Association between tendency towards depression and severity of rheumatoid arthritis from a national representative sample: the Medical Expenditure Panel Survey

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

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

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

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

Gender differences in the prevalence and impact factors of adolescent dissociative symptoms during the coronavirus disease 2019 pandemic

The purpose of this study was to explore the differences between the prevalence and impact factors of adolescent dissociative symptoms (ADSs) by using sex-stratification during the coronavirus disease 2019 (COVID-19) pandemic. A school-based, two-center cross-sectional study was conducted in Hangzhou City, China, between January 1, 2021 and April 30, 2022. The sample included 1,916 adolescents aged 13-18 years that were randomly selected using a multiphase, stratified, cluster sampling technique. A two-stage assessment procedure was used to find out the ADSs. We used a multivariate logistic regression analysis to assess the impact factors of ADSs during the COVID-19 pandemic. The adolescent dissociative scores (t = 4.88, P < 0.001) and positive ADSs rate (Chi-square = 15.76, P < 0.001) in males were higher than in females. Gender-stratified, stepwise multiple logistic regression analysis revealed that the conflict relationship of teacher-student [adjusted odds ratio (AOR) 1.06, 95% confidence interval (CI) 1.01-1.10], family expressiveness (AOR 0.87, 95% CI 0.78-0.98), family conflict (AOR 1.15, 95% CI 1.05-1.27), family organization (AOR 0.88, 95% CI 0.78-0.99), and family cohesion (AOR 0.87, 95% CI 0.77-0.99) were linked to ADSs only in males, while individual psychological states of somatic complaint (AOR 1.04, 95% CI 1.00-1.08) and paranoid ideation (AOR 1.09, 95% CI 1.01-1.19) were associated with female ADSs only. The ADSs seemed to be prevalent in Hangzhou City, studied during the COVID-19 pandemic. Gender differences in the prevalence and impact factors of dissociative symptoms seem to be significant among adolescents. Thus, gender-specific intervention programs against ADSs should be considered as reducing this risk.

Characteristics Associated with Good Self-Perceived Mental Health among United States Adults with Arthritis

Mental health disorders are prevalent among United States (US) adults with arthritis. Yet, little is known about characteristics associated with mental health among US adults with arthritis. This retrospective cross-sectional study used 2019 Medical Expenditures Panel Survey data to assess the association between multiple personal characteristics and mental health status among US adults with arthritis. Hierarchical logistic regression models modeled associations between personal characteristics and mental health status. Model 1 included predisposing factors, model 2 included predisposing and enabling factors, while model 3 included predisposing, enabling, and need factors. The a priori alpha level was 0.05. Analyses accounted for the complex survey design and were weighted to produce national estimates. Among 28,512 individuals, 4984 met the inclusion criteria. Of these, 4181 had good mental health (85.5%, 95% confidence interval (CI) = 84.3%, 86.7%). The following characteristics were associated with good mental health status in the final adjusted model: age 18–64 vs. ≥65 (adjusted odds ratio (AOR) = 0.29, 95% CI = 0.12, 0.71), Midwest vs. West census region (AOR = 5.17, 95% CI = 1.63, 16.46), no degree vs. higher than high school education (AOR = 0.34, 95% CI = 0.12, 0.92), and high school diploma vs. higher than high school education (AOR = 0.40, 95% CI = 0.18, 0.86). In conclusion, this study suggests such characteristics may be targeted to help improve mental health among this population. Additional efforts are needed to help satisfy the unmet need for mental healthcare among this population.

Explaining the gap in the experience of depression among arthritis patients

OBJECTIVE

To explain the factors contributing to the gap in depression between employed arthritis patients with and without paid sick leave.

METHODS

Blinder-Oaxaca decomposition analysis was used to identify factors that explain the gap in the experience of depressive symptoms among arthritis patients with paid and unpaid sick leave. Data from the 2018 National Health Interview Survey, USA, was used.

RESULTS

A total of 7189 of the NHIS survey participants given the diagnosis of arthritis were identified, of which 39% were male and 61% were female, with mean age of 63.5 years. The decomposition findings suggest patients in the unpaid sick leave group were more likely to report depressive symptoms compared to patients with paid sick leave. The major contributors to the gap in the report of depressive symptoms are sex (female) and annual income (less than 35,000 USD).

CONCLUSION

Findings suggest that the absence of paid sick leave is a key determinant for experiencing depressive symptoms among individuals with arthritis. The provision of paid sick leave may reduce report of depressive symptoms among employed arthritis patients in the USA.

KEY POINTS

• Individuals with arthritis are consistently at greater risk of depression and unemployment as compared to individuals without arthritis. • To date greater emphasis is put on determinants of unemployment, while there is no available data on benefits associated with being employed, such as sick leave, and how it affects mental health. • Patients with unpaid sick leave appear to experience more persistent depressive symptoms than patients with access to paid sick leave. • To tackle burden of depression among arthritis patients, provision of paid sick leave may be an effective intervention.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Rheumatoid arthritis and depression

Depression constitutes the most frequent comorbid condition associated with rheumatoid arthritis (RA), with prevalence rates ranging from 14% to 48%. This wide range can be explained by several factors including subtypes of depression considered, instrument of measure (i.e. self-questionnaires versus clinical interview), threshold applied but also the overlap of symptoms between the two conditions. Despite being a frequent comorbid condition in RA, depressive states are repeatedly underdiagnosed and thus, often remain untreated. Consequences are dramatic as conclusive evidence show that depression deleteriously impacts just about all outcomes of RA, including disease activity, arthritis-related complications, level of pain, chance of remission, quality of life and mortality. Importantly, links between depression and RA appear to be bidirectional as if RA patients show increased prevalence of depression. Conversely, patients with depression compared to the general population have higher risk to develop RA. Among the factors explaining this strong association between depression and RA, recent advances have underlined the putative role of models based on the inflammatory hypothesis. Pro-inflammatory cytokines such as tumor necrosis factor, interleukin (IL)-1, IL-6, and IL-18 are involved in RA pathogenesis, but also in depression. Furthermore, the connections between the central nervous system, the peripheral system and the immune system are now better understood. As a consequence of the strong comorbidity and the aggravate prognostic, the management of patient showing this dual diagnosis should be carefully monitor. The common physiopathology also opens the path to utilization of RA treatment in severe depression or treatment-resistant depression.

Influence of Ambient Air Pollution on Rheumatoid Arthritis Disease Activity Score Index

Rheumatoid arthritis (RA) is a chronic autoimmune of an unknown etiology. Air pollution has been proposed as one of the possible risk factors associated with disease activity, although has not been extensively studied. In this study, we measured the relationship between exposure to air pollutants and RA activity. Data on RA patients were extracted from the Kuwait Registry for Rheumatic Diseases (KRRD). Disease activity was measured using disease activity score with 28 examined joints (DAS-28) and the Clinical Disease Activity Index (CDAI) during their hospital visits from 2013 to 2017. Air pollution was assessed using air pollution components (PM10, NO2, SO2, O3, and CO). Air pollution data were obtained from Kuwait Environmental Public Authority (K-EPA) from six different air quality-monitoring stations during the same period. Multiple imputations by the chained equations (MICE) algorithm were applied to estimate missing air pollution data. Patients data were linked with air pollution data according to date and patient governorate address. Descriptive statistics, correlation analysis, and linear regression techniques were employed using STATA software. In total, 1651 RA patients with 9875 follow-up visits were studied. We detected an increased risk of RA using DAS-28 in participants exposed to SO2 and NO2 with β=0.003 (95% CI: 0.0004–0.005, p<0.01) and β=0.003 (95% CI: 0.002–0.005, p<0.01), respectively, but not to PM10, O3, and CO concentrations. Conclusively, we observed a strong association between air pollution with RA disease activity. This study suggests air pollution as a risk factor for RA and recommends further measures to be taken by the authorities to control this health problem.

[Higher prevalence of depressive and anxiety symptoms in early arthritis patients in comparison to the normal population]

BACKGROUND

Many studies and registry data confirm that depression, often associated with anxiety disorders is very often found in patients with rheumatoid arthritis (RA). To what extent these psychiatric disorders are already relevant at a very early stage of the disease, has currently not been adequately investigated.

METHODS

In this study 176 patients with early joint symptoms (<1 year) were surveyed in an early arthritis consultation (EAC). The hospital anxiety and depression scale (HADS) was completed by the patients to examine the prevalence of depressive and anxiety symptoms. The results were compared to normative data of the general German population and between the diagnosis groups.

RESULTS

With 47.7% the prevalence of global distress for EA patients was almost twice as high compared to the corresponding group from the general population. This was also confirmed for depressive and anxiety symptoms. The EA patients without confirmed evidence of musculoskeletal inflammatory rheumatic disease (RD) showed nearly the same point prevalence as patients with confirmed RD. In multiple logistic regression the health assessment questionnaire (HAQ) was positively associated with global distress (odds ratio, OR 3.63) while the visual analogue scale (VAS) for global disease activity was positively associated with symptoms of depression (OR 1.03). Female EA patients (OR 5.45) appear to have a higher probability for experiencing corresponding symptoms, whereas patients over 60 years old appear to have less anxiety than younger patients (OR 0.11).

CONCLUSION

The high prevalence of symptoms of depression and anxiety in EA patients compared to the general population is a challenge for rheumatologists, orthopedists and general practitioners, particularly with respect to the differentiation of possible psychosomatic components in noninflammatory joint complaints. The results suggest that screening for psychiatric problems in patients with rheumatism should be evaluated as soon as possible as these can have a great impact on the perception of pain and physical functional status from the very beginning.

Health care utilization and expenditures among adults with rheumatoid arthritis using specialty pharmaceuticals

BACKGROUND

Despite the rising popularity of using specialty medications for patients with rheumatoid arthritis (RA), little is known about the use or spending on medical services among these patients.

OBJECTIVE

The objective of this study was to investigate health care utilization and expenditures among patients with RA using specialty medications compared with those using non-specialty (i.e., traditional) medications.

METHODS

This was a retrospective cohort study using Medical Expenditure Panel Survey data from 2009 through 2015. Health care use and expenditures were examined using a (zero-truncated or zero-inflated) negative binomial model and a generalized linear model with a log link function and gamma distribution (or a two-part model).

RESULTS

Compared to patients with RA who were traditional medication users (TMUs), those categorized as specialty medication users (SMUs) were prescribed about 24% fewer medications (incidence rate ratio [IRR] = 0.76, 95% CI = 0.66-0.89) and received fewer office-based visits (IRR = 0.84, 95% CI = 0.70-0.99). Although SMUs' spending on emergency department visits was lower, their spending on total health care was $14,570 higher than that of TMUs. Compared with TMUs, users of both specialty and traditional medications (BMUs) had fewer emergency department visits (IRR = 0.57, 95% CI = 0.39-0.81) with less spending on emergency service use. Overall, BMUs' total health care spending was $5720 higher than TMUs' total spending.

CONCLUSIONS

There were some differences in health care use and expenditures for treating RA between patients using specialty medications and those using traditional medications. Total health care spending was higher for SMUs/BMUs despite their less frequent use of some types of medical services and lower spending on emergency department visits, because of the high cost of specialty medications for RA. The high costs of specialty medications implies the importance of the efficient use of these medications.

ATP-activated P2X7 receptor in the pathophysiology of mood disorders and as an emerging target for the development of novel antidepressant therapeutics

Mood disorders are a group of psychiatric conditions that represent leading global disease burdens. Increasing evidence from clinical and preclinical studies supports that innate immune system dysfunction plays an important part in the pathophysiology of mood disorders. P2X7 receptor, belonging to the ligand-gated ion channel P2X subfamily of purinergic P2 receptors for extracellular ATP, is highly expressed in immune cells including microglia in the central nervous system (CNS) and has a vital role in mediating innate immune response. The P2X7 receptor is also important in neuron-glia signalling in the CNS. The gene encoding human P2X7 receptor is located in a locus of susceptibility to mood disorders. In this review, we will discuss the recent progress in understanding the role of the P2X7 receptor in the pathogenesis and development of mood disorders and in discovering CNS-penetrable P2X7 antagonists for potential uses in in vivo imaging to monitor brain inflammation and antidepressant therapeutics.

Psychological well-being among US adults with arthritis and the unmet need for mental health care

PURPOSE

Mental health conditions can increase the risk of disability among adults with arthritis. The objective of this analysis was to compare the prevalence of serious psychological distress (SPD), depression, and anxiety among US adults with arthritis vs. those without; characterize adults with arthritis with and without SPD; and determine correlates of seeing a mental health professional during the year for adults with arthritis and SPD.

MATERIALS AND METHODS

Cross-sectional analysis of adults in the 2011-2013 National Health Interview Survey.

RESULTS

Higher proportions of adults with arthritis had SPD (6.8% vs. 2.4%), depression (19.4% vs. 7.3%), and anxiety (29.3% vs. 16.3%) compared to those without. Of the estimated 3.5 million adults with arthritis and SPD, only 39% saw a mental health professional during the year. Adjusted analyses identified the following statistically significant relationships: those who were older (45-64 and ≥65 [vs.18-44], prevalence ratio [PR]=0.8 and 0.4, respectively), less educated (PR=0.5 and 0.7 for high school or less vs. college degree, respectively), and without health insurance coverage (vs. any private, PR=0.7), were less likely to see a mental health professional, whereas the disabled or unemployed (vs. employed, PR=1.6 and 1.5, respectively), and those unable to afford mental health care throughout the year (PR=1.3) were more likely.

CONCLUSION

The high prevalence of SPD, anxiety, and depression in adults with arthritis suggests the need for increased mental health screening, with subsequent referral to mental health professionals or other treatment programs, in that population.

Longitudinal assessment of injury recidivism among adults in the United States: findings from a population-based sample

Background

Repeated injuries, as known as injury recidivism, pose a significant burden on population health and healthcare settings. Therefore, identifying those at risk of recidivism can highlight targeted populations for primary prevention in order to improve health and reduce healthcare expenditures. There has been limited research on factors associated with recidivism in the U.S. Using a population-based sample, we aim to: 1) identify the prevalence and risk factors for injury recidivism among non-institutionalized adults; 2) investigate the trend in nationwide recidivism rates over time.

Methods

Using the Medical Expenditure Panel Survey (MEPS), 19,134 adults with at least one reported injury were followed for about 2 years. Reported injuries were those associated with healthcare utilization, disability days or any effects on self-reported health. The independent associations between risk factors for recidivism were evaluated incorporating a weighted logistic regression model.

Results

There were 4,136 recidivists representing over nine million individuals in the U.S. over a 2-year follow-up. About 44 % of recidivists sustained severe injuries requiring a hospitalization, a physician’s office visit or an emergency department visit. Compared with those who sustained a single injury, recidivists were more likely to be white, unmarried, reside in metropolitan areas, and report a higher prevalence of chronic conditions. Age, sex, race/ethnicity, marital status, urbanicity, region, diabetes, stroke, asthma and depression symptoms were significant predictors of recidivism. Significant interaction effects between age and gender suggested those in the 18–25 age group, the odds of being a recidivist were 1.45 higher among males than females adjusting for other covariates. While having positive screens for depression in both follow-up years was associated with 1.46 (95 % CI = 1.21–1.77) higher odds of recidivisms than the reference group adjusting for other variables.

Conclusions

We observed a higher recidivism rate among injured individuals in this study than previously reported. Our findings emphasize the pressing need for injury prevention to reduce the burden of repeated injuries. Preventative efforts may benefit from focusing on males between 18 and 25 years of age and those with comorbidities such as diabetes, stroke and depression.

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.

An Integrative Review of Correlates and Predictors of Depression in Patients with Rheumatoid Arthritis

Depression creates an additional burden for adults with rheumatoid arthritis (RA), negatively affecting disease outcomes and quality of life. An integrative literature review of twenty-three quantitative studies was conducted on correlates and factors predictive of depression in adults with RA. Methodological assessment tools were used to independently evaluate the data quality by two reviewers. Prevalence rates ranged from 6.6 to 66.25%. Correlates included pain, functional status, disease duration, and RA treatment. Predictors, including sociodemographics, pain, coping ability, support, functional status, and clinical factors, varied depending upon the sample, standardized measure, and geographic location. Understanding correlates/predictors could guide the development of comprehensive care.

Temporal effect of depressive symptoms on the longitudinal evolution of rheumatoid arthritis disease activity

OBJECTIVE

Depression is common in the rheumatoid arthritis (RA) population, yet little is known of its effect on the course of disease activity. The aim of our study was to determine if prevalent and incident depressive symptoms influenced longitudinal changes in RA disease activity.

METHODS

RA patients with and without depressive symptoms were identified using single-item questions from an existing registry sample. Mixed-effects models were used to examine changes in disease activity over 2 years in those with and without prevalent and incident depressive symptoms. Outcome variables included composite disease activity, joint counts, global assessments, pain, function, and acute-phase reactants. Model-based outcome estimations at the index dates and corresponding 1- and 2-year changes were calculated.

RESULTS

Rates of disease activity change were significantly different in patients with a lifetime prevalence of symptomology, but not incident depressive symptoms, when compared to controls. Prior symptoms were associated with slower rates of disease activity decline, evidenced by the estimated 1-year Clinical Disease Activity Index changes: -3.0 (-3.3, -2.6) and -4.0 (-4.3, -3.6) in patients with and without lifetime prevalence, respectively. Analogous results were obtained for most of the other disease activity outcomes; although, there was no temporal effect of prevalent symptoms of depression on swollen joints and acute-phase reactants.

CONCLUSION

Depressive symptoms temporally influence the evolution of RA disease activity, and the magnitude is dependent on the time of symptomatic onset. However, the effect is limited to patient-reported pain, global assessment, and function, as well as physician-reported global assessment and tender joints.

From head to tail it's a 2 way street for neuro-immune communication

Animals need to be able to rapidly and effectively respond to changes in their external and internal environment. To achieve this the nervous and immune systems need to coordinate their responses, integrating multiple cues including presence of potential pathogens, and availability of food. In our recent study (1) we demonstrate that signaling by sensory neurons in the head using the classical neurotransmitter serotonin can negatively regulate the rectal epithelial immune response upon infection of C. elegans with the naturally occurring bacterial pathogen Microbacterium nematophilum (M. nematophilum). The complicated nature of the mammalian brain and immune system has made it difficult to identify the molecular mechanisms mediating these interactions. With its simple, well described, nervous system and a rapidly growing understanding of its immune system, C. elegans has emerged as an excellent model to study the mechanisms by which animals recognize pathogens and coordinate behavioral and cellular immune responses to infection.

Temporal associations between the different domains of rheumatoid arthritis disease activity and the onset of patient-reported depressive symptoms

BACKGROUND

Depression is a frequently occurring comorbid condition in patients with rheumatoid arthritis (RA), and research into the temporal relationships regarding its onset has mainly focused on functional status. The study aim was to examine temporal associations of the diverse measures of RA disease activity with incident self-reports of depressive symptoms.

METHODS

RA patients from the Consortium of Rheumatology Researchers of North America (CORRONA) registry were utilized. Cox regression was used to assess the lagged time-varying association of RA disease activity with the incident onset of depressive symptoms as measured using a single-item depression question. Predictor variables included joint counts, global assessments, pain, function, serum biomarkers, and composite disease activity. Hazard ratios (HRs) comparing categorical quintiles were estimated with 95 % confidence intervals.

RESULTS

Every metric of disease activity, except inflammatory markers, were significantly associated with the self-reported onset of depressive symptoms. Adjusted HRs comparing fifth quintiles to first quintiles were the following: CDAI = 2.3 [2.1-2.7]; pain = 2.3 [2.0-2.6]; SJC = 1.4 [1.4-1.6]. When examining successive self-reports (two consecutive), the magnitude of the associations greatly increased: CDAI = 3.6 [2.5-5.0].

CONCLUSIONS

The data suggest depressive symptom onset in RA patients is related to measures reported by the patient: pain, functional status, and global disease activity; and measures reported by providers, rather than biological markers. The magnitude of the associations, however, were greater for the patient-reported measures when compared to physician assessments, implying that patients' experience of their disease activity may be a precipitating factor of depression onset.

Mind and body: how the health of the body impacts on neuropsychiatry

It has long been established in traditional forms of medicine and in anecdotal knowledge that the health of the body and the mind are inextricably linked. Strong and continually developing evidence now suggests a link between disorders which involve Hypothalamic-Pituitary-Adrenal axis (HPA) dysregulation and the risk of developing psychiatric disease. For instance, adverse or excessive responses to stressful experiences are built into the diagnostic criteria for several psychiatric disorders, including depression and anxiety disorders. Interestingly, peripheral disorders such as metabolic disorders and cardiovascular diseases are also associated with HPA changes. Furthermore, many other systemic disorders associated with a higher incidence of psychiatric disease involve a significant inflammatory component. In fact, inflammatory and endocrine pathways seem to interact in both the periphery and the central nervous system (CNS) to potentiate states of psychiatric dysfunction. This review synthesizes clinical and animal data looking at interactions between peripheral and central factors, developing an understanding at the molecular and cellular level of how processes in the entire body can impact on mental state and psychiatric health.

Evidence for a dysregulated immune system in the etiology of psychiatric disorders

There is extensive bi-directional communication between the brain and the immune system in both health and disease. In recent years, the role of an altered immune system in the etiology of major psychiatric disorders has become more apparent. Studies have demonstrated that some patients with major psychiatric disorders exhibit characteristic signs of immune dysregulation and that this may be a common pathophysiological mechanism that underlies the development and progression of these disorders. Furthermore, many psychiatric disorders are also often accompanied by chronic medical conditions related to immune dysfunction such as autoimmune diseases, diabetes and atherosclerosis. One of the major psychiatric disorders that has been associated with an altered immune system is schizophrenia, with approximately one third of patients with this disorder showing immunological abnormalities such as an altered cytokine profile in serum and cerebrospinal fluid. An altered cytokine profile is also found in a proportion of patients with major depressive disorder and is thought to be potentially related to the pathophysiology of this disorder. Emerging evidence suggests that altered immune parameters may also be implicated in the neurobiological etiology of autism spectrum disorders. Further support for a role of immune dysregulation in the pathophysiology of these psychiatric disorders comes from studies showing the immunomodulating effects of antipsychotics and antidepressants, and the mood altering effects of anti-inflammatory therapies. This review will not attempt to discuss all of the psychiatric disorders that have been associated with an augmented immune system, but will instead focus on several key disorders where dysregulation of this system has been implicated in their pathophysiology including depression, schizophrenia and autism spectrum disorder.

Imaging pain in arthritis: advances in structural and functional neuroimaging

Arthritis is a heterogeneous disease characterized by joint stiffness, swelling, and pain. Although primarily considered a peripheral joint disease, the severity of pain reported by arthritis patients does not always reflect the extent of joint pathology detectable by conventional means. Using structural and functional brain imaging techniques, a growing number of evolving neuroimaging methods are providing insight into these observed discrepancies at different time-scales. Of these methods, functional magnetic resonance imaging is exploited for short-term evoked pain examination and treatment evaluation; 'resting-state' approaches provide insight into fluctuations in pain; perfusion imaging captures elements of on-going clinical pain; and morphological brain assessment provides evidence for long-term structural changes in the brain associated with chronic pain. Further insight into arthritic pain processing at the brain-systems level could in the future be provided by combined neuroimaging approaches, specifically investigating the interactions between functional and structural alterations.

The role of the innate immune system in psychiatric disorders

There is by now substantial clinical evidence for an association between specific mood disorders and altered immune function. More recently, a number of hypotheses have been forwarded to explain how components of the innate immune system can regulate brain function at the cellular and systems levels and how these may underlie the pathology of disorders such as depression, PTSD and bipolar disorder. In this review we draw reference to biochemical, cellular and animal disease models, as well as clinical observations to elucidate the role of the innate immune system in psychiatric disorders. Proinflammatory cytokines, such as IL-1β IL-6 and TNFα, which feature prominently in the immune response to pathogen in the periphery, have unique and specific actions on neurons and circuits within the central nervous system. Effects of these signaling molecules on neurotransmission, memory, and glucocorticoid function, as well as animal behaviors such as social withdrawal and fear conditioning relevant to psychiatric disorders are elucidated. Finally, we highlight future directions for studies, including the use of peripheral biomarkers, relevant for developing new therapeutic approaches for treating psychiatric illnesses. This article is part of Special Issue entitled 'neuroinflammation in neurodegeneration and neurodysfunction'.

A multidimensional model of fatigue in patients with rheumatoid arthritis

OBJECTIVE

To evaluate a multidimensional model testing disease activity, mood disturbance, and poor sleep quality as determinants of fatigue in patients with rheumatoid arthritis (RA).

METHOD

The data of 106 participants were drawn from baseline of a randomized comparative efficacy trial of psychosocial interventions for RA. Sets of reliable and valid measures were used to represent model constructs. Structural equation modeling was used to test the direct effects of disease activity, mood disturbance, and poor sleep quality on fatigue, as well as the indirect effects of disease activity as mediated by mood disturbance and poor sleep quality.

RESULTS

The final model fit the data well, and the specified predictors explained 62% of the variance in fatigue. Higher levels of disease activity, mood disturbance, and poor sleep quality had direct effects on fatigue. Disease activity was indirectly related to fatigue through its effects on mood disturbance, which in turn was related to poor sleep quality. Mood disturbance also indirectly influenced fatigue through poor sleep quality.

CONCLUSION

Our findings confirmed the importance of a multidimensional framework in evaluating the contribution of disease activity, mood disturbance, and sleep quality to fatigue in RA using a structural equation approach. Mood disturbance and poor sleep quality played major roles in explaining fatigue along with patient-reported disease activity.