 patients recruited to the Early Rheumatoid Arthritis Study or Early Rheumatoid Arthritis Network with year of diagnosis from 1986 to 2011. The 5-year progression rates for patients diagnosed at different points in time were modelled using mixed-effects regression; 1990, 2002 and 2010, were compared. Clinical markers of disease included the 28-joint count DAS and the ESR. Patient-reported markers included the HAQ, visual analogue scale of pain and global health, and the Short-Form 36.

Results

Statistically significant improvements in both 28-joint count DAS and ESR were seen over the 5 years in patients diagnosed with RA compared with those diagnosed earlier. By 5 years, 59% of patients with diagnosis in 2010 were estimated to reach low disease activity compared with 48% with diagnosis in 2002 and 32% with diagnosis in 1990. Whilst HAQ demonstrated statistically significant improvements, these improvements were small, with similar proportions of patients achieving HAQ scores of ≤1.0 by 5 years with a diagnosis in 1990 compared with 2010. Levels of the visual analogue scale and the Mental Component Scores of the Short-Form 36 indicated similar, statistically non-significant levels over the 5 years, irrespective of year diagnosed.

Conclusion

This study demonstrates improvements in inflammatory markers over time in early RA, in line with improved treatment strategies. These have not translated into similar improvements in patient-reported outcomes relating to either physical or mental health.

The Relationship Between Psychological Aspects and Trajectories of Symptoms in Total Knee Arthroplasty and Total Hip Arthroplasty

BACKGROUND

This study aimed to examine different trajectories of physical symptoms in hip and knee arthroplasty patients from presurgery to 1 year postsurgery and relate this to preoperative anxiety and depressive symptoms.

METHODS

Patients (N = 345) completed the Hip injury and Osteoarthritis Outcome Score or the Knee injury and Osteoarthritis Outcome Score to examine their preoperative and postoperative pain, stiffness, and function, presurgery, and 3, 6, and 12 months postsurgery. Presurgery anxiety and depressive symptoms were assessed using the 7-item Generalized Anxiety Disorder Scale and the 9-item Patient Health Questionnaire. Latent trajectory analysis was used to identify different subgroups in trajectories. The step-3 method was used to assess subgroup characteristics.

RESULTS

The effect of time on pain, function, and stiffness was different between subgroups of patients. Knee patients belonged mainly to classes with least improvement. Least improvement in pain was characterized by a combination of high levels of both anxiety and depressive symptoms. Anxiety and depressive symptoms were independently related to less reduction in stiffness while little improvement in function was characterized by higher depressive symptoms.

CONCLUSION

The results of this study indicate that anxiety and depressive symptoms were significantly, but differently, related to the distinct physical symptoms examined.

Depressive Symptoms and the Arthritis-Employment Interface: A Population-Level Study

OBJECTIVE

To examine the relationship between depressive symptoms, arthritis, and employment, and to determine whether this relationship differs across young, middle-age, and older working-age adults with arthritis.

METHODS

Data from the US National Health Interview Survey from 2013-2017 were analyzed. Analyses were restricted to adults with doctor-diagnosed arthritis of working age (ages 18-64 years) with complete data on depressive symptoms (n = 11,380). Covariates were sociodemographic information, health, and health system utilization variables. Employment prevalence was compared by self-reported depressive symptoms. We estimated percentages, as well as univariable and multivariable logistic regression models, to examine the relationship between depression and employment among young adults (ages 18-34 years), middle-age adults (ages 35-54 years), and older adults (ages 55-64 years).

RESULTS

Among all working-age US adults with arthritis, the prevalence of depressive symptoms was 13%. Those reporting depressive symptoms had a higher prevalence of fair/worse health (60%) and arthritis-attributable activity limitations (70%) compared to those not reporting depression (23% and 39%, respectively). Respondents with depressive symptoms reported significantly lower employment prevalence (30%) when compared to those not reporting depressive symptoms (66%) and lower multivariable-adjusted association with employment (prevalence ratio 0.88 [95% confidence interval (95% CI) 0.83-0.93]). Middle-age adults reporting depression were significantly less likely to be employed compared to their counterparts without depression (prevalence ratio 0.83 [95% CI 0.77-0.90]); similar but borderline statistically significant relationships were observed for both young adults (prevalence ratio 0.86 [95% CI 0.74-0.99]) and older adults (prevalence ratio 0.94 [95% CI 0.86-1.03]).

CONCLUSION

For adults with arthritis, depressive symptoms are associated with not participating in employment. Strategies to reduce arthritis-related work disability may be more effective if they simultaneously address mental health.

Evolution and Emerging Trends in Depression Research From 2004 to 2019: A Literature Visualization Analysis

Depression has become a major threat to human health, and researchers around the world are actively engaged in research on depression. In order to promote closer research, the study of the global depression knowledge map is significant. This study aims to map the knowledge map of depression research and show the current research distribution, hotspots, frontiers, and trends in the field of depression research, providing researchers with worthwhile information and ideas. Based on the Web of Science core collection of depression research from 2004 to 2019, this study systematically analyzed the country, journal, category, author, institution, cited article, and keyword aspects using bibliometric and data visualization methods. A relationship network of depression research was established, highlighting the highly influential countries, journals, categories, authors, institutions, cited articles, and keywords in this research field. The study identifies great research potential in the field of depression, provides scientific guidance for researchers to find potential collaborations through collaboration networks and coexistence networks, and systematically and accurately presents the hotspots, frontiers, and shortcomings of depression research through the knowledge map of global research on depression with the help of information analysis and fusion methods, which provides valuable information for researchers and institutions to determine meaningful research directions.