Psychological disorders in rheumatoid arthritis: a growing consensus?

Immunoinflammatory rheumatic diseases: the role of the perception of the disease and coping with it in the psychological adaptation of the patient

Objective: to analyze the subjective perception of the disease, coping behavior and adherence to treatment as parameters of psychological adaptation of patients with immunoinflammatory rheumatic diseases (IIRD).

Patients and methods. 163 women with IIRD who were on inpatient treatment were examined: 63 with systemic lupus erythematosus, 50 with rheumatoid arthritis, and 50 with systemic scleroderma. The mean age of the patients was 34.00±17.46 years.

Results and discussion. Groups of patients with different types of perception of the disease were identified: "Unformed perception of the disease" (group 1), "Positive perception of disease control" (group 2), "Negative perception of disease threat" (group 3). When comparing the three groups, it was found that in the group with an unformed perception of the disease, negative emotional experiences were less pronounced than in the other two groups. At the same time, the coping strategies "Self-control" and "Problem solving planning" were significantly higher in the group of patients who positively perceived the control of their disease.

Conclusion. Psychological adaptation of patients with IIRD depends on the type of perception of the disease. The identification of two basic profiles (“Disease threat perception” and “Disease and treatment control perception”) and three types of disease perception (“Unformed type of disease perception”, “Positive perception of disease control”, “Negative perception of the disease threat”) made it possible to obtain new, more differentiated ideas about the perception of the disease, which is the target of correctional psychological work with patients suffering from IIRD.

Risk Factors for Chronic Stress in Sows Housed in Groups, and Associated Risks of Prenatal Stress in Their Offspring

Chronic stress has a detrimental effect on sow welfare and productivity, as well as on the welfare and resilience of their piglets, mediated prenatally. Despite this, the specific risk factors for chronic stress in pregnant sows are understudied. Group-housed pregnant sows continuously face numerous challenges associated with aspects of the physical (group type and size, flooring, feeding system) and social (stocking density, mixing strategy) environment. There are many well-known potent stressors for pigs that likely contribute to chronic, physiological stress, including overcrowding, hot temperatures, feed restriction, inability to forage, uncomfortable floors, and poor handling. Some of these stressors also contribute to the development of production diseases such as lameness, which in turn are also likely causes of chronic stress because of the associated pain and difficulty accessing resources. The aim of this review is to discuss potential risk factors for chronic stress in pregnant sows such as space allowance, group size and type (stable/dynamic), feeding level, lameness, pen design, feed system, enrichment and rooting material, floor type, the quality of stockmanship, environmental conditions, and individual sow factors. The mechanisms of action of both chronic and prenatal stress, as well as the effects of the latter on offspring are also discussed. Gaps in existing research and recommendations for future work are outlined.

Behavioral Health Integration and Outcomes that Matter to Patients: a Longitudinal Mixed-Methods Observational Study

Research on behavioral health integration (BHI) often explores outcomes for quality and cost, but less is known about impacts of integration work on key patient experience outcomes. A mixed-methods longitudinal study of BHI was conducted in 12 primary care clinics in Oregon to assess how adoption of key integration practices including integrated staffing models, integrated care trainings for providers, and integrated data sharing impacted a set of patient experience outcomes selected and prioritized by an advisory panel of active patients. Results showed that adopting key aspects of integration was not associated with improved patient experience outcomes over time. Patient interviews highlighted several potential reasons why, including an overemphasis by health systems on the structural aspects of integration versus the experiential components and potential concerns among patients about stigma and discrimination in the primary care settings where integration is focused.

Expert recommendations on the psychological needs of patients with rheumatoid arthritis

OBJECTIVE

To establish feasible and practical recommendations for the management of the psychological needs of patients with rheumatoid arthritis (RA) from the moment of diagnosis through the course of the disease.

METHODS

A nominal group meeting was held with an RA expert team including rheumatologists and psychologists, at which a guided discussion addressed the most important psychological and emotional needs in RA. Based on the comments collected, and a literature review, a matrix document of recommendations for telematics discussion was prepared, as well as a Delphi survey to test agreement with these recommendations. Agreement was defined if at least 80% of participants voted ≥ 7 (from 1, totally disagree to 10, totally agree). For each recommendation, the level of evidence and grading of recommendations was established following the Oxford criteria, and the degree of agreement through the Delphi.

RESULTS

Thirteen recommendations were established, addressing several key processes: (1) identification of psychological problems and needs in patients with RA, and a guideline for their management in daily practice; (2) communication with patients; (3) referral criteria to mental health professionals.

CONCLUSIONS

These recommendations are intended to help health care professionals openly address the psychological aspects of patients in daily practice to follow and treat them properly.

Anxiety and depression in Slovak patients with rheumatoid arthritis

BACKGROUND

Rheumatoid arthritis (RA) is significantly associated with psychiatric morbidity. Mental health conditions are often unrecognized and untreated in primary care.

AIMS

To assess prevalence of anxiety and depression and their impact on arthritis pain and functional disability in Slovak patients with rheumatoid arthritis.

METHODS

Anxiety was assessed by the Beck Anxiety Inventory (BAI), depression by the Zung self-rating depression scale (SDS), pain by the visual analog scale (VAS) and functional disability by the health assessment questionnaire - disability index (HAQ-DI) in 142 patients with rheumatoid arthritis. Spearman's rho was calculated to assess relations between variables. Stepwise linear regression analysis was used to assess impact of anxiety and depression on arthritis pain and functional disability.

RESULTS

High prevalence of anxiety and depression was observed in arthritis patients. Anxiety and depression were significant predictors of arthritis pain and functional disability. Sex, education, marital status, disease duration and comorbidity had no impact on arthritis pain and functional disability.

CONCLUSION

These findings support the notions that psychological negative affect can influence subjective perception of arthritis pain and disability. The regular screening of anxiety and depression and the psychological approaches can be useful for managing arthritis patients.

Depression risk in patients with late-onset rheumatoid arthritis in Germany

GOAL

The goal of this study was to determine the prevalence of depression and its risk factors in patients with late-onset rheumatoid arthritis (RA) treated in German primary care practices.

METHODS

Longitudinal data from general practices (n=1072) throughout Germany were analyzed. Individuals initially diagnosed with RA (2009-2013) were identified, and 7301 patients were included and matched (1:1) to 7301 controls. The primary outcome measure was the initial diagnosis of depression within 5 years after the index date in patients with and without RA. Cox proportional hazards models were used to adjust for confounders.

RESULTS

The mean age was 72.2 years (SD: 7.6 years). A total of 34.9 % of patients were men. Depression diagnoses were present in 22.0 % of the RA group and 14.3 % of the control group after a 5-year follow-up period (p < 0.001). In the multivariate regression model, RA was a strong risk factor for the development of depression (HR: 1.55, p < 0.001). There was significant interaction of RA and diagnosed inflammatory polyarthropathies (IP) (RA*IP interaction: p < 0.001). Furthermore, dementia, cancer, osteoporosis, hypertension, and diabetes were associated with a higher risk of developing depression (p values <0.001).

CONCLUSION

The risk of depression is significantly higher in patients with late-onset RA than in patients without RA for subjects treated in primary care practices in Germany. RA patients should be screened routinely for depression in order to ensure improved treatment and management.

Problematic and Positive Support in Relation to Depression in People with Rheumatoid Arthritis

This study focuses on the associations of both positive and problematic aspects of social support with depression in patients with rheumatoid arthritis. In a hierarchical multiple regression analysis we found that stressors such as functional limitations and pain are strongly related to depression. Positive and problematic support each explain an additional significant portion of the variance in depression. More positive support is associated with fewer feelings of depression and more problematic support is associated with more feelings of depression. An interaction effect between positive and problematic social support indicates that the negative aspects of problematic support may be partly diminished by positive support (buffering effect). Patients receiving more problematic support and less positive support experience the most feelings of depression.

Novel Application of Behavioral Assays Allows Dissociation of Joint Pathology from Systemic Extra-Articular Alterations Induced by Inflammatory Arthritis

Introduction

Although rheumatoid arthritis (RA) is a disease of articular joints, patients often suffer from co-morbid neuropsychiatric changes, such as anxiety, that may reflect links between heightened systemic inflammation and abnormal regulation of the hypothalamic-pituitary-adrenal (HPA) axis. Here, we apply behavioral neuroscience methods to assess the impact of antigen-induced arthritis (AIA) on behavioral performance in wild type (WT) and interleukin-10 deficient (Il10-/-) mice. Our aim was to identify limb-specific motor impairments, as well as neuropsychological responses to inflammatory arthritis.

Methods

Behavioral testing was performed longitudinally in WT and Il10-/- mice before and after the induction of arthritic joint pathology. Footprint analysis, beam walking and open field assessment determined a range of motor, exploratory and anxiety-related parameters. Specific gene changes in HPA axis tissues were analyzed using qPCR.

Results

Behavioral assessment revealed transient motor and exploratory impairments in mice receiving AIA, coinciding with joint swelling. Hind limb coordination deficits were independent of joint pathology. Behavioral impairments returned to baseline by 10 days post-AIA in WT mice. Il10-/- mice demonstrated comparable levels of swelling and joint pathology as WT mice up to 15 days post-AIA, but systemic differences were evident in mRNA expression in HPA axis tissues from Il10-/- mice post-AIA. Interestingly, the behavioral profile of Il10-/- mice revealed a significantly longer time post-AIA for activity and anxiety-related behaviors to recover.

Conclusions

The novel application of sensitive behavioral tasks has enabled dissociation between behaviors that occur due to transient joint-specific pathology and those generated by more subtle systemic alterations that manifest post-AIA.

Healthcare Expenditures Associated with Depression Among Individuals with Osteoarthritis: Post-Regression Linear Decomposition Approach

BACKGROUND

Depression is common among individuals with osteoarthritis and leads to increased healthcare burden. The objective of this study was to examine excess total healthcare expenditures associated with depression among individuals with osteoarthritis in the US.

DESIGN

Adults with self-reported osteoarthritis (n = 1881) were identified using data from the 2010 Medical Expenditure Panel Survey (MEPS). Among those with osteoarthritis, chi-square tests and ordinary least square regressions (OLS) were used to examine differences in healthcare expenditures between those with and without depression. Post-regression linear decomposition technique was used to estimate the relative contribution of different constructs of the Anderson's behavioral model, i.e., predisposing, enabling, need, personal healthcare practices, and external environment factors, to the excess expenditures associated with depression among individuals with osteoarthritis. All analysis accounted for the complex survey design of MEPS.

KEY RESULTS

Depression coexisted among 20.6 % of adults with osteoarthritis. The average total healthcare expenditures were $13,684 among adults with depression compared to $9284 among those without depression. Multivariable OLS regression revealed that adults with depression had 38.8 % higher healthcare expenditures (p < 0.001) compared to those without depression. Post-regression linear decomposition analysis indicated that 50 % of differences in expenditures among adults with and without depression can be explained by differences in need factors.

CONCLUSIONS

Among individuals with coexisting osteoarthritis and depression, excess healthcare expenditures associated with depression were mainly due to comorbid anxiety, chronic conditions and poor health status. These expenditures may potentially be reduced by providing timely intervention for need factors or by providing care under a collaborative care model.

Mental health status of women with rheumatoid arthritis in iran

Background:

Chronic diseases are usually accompanied by psychological abnormalities. Anxiety and depression occur in a significant number of patients with rheumatoid arthritis (RA). These psychological problems are likely, to be the results of chronic physical symptoms such as pain and disability.

Objectives:

The aim of this study was the evaluation of mental health in patients with rheumatoid arthritis in Iran.

Patients and Methods:

One hundred women with definite diagnosis of RA were evaluated in the outpatient clinic of the Tabriz University of Medical Sciences during one year period. Activity of RA disease was determined according to the Disease Activity Score-28 (DAS-28) scaling system and mental health was evaluated using the General Health Questionnaire-28 (GHQ-28). Based on the cut of point score of 22, prevalence of psychological problems was determined and a comparison was made the between two groups (with and without psychological problems).

Results:

GHQ28 screening test showed that psychological problems were seen in 49% of studied patients. There were significant difference between duration of disease and DAS-28 score between the two groups (P = 0.001 and P = 0.001, respectively). Somatic symptoms were more frequent in patients with psychological problems (P = 0.001). Somatic symptoms in patient with high disease activity was also more frequent than the other group (P = 0.002). There was a significant positive correlation between the scores of DAS-28 and GHQ-28 (r = 0.329, P = 0.001).

Conclusions:

This study showed that a considerable portion of patients with RA may have mental problems. The probability of these problems increased with more severe and more prolonged disease.

Rational/antiemotional behaviors in interpersonal relationships and the functional prognosis of patients with rheumatoid arthritis: a Japanese multicenter, longitudinal study

Background

The repression of negative emotions is a personality factor that received considerable attention in the 1950-60s as being relevant to the onset and course of rheumatoid arthritis (RA). Despite subsequent, repeated criticisms of the cross-sectional nature of the earlier studies, even to date few prospective studies have been reported on this issue. This multicenter study prospectively examined if “rational and antiemotional” behavior (antiemotionality), characterized by an extreme tendency to suppress emotional behaviors and to rationalize negative experiences in conflicting interpersonal situations, is associated with the functional prognosis of patients with RA.

Methods

532 patients with RA who regularly visited one of eight hospitals/clinics in Japan in 2000 were recruited for study. All completed a self-administered baseline questionnaire about lifestyle and psychosocial factors including antiemotionality. Two years after, 460 (mean age, 56.1 years; 54 men and 406 women) of 471 patients who continued to visit the clinics agreed to take the follow-up questionnaire. The functional status of the patients was evaluated by rheumatologists based on the ACR classification system.

Results

A multiple logistic regression model that included baseline demographic, disease activity/severity-related, therapeutic, and socioeconomic factors as covariates found a tendency toward higher antiemotionality to be related to poorer functional status at follow-up. This relationship was not explained by lifestyle factors.

Conclusions

Antiemotionality may be a prognostic factor for the functional status of patients with RA. This finding sheds light on a seemingly forgotten issue in the care of patients with RA.

The first 2 years of rheumatoid arthritis: The influence of acceptance on pain, physical limitation and depression

The influence of acceptance in the progression of pain, physical limitation and depression was explored in the first 2 years of rheumatoid arthritis. Latent growth curve models showed significant increases in pain, physical limitation and depression. Besides that, the levels of pain and physical limitation at the baseline were associated with acceptance but not its progression across time. Therefore, patients with higher scores of acceptance reported less pain and physical limitation. The progression of depression was associated with acceptance; higher acceptance patients had slower growth rates of depression across time, even when pain and physical limitations increased. The inclusion of pain acceptance in clinical practice is discussed.

Practice-Based Interventions Addressing Concomitant Depression and Chronic Medical Conditions in the Primary Care Setting

Background: Depression concomitant with chronic medical conditions is common and burdensome in primary care. Objective: To assess the effectiveness of practice-based interventions for improving depression and chronic medical outcomes. Data Sources: MEDLINE, Embase, the Cochrane Library, CINAHL, and PsycINFO from inception to June 11, 2012. Study Selection, Appraisal, and Synthesis: Two reviewers independently selected, extracted data from, and rated the quality of trials and systematic reviews. Strength of evidence (SOE) was graded using established criteria. Results: Twenty-four published articles reported data from 12 studies, all at least 6 months long. All studies compared a form of collaborative care with usual or enhanced usual care. Studies evaluated adults with arthritis, cancer, diabetes, heart disease, HIV, or multiple medical conditions. Meta-analyses found that intervention recipients achieved greater improvement than controls in depression symptoms, response, remission, and depression-free days (moderate SOE); satisfaction with care (moderate SOE); and quality of life (moderate SOE). Few data were available on outcomes for chronic medical conditions. Meta-analyses revealed that patients with diabetes receiving collaborative care exhibited no difference in diabetes control compared with control groups (change in HbA1c: weighted mean difference 0.13, 95% confidence interval = −0.22 to 0.48 at 6 months; 0.24, 95% confidence interval = −0.14 to 0.62 at 12 months; low SOE). The only study to use HbA1c as a predefined outcome measure and a “treat-to-target” intervention for diabetes as well as depression, TEAMcare, reported significant reductions in HbA1c (7.42 vs 7.87 at 6 months; 7.33 vs 7.81 at 12 months; overall P < .001). Limitations: Few relevant trials reported on medical outcomes. Conclusions: Collaborative care interventions improved outcomes for depression and quality of life in primary care patients with varying medical conditions. Few data were available on medical outcomes. Future studies of concomitant depression and chronic medical conditions should consider measures of medical outcomes as primary outcomes.

Possible rheumatoid arthritis subtypes in terms of rheumatoid factor, depression, diagnostic delay and emotional expression: an exploratory case-control study

Introduction

Dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis has been implicated in the pathology of rheumatoid arthritis (RA), particularly as vulnerable personality types are exposed to chronic stress. Emotions are powerful modulators of stress responses. However, little is known about whether patients with RA process emotions differently to matched controls. In this study we: 1) assessed whether the trait emotional intelligence (trait EI) scores of patients with RA differ from healthy controls at the facet level; 2) explored any subgroups in RA, in terms of trait EI and common risk factors.

Methods

A total of 637 patients with RA were compared to 496 controls on the trait EI Questionnaire (TEIQue). RA subgroups were explored in terms of trait EI, rheumatoid factor status (RF+/-), depression and time from onset of symptoms until diagnosis (diagnostic delay).

Results

The RA group rated themselves lower on Adaptability, Stress-management, Emotion management, Self-esteem, Sociability, Assertiveness, Impulsiveness and Well-being, and higher on Empathy and Relationships than healthy controls. The RF- subtype reported more time with depression (25.2 vs. 11.3 months), a longer diagnostic delay (3.0 vs. 1.7 years), and greater emotional expression (5.15 vs. 4.72), than the RF+ subtype. These differences were significant at the P <0.05 level, but not following strict Bonferroni corrections and should therefore be treated as indicative only. RF- patients with a longer diagnostic delay reported depression lasting three times longer (42.7 months), when compared to three other subtypes (11.0 to 12.7 months).

Conclusions

RA patients and controls differ in their emotion-related personality traits, as operationalized by trait EI. These differences may make people with RA more susceptible to chronic stress and HPA-axis dysregulation. RA may be a highly heterogeneous illness where at least two subtypes may be characterized by personality, psychiatric and immunological differences. RF- status, as well as diagnostic delay and emotional expression, may predict future risk of depression. Research on the causes of RA could benefit from a systems science approach.

Perceived illness stigma is associated with depression in female patients with systemic lupus erythematosus

OBJECTIVES

1) To assess the prevalence of depression in a sample of female patients with systemic lupus erythematosus (SLE) 2) To evaluate the association between perceived illness stigma and depression in those patients.

METHODS

In a cross-sectional study, 80 female SLE patients were evaluated for the presence of depression and perceived illness stigma. Depression was diagnosed using the Structured Clinical Interview for DSM-IV Axis Ι disorders, clinical version (SCID-I-CV), the severity of the depressive symptoms was evaluated using the Hospital Anxiety and Depression Scale-Depression Subscale (HADS-D), and the stigma of illness was assessed using the Stigma Impact Scale (SIS).

RESULTS

The prevalence of depression among female SLE patients was 18.75% (15/80). The perceived illness stigma was higher among the depressed group than among the non-depressed group (SIS mean scores were 43.87±7.87 and 26.62±3.79 respectively P<.001), there was a significant positive correlation between SIS and HAD-D scores (r=0.73, P=.002), and there was a significant association between perceived illness stigma and diagnosis of depression (R(2)=0.53, P=.002, odds ratio=3.2), which increased the severity of depressive symptoms (R(2)=0.64, P<.001).

CONCLUSION

This study demonstrates a significant association between illness stigma and depression in female SLE patients which may be important in promoting optimal coping for these women .

The future of rheumatoid arthritis and hand surgery - combining evolutionary pharmacology and surgical technique

Rheumatoid arthritis is a systemic autoimmune disease of uncertain aetiology, which is characterized primarily by synovial inflammation with secondary skeletal destructions.Rheumatoid Arthritis is diagnosed by the presence of four of the seven diagnostic criteria, defined by The American College of Rheumatology.Approximately half a million adults in the United Kingdom suffer from rheumatoid arthritis with an age prevalence between the second and fourth decades of life; annually approximately 20,000 new cases are diagnosed.The management of Rheumatoid Arthritis is complex; in the initial phase of the disease it primarily depends on pharmacological management. With disease progression, surgical input to correct deformity comes to play an increasingly important role. The treatment of this condition is also intimately coupled with input from both the occupational therapists and physiotherapy.

The association between physical health and delusional-like experiences: a general population study

OBJECTIVE

Delusional-like experiences (DLE) are prevalent in the community. Recent community based studies have found that DLE are more common in those with depression and anxiety disorders, and in those with subclinical symptoms of depression and anxiety. Chronic physical disorders are associated with comorbid depression and anxiety; however, there is a lack of evidence about the association of DLE with common physical conditions. The aim of this study was to explore associations between the common physical disorders and DLE using a large population sample.

METHODS

Subjects were drawn from the Australian National Survey of Mental Health and Wellbeing 2007, a national household survey of 8841 residents aged between 16 and 85 years. The presence of DLE, selected common physical disorders and symptoms were assessed using a modified World Mental Health Composite International Diagnostic Interview (CIDI) schedule. We examined the relationship between DLE, and physical health-related variables using logistic regression, with adjustments for potential confounding factors.

RESULTS

Of the 8771, 776 (8.4%) subjects positively endorsed one or more DLE. Of the six physical disorders examined, only diabetes and arthritis were significantly associated with the endorsement of DLE. Of the seven broad physical symptoms explored, only hearing problems were consistently associated with DLE.

CONCLUSION

Delusional-like experiences are common in the Australian community, and are associated with selected chronic physical disorders and with impaired hearing. The direction of causality between these variables warrants closer research scrutiny.

Cerebral Blood Flow in Depressed Patients with Systemic Lupus Erythematosus

Objective.

To characterize the neural circuitry involved in depression associated with systemic lupus erythematosus (SLE), we used single photon emission computed tomography (SPECT) to study regional cerebral blood flow (CBF) in patients with SLE.

Methods.

SPECT with 99mTc-ethylcysteinate dimer was performed in 30 depressed women patients with SLE, in 14 women patients with SLE and without history of neuropsychiatric disorders, and in 25 healthy women controls. Magnetic resonance imaging was done for all subjects for diagnostic purposes. Analysis of CBF patterns was performed using statistical parametric mapping. Statistical significance was taken at uncorrected p < 0.001 at cluster level.

Results.

There were no significant differences between depressed and nondepressed patients with SLE for any rheumatologic variable. In comparison to healthy controls, depressed patients with SLE had significantly reduced CBF in bilateral frontal and temporal cortex; global maximum was located in the left precentral gyrus. There were no significant CBF differences between nondepressed patients with SLE and controls. Compared to nondepressed patients with SLE, depressed patients with SLE had significantly lower CBF in 2 clusters that had their local maxima in the right precentral gyrus and in the left superior temporal gyrus. The duration of SLE correlated with decreased perfusion in the left middle and superior frontal gyrus.

Conclusion.

Depressed patients with SLE have CBF reductions in discrete temporal and frontal regions that may account for depressive symptoms.

Does a special relationship between personality and rheumatoid arthritis exist? Experiences with an Austrian Psychological Questionnaire

The aim of this study was to investigate whether the personalities of rheumatoid arthritis (RA) differ from those of non-rheumatologic patients. For the purpose of this study, the authors designed a psychological questionnaire, compiling relevant questions and impressions of several psychological questionnaires. A total of 226 patients (113 RA patients and 113 control persons (CO)) were asked to fill in the questionnaire assessing their psychological profile as well as demographic data on their family history. The control group consisted of healthy controls as well as scarcely affected individuals and chronically ill patients. The questionnaire was completed without any problems by 98% of patients. No statistical difference in any of the 26 questions was to be observed. Only the question concerning sibship revealed a trend towards single childhood in the RA group (p = 0.07). No differences between patients suffering from early RA and those in a later stage of the disease were revealed. There was no difference in the psychological profile of RA and CO detectable nor did disease duration or disability have an impact on the questionnaire's outcome. An interesting finding was the higher prevalence of single children in the RA group, although this difference did not reach statistical significance. This topic seems to be worth being addressed in a larger cohort of patients.

Symptoms of Depression Predict the Trajectory of Pain Among Patients with Early Inflammatory Arthritis: A Path Analysis Approach to Assessing Change

Objective.

To assess the longitudinal relationships, including directionality, among chronic pain, symptoms of depression, and disease activity in patients with early inflammatory arthritis (EIA).

Methods.

One hundred eighty patients with EIA completed an examination, including swollen joint count, and were administered the Center for Epidemiological Studies Depression Scale (CES-D) and the McGill Pain Questionnaire (MPQ) at 2 timepoints 6 months apart. Cross-lagged panel path analysis was used to simultaneously assess concurrent and longitudinal relationships among pain, symptoms of depression, and number of swollen joints.

Results.

Pain, symptoms of depression, and number of swollen joints decreased over time (p < 0.001) and were prospectively linked to pain, symptoms of depression, and number of swollen joints, respectively, at 6 months. Symptoms of depression and pain were correlated with each other at baseline (0.47) and at 6-month followup assessments (0.28). Baseline symptoms of depression significantly predicted pain symptoms at 6 months (standardized regression coefficient = 0.28, p = 0.001), whereas pain and disease activity did not predict the course of any other variable after controlling for baseline values.

Conclusion.

Symptoms of depression predicted the trajectory of pain from baseline to 6 months. In addition, there were reciprocal/bidirectional associations between pain and symptoms of depression over time. More research is needed to better understand the relationship between pain and depressive symptoms and how to best manage patients with EIA who have high levels of both.

Articular damage in adults with juvenile idiopathic arthritis

The goal of this study was to assess the long-term articular damage in adults with juvenile idiopathic arthritis (JIA) using the Rheumatoid Arthritis Articular Damage (RAAD) score and to determine any associations between the disease-related parameters and RAAD score. Thirty-eight adults identified with JIA at 18 years of age or older with disease duration of at least 5 years were assessed by means of the RAAD score. Patients were divided into three groups according to disease duration as 5-10 years (group 1), 11-15 years (group 2) and more than 16 years (group 3), and into three groups according to JIA subtypes as seropositive polyarticular (group A), seronegative polyarticular (group B), and oligoarticular (group C). Functional disability, functional status, disease activity and depression were measured by Health Assessment Questionnaire (HAQ), Steinbrocker classification, Disease Activity Score 28 (DAS 28), and Beck Depression Inventory, respectively. We investigated any possible associations between the RAAD score and groups, sex, age at onset of the disease, HAQ, Steinbrocker classification, DAS 28, and Beck Depression Inventory. We observed significant differences in RAAD scores according to groups A, B, C (p < 0.01), but not according to groups 1, 2, 3 or sex (p > 0.05). While the RAAD score correlated well with HAQ (p < 0.001), Steinbrocker classification (p < 0.001) and DAS 28 (p < 0.01), it did not correlate with age at onset of the disease (p > 0.05) or Beck Depression Inventory (p > 0.05). Seropositive polyarticular patients demonstrate the worst articular damage scores. Even though articular damage does not progress over time and JIA frequently has a benign course, care should be given to establishing regular follow-up periods and well-arranged treatments, especially for seropositive polyarticular groups, to maintain satisfactory long-term disease outcome throughout the lives of JIA patients.

Quality of life in chronic musculoskeletal pain

This chapter reviews the impact of chronic musculoskeletal pain on patients' health-related quality of life. In addition to the physical health consequences, chronic musculoskeletal pain can have a profound negative impact on an individual's emotional and social well-being. Although efforts in the health sector are obviously of crucial importance in the management of chronic musculoskeletal pain, a high level of patient and societal involvement is key to reducing the burden of this condition. Patients should work in partnership with health-care professionals, actively participating in their care. Family members should encourage their loved ones to be as independent as possible. The employer of a person with chronic musculoskeletal pain has a vital role in returning him or her to work as soon as possible. Removing all barriers to the use of preventive and therapeutic services will help us to reduce the burden of musculoskeletal pain conditions on both patients and society.

Overview of the psychosocial concerns of young adults with juvenile arthritis

Young adults who develop juvenile idiopathic arthritis in childhood have a significant risk of long-term morbidity and continuing disease activity in adulthood. The impact of a physically restricting and painful chronic illness can make the transition from adolescence to adulthood more challenging. In this overview of the psychological and social impact of juvenile arthritis on young adults, particular attention is given to those areas that are of concern to this age group. The transition from adolescence to adulthood can be detrimentally affected not only by the attitudes of peers and parents, but also by the attitudes of the individual with arthritis. Chronic arthritis, including juvenile arthritis, is related to increased rates of anxiety and depression. In the face of functional restriction, pain, and poor body image, social and sexual relationships may be harder to develop and maintain. The family of the young adult may also be affected on many levels. Employment and financial security are common and well-founded concerns of young disabled adults.

The association of depression and anxiety with medical symptom burden in patients with chronic medical illness

BACKGROUND

Primary care patients with anxiety and depression often describe multiple physical symptoms, but no systematic review has studied the effect of anxiety and depressive comorbidity in patients with chronic medical illnesses.

METHODS

MEDLINE databases were searched from 1966 through 2006 using the combined search terms diabetes, coronary artery disease (CAD), congestive heart failure (CHF), asthma, COPD, osteoarthritis (OA), rheumatoid arthritis (RA), with depression, anxiety and symptoms. Cross-sectional and longitudinal studies with >100 patients were included as were all randomized controlled trials that measure the impact of improving anxiety and depressive symptoms on medical symptom outcomes.

RESULTS

Thirty-one studies involving 16,922 patients met our inclusion criteria. Patients with chronic medical illness and comorbid depression or anxiety compared to those with chronic medical illness alone reported significantly higher numbers of medical symptoms when controlling for severity of medical disorder. Across the four categories of common medical disorders examined (diabetes, pulmonary disease, heart disease, arthritis), somatic symptoms were at least as strongly associated with depression and anxiety as were objective physiologic measures. Two treatment studies also showed that improvement in depression outcome was associated with decreased somatic symptoms without improvement in physiologic measures.

CONCLUSIONS

Accurate diagnosis of comorbid depressive and anxiety disorders in patients with chronic medical illness is essential in understanding the cause and in optimizing the management of somatic symptom burden.

Relationship of psychiatric history to pain reports in rheumatoid arthritis

OBJECTIVE

The purpose was to examine the relationship of pre-existing psychiatric history to pain reports in a cohort of persons with RA and concomitant major depression who were receiving a trial of antidepressant medication.

METHOD

RA patients (n = 41) with a current episode of major depression were divided into two subgroups comprised of those with a previous psychiatric history (PSY+) (n = 20) and those without a previous psychiatric history (PSY-) (n = 21). The groups were compared with regard to their responsiveness to a regimen of antidepressive medication on measures of depression, pain, coping, and life stress over a period of 15 months.

RESULTS

Although depression scores for both the PSY+ and the PSY- groups decreased significantly from baseline to 15-month follow-up, the composite pain score was found to be significantly decreased only for the PSY- group.

CONCLUSION

Psychiatric history appears to predispose persons with concomitant RA and major depression to report less pain reduction following antidepressive treatment than those persons without a psychiatric history.

Disability, social support, and distress in rheumatoid arthritis: results from a thirteen-year prospective study

OBJECTIVE

To examine the strength and stability of the relationships between disease-related factors (joint tenderness, pain, and functional disability), social support, and distress over time, and to investigate to what extent disease-related factors and social support can predict distress in short-term and long-term rheumatoid arthritis (RA).

METHODS

The study was a Dutch extension of the European Research on Incapacitating Diseases and Social Support and started with 292 patients. After 5 waves of data collection, 129 patients remained. Composite measures were computed following the area under the curve approach. Interaction terms were computed between functional disability and social support satisfaction. Correlational and hierarchical regression analyses were performed.

RESULTS

In patients with short-term RA, disease-related factors and social support were important in determining distress. Also, a buffering effect of social companionship was found. In total, 51% of the variance in distress in short-term RA could be explained primarily by mean distress over the previous years. In patients with long-term RA, disease-related factors remained important in determining distress, but to a lesser extent. Seventeen percent of the variance in distress in long-term RA could be explained primarily by mean distress over the years before.

CONCLUSION

During the course of the disease, patients may learn to adjust to their disease and its consequences and are able to maintain a normal distress level. The effect of the disease on psychological distress decreased over the years. Some support for the buffering hypothesis of social support was found in short-term RA, but not in long-term RA.

Neuropsychiatric manifestations of systemic lupus erythematosus

Central nervous system (CNS) involvement in systemic lupus erythematosus (SLE) can produce a broad range of disease-specific neuropsychiatric manifestations that must be differentiated from infections, metabolic complications, and drug-induced toxicity. Despite the development of classification criteria by the American College of Rheumatology, the prevalence of neuropsychiatric systemic lupus erythematosus (NPSLE) varies widely across studies. Some of the neuropsychiatric manifestations are extremely rare, indicating a need for multicenter studies. Mechanisms that can lead to neuropsychiatric manifestations include intracranial vascular lesions (vasculitis and thrombosis); production of autoantibodies to neuronal antigens, ribosomes, and phospholipids; and inflammation related to local cytokine production. As a rule, no reference standard is available for establishing the diagnosis of NPSLE. Several investigations can be used to assist in the clinical diagnosis and to evaluate severity. Treatment remains largely empirical, given the absence of controlled studies. Variable combinations of corticosteroids, immunosuppressants, and symptomatic drugs are used according to the presumptive main pathogenic mechanism.

Clinical significance of lifetime mood and panic-agoraphobic spectrum symptoms on quality of life of patients with rheumatoid arthritis

BACKGROUND

Previous studies suggested that rheumatoid arthritis (RA) is associated with depressive and anxiety symptomatology. The well-being and functioning of patients with RA may be significantly influenced by subthreshold psychiatric comorbidity. Health-related quality of life (HRQoL) of patients with RA, compared with the Italian norms and patients with diabetes, was assessed by the influence of lifetime mood and panic-agoraphobic spectrum symptoms and demographic and clinical variables.

METHODS

Ninety-two patients were consecutively recruited at the Department of Rheumatology at the University Hospital of Pisa, Italy. All patients met diagnostic criteria of RA according to the American College of Rheumatology. Health-related quality of life was measured using the Medical Outcomes Study 36-Item Short-Form Health Survey questionnaire (MOS SF-36). Mood and panic-agoraphobic spectra were assessed by two different structured self-report instruments: the Mood Spectrum (MOODS-SR) and the Panic-Agoraphobic Spectrum (PAS-SR), respectively.

RESULTS

Patients with RA were compared, as regards the MOS SF-36 scale scores, with the Italian normative population and patients with diabetes. Compared with the Italian population, patients with RA showed significantly lower MOS SF-36 scale scores, except for role emotional. Moreover, patients with RA scored significantly lower on the role physical, bodily pain, and social functioning scales compared with patients with diabetes and higher on role emotional and mental health. A significant worsening of all MOS SF-36 scale scores was related to higher scores of the depressive domains of MOODS-SR, except for social functioning and bodily pain. A statistically significant negative association was also found between PAS-SR total score and the MOS SF-36 scales physical functioning, vitality, role emotional, and mental health. There were no statistically significant correlations between MOS SF-36 scales and the manic MOODS spectrum. In the multivariate models, the negative correlations between depressive MOODS, role emotional, and mental health were confirmed and the severity of arthritis showed a significant impact on all MOS SF-36 areas with the exception for social functioning; moreover, manic MOODS was associated with better general health.

CONCLUSIONS

The present report shows that lifetime depressive spectrum symptoms negatively affects HRQoL of patients with RA and subthreshold mania improves the perception of general health. Diagnosis and appropriate clinical management of depression, including subthreshold symptoms, might enhance HRQoL in these patients.

Depression in rheumatoid arthritis patients: demographic, clinical, and psychological predictors

OBJECTIVE

To confirm the prevalence of depression in a sample of rheumatoid arthritis (RA) patients; to identify the most significant predictors of depression in RA and to explore patients attitudes to medication in relation to depression.

METHODS

A cross-sectional survey was used to collect data from 134 RA patients (77% female, 23% male). Participants were divided into depressed and nondepressed groups based on their scores on the Center for Epidemiological Studies-Depression (CES-D) scale. Discriminant analysis was conducted to identify the predictors that would best categorise patients into those two groups.

RESULTS

Twelve predictors correctly classified 80% of patients into depressed or nondepressed groups. The strongest predictors of depression were high tension and low self-esteem followed by the perceived impact of RA, fatigue, passive coping, pain, and physical disability. Other predictors included medication effectiveness and importance as well as perceived lack of control over pain.

CONCLUSION

Both physical and psychological factors have an impact on depression in RA. The key predictors identified in this study need to be considered within the regular RA management as possible cues to depression development.

The development of emotional distress in 158 patients with recently diagnosed rheumatoid arthritis: a prospective 5-year follow-up study

OBJECTIVES

To describe the development of emotional distress among patients with newly diagnosed rheumatoid arthritis (RA), and to explore for early predictors of elevated distress over time.

METHODS

The study group consisted of 158 early RA patients (64% females) with mean age of 51.4 (SD = 12.7) years at disease onset. The patients were evaluated once a year for up to at least 4 years after baseline. Emotional distress was measured with the Symptom Checklist (SCL-90), disability with the Health Assessment Questionnaire (HAQ), pain with a visual analogue scale (VAS), and disease activity by an active joint count and erythrocyte sedimentation rate (ESR). Questions concerning social support were also included.

RESULTS

Emotional distress decreased slowly for a majority of the patients. The change reached statistical significance in the third year from study start. A minority (12%) showed continuously high and increasing levels of distress. Measures of disease activity were poor predictors of distress. The best predictor of distress over time was distress at baseline. Other predictors were gender, age, civil status, and social support.

CONCLUSIONS

Emotional distress tended to decrease for most patients in this cohort, but a minority showed continuously high levels. Patients at higher risk of developing emotional distress over time had higher levels of distress at baseline, were younger, more often female, and cohabiting, and experienced less social support.

Scholarly Literature Review: Efficacy of Psychological Interventions for Pediatric Chronic Illnesses

OBJECTIVE

To review empirical studies of the efficacy of psychological interventions as adjuvant therapies for children with pediatric diabetes, cancer, cystic fibrosis, and sickle cell disease.

METHODS

A search was conducted for qualifying studies published since 1980. Only studies meeting basic criteria for external and internal validity were included. Nineteen studies were identified, providing data on 62 outcome variables. Effect sizes (ESs) were analyzed by illness type, intervention type, and strength of internal and external validity of the research design.

RESULTS

Overall, interventions were associated with large ESs, which were not significantly moderated by illness type or intervention type. However, larger ESs were associated with lower scores on validity of research design.

CONCLUSIONS

Adjuvant psychological interventions for pediatric chronic illnesses appear in general to be efficacious, associated with a large mean ES across a range of outcome variables. However, until more studies have been completed using stronger research designs, only tentative conclusions can be drawn.

Chronic disease and mental disorder

The aim of this study was to achieve a better understanding of the relationship between chronic medical illness and mental distress. Therefore, the association between chronic medical illness and mental distress was analysed, taking into account the modifying effects of generic disease characteristics (concerning course, control and possible stressful consequences), physical quality of life indicators and social and relationship problems. Panel data from the Dutch national Panel of Patients with a Chronic Disease (PPCZ) were used. Data from 1788 chronically medical ill patients (nine disease categories) concerning their mental and physical health have been used in a cross-sectional, multivariate analysis. Somatic disease, generic disease characteristics and physical quality of life were assessed by medical doctors. Mental distress and social/ relationship problems were assessed by questionnaire (respectively, GHQ-12 and Biopro). Members of the panel had more mental distress than a random community sample. However, there were no differences between specific somatic diseases. Relationship, job-related and financial problems increased the probability of mental disorder considerably. Relationship problems may be considered a generic characteristic of chronically ill patients, causing an increased risk of mental disorder. Poor physical health condition contributed to a higher probability of mental disorder as well. General practitioners, home care providers and medical specialists should be aware that people with chronic diseases are in general more at risk of mental disorder. For many chronically ill people, this risk is further exacerbated by social/relationship problems, and a poor level of perceived health.

Brain-immune interactions and disease susceptibility

Many studies have established the routes by which the immune and central nervous (CNS) systems communicate. This network of connections permits the CNS to regulate the immune system through both neuroendocrine and neuronal pathways. In turn, the immune system signals the CNS through neuronal and humoral routes, via immune mediators and cytokines. This regulatory system between the immune system and CNS plays an important role in susceptibility and resistance to autoimmune, inflammatory, infectious and allergic diseases. This review focuses on the regulation of the immune system via the neuroendocrine system, and underlines the link between neuroendocrine dysregulation and development of major depressive disorders, autoimmune diseases and osteoporosis.

Evaluation of a community rehabilitation service for people with rheumatoid arthritis

This study aims to evaluate the outcomes of a community rehabilitation service for people with rheumatoid arthritis, provided by the Community Rehabilitation Network (CRN) in Hong Kong. The three-phase community rehabilitation service consists of a number of standardized program elements, including orientation meeting, self-help course, stress management program, water exercises class, as well as informal social and recreational activities. Using a pre-, post-test non-equivalent groups design, the outcomes of 29 clients of the treatment group were compared with 16 clients of the comparison group at baseline and at the end of 9 months, using an 86-item self-completed questionnaire. The treatment group achieved significant more increases in self-efficacy of managing the illness, more increases in self-management behaviors, but no significant increases in the overall health status or health care utilization patterns, when compared with the comparison group.

Perceptions about perceived functional disabilities and pain of people with rheumatoid arthritis: differences between patients and their spouses and correlates with well-being

OBJECTIVE

In this study we examined the differences in perceptions of the patient's health status between rheumatoid arthritis (RA) patients and their spouses, and correlates of these differences with patients' and spouses' well-being.

METHODS

A sample of 188 couples with one member receiving treatment for RA were selected from the rheumatology clinics in Twente, The Netherlands. The mean age of both RA patients and spouses was 56 years. Respondents completed questionnaires, including estimations of both patients and spouses on the patient's functional disabilities and pain, and scales on affect and marital commitment for patients and spouses.

RESULTS

Differences in estimations of patients and spouses were considerable. Both over- and underestimations of the patient's functional disabilities by the spouse were associated with the patient's poorer mental health status. Overestimations of the patient's functional disabilities were associated with poorer mental health among spouses.

CONCLUSION

It is essential that any support intended by the spouse is in accordance with the patient's needs. If the patient's condition is misperceived by the spouse, this can lead to ineffective and inappropriate support being given.

Association of depression and rheumatoid arthritis

This study assessed the relative strength of the association of physical characteristics and social stresses with a diagnosis of depression in patients with rheumatoid arthritis. Depression and social difficulties were assessed in 74 patients with rheumatoid arthritis by using standardized research interviews. Rheumatoid arthritis activity, damage related to rheumatoid arthritis, and subjective functional disability were assessed with well-validated methods. Twenty-nine patients (39.2%) were depressed. Compared to nondepressed patients, depressed patients had more marked social difficulties related to rheumatoid arthritis (72.4% versus 46.7%, respectively) and more marked social difficulties independent of rheumatoid arthritis (55.2% versus 31.1%, respectively). With logistic regression, social difficulties, independent of rheumatoid arthritis, was the only variable significantly associated with depression. Demographic characteristics and rheumatoid arthritis were not associated with a diagnosis of depression. Recognition by clinicians of the importance of social stresses, independent of disease state, should lead to more appropriate and specific psychological and social treatment of depression in rheumatoid arthritis.

Life events and depressiveness - the effect of adjustment for psychosocial factors, somatic health and genetic liability

OBJECTIVE

To study the nature of the relationship of life events with depressiveness.

METHOD

In 1990, 9947 Finnish adult twins aged 33-60 years participated in a questionnaire study, with no missing data on the analysed variables. The relationship between stressful life-events and depressiveness, based on Beck Depression Inventory (BDI) classified as normal, mild or moderate, was analysed using multinomial regression for all subjects with adjustment for the effect of age, sex, health status, social support, marital status, social class, and personality variables. These same factors were analyzed among 643 twin pairs discordant for depressiveness.

RESULTS

High BDI score categories were strongly associated with stressful life events in all individuals and equally strongly within discordant twin pairs, both monozygotic and dizygotic. Poor somatic health and lack of social support also increased depressiveness.

CONCLUSION

The effect of life events predicting depressiveness was independent of social support, somatic disease, sex and genetic liability.

Increased IgG 3:4 ratios in adolescent antisocial females: evidence of Th1/Th2 imbalance?

Female antisocial behavior in adolescence and late childhood has been associated with low basal cortisol levels. Because low cortisol has also been correlated with T helper cell Type 1 (Th1) predominance and suppression of T helper cell Type 2 (Th2), we investigated whether adolescent antisocial girls demonstrated this immunologic profile. Using plasma levels of IgG3 and IgG4 as markers for Th1 and Th2 activity, we studied IgG 3:4 ratios in 16-year-old girls with conduct disorder (CD) (n=42) or no psychiatric disorder (normal controls (NC)) (n=35). The mean IgG 3:4 ratio was higher in the CD group; this relationship remained significant after controlling for the effects of other variables. These data indicate that immunologic abnormalities are present in adolescent antisocial girls. Future studies should measure cytokine levels and investigate the clinical implications of these findings.

Is anxiety a more common disorder than depression in rheumatoid arthritis?

OBJECTIVE

As most of the previous studies were done to study depressive disorders and/or symptoms in patients with rheumatoid arthritis, this study was performed to investigate whether anxiety disorder is as common as depressive disorder in these patients and to look for the socio-demographic as well as the clinical characteristics of the patients developing these disorders.

METHODS

A detailed physical assessment of 80 patients with rheumatoid arthritis was performed. Also psychiatric assessment was done using Research Diagnostic Criteria for the International Classification of Diseases-10 (ICD-10). In addition, patients answered a Health Assessment Questionnaire (HAQ) to assess their functional capacity.

RESULTS

Depression was diagnosed in 66.2% of the total sample while anxiety was diagnosed in 70%. Functional disability, social stress and morning stiffness were the factors highly associated with depression. Using multiple regression analysis, anxiety was highly associated with depression as well as Ritchie articular index.

CONCLUSION

Psychiatric illness is a relatively common disorder in patients with RA, with a frequency higher than that of other general medical conditions. Anxiety is a more common disorder than depression. The first step in correct management is recognition of anxiety and depression so that appropriate treatment can be tried. Particular attention has to be paid to social stress and lack of social support.

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

OBJECTIVE

This systematic review and meta-analysis examined the strength of association between rheumatoid arthritis and depression. In addition, we investigated the extent to which sociodemographic characteristics, level of pain, and method of assessing depression might affect the degree of depression.

METHODS

CD-ROM databases and bibliographies were searched to identify all studies comparing depression in patients with rheumatoid arthritis and control subjects using standardized assessments. Effect sizes (Pearson's r) and probabilities were combined across studies. We examined the extent to which the association between rheumatoid arthritis and depression could be attributed to level of pain (using contrasts), sociodemographic differences between groups (combining methodologically restricted studies), and methods of assessing depression (examining heterogeneity across studies).

RESULTS

Twelve independent studies comparing depression in patients with rheumatoid arthritis with depression in healthy control subjects were found. Effect sizes for depression were small to moderate (r =.21, p <.0001; heterogeneous). This effect was not reduced in studies controlling for sociodemographic characteristics (r =.27, p <.0001). The effect sizes did vary in a linear manner in proportion to the effect size for pain (z = 2.67, p =.0064). The effect sizes produced by different measures of depression were heterogeneous (chi(2) for Fisher's Z = 24.6, p =.0002), with the Hospital Anxiety and Depression Scale giving effect sizes most dissimilar to those of other measures.

CONCLUSIONS

Depression is more common in patients with rheumatoid arthritis than in healthy individuals. This difference is not due to sociodemographic differences between groups, but it may be attributable, in part, to the levels of pain experienced. Variation in the methods of assessing depression partly accounts for the differences among studies examining the levels of depression in patients with rheumatoid arthritis.

The course of depression in recent onset rheumatoid arthritis: the predictive role of disability, illness perceptions, pain and coping

BACKGROUND

This study aimed to investigate the course of depression for patients with recently diagnosed rheumatoid arthritis (RA) and to investigate predictors of depression.

METHODS

Twenty-two patients with a history of recently diagnosed RA of less than 2 years were assessed on a variety of clinical outcome and process measures on six assessment occasions over a 21-month period. These 22 patients constituted the control group of a controlled trial and received standard outpatient clinic treatment during follow-up.

RESULTS

Patients became significantly more depressed over time. A set of five factors were found to consistently predict depression at the following assessment. These were initial level of depression, disability, pain, beliefs about the consequences of arthritis and coping strategies.

CONCLUSIONS

The results confirm the importance of psychological factors in early RA and their relative independence from physical findings. This is the first study to document the importance of illness perceptions in recent onset RA.