The Relationship Between Mental Health, Disease Severity, and Genetic Risk for Depression in Early Rheumatoid Arthritis

The relationship between pain and depression and anxiety in patients with inflammatory arthritis: a systematic review protocol

Pain is a major challenge for patients with inflammatory arthritis (IA). Depression and anxiety are common comorbidities in IA, associating with worse outcomes. How they relate to pain is uncertain, with existing systematic reviews (a) mainly considering cross-sectional studies, (b) focusing on the relationship between pain and mental health in the context of disease activity/quality of life, and (c) not specifically considering the impact of treating depression/anxiety on pain. This PROSPERO-registered (CRD42023411823) systematic review will address this knowledge-gap by synthesizing evidence to summarise the associations (and potential mediators) between pain and depression/anxiety and evaluate the impact of treating co-morbid depression/anxiety on pain in IA. Relevant databases will be searched, articles screened and their quality appraised (using Joanna Briggs Institute critical appraisal tools) by two reviewers. Eligible studies will include adults with rheumatoid arthritis or spondyloarthritis, be a clinical trial or observational study, and either (a) report the relationship between pain and depression/anxiety (observational studies/baseline trials), or (b) randomise participants to a pharmacological or psychological treatment to manage depression/anxiety with a pain outcome as an endpoint (trials). To synthesise data on the association between pain and depression/anxiety, where available adjusted coefficients from regression models will be pooled in a random-effects meta-analysis. A synthesis without meta-analysis will summarise mediators. To evaluate the impact of treating depression/anxiety on pain, endpoint mean differences between treatment arms will be combined in a random-effects meta-analysis. Through understanding how depression/anxiety contribute to pain in IA, our review has the potential to help optimise approaches to IA pain.

Ongoing shielding behavior one year post COVID-19: results from a longitudinal study of patients with inflammatory arthritis

Many patients with inflammatory arthritis (IA) were instructed to shield during the COVID-19 pandemic. Despite the ending of lockdowns and vaccination, large proportions of IA patients were continuing to shield when it is no longer needed. Given the detrimental effects of shielding on mental and physical health, understanding the rates and reasons for shielding is needed to help clinicians advise patients accordingly. This study was a 12-month prospective study following participants with IA during the COVID-19 pandemic. The proportions of IA patients shielding at each time point were calculated. Additionally, regressions and odds ratios for shielding were determined to assess medication type, mental health, and risk perception. While the extent of shielding fluctuated over the year of lockdowns, nearly all IA patients (93.5%) were still engaging in some shielding in 2021, with nearly half (43%) still shielding most or all of the time. Medications that were previously considered higher risk were not significantly associated with higher rates of shielding (OR = 1.60, p = 0.29), but greater symptoms of depression in June 2020 (OR = 1.07, p = 0.03) was both associated with increased the odds of shielding in June 2021. The high rates of IA patients continuing to shield in 2021 put more strain on patients and professionals as social isolation is linked with worsening mental and physical health, as well as greater difficulty with self-management. It is important for clinicians to be aware of this trend to ease the stress on patients.

Maternal rheumatoid arthritis and risk of autism in the offspring

BACKGROUND

Maternal Rheumatoid Arthritis (RA) is suggested to increase the risk of Autism Spectrum Disorder (ASD) in the offspring, mainly through inflammation/autoimmunity, but the association is unclear. A prospective population-based cohort study was implemented to examine the association between maternal RA and offspring ASD.

METHODS

We included all children born alive in Sweden from 1995 to 2015, followed up through 2017. Diagnoses of ASD and RA were clinically ascertained from National Patient Register. We quantified the association by hazard ratios (HR) and two-sided 95% confidence intervals (CI), from Cox regression after detailed adjustment for potential confounders. We examined RA serostatus, etiological subgroups and the timing of exposure. To closer examine the underlying mechanism for the association, we included a negative control group for RA, arthralgia, with similar symptomology as RA but free from inflammation/autoimmunity.

RESULTS

Of 3629 children born to mothers with RA, 70 (1.94%) were diagnosed with ASD, compared to 28 892 (1.92%) of 1 503 908 children born to mothers without RA. Maternal RA before delivery was associated with an increased risk of offspring ASD (HR = 1.43, 95% CI 1.11-1.84), especially for seronegative RA (HR = 1.61, 95% CI 1.12-2.30). No similar association was observed for paternal RA, maternal sisters with RA, or RA diagnosed after delivery. Maternal arthralgia displayed as high risks for offspring ASD as did maternal RA (HR = 1.41, 95% CI 1.24-1.60).

CONCLUSIONS

In Sweden, maternal RA before delivery was associated with an increased risk of offspring ASD. The comparable association between maternal arthralgia and ASD risk suggests other pathways of risk than autoimmunity/inflammation, acting jointly or independently of RA.

Multimorbidity in rheumatoid arthritis: common mechanistic links and impact and challenges in routine clinical practice

Early identification and management of multimorbidity in patients with rheumatic and musculoskeletal diseases (RMDs), such as RA, is an integral, but often neglected, aspect of care. The prevalence and incidence of conditions such as osteoporosis, cardiovascular disease, pulmonary disease and malignancies, often co-existing with RA, continues to have significant implications for the management of this patient group. Multimorbidity in RMDs can be associated with inflammatory disease activity and target organ damage. Lifestyle factors, such as smoking and inactivity, further contribute to the burden of disease. Inflammation is the underlying factor, not just in RA but also many comorbidities. The current framework of a treat-to-target approach focuses on achieving early remission and inflammatory activity suppression. We describe how the comorbidity burden in people with RMDs impacts on disease outcome and treatment response. The importance of addressing comorbidity at an early stage and adopting a patient centred approach is critical in modern practice.

Increasing global burden of rheumatoid arthritis: an epidemiological analysis from 1990 to 2019

INTRODUCTION

To examine the burden of rheumatoid arthritis (RA) at the global, regional, and national levels in terms of sex, age, geographic distribution, and the Socio-demographic Index (SDI).

MATERIAL AND METHODS

Using Global Burden of Disease study data, the global incidence, disability-adjusted life years (DALYs), and estimated annual percentage change (EAPC) of RA from 1990 to 2019 were analysed.

RESULTS

From 1990 to 2019, the global RA incidence and DALYs increased by 6.47% and 1.15%, respectively. Moreover, both the global age-standardized incidence rate (EAPC = 0.30; 95% confidence interval (CI): 0.25-0.34) and DALYs (EAPC = 0.12; 95% CI: 0.08-0.17) increased. The age-standardized RA incidence was substantially higher in the high-SDI regions than in the other regions. By geographical region, the largest increases in the age-standardized RA incidence and DALYs were observed in Andean Latin America. By country, the largest increase in RA incidence was observed in Equatorial Guinea (EAPC = 1.78), followed by Bhutan (EAPC = 1.54) and Peru (EAPC = 1.53). The age-standardized RA incidence was lower in men than in women. Positive correlations were found between the EAPC of the age-standardized RA incidence and the SDI.

CONCLUSIONS

Increasing trends in the age-standardized RA incidence and DALYs worldwide were shown. Future strategies for RA prevention should focus on women and older adults, as well as individuals from Andean Latin America, southern Latin America, central Asia, western sub-Saharan Africa, and other high-risk regions.

Perceived treatment satisfaction in patients with systemic rheumatic diseases treated with biologic therapies: results of a self-reported survey

Biological agents are widely used for the management of systemic rheumatic diseases (SRDs) and their therapeutic implications have been expanded beyond inflammatory arthropathies to more complicated autoimmune disorders, such as systemic lupus erythematosus, vasculitis, and systemic sclerosis. The aim of this study was to investigate treatment satisfaction and overall experience of SRDs' patients receiving biologics as well as to explore patient's perspectives on the quality of services provided by rheumatology departments and to determine factors related to the level of satisfaction. We performed a synchronous correlation study. Patients with SRDs answered an anonymous questionnaire assessing their satisfaction and how treatment with biologics has affected their quality of life and functionality. Sample consisted by 244 patients (65.2% women), with mean age of 50.4 years, and the most common diagnosis was rheumatoid arthritis (37.3%). Sixty one percent of patients received intravenous therapy and 39% subcutaneously. Overall, 80.5% of the patients reported a positive/very positive effect of their treatment on their life. The average total patient satisfaction from the unit was 79.8%. The presence of mental disease was significantly associated with less positive impact of the treatment on patients' life, worse quality of life, and greater pain. In conclusion, patients with a broad spectrum of SRDs were generally satisfied and treatment with biologic regimens appeared to have a positive impact on several aspects of their life. The majority of patients were at least satisfied with all the characteristics of the unit staff and better quality of life was associated with greater satisfaction about the Unit and more positive affect of the treatment in patients' life.

Does Having Rheumatoid Arthritis Increase the Dose of Depression Medications? A Mendelian Randomization Study

BACKGROUND

Rheumatoid arthritis (RA) increases the risk of depression. However, studies on the effects of RA on the dose of depression medications are limited. Therefore, in this study, we used two-sample Mendelian randomization (MR) to explore whether RA increases the dose of depression medications and gain a more comprehensive understanding of the relationship between RA and depression.

METHODS

Two-sample MR was used to evaluate the causal effect of RA on the dose of depression medications. The aggregated data on RA originated from extensive genome-wide association studies (GWASs) of European descent (14,361 cases and 42,923 controls). The summary GWAS data for the dose of depression medications were derived from the FinnGen consortium (58,842 cases and 59,827 controls). Random effects inverse-variance weighted (IVW), MR-Egger regression, weighted median, and fixed effects IVW methods were used for the MR analysis. Random effects IVW was the primary method. The heterogeneity of the MR results was detected using the IVW Cochran's Q test. The pleiotropy of the MR results was detected using MR-Egger regression and the MR pleiotropy residual sum and outlier (MR-PRESSO) test. Finally, a leave-one-out analysis was performed to determine whether the MR results were affected by a specific single-nucleotide polymorphism (SNP).

RESULTS

The primary method, random effects IVW, revealed that genetically predicted RA had a positive causal association with the dose of depression medications (Beta, 0.035; 95% confidence interval (CI), 0.007-0.064; p = 0.015). The IVW Cochran's Q test results revealed no heterogeneity in the MR analysis (p > 0.05). The MR-Egger regression and MR-PRESSO tests revealed that there was no pleiotropy in our MR analysis. The leave-one-out analysis confirmed that a single SNP did not affect the MR results, indicating the study's robustness.

CONCLUSION

Using MR techniques, we discovered that having RA increases the dose of depression medications; however, the exact mechanisms and pathways still need to be further explored.

Association of mental distress with chronic diseases in 1.9 million individuals: A population-based cross-sectional study

OBJECTIVE

Mental distress has a high global prevalence and is associated with poor health outcomes. This study aimed to estimate the relationship between mental distress and the risk of 10 chronic diseases using data from the Behavioral Risk Factor Surveillance System (BRFSS).

METHODS

Cross-sectional data from the 2013, 2014, 2015, 2016 and 2017 BRFSS were analyzed. The association between mental distress based on the number of days of poor mental health and the risk of 10 chronic diseases, namely obesity, diabetes, asthma, chronic obstructive pulmonary disease (COPD), arthritis, kidney disease, coronary heart disease (CHD), stroke, skin cancer, and other cancers, were assessed by logistic regression models to calculate odds ratios and 95% confidence intervals. Subgroup analyses stratified by age and sex were also conducted.

RESULTS

Positive associations between mental distress and chronic diseases were observed. We also found a dose-response gradient between mental distress levels and the risk of all chronic diseases except skin cancer. In respondents aged 18-44 years reporting ≥23 days/month of mental distress, there has the largest odds ratio between mental distress levels and each chronic disease. Moreover, mental distress was associated with higher risks of obesity and arthritis in women relative to men.

CONCLUSIONS

Mental distress was positively associated with chronic diseases. Age and sex are crucial in this relationship. Further studies with longitudinal data are needed to clarify the direction of this association.

Pain Is Associated With Depressive Symptoms, Inflammation, and Poorer Physical Function in Older Adults With HIV

OBJECTIVE

People living with HIV (PLWH) frequently experience pain, which often co-occurs with psychological symptoms and may impact functional outcomes. We investigated cross-sectional associations between pain, depressive symptoms, and inflammation, and then explored whether pain was related to poorer physical function among older PLWH.

METHODS

We examined data from PLWH aged 54 to 78 years ( n = 162) recruited from a single outpatient program for a larger study on HIV and aging. Participants reported depressive symptoms (10-item Center for Epidemiological Studies Depression Scale) and then attended a biomedical visit in which they reported past-month pain (Medical Outcomes Study-HIV pain subscale), completed physical function assessments, and provided blood samples (assayed for interleukin 6, interferon-γ, tumor necrosis factor α, and C-reactive protein). Links between pain, depressive symptoms, inflammation, and physical function were tested using linear regression models.

RESULTS

PLWH with greater depressive symptoms experienced more pain than did those with fewer depressive symptoms ( B = 1.31, SE = 0.28, p < .001), adjusting for age, sex, race, body mass index, smoking, disease burden, time since HIV diagnosis, and medication use. Higher composite cytokine levels were associated with worse pain ( B = 5.70, SE = 2.54, p = .027 in adjusted model). Poorer physical function indicators, including slower gait speed, weaker grip strength, recent falls, and prefrail or frail status, were observed among those with worse pain. Exploratory mediation analyses suggested that pain may partially explain links between depressive symptoms and several physical function outcomes.

CONCLUSIONS

Pain is a potential pathway linking depressive symptoms and inflammation to age-related health vulnerabilities among older PLWH; longitudinal investigation of this pattern is warranted. PLWH presenting with pain may benefit from multidisciplinary resources, including behavioral health and geriatric medicine approaches.

Defining the relationship between pain intensity and disease activity in patients with rheumatoid arthritis: a secondary analysis of six studies

Background

Pain is the main concern of patients with rheumatoid arthritis (RA) while reducing disease activity dominates specialist management. Disease activity assessments like the disease activity score for 28 joints with the erythrocyte sedimentation rate (DAS28-ESR) omit pain creating an apparent paradox between patients’ concerns and specialists’ treatment goals. We evaluated the relationship of pain intensity and disease activity in RA with three aims: defining associations between pain intensity and disease activity and its components, evaluating discordance between pain intensity and disease activity, and assessing temporal changes in pain intensity and disease activity.

Methods

We undertook secondary analyses of five trials and one observational study of RA patients followed for 12 months. The patients had early and established active disease or sustained low disease activity or remission. Pain was measured using 100-mm visual analogue scales. Individual patient data was pooled across all studies and by types of patients (early active, established active and established remission). Associations of pain intensity and disease activity were evaluated by correlations (Spearman’s), linear regression methods and Bland-Altman plots. Discordance was assessed by Kappa statistics (for patients grouped into high and low pain intensity and disease activity). Temporal changes were assessed 6 monthly in different patient groups.

Results

A total of 1132 patients were studied: 490 had early active RA, 469 had established active RA and 173 were in remission/low disease activity. Our analyses showed, firstly, that pain intensity is associated with disease activity in general, and particularly with patient global assessments, across all patient groups. Patient global assessments were a reasonable proxy for pain intensity. Secondly, there was some discordance between pain intensity and disease activity across all disease activity levels, reflecting similar discrepancies in patient global assessments. Thirdly, there were strong temporal relationships between changes in disease activity and pain intensity. When mean disease activity fell, mean pain intensity scores also fell; when mean disease activity increased, there were comparable increases in pain intensity.

Conclusions

These findings show pain intensity is an integral part of disease activity, though it is not measured directly in DAS28-ESR. Reducing disease activity is crucial for reducing pain intensity in RA.

The impact of consecutive COVID-19 lockdowns in England on mental wellbeing in people with inflammatory arthritis

Background

During the first UK COVID-19 lockdown, studies identified over half of inflammatory arthritis (IA) patients in the UK reported a worsening of emotional distress. Given the prolonged nature of the pandemic, and the strict ‘shielding’ restrictions imposed on ‘extremely clinically vulnerable’ populations, it is likely that the implementation of the second lockdown period in England, during November 2020, may also have had a negative impact on the mental health of IA patients. The aim of this study was to qualitatively explore the impact of consecutive lockdown periods on mental wellbeing in people with IA.

Methods

Nine IA patients took part in semi-structured telephone interviews at both baseline (June/July 2020) and follow-up (November 2020). The interview schedule, which was developed and piloted with a Patient Research Partner, explored patient experiences and mental health impacts of the COVID-19 lockdown periods. Interviews were analysed using inductive thematic analysis.

Results

Five males and four females, with rheumatoid arthritis, psoriatic arthritis, or spondylarthritis, aged between 24–79 years (mean = 49.9, SD = 20.9) were included in the sample. Four main themes impacting on mental wellbeing were identified from the data: (1) Pandemic fatigue versus pandemic acclimatisation, (2) Social interaction and isolation, (3) Clarity of information, (4) Seasonal changes.

Conclusion

The first two COVID-19 lockdown periods in England had an ongoing impact on the mental health of patients with IA. Healthcare professionals, in conjunction with government support, should ensure that adequate information and mental health resources are available to support IA patients during periods of ongoing restrictions, whilst also continuing to encourage behaviours which promote good mental health and wellbeing.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41927-022-00266-y.

The point of no return? Functional disability transitions in patients with and without rheumatoid arthritis: A population-based cohort study

OBJECTIVE

To assess transition probability between different levels of functional disability (FD) and time spent with FD in patients with versus without rheumatoid arthritis (RA) after RA incidence/index date.

METHODS

This retrospective population-based cohort study included Olmsted County, Minnesota residents (1987 ACR criteria met in 1999-2013) and comparators without RA from the same area with similar age, sex and RA incidence/index date. Activities of Daily Living (ADL) were obtained by self-report questionnaires annually since 1999. FD was defined as having difficulty with ≥1 ADL. Multistate modeling was used to estimate the probability of transitioning between FD states.

RESULTS

Five hundred fifty-eight patients with RA and 457 comparators completed ≥2 questionnaires and were included. Patients with RA had increased risk of transitioning from no FD to FD: Hazard Ratio (HR) 2.4; 95%CI:1.9-3.0. Each additional FD at RA onset reduced the probability of returning to no FD by 14%. However, the probability of having ≥1 FD was stable between RA incidence and 10-year follow-up. In the first 15 years of disease, patients with RA spent on average 10.1 years without FD and 3.4 years with ≥1 FD versus 11.6 years and 2.0 years (p<0.001) in comparators.

CONCLUSION

Patients with RA remain functionally disadvantaged compared to individuals without RA. The likelihood of returning to no FD in RA decreases with each additional preexisting FD. However, the probability of FD does not increase within 10 years of RA onset, potentially reflective of the benefits of disease-modifying treatments in RA.

The Association Between Mental Health Disorders and Non-Infectious Scleritis: A Prevalence Study and Review of the Literature

Chronic inflammatory diseases can cause significant psychosocial stress in affected patients. Few studies have examined the psychological effects of ocular inflammatory disease and no studies have examined the psychological effects of scleritis. In this study we evaluate the prevalence of mental health disorders in scleritis patients and we conduct a comprehensive review of the literature on the mental health effects of ocular inflammatory diseases. 162 patients (195 eyes) presenting to a tertiary care center with scleritis were identified. At least one comorbid mental health disorder was diagnosed in 35 patients (21.6%), most commonly major depression in 11.7%, generalized anxiety disorder in 9.3%, and substance use disorder in 6.2%. There were no significant differences in the length of an episode of scleritis or in the probability of symptom resolution between patients with a mental health disorder and other patients. In a review of the literature, 30 manuscripts met the inclusion criteria. The majority of manuscripts (83.3%) were focused on uveitis patients. Eight of these studies were focused on patients with uveitis in the context of systemic disease. The most commonly reported mental health disorders reported were anxiety and depression. An average of 31.3% of patients with ocular inflammatory disease had depression and 35.0% had anxiety. Similar to other chronic illnesses, ocular inflammatory disease may be a significant psychosocial stressor. Future studies will further elucidate the relationship between these diseases and mental health.

The association between disease duration and mood disorders in rheumatoid arthritis patients

AIMS

The mood disorders have been recognized as common comorbidities of rheumatoid arthritis (RA), however unknown in patients with different RA courses. Therefore, we aimed to investigate the status of mood disorders in early RA and non-early RA patients and further identify the associated factors for mood disorders.

METHODS

Self-rating anxiety scale (SAS) and self-rating depression scale (SDS) were assessed in all enrolled RA patients. Besides clinical assessments, power Doppler and greyscale (GS) ultrasound of 28 joints was performed. The frequency of mood disorders was compared between early RA and non-early RA patients. Multivariate regression was used to identify the associated factors for mood disorders.

RESULTS

Tow hundred one RA patients were enrolled, with 76 early RA (disease duration ≤ 2 years) and 125 non-early RA (disease duration > 2 years). Mood disorders (depression and/or anxiety) were found in 42 (20.9%) patients. Depression was more frequently observed in early RA than non-early RA patients (26.3% vs. 14.4%, P = 0.036). A similar trend for anxiety was also observed in early RA compared to non-early RA patients, although the difference was insignificant (13.2% vs. 5.6%, P = 0.062). Disease duration (OR = 0.991, 95% CI 0.985-0.998, P = 0.009), health assessment questionnaire disability index (HAQ-DI) (OR = 1.045, 95% CI 1.005-1.086, P = 0.029) and GS synovitis score (OR = 1.065, 95% CI 1.017-1.115, P = 0.007) were identified as factors associated with depression. Disease duration (OR = 0.981, 95% CI 0.967-0.995, P = 0.009), HAQ-DI (OR = 1.071, 95% CI 1.013-1.133, P = 0.017) and GS synovitis score (OR = 1.072, 95% CI 1.012-1.136, P = 0.019) were identified to be associated with anxiety.

CONCLUSIONS

Depression and anxiety were almost doubled in frequency in early RA than in long-standing RA patients. RA patients with short disease duration, high HAQ-DI and GS score were more likely to be in depression and anxiety. Key Points • Mood disorders were more frequent in early RA than non-early RA patients. • More attention to psychological status is needed in RA patients. • RA patients with short disease duration, poor physical function and severe synovitis were more likely to have depression and/or anxiety.

Clinical characteristics and lifestyle behaviors among individuals with arthritis: an analysis of 2017 Behavioral Risk Factor Surveillance System data

Context

The combination of osteoarthritis and rheumatoid arthritis affects nearly one-fourth of Americans. Many of the risk factors for arthritis are lifestyle related, such as obesity, physical activity, dietary behaviors, and alcohol and tobacco use.

Objective

To analyze lifestyle behaviors of patients with vs. those without arthritis.

Methods

A cross-sectional analysis of 2017 Behavioral Risk Factor Surveillance System (BRFSS) data was conducted on patients with and without a history of arthritis. Physical activity, smoking status, alcohol use, and dietary behaviors were extracted. Logistic regression models were constructed to calculate adjusted risk ratios (ARRs). All confidence intervals (CIs) were reported at 95%.

Results

The median response rate for the 2017 BRFSS survey was 45.1% (sample n=292,808; population N=118,751,156). The overall prevalence of arthritis was 44% (n=128,850). Respondents with arthritis were significantly more likely to be physically inactive than nonarthritic respondents, with a significant gender interaction (male absolute risk reduction [ARR], 1.2 [CI, 1.15-1.25]; female ARR, 1.29 [CI, 1.24-1.33]). Those with arthritis were also more likely to be current smokers (ARR 1.1; CI, 1.05-1.15) and less likely to have attempted to quit smoking in the last 12 months (ARR, 0.91; CI, 0.87-0.96). Finally, men with arthritis were more likely to drink alcohol heavily (ARR, 1.14; CI, 1.02-1.27]).

Conclusion

Patients with arthritis were more likely to be women, White, current smokers, and physically inactive, and to have poor mental health, lower education levels, and difficulty paying for healthcare and medications than those without arthritis. Further efforts should be made to address these findings through resource allocation in the care of patients with arthritis. Practitioners should also seek increased understanding of the psychological, social, and economic impacts of physical activity and smoking in patients with arthritis.

High Prevalence of Depressive Symptoms Among Ugandan Patients with Rheumatoid Arthritis

Background

There is a scarcity of data on the burden of depression among Ugandans with rheumatoid arthritis (RA) patients. We aimed to screen for symptoms of depression, their severity and associated factors among patients with RA in Uganda.

Patients and Methods

A descriptive, cross-sectional study was conducted between September and December 2020 at Mulago National Referral Hospital (MNRH) and Nsambya Hospital. Patients with RA were enrolled consecutively. Data on demographics, disease course and comorbidities and depression symptomatology were collected through an interviewer administered questionnaire. Symptoms of depression were screened for using the depression/anxiety dimension of the EuroQoL questionnaire.

Results

Forty-eight patients with a median age of 52 (IQR: 43.5–60.5) years were recruited in the study. The majority of the patients were female (91.7%, n=44). Twenty-nine patients (60.4%) had comorbidities with a median Charlson comorbidity score of 3 (IQR: 2–4). Overall, 70.8% (n=34) had depressive symptoms. Patients attending MNRH were more likely to have depressive symptoms (p=0.025). Significantly, patients with depressive symptoms were younger (p=0.027), had lower health index value (p<0.001), and lower overall self-reported health status (p=0.013). At binary logistic regression, patients at MNRH (crude odds ratio (COR): 4.32, 95% confidence interval (CI): 1.16–16.15, P=0.030), patients aged <52 years (COR: 5.24, 95% CI: 1.23–22.28, P=0.025) and those with mild RA (COR: 5.71, 95% CI: 1.15–28.35, P=0.033) were significantly more likely to have depressive symptoms. Increase in age (COR: 0.94, 95% CI: 0.89–0.99, P=0.025), and high visual analogue score (COR: 0.94, 95% CI: 0.89–0.99, P=0.013) were protective.

Conclusion

Depressive symptoms were common among RA patients in Uganda. Routine screening, diagnosis and management of depression is recommended among young patients to improve quality of life and patient outcomes.

Depression in disabling medical conditions - current perspectives

Chronic diseases commonly entail disability and are highly comorbid with mental health problems, particularly depression. Prevalence of depression across different disabling conditions affecting adult patients, as well as risk factors for depression in these patient groups are reviewed in the current work, with a particular focus on the literature published in the past 5 years. The prevalence of depression in disabling conditions is higher than in the general population and is associated with different factors. Examples of disease-specific factors include neurological implications of stoke, diabetic related conditions (e.g. amputation), limitations imposed by vision loss caused by age-related eye diseases, fatigue in rheumatoid arthritis, and pain in cancer. Common factors identified across different conditions include pre-morbid depression, history of mental health problems, poor social support, disease-related disability, multi-morbidity, and less adaptive coping strategies. We also reviewed studies suggesting a potential bidirectional relationship between depression and chronic disease, particularly for stroke, cardiovascular disease, diabetes, and potential factors mediating that relationship. Current findings suggested that long-term depression might be associated with an increased risk of subsequent physical health problems, although the nature of that relationship and its underlying mechanisms are still unclear.

Pain: A Review of Interleukin-6 and Its Roles in the Pain of Rheumatoid Arthritis

Pain is a major and common symptom reported as a top priority in patients with rheumatoid arthritis (RA). Intuitively, RA-related pain is often considered to be a natural consequence of peripheral inflammation, so treatment of RA is expected to manage pain concurrently as part of inflammation control. However, pain in patients with RA can be poorly correlated with objective measures of inflammation, for example, in patients who are otherwise in remission. Joint damage appears to account for only a fraction of this residual pain. Emerging evidence suggests that alteration of peripheral and central pain processing contributes to RA-related pain; this is parallel to, but somewhat independent of, joint inflammation. Interleukin (IL)-6 is a proinflammatory cytokine that contributes to the pathogenesis of RA. It exerts systemic effects via signaling through soluble forms of the IL-6 receptor (“trans-signaling”). Evidence from preclinical studies demonstrates that intra-articular IL-6 can produce long-lasting peripheral sensitization to mechanical stimulation and suggests an important role for IL-6 in central pain sensitization. This may be partly explained by its ability to activate neurons through trans-signaling, affecting nociceptive plasticity and nerve fiber regrowth. Local activity at neuron endings may culminate in altered pain processing in the central nervous system because of persistent signaling from sensitized peripheral neurons. Peripheral and central sensitization can promote the development of chronic pain, which can have a significant impact on patients’ health and quality of life. A proportion of pain in RA may be more appropriately managed as an entity separate from inflammation. Both the peripheral and central nervous systems should be recognized as important potential systems targeted by RA. The substantial burden of RA-related chronic pain suggests that pain should be a key focus in RA management and should be assessed and addressed early and separately from the inflammatory component.

Assessment of Treatment Safety and Quality of Life in Patients Receiving Etanercept Biosimilar for Autoimmune Arthritis (ASQA): A Multicenter Post-marketing Surveillance Study

INTRODUCTION

Phase IV post-marketing surveillance studies are needed to evaluate the real-world safety and effectiveness of drug products. This study aimed to evaluate the safety and effectiveness of biosimilar etanercept (Altebrel, AryoGen Co., Iran) in patients with rheumatoid arthritis (RA), ankylosing spondylitis (AS), and psoriatic arthritis (PsA).

METHODS

In this open-label, multicenter, prospective, observational, post-marketing surveillance study, 583 patients received biosimilar etanercept 25 mg twice weekly or 50 mg once weekly and were followed up to 12 months. The primary objective was to evaluate the safety of biosimilar etanercept by documenting all the adverse events in the case report forms throughout the study period. The secondary objective was to evaluate the effectiveness of biosimilar etanercept in study patients, where longitudinal changes in health assessment questionnaire (HAQ), pain, and disease activity scores were assessed.

RESULTS

A total of 583 patients (44.80 ± 13.09 years of age) were included and followed for an average of 8.12 ± 3.96 months. Among all patients, 172 (29.50%) experienced at least one adverse event, and injection site reaction, abdominal pain, and upper respiratory tract infection were the most common. HAQ scores decreased from 1.32 ± 0.77 at baseline to 0.81 ± 0.61 at 12 months in patients with RA/PsA (p < 0.01) and from 0.82 ± 0.58 at baseline to 0.66 ± 0.63 at 12 months in patients with AS (p = 0.18). Pain scores decreased from 6.49 ± 2.41 at baseline to 3.51 ± 2.39 at 12 months (p < 0.01).

CONCLUSION

The results demonstrated the real-world safety and effectiveness of biosimilar etanercept in patients with RA, PsA, and AS.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT04582084.

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

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

Rheumatoid Arthritis: The Impact of Mental Health on Disease: A Narrative Review

Over 60% of rheumatoid arthritis (RA) patients achieve a good response after 12 months of treatment when following the European league against rheumatism (EULAR) guidelines for treatment. However, almost half of patients still suffer from moderate to severe disease activity despite this. In addition, mental health problems may remain despite reduced measures of inflammation systemically and within joints. Depression is two times more common in RA patients than in the general population, and intriguingly a bi-directional relationship with RA has been shown in cross-sectional studies. Chronic inflammation impairs the physiological responses to stress including effective coping behaviours, resulting in depression, which leads to a worse long-term outcome in RA. In RA patients, the pain score is not always solely related to inflammatory arthritis and immunological disease activity by Bąk et al. (Patient Prefer Adherence 13:223-231, [1]). Non-inflammatory pain secondary to anxiety, depression, sleep disturbance and the psychosocial situation needs to be considered whilst fibromyalgia, mechanical pain and neuropathic pain can also contribute to overall pain scores by Chancay et al. (Women's Midlife Health 5:3, [2]). Hence, the UK National Institute for Health and Care Excellence (NICE) guideline for the management of RA included psychological interventions for fatigue, low mood and social well-being (NICE NG100, 2018) [3], and the NICE clinical guidelines (CG91) [4] suggest managing mental health and depression in chronic medical conditions to improve treatment outcomes. This is a narrative review of the impact of mental health on RA disease activity in terms of patient-reported outcomes (PROs).

Extended overview of the longitudinal pain-depression association: A comparison of six cohorts treated for specific chronic pain conditions

BACKGROUND

The aim was to quantify and to compare the associations between longitudinal changes in pain and depression in different chronic pain conditions.

METHODS

Data were retrieved from 6 observational cohort studies. From baseline to the 6-month follow-up, the score changes on the Short Form (36) Health Survey (SF-36) bodily pain (pain) and the SF-36 mental health (depression) scales (0=worst, 100=best) were quantified, using partial correlations obtained by multiple regression. Adjustment was performed by age, living alone/with partner, education level, number of comorbidities, baseline pain and baseline depression.

RESULTS

Stronger associations were found between changes in levels of pain and depression for neck pain after whiplash (n = 103, mean baseline pain=21.4, mean baseline depression=52.5, adjusted correlation r = 0.515), knee osteoarthritis (n = 177, 25.4, 64.2, r = 0.502), low back pain (n = 134, 19.0, 49.4, r = 0.495), and fibromyalgia (n = 125, 16.8, 43.2, r = 0.467) than for lower limb lipedema (n = 68, 40.2, 62.6, r = 0.452) and shoulder arthroplasty (n = 153, 35.0, 76.4, r = 0.292). Those correlations were somewhat correlated to baseline pain (rank r=-0.429) and baseline depression (rank r=-0.314).

LIMITATIONS

The construct of the full range of depressive symptoms is not explicitly covered by the SF-36.

CONCLUSIONS

Moderate associations between changes in pain and depression levels were demonstrated across 5 of 6 different chronic pain conditions. The worse the pain and depression scores at baseline, the stronger those associations tended to be. Both findings indicate a certain dose-response relationship - an important characteristic of causal interference. Relieving pain by treatment may lead to the relief of depression and vice versa.

Acute mental health service use is increased in rheumatoid arthritis and ankylosing spondylitis: a population-based cohort study

Background

Rheumatoid arthritis (RA) and ankylosing spondylitis (AS) are associated with mental illness. Whether acute mental health (MH) service utilization (i.e. emergency visits or hospitalizations) is increased in RA or AS is not known.

Methods

Two population-based cohorts were created where individuals with RA (n = 53,240) or AS (n = 13,964) were each matched by age, sex, and year to unaffected comparators (2002-2016). Incidence rates per 1000 person-years (PY) were calculated for a first MH emergency department (ED) presentation or MH hospitalization. Hazard ratios (HR) and 95% confidence intervals (CI) were calculated, adjusting for demographic, clinical, and health service use variables.

Results

Individuals with RA had higher rates of ED visits [6.59/1000 person-years (PY) versus 4.39/1000 PY in comparators] and hospitalizations for MH (3.11/1000 PY versus 1.80/1000 PY in comparators). Higher rates of ED visits (7.92/1000 PY versus 5.62/1000 PY in comparators) and hospitalizations (3.03/1000 PY versus 1.94/1000 PY in comparators) were also observed in AS. Overall, RA was associated with a 34% increased risk for MH hospitalization (HR 1.34, 95% CI 1.22-1.47) and AS was associated with a 36% increased risk of hospitalization (HR 1.36, 95% CI 1.12-1.63). The risk of ED presentation was attenuated, but remained significant, after adjustment in both RA (HR 1.08, 95% CI 1.01-1.15) and AS (HR 1.14, 95% CI 1.02-1.28).

Conclusions

RA and AS are both independently associated with a higher rate and risk of acute ED presentations and hospitalizations for mental health conditions. These findings underscore the need for routine evaluation of MH as part of the management of chronic inflammatory arthritis. Additional research is needed to identify the underlying individual characteristics, as well as system-level variation, which may explain these differences, and to help plan interventions to make MH service use more responsive to the needs of individuals living with RA and AS.

[Depression and severity of articular destruction in patients with rheumatoid arthritis]

AIM

To assess the influence of anxiety and depressive disorders on joint destruction in patients with rheumatoid arthritis (RA).

MATERIALS AND METHODS

128 RA-patients were included, 87% were women with a mean age of 47.411.3 years and a median of RA duration 96 [48; 228] months. At the inclusion most patients had moderate (n=56, 43.7%) and severe (n=48, 37.5%) disease activity according to DAS28. Joint destruction was classified as maximal in patients with radiographic stage III, IV and/or osteonecrosis) and minimal in patients with stage I, II and no osteonecrosis. Pain intensity was measured with the BPI (Brief Pain Inventory) scale, severity of fatigue with fatigue severity scale (FSS), clinically important fatigue was diagnosed in patients with FSS4. Anxiety and depressive disorders (ADD) were diagnosed by a licensed psychiatrist in 123 (96.1%) of RA-patients in accordance with ICD-10 in semi-structured interview. Severity of depression and anxiety was evaluated with Montgomery-Asberg Depression Rating Scale (MADRS) and Hamilton Anxiety Rating Scale (HAM-A). RA-patients with ADD were divided into the following treatment groups: 1 сDMARDs (n=39), 2 сDMARDs+PPT (sertraline or mianserine), n=43, 3 сDMARDs+bDMARDs (n=32), 4 сDMARDs+bDMARDs+PPT (sertraline or mianserine), n=9. Biologics treatment duration varied from 1 to 6 years, antidepressants from 6 to 96 weeks. 83 (67.5%) RA patients were assessed at five-years follow-up. Linear regression analysis was conducted to determine factors associated with maximal join destruction.

RESULTS

According to linear regression analysis, maximal joint destruction at 5 years follow-up was associated with higher baseline BPImax, longer RA and ADD duration, clinically important fatigue at baseline, baseline extraarticular RA manifestations, recurrent depressive disorder at 5-years follow-up and treatment with cDMARDs only.

CONCLUSION

Recurrent depressive disorder without antidepressant treatment is an important predictor of progression of joint destruction in patients with rheumatoid arthritis.

Examining the cross-sectional and longitudinal effects of anxiety sensitivity on indicators of disease severity among patients with inflammatory arthritis

Few studies have investigated anxiety sensitivity (AS) in the context of inflammatory arthritis (IA), despite evidence of a relationship between AS and pain. This study examined cross-sectional and longitudinal relationships between AS and indicators of IA severity in 148 participants with IA. AS and its factors (social, physical, cognitive) were self-reported. Arthritis severity was physician-assessed (disease activity scales) and self-reported (physical function; pain and fatigue). Cross-sectional correlations assessed the association between AS and arthritis severity outcomes. Longitudinal multivariable mixed-effect regressions assessed the association of AS total and AS factors at each visit with disease severity outcomes. All AS factors were significantly and positively correlated (at the same visit) with function, pain, and fatigue. AS total significantly predicted pain, fatigue, and function. Cognitive AS significantly predicted fatigue, and physical AS significantly predicted pain and fatigue. Social AS significantly predicted pain, fatigue, function and weighted joint count (articular burden). AS is associated with several indicators of disease severity among those with IA; unique findings emerged across factors with the broadest disease impact by social AS. The AS factors, especially social AS, may contribute to the development and severity of IA symptoms, which may have implications for interventions.

The economic burden of depression among adults with rheumatoid arthritis in the United States

AIMS

Depression is the most frequent comorbidity reported among patients with rheumatoid arthritis (RA). Comorbid depression negatively impacts RA patients' health-related quality-of-life, physical function, mental function, mortality, and experience of pain and symptom severity. The objective of this study was to assess healthcare utilization, expenditures, and work productivity among patients with RA with or without depression.

MATERIALS AND METHODS

Data from adult patients who had at least two visits each related to RA and depression over a 1-year period were extracted from the Truven Health MarketScan research databases. Outcomes comprised healthcare resource utilization, work productivity loss, and direct healthcare costs comparing patients with RA with depression (n = 3,478) vs patients with RA without depression (n = 43,222).

RESULTS

Patients with RA and depression had a significantly greater relative risk of hospitalization and number of all-cause and RA-related hospitalizations, utilization of emergency services, days spent in the hospital, physician visits, and RA-related surgeries compared with RA patients without depression. Patients with RA and depression had a higher risk of and experienced more events and days of short-term disability compared with patients without depression. The incremental adjusted annual all-cause and RA-related direct costs were $8,488 (95% CI = $6,793-$10,223) and $578 (95% CI = -$98-$1,243), respectively, when comparing patients with RA and depression vs RA only.

LIMITATIONS

The current analysis is subject to the known limitations of retrospective studies based on administrative claims data.

CONCLUSIONS

This study suggested increased healthcare utilization, work productivity loss, and economic burden among RA patients due to comorbid depression. These findings emphasize the importance of managing depression and including depression as a factor when devising treatment algorithms for patients with RA.

The Role of the Eukaryotic Translation Initiation Factor 4E (eIF4E) in Neuropsychiatric Disorders

Protein synthesis in eukaryotic cells is a complex, multi-step and tightly regulated process. Translation initiation, the rate limiting step in protein synthesis, is dependent on the activity of eukaryotic translation Initiation Factor 4E (eIF4E). eIF4E is the cap-binding protein which, in synergy with proteins such as the helicase eIF4A and the scaffolding protein eIF4G, binds to mRNA, allowing the recruitment of ribosomes and translation initiation. The function of eIF4E is tightly regulated in cells under normal physiological conditions and can be controlled by post-translational modifications, such as phosphorylation, and by the binding of inhibitory proteins, including eIF4E binding proteins (4E-BPs) and CYFIP1. Recent studies have highlighted the importance of eIF4E in normal or aberrant function of the nervous system. In this mini-review, we will highlight the role of eIF4E function and regulation in the pathophysiology of neurodevelopmental and neuropsychiatric disorders.

The severity of psychiatric disorders

The issue of the severity of psychiatric disorders has great clinical importance. For example, severity influences decisions about level of care, and affects decisions to seek government assistance due to psychiatric disability. Controversy exists as to the efficacy of antidepressants across the spectrum of depression severity, and whether patients with severe depression should be preferentially treated with medication rather than psychotherapy. Measures of severity are used to evaluate outcome in treatment studies and may be used as meaningful endpoints in clinical practice. But, what does it mean to say that someone has a severe illness? Does severity refer to the number of symptoms a patient is experiencing? To the intensity of the symptoms? To symptom frequency or persistence? To the impact of symptoms on functioning or on quality of life? To the likelihood of the illness resulting in permanent disability or death? Putting aside the issue of how severity should be operationalized, another consideration is whether severity should be conceptualized similarly for all illnesses or be disorder specific. In this paper, we examine how severity is characterized in research and contemporary psychiatric diagnostic systems, with a special focus on depression and personality disorders. Our review shows that the DSM-5 has defined the severity of various disorders in different ways, and that researchers have adopted a myriad of ways of defining severity for both depression and personality disorders, although the severity of the former was predominantly defined according to scores on symptom rating scales, whereas the severity of the latter was often linked with impairments in functioning. Because the functional impact of symptom-defined disorders depends on factors extrinsic to those disorders, such as self-efficacy, resilience, coping ability, social support, cultural and social expectations, as well as the responsibilities related to one's primary role function and the availability of others to assume those responsibilities, we argue that the severity of such disorders should be defined independently from functional impairment.

FACTORS INFLUENCING THE EFFICIENCY OF THERAPY IN PATIENTS WITH RHEUMATOID ARTHRITIS: THE ROLE OF COMORBID MENTAL AND SOMATIC DISEASES

The response rate to therapy for rheumatoid arthritis (RA) rarely exceeds 60%. Mental disorders (MDs) of the anxiety-depressive spectrum (ADS) and cognitive impairment (CI) substantially affect the evaluation of the efficiency of RA therapy. Adequate psychopharmacotherapy is one of the possible approaches to optimizing the treatment of RA. The factors influencing the efficiency of RA therapy with standard disease-modifying antirheumatic drugs (DMARDs) and biological agents (BAs) in combination with adequate psychopharmacotherapy have not been previously identified. Objective: to determine the predictors of response to therapy in patients with RA receiving DMARDs and BAs with or without adequate psychopharmacotherapy for ADS disorders. Subjects and methods. The investigation included 128 patients (13% men and 87% women) with a reliable diagnosis of RA. At baseline, 75.1% of patients received DMARDs; 7.8% – BAs. ADS disorders were detected in 123 (96.1%) patients. Psychopharmacotherapy was offered to all the patients with MDs; 52 patients agreed to treatment and 71 refused. The following therapeutic groups were identified according to the performed therapy: 1) DMARDs (n = 39); 2) DMARDs + psychopharmacotherapy (n = 43); 3) DMARDs + BAs (n = 32); 4) DMARDs + BAs + psychopharmacotherapy (n = 9). The changes of MDs symptoms and the outcomes of RA were assessed in 83 (67.5%) patients at five-year follow-up. The efficiency of RA therapy was evaluated with DAS28 (EULAR criteria). Predictors of response to therapy were determined using linear regression modeling. Results and discussion. At 5 years, 22 (26.5%) and 37 (44.6%) patients were recorded to show good and moderate responses to therapy, respectively; 24 (28.9%) patients were non-respondents. The linear regression model included 14 factors (p<0.001). The high values of DAS28 (β=0.258) at the inclusion; belonging to therapeutic groups 2 (β=0.267), 3 (β=0.235), and 4 (β=0.210), the absence of diabetes mellitus (β=-0.230), and experience in using glucocorticoids (β=-0.230) were associated with a high likelihood of response to therapy; high body mass index (β=-0.200) and long RA duration (β=-0,181), a high level of rheumatoid factor (β=-0.176), a history of myocardial infarction (β=-0.153), schizotypic disorder (β=-0.132), and extra-articular manifestations of RA (β=-0.106), and older age (β=-0.102) were related to a low probability of response. The area under the ROC curve for the model was 0.99 (p><0.001). Conclusion. BA therapy and psychopharmacotherapy, along with younger age, shorter duration and high activity of RA, a low level of rheumatoid factor, lower body mass index, the absence of diabetes mellitus, myocardial infarction, and extra-articular manifestations of RA in the history, schizotypic disorder, and experience in using glucocorticoids are associated with a greater likelihood of a good and moderate treatment response. Keywords: rheumatoid arthritis; mental disorders; disease-modifying antirheumatic drugs; biological agents; efficiency of therapy; predictors; psychopharmacotherapy; therapy adherence><0.001). The high values of DAS28 (β=0.258) at the inclusion; belonging to therapeutic groups 2 (β=0.267), 3 (β=0.235), and 4 (β=0.210), the absence of diabetes mellitus (β=-0.230), and experience in using glucocorticoids (β=-0.230) were associated with a high likelihood of response to therapy; high body mass index (β=-0.200) and long RA duration (β=-0,181), a high level of rheumatoid factor (β=-0.176), a history of myocardial infarction (β=-0.153), schizotypic disorder (β=-0.132), and extra-articular manifestations of RA (β=-0.106), and older age (β=-0.102) were related to a low probability of response. The area under the ROC curve for the model was 0.99 (p<0.001). Conclusion. BA therapy and psychopharmacotherapy, along with younger age, shorter duration and high activity of RA, a low level of rheumatoid factor, lower body mass index, the absence of diabetes mellitus, myocardial infarction, and extra-articular manifestations of RA in the history, schizotypic disorder, and experience in using glucocorticoids are associated with a greater likelihood of a good and moderate treatment response. Keywords: rheumatoid arthritis; mental disorders; disease-modifying antirheumatic drugs; biological agents; efficiency of therapy; predictors; psychopharmacotherapy; therapy adherence><0.001). Conclusion. BA therapy and psychopharmacotherapy, along with younger age, shorter duration and high activity of RA, a low level of rheumatoid factor, lower body mass index, the absence of diabetes mellitus, myocardial infarction, and extra-articular manifestations of RA in the history, schizotypic disorder, and experience in using glucocorticoids are associated with a greater likelihood of a good and moderate treatment response.

Depressive mood and low social support are not associated with arthritis development in patients with seropositive arthralgia, although they predict increased musculoskeletal symptoms

Objective

Studies on the role of psychosocial vulnerability in the development of arthritis must be performed early in the disease course to exclude the reverse explanation that arthritis leads to psychological symptoms. Therefore, the objective of this study was to investigate the longitudinal (5-year) association between depressive mood, daily stressors, avoidance coping and social support as predictors, and the development of arthritis and other clinical parameters as outcomes, in persons with seropositive arthralgia at risk of developing rheumatoid arthritis.

Methods

Five-year follow-up data of 231 patients from the Reade seropositive arthralgia cohort were used. Clinical and psychological data were collected using physical examinations and questionnaires. Mixed models and Cox regression analyses were used to assess the 5-year associations between depressive mood, daily stressors, avoidance coping or social support, and the development of arthritis or clinical parameters (tender joint count, Visual Analogue Scale (VAS) pain, VAS morning stiffness and erythrocyte sedimentation rate (ESR)).

Results

Higher scores for depressive mood and lower scores for social support were not associated with the development of arthritis nor with ESR. However, they were longitudinally associated with an increase in pain (p<0.001), morning stiffness (p<0.01) and tender joint count (p<0.001). No consistent associations were found between daily stressors, avoidance coping and the development of arthritis or other clinical parameters.

Conclusion

Although an effect on the development of arthritis could not be demonstrated, a strong longitudinal association was found between high depressive mood, low social support and clinical parameters. In persons with seropositive arthralgia, depressive symptoms and low social support may increase musculoskeletal symptoms.

High Disease Activity Is Associated with Self-reported Depression and Predicts Persistent Depression in Early Rheumatoid Arthritis: Results from the Ontario Best Practices Research Initiative

Objective.

We sought to determine if initial high disease activity or changes in disease activity contribute to persistent depression in early rheumatoid arthritis (ERA). We also determined if disease activity and depression is modified by sex.

Methods.

Depression was ascertained by self-report among patients enrolled in the Ontario Best Practices Research Initiative. The association between baseline disease activity, measured by the Clinical Disease Activity Index (CDAI), and persistent depression was evaluated with multivariate regression models, and effect modification by sex was tested. A general estimating equation assessed the association between change in CDAI over time and risk of depression.

Results.

The sample of 469 ERA subjects was predominantly female (73%). At baseline, the prevalence of depression was 26%, and 23% reported persistent depression. After adjusting for potential confounders, higher baseline CDAI was associated with both baseline and persistent depression (OR 1.03, 95% CI 1.01–1.05). Female sex was an effect modifier of this relationship (OR 1.04, 95% CI 1.01–1.06). Maintaining a moderate or high CDAI score over 2 years also increased the risk of future depression.

Conclusion.

Depression in ERA is common and initial high disease activity is associated with the probability of depression and its persistence. This risk seems particularly modified in women with active disease and represents an area for targeted focus and screening. Future studies in ERA are needed to determine if intervening during the “window of opportunity” to control disease activity has the potential to mitigate the development and maintenance of adverse mental health outcomes, including depression.

A bidirectional relationship between depression and the autoimmune disorders - New perspectives from the National Child Development Study

Background

Depression and the autoimmune disorders are comorbid—the two classes of disorders overlap in the same individuals at a higher frequency than chance. The immune system may influence the pathological processes underlying depression; understanding the origins of this comorbidity may contribute to dissecting the mechanisms underlying these disorders.

Method

We used population cohort data from the 1958 British birth cohort study (the National Child Development Study) to investigate the ages at onset of depression and 23 autoimmune disorders. We used self-report data to ascertain life-time history of depression, autoimmune disorders and their ages at onset. We modelled the effect of depression onset on subsequent autoimmune disorder onset, and vice versa, and incorporated polygenic risk scores for depression and autoimmune disorder risk.

Results

In our analytic sample of 8174 individuals, 315 reported ever being diagnosed with an autoimmune disorder (3.9%), 1499 reported ever experiencing depression (18.3%). There was significant comorbidity between depression and the autoimmune disorders (OR = 1.66, 95% CI = 1.27–2.15). Autoimmune disorder onset associated with increased subsequent hazard of depression onset (HR = 1.39, 95% CI = 1.11–1.74, P = 0.0037), independently of depression genetic risk. Finally, depression increased subsequent hazard of autoimmune disorder onset (HR = 1.40, 95% CI = 1.09–1.80, P = 0.0095), independently of autoimmune disorder genetic risk.

Discussion

Our results point to a bidirectional relationship between depression and the autoimmune disorders. This suggests that shared risk factors may contribute to this relationship, including both common environmental exposures that increase baseline inflammation levels, and shared genetic factors.