The association of depression and anxiety with treatment outcomes in patients with rheumatoid arthritis - a pooled analysis of five randomised controlled trials

The Effect of Depression on Disease Activity and Treatment Response in Patients with Inflammatory Arthritis: Results from a Narrative Literature Review

Background

Inflammatory arthritis refers to a group of diseases that have a common presentation of joint pain, stiffness, and inflammation. Meanwhile, major depressive disorder is a mental health disorder characterized by anhedonia and low mood. Inflammatory arthritis patients have high rates of major depressive disorder, estimated at being up to 38.8%. Depression leads to a significant reduction in patient's health-related quality of life, treatment adherence, and many other measures of health, both subjective and clinical.

Purpose

This literature review explores the effect that depression has on treatment response for the drugs used in inflammatory arthritis.

Methods

A systematic search using PubMed was conducted identifying articles which were each reviewed for relevance and eligibility.

Results

Depression was negatively associated with treatment response to all classes of drugs used to manage inflammatory arthritis, with an increased disease activity and/or number of swollen/tender joints, as well as a reduced rate of remission being recorded for patients with depression compared to those without. However, this effect on treatment response was less clear when conventional synthetic Disease Modifying Anti-rheumatic Drugs were studied, possibly because their anti-inflammatory effects have wide impacts on the whole immune system, whereas biologic Disease Modifying Anti-rheumatic Drugs have very specific targets.

Conclusion

Inflammatory arthritis patients have a significantly lowered response to most drugs when they have depression. Screening and treating depression may attenuate this association. It is recommended that further research focuses on screening for and treating depression in inflammatory arthritis patients.

Predictors for severe persisting pain in rheumatoid arthritis are associated with pain origin and appraisal of pain

OBJECTIVES

To determine the proportion of patients with rheumatoid arthritis (RA) with severe persisting pain and to identify predictive factors despite treatment-controlled disease activity.

METHODS

This prospective multicentre study included outpatients with RA scheduled for escalation of anti-inflammatory treatment due to active disease and severe pain (Disease Activity Score 28 (DAS28)>3.2 and Visual Analogue Scale (VAS)>50). At week 24, patients were stratified into reference group (DAS28 improvement>1.2 or DAS28≤3.2 and VAS pain score<50), non-responders (DAS28 improvement≤1.2 and DAS28>3.2, regardless of VAS pain score) and persisting pain group (DAS28 improvement>1.2 or DAS28≤3.2 and VAS pain score≥50). The former two subgroups ended the study at week 24. The latter continued until week 48. Demographic data, DAS28-C reactive protein, VAS for pain, painDETECT Questionnaire (PD-Q) to identify neuropathic pain (NeP) and the Pain Catastrophising Scale were assessed and tested for relation to persisting pain.

RESULTS

Of 567 patients, 337 (59.4%) were classified as reference group, 102 (18.0%) as non-responders and 128 (22.6%) as patients with persisting pain. 21 (8.8%) responders, 28 (35.0%) non-responders and 27 (26.5%) persisting pain patients tested positive for NeP at week 24. Pain catastrophising (p=0.002) and number of tender joints (p=0.004) were positively associated with persisting pain at week 24. Baseline PD-Q was not related to subsequent persisting pain.

CONCLUSIONS

Persisting and non-nociceptive pain occur frequently in RA. Besides the potential involvement of NeP, pain catastrophising and a higher number of tender joints coincide with persisting pain.

Rheumatoid Arthritis and Risk of Depression in South Korea

Importance

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

Objective

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

Design, Setting, and Participants

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

Exposures

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

Main Outcomes and Measures

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

Results

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

Conclusions and Relevance

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

Hyperactive lateral habenula mediates the comorbidity between rheumatoid arthritis and depression-like behaviors

Rheumatoid arthritis (RA) patients have a high prevalence for depression. On the other hand, comorbid with depression is associated with worse prognosis for RA. However, little is known about the underlying mechanisms for the comorbidity between RA and depression. It remains to be elucidated which brain region is critically involved in the development of depression in RA, and whether alterations in the brain may affect pathological development of RA symptoms. Here, by combining clinical and animal model studies, we show that in RA patients, the level of depression is significantly correlated with the severity of RA disease activity and affects patients' quality of life. The collagen antibody-induced arthritis (CAIA) mouse model of RA also develops depression-like behaviors, accompanied by hyperactivity and alterations in gene expression reflecting cerebrovascular disruption in the lateral habenula (LHb), a brain region critical for processing negative valence. Importantly, inhibition of the LHb not only alleviates depression-like behaviors, but also results in rapid remission of RA symptoms and amelioration of RA-related pathological changes. Together, our study highlights a critical but previously overlooked contribution of hyperactive LHb to the comorbidity between RA and depression, suggesting that targeting LHb in conjunction with RA treatments may be a promising strategy for RA patients comorbid with depression.

Comorbidities and chance of remission in patients with early rheumatoid arthritis receiving methotrexate as first-line therapy: a Swedish observational nationwide study

OBJECTIVES

This study aims to examine whether comorbidities affect the likelihood of reaching primary remission on methotrexate monotherapy as the first disease-modifying antirheumatic drug (DMARD) in early rheumatoid arthritis (RA).

METHODS

We used nationwide Swedish clinical and quality registers to collect RA disease activity measures and comorbidity data for patients diagnosed with RA 2007-2020 (n=11 001). The primary outcome was failure to reach 28-joint Disease Activity Score (DAS28) remission at 3 months. Secondary outcomes included Boolean, Simplified Disease Activity Index/Clinical Disease Activity Index remission, European Alliance of Associations for Rheumatology response and no swollen joint count at 3 and 6 months. For each comorbidity, and for combinations thereof, we calculated adjusted relative risks (RRs) of failure to reach remission, using modified Poisson regression.

RESULTS

In total, 53% (n=4019/7643) failed to reach DAS28 remission after 3 months of methotrexate monotherapy, ranging from 66% (n=25/38) among patients with chronic kidney disease to 48% (n=154/319) in patients with previous cancer. The risk of not reaching DAS28 remission at 3 months (RR adjusted for sex and age) was increased among patients with endocrine (RR 1.08, 95% CI 1.01 to 1.15), gastrointestinal (RR 1.16, 95% CI 1.03 to 1.30), infectious (RR 1.21, 95% CI 1.06 to 1.38), psychiatric (RR 1.24, 95% CI 1.15 to 1.35) and respiratory comorbidities (RR 1.16, 95% CI 1.01 to 1.32). Having three or more comorbidity categories was associated with a 27% higher risk of DAS28 remission failure at 3 months. A similar pattern was observed for the secondary outcomes.

CONCLUSIONS

Comorbidities decrease the chance of reaching remission on methotrexate as DMARD monotherapy in patients with early RA and are important to consider when assessing treatment outcomes.

Identification of ferroptosis related markers by integrated bioinformatics analysis and In vitro model experiments in rheumatoid arthritis

BACKGROUND

Rheumatoid arthritis (RA) is an autoimmune disease characterized by destructive and symmetrical joint diseases and synovitis. This research attempted to explore the mechanisms involving ferroptosis in RA, and find the biological markers by integrated analysis.

METHODS

Gene expression data (GSE55235 and GSE55457) of synovial tissues from healthy and RA individuals were downloaded. By filtering the differentially expressed genes (DEGs) and intersecting them with the 484 ferroptosis-related genes (FRGs), the overlapping genes were identified. After the enrichment analysis, the machine learning-based approaches were introduced to screen the potential biomarkers, which were further validated in other two datasets (GSE77298 and GSE93272) and cell samples. Besides, we also analyze the infiltrating immune cells in RA and their correlation with the biomarkers.

RESULTS

With the criteria, 635 DEGs in RA were included, and 29 of them overlapped in the reported 484 FRGs. The enrichments of the 29 differentially expressed ferroptosis-related genes indicated that they may involve in the FoxO signaling pathway and inherited metabolic disorder. RRM2, validating by the external datasets and western blot, were identified as the biomarker with the high diagnostic value, whose associated immune cells, such as Neutrophils and Macrophages M1, were also further evaluated.

CONCLUSION

We preliminary explored the mechanisms between ferroptosis and RA. These results may help us better comprehend the pathophysiological changes of RA in basic research, and provide new evidences for the clinical transformation.

Depression in Rheumatoid Arthritis: A Narrative Review-Diagnostic Challenges, Pathogenic Mechanisms and Effects

Depression is one of the most frequent comorbidities in rheumatoid arthritis (RA); it takes an important toll on the quality of life of these patients and also leads to a decrease in life expectancy. The current article is a narrative review on depression in RA, with the objective to emphasize and raise awareness on the high prevalence, pathogenic mechanisms, and effects that depression has on RA patients. In RA, the prevalence of depression has been shown to be 2 to 3 times higher than in the general population, with a meta-analysis reporting that 16.8% of RA patients have a major depressive disorder. Future studies are needed to determine the most accurate self-reported depression questionnaires and their ideal threshold for defining depression as compared to diagnostic interview as gold-standard for patients with RA to allow better comparisons across studies. The pathogenesis of depression remains to be fully understood, but recent specialty literature suggests that immune-mediated processes are involved and that there are similarities between the neural networks recruited in inflammation and those implicated in the pathophysiology of depression. Depression in patients with RA is associated with poor long-term outcomes. Multiple studies have shown that depression in RA is associated with increased pain, fatigue, and physical disability. It alters treatment compliance, causes more comorbidities, and leads to higher mortality, partly through increased suicide risk. Depression in RA also increases health service utilization and healthcare costs directly through hospitalization, but also indirectly through loss of work productivity. Assessing depression could be a significant psychomarker of rheumatological outcome in RA.