History of affective disorder and the temporal trajectory of fatigue in rheumatoid arthritis

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.

Prevalence, Severity, and Measures of Anxiety in Rheumatoid Arthritis: A Systematic Review

OBJECTIVE

Many studies have reported high rates of anxiety in adults with rheumatoid arthritis (RA). The aim of this systematic review was to examine those findings and determine the overall prevalence, severity, and commonly used measures of anxiety in individuals with RA.

METHODS

Six databases were searched from January 2000 without restrictions on language/location, study design, or gray literature. All identified studies that examined anxiety prevalence and severity in adults with RA, as assessed with clinical diagnostic interview and/or standardized self-report measures, were considered for inclusion. Quality assessment of included studies was conducted using a modified Newcastle-Ottawa Evaluation Scale, and the findings were synthesized via a narrative approach.

RESULTS

Across the 47 studies (n = 11,085 participants), the sample size ranged from 60 to 1,321 participants with seven studies including healthy controls or groups with other health conditions. The studies were conducted across 23 countries, and anxiety prevalence ranged from 2.4% to 77%, predominantly determined with standardized self-report measures, of which Hospital Anxiety and Depression scale was used most frequently; only eight studies used a clinical diagnostic interview to confirm a specific anxiety diagnosis. Notable associations with anxiety in RA were physical disability, pain, disease activity, depression, and quality of life.

CONCLUSION

The reported prevalence of anxiety in RA varied widely potentially because of use of different self-report measures and cutoff points. Such cutoff points will need to be standardized to clinical thresholds to inform appropriate interventions for anxiety comorbidity in RA.

Patient self-reported instruments for assessing symptoms in rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic joint autoimmune disease with a higher prevalence of depressive symptoms due to the burden of the disease. There are several patient-self-depression scales used for the assessment and a wide range of variations in the prevalence of depression could be related to this. No evidence was found that reports the most accurate, sensitive, and specific depression instrument through an extensive review in the literature. To determine the most precise depression instrument to evaluate RA patients. A systematic review search was directed, considering type of study, prevalence of depressive symptoms, usage of validated depression scales, and reported scale performance measurements. The data extraction followed the PRISMA guidelines, and the risk of bias was assessed using RoB 2, ROBINS-I, and QUADAS-2. From a total of 1958, only 28 articles included in the analysis. The total number of patients analyzed was 6405, with a mean age of 56.53 years, 4474 women (75.22%), and a mean prevalence of depressive symptoms of 27.4%. The most frequent and the best scale used was the CES-D (n = 12), considering all characteristics. The CES-D reported the best psychometric properties, and it was the most frequently used tool.

Remote sampling of biomarkers of inflammation with linked patient generated health data in patients with rheumatic and musculoskeletal diseases: an Ecological Momentary Assessment feasibility study

Background

People with rheumatic diseases experience troublesome fluctuations in fatigue. Debated causes include pain, mood and inflammation. To determine the relationships between these potential causes, serial assessments are required but are methodologically challenging. This mobile health (mHealth) study explored the viability of using a smartphone app to collect patient-reported symptoms with contemporaneous Dried Blood Spot Sampling (DBSS) for inflammation.

Methods

Over 30 days, thirty-eight participants (12 RA, 13 OA, and 13 FM) used uMotif, a smartphone app, to report fatigue, pain and mood, on 5-point ordinal scales, twice daily. Daily DBSS, from which C-reactive Protein (CRP) values were extracted, were completed on days 1–7, 14 and 30. Participant engagement was determined based on frequency of data entry and ability to calculate within- and between-day symptom changes. DBSS feasibility and engagement was determined based on the proportion of samples returned and usable for extraction, and the number of days between which between-day changes in CRP which could be calculated (days 1–7).

Results

Fatigue was reported at least once on 1085/1140 days (95.2%). Approximately 65% of within- and between-day fatigue changes could be calculated. Rates were similar for pain and mood. A total of 287/342 (83.9%) DBSS, were returned, and all samples were viable for CRP extraction. Fatigue, pain and mood varied considerably, but clinically meaningful (≥ 5 mg/L) CRP changes were uncommon.

Conclusions

Embedding DBSS in mHealth studies will enable researchers to obtain serial symptom assessments with matched biological samples. This provides exciting opportunities to address hitherto unanswerable questions, such as elucidating the mechanisms of fatigue fluctuations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05723-w.

Se-[(2,2-Dimethyl-1,3-dioxolan-4-yl)methyl] 4-Chlorobenzoselenolate Attenuates Inflammatory Response, Nociception, and Affective Disorders Related to Rheumatoid Arthritis in Mice

Despite major advances, not all patients achieve rheumatoid arthritis (RA) remission, thus highlighting a pressing need for new therapeutic treatments. Given this scenario, this study sought to evaluate Se-[(2,2-dimethyl-1,3-dioxolan-4-yl)methyl] 4-chlorobenzoselenolate (Se-DMC) potential on a complete Freund's adjuvant (CFA)-induced unilateral arthritis model. The effects of Se-DMC (5 mg/kg; oral dose) and meloxicam (5 mg/kg; oral dose), both administered to animals daily for 14 days, on paw edema, mechanical sensitivity, neurobehavioral deficits (anxiogenic- and depressive-like behaviors), Na⁺/K⁺-ATPase activity, oxidative stress, and inflammation were evaluated in male Swiss mice exposed to CFA (intraplantar injection of 0.1 mL; 10 mg/mL). Se-DMC reduced the paw withdrawal threshold and CFA-induced paw edema. Histopathological results revealed the antiedematogenic potential of the compound, which was evidenced by lower quantities of dilated lymphatic vessels compared with the CFA group. Se-DMC reduced mRNA relative expression levels of tumor necrosis factor-α (TNF-α) and nuclear factor-κB (NF-κB) in the hippocampus and paw of CFA mice. The CFA-induced anxiogenic- and depressive-like behaviors were reversed by Se-DMC to the control levels in the elevated plus-maze and tail suspension tests. Se-DMC reduced the paw reactive species levels and restored the superoxide dismutase (hippocampus and paw) and Na⁺/K⁺-ATPase (hippocampus) activities previously increased by CFA. Moreover, CFA administration inhibited serum creatinine kinase activity, albeit the Se-DMC effects did not appear to involve the modulation of this enzyme and were equal to or greater than meloxicam. Se-DMC attenuates CFA-induced inflammatory response, nociception, and neurobehavioral deficits in mice.

Predictors of fatigue in rheumatoid arthritis

People with RA commonly experience fatigue. Fatigue is a key contributor to increased clinical care costs, primary care consultations and employment loss. Despite this, our understanding of the prognostic of factors of poor fatigue outcomes is lacking and fatigue is poorly managed. Examining longitudinal predictors of fatigue can identify both individuals ‘at risk’ of poor prognosis, and candidate mechanisms that are worthy of greater inspection. This review discusses the factors most commonly investigated as being implicated in the prognosis of RA fatigue. The available data appears to implicate generic factors such as pain, mental health, disability and sleep as consistent predictors of fatigue outcome, while the role of disease activity and inflammation seems less clear. However, the existing data are not without methodological limitations and there have been no specific studies primarily designed to investigate the inflammatory biomarkers of fatigue. Future studies are required to more comprehensively and robustly determine the mechanisms of fatigue.

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

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

Mental Health and Rheumatoid Arthritis: Toward Understanding the Emotional Status of People with Chronic Disease

Introduction

Rheumatoid arthritis (RA) is a long-term disorder significantly impairing the somatic, emotional, and psychological functioning of its sufferers. Previous research has shown that affected individuals are characterized by an increased level of anxiety and depression. Currently, there are two main treatment schemes for RA; the first uses anti-inflammatory drugs, and the second utilizes biologic agents. This begs the question whether sufferers differ in intensities of pain, anxiety, and depression depending on the type of treatment and what the determinants of these affective states in patients treated using different methods are.

Methods

The study comprised 85 patients affected by RA (including 57 receiving biologically inactive medication). Research participants filled out a set of questionnaires measuring levels of anxiety and depression, intensity of experienced pain, strategies of coping with pain, and ego resiliency.

Results

The collected data was analyzed through intergroup comparisons, calculating simple correlation coefficients, developing and solving regression equations. The results imply that the choice of treatment differentiates the intensity of pain experienced by patients. Those receiving biologic agents reported lower levels of pain compared to those taking anti-inflammatory medication. It has also been noted that there are distinct configurations of conditions conducive to anxiety and depression in both anti-inflammatory and biologic agent groups.

Discussion

The observed constellation of dependencies between variables indicates that the choice of treatment scheme differentiates pain levels. This confirms the assumption that pain intensity, coping strategies, and ego resiliency depend on the severity of anxiety and depression.

Affective disturbance in rheumatoid arthritis: psychological and disease-related pathways

In addition to recurrent pain, fatigue, and increased rates of physical disability, individuals with rheumatoid arthritis (RA) have an increased prevalence of some mental health disorders, particularly those involving affective or mood disturbances. This narrative Review provides an overview of mental health comorbidities in RA, and discusses how these comorbidities interact with disease processes, including dysregulation of inflammatory responses, prolonged difficulties with pain and fatigue, and the development of cognitive and behavioural responses that could exacerbate the physical and psychological difficulties associated with RA. This article describes how the social context of individuals with RA affects both their coping strategies and their psychological responses to the disease, and can also impair responses to treatment through disruption of patient-physician relationships and treatment adherence. Evidence from the literature on chronic pain suggests that the resulting alterations in neural pathways of reward processing could yield new insights into the connections between disease processes in RA and psychological distress. Finally, the role of psychological interventions in the effective and comprehensive treatment of RA is discussed.

Pregnancy in patients with rheumatic diseases: psychological implication of a chronic disease and neuropsychological evaluation of the children

As a consequence of the general improvement in the diagnosis and management of rheumatic diseases, patients achieve a better quality of life, with the possibility of a normal family life including one or more pregnancies. It is important, therefore, to consider the psychological aspects of these mothers’ life and the influence of their chronic disease on their children is development. Several papers have reported the impact of systemic lupus erythematosus (SLE) on the quality of life. They found higher incidence of anxiety (from 15 to 45%) and depression (from 25 to 47%) compared to the general population. We have investigated the psychological influence of SLE on family planning, and we observed that it can interfere with physiological phenomena such as parenthood and the upbringing of children. The children of lupus mothers have a normal intelligence level for their age. What is emerging, however, is an increased incidence of learning disabilities compared to the general population. This observation suggests the importance of an early neuropsychological examination, in order to identify the children needing particular care. Therefore, psychological support seems to be an important help in the counseling of patients with rheumatic disease and in the future life of their children.

The mediating role of dysfunctional coping in the relationship between beliefs about the disease and the level of depression in patients with rheumatoid arthritis

Aim. Rheumatoid arthritis is one of the most severe chronic diseases. In many cases it leads to disability and results in a decreased quality of life and increased levels of anxiety and depression. The problem that needs to be addressed is the following: which mental processes lead to increased levels of depression in patients with rheumatoid arthritis? Methods. 210 patients with rheumatoid arthritis hospitalized in rheumatology wards took part in the research. They filled in illness perception questionnaires (IPQ-R) and questionnaires for testing strategies of handling stress (Mini-COPE) and the level of depression (CES-D). Results. The observed correlation coefficients indicate that several elements of the perception of one's disease moderately contribute to a high level of depression. Moreover, frequent use of dysfunctional coping strategies contributed to high levels of depression. Dysfunctional coping was moderately linked to depression. Conclusion. The conducted analyses confirmed the links between the beliefs about the disease and levels of depression and showed that the use of dysfunctional coping strategies mediates the relationship between the following elements of the representation of the disease: illness coherence, emotional representation, psychological attribution, risk factors, and the level of depression.

Fatigue and factors related to fatigue in rheumatoid arthritis: a systematic review

OBJECTIVE

Although patients with rheumatoid arthritis (RA) experience fatigue, little is known about its causes and consequences, and a fully developed theoretical model explaining the experience of fatigue in RA is lacking. Our goal was to systematically review studies in RA that examined factors related to fatigue to gain more insight into its possible causes and consequences.

METHODS

Medline, Web of Science, Scopus, and PsycINFO were searched for relevant studies. All studies with RA samples about the relationship between fatigue and other variables that defined dependent and independent variables and used multivariate statistical methods were preliminarily included. After reviewing 129 full texts, we identified 25 studies on possible causes of fatigue and 17 studies on possible consequences of fatigue.

RESULTS

The studies found possible causes of fatigue in illness-related aspects, physical functioning, cognitive/emotional functioning, and social aspects. Additionally, being a woman was related to higher levels of fatigue. Inflammatory activity showed an unclear relationship with fatigue in RA. Possible consequences of fatigue were also found among illness-related aspects, physical functioning, cognitive/emotional functioning, and social aspects. The strongest evidence for a relationship between fatigue and other variables was found regarding pain, physical functioning, and depression.

CONCLUSION

This review summarizes the current knowledge in the field in order to inform future research on causes and consequences of fatigue in RA. However, the results are based on cross-sectional and longitudinal studies with different designs and different fatigue scales. For a better identification of causal associations between fatigue in RA and related factors, longitudinal prospective designs with adequate fatigue measurements are suggested.

Peripheral and central mechanisms of fatigue in inflammatory and noninflammatory rheumatic diseases

Fatigue is a common symptom in a large number of medical and psychological disorders, including many rheumatologic illnesses. A frequent question for health care providers is related to whether reported fatigue is "in the mind" or "in the body"-that is, central or peripheral. If fatigue occurs at rest without any exertion, this suggests psychological or central origins. If patients relate their fatigue mostly to physical activities, including exercise, their symptoms can be considered peripheral. However, most syndromes of fatigue seem to depend on both peripheral and central mechanisms. Sometimes, muscle biopsy with histochemistry may be necessary for the appropriate tissue diagnosis, whereas serological tests generally provide little reliable information about the origin of muscle fatigue. Muscle function and peripheral fatigue can be quantified by contractile force and action potential measurements, whereas validated questionnaires are frequently used for assessment of mental fatigue. Fatigue is a hallmark of many rheumatologic conditions, including fibromyalgia, myalgic encephalitis/chronic fatigue syndrome, rheumatoid arthritis, systemic lupus, Sjogren's syndrome, and ankylosing spondylitis. Whereas many studies have focused on disease activity as a correlate to these patients' fatigue, it has become apparent that other factors, including negative affect and pain, are some of the most powerful predictors for fatigue. Conversely, sleep problems, including insomnia, seem to be less important for fatigue. There are several effective treatment strategies available for fatigued patients with rheumatologic disorders, including pharmacological and nonpharmacological therapies.

Rheumatoid arthritis and sexuality: a patient survey in France

Background

The objective of this study was to evaluate the impact of rheumatoid arthritis (RA) on patients’ sexuality and identify disease and other factors such as fatigue that most influence sexual relationships.

Methods

A specific pretested questionnaire was sent to all members of a French patient association (ANDAR). Questions related to demographics, disease status, quality of life (utility, EQ-5D), pain, psychological status (mood), fatigue and emotional and sexual relationships. To isolate the impact of RA, an attempt was made to include a matched sample from the general population.

Results

The analysis included 1271 patients, but only 70 controls agreed to participate and comparisons should therefore be considered with caution. The two groups were similar in terms of age, gender distribution, living conditions and diseases other than RA. However, patients scored worse for global health, mood, fatigue, had a lower utility (0.55 versus 0.65). Controls were more active sexually (69% versus 63%), in particular women (71% versus 60%). Age, gender, living alone, physical function and mood were significant predictors for being sexually active for patients; for controls, age and overall quality of life (utility) were significant predictors.

Conclusions

While it is known that RA has a negative impact on patients’ sexuality, there have been few attempts to quantify the problem. Our study highlights the negative impact of RA on patients’ sexuality, and triggers the question how to include this aspect into care.

Fatigue in systemic lupus erythematosus and rheumatoid arthritis

Two inflammatory autoimmune diseases, systemic lupus erythematosus and rheumatoid arthritis, are characterized by fatigue. Patient reports support the significant negative impact of the symptom on functioning and well-being. The prevalence, trajectory, mechanism, and correlates of fatigue in each disease are reviewed. Some disease-focused treatments have demonstrated a reduction in fatigue. However, until recently, clinical trials have not routinely assessed fatigue. Analyses and interpretation of data have been hindered by variability in the reliability and validity of fatigue measures. Empirically based fatigue treatment guidelines are needed in both conditions.

History of major depressive disorder and diabetes outcomes in diet- and tablet-treated post-menopausal women: a case control study

AIMS

Little is known about the long-term associations between remitted major depressive disorder (MDD) and clinical diabetes outcomes. This study investigated associations between a remote history of fully remitted MDD and (i) glycaemic control, (ii) diabetes symptoms, and (iii) physical and emotional functioning in post-menopausal women with Type 2 diabetes (T2DM).

METHODS

Forty-four post-menopausal women with diet- or tablet-treated T2DM participated. Twenty-three had never experienced depression and 21 had a history of MDD. All participants had been free of MDD and antidepressant treatment for > or = 1 year.

RESULTS

Compared with their never-depressed counterparts, women with a history of MDD had significantly higher HbA(1c) (7.0 vs. 6.5%), more diabetes symptoms, and worse emotional functioning, after controlling for confounding variables. Differences in HbA(1c) and diabetes symptoms were not accounted for by the higher current subclinical depressive symptoms observed in the previously depressed group. Differences in emotional functioning were accounted for by current subclinical depressive symptoms.

CONCLUSIONS

Most health-care providers overlook fully remitted depression. However, previously depressed patients, who outnumber currently depressed patients, may still have poorer glycaemic control than never-depressed patients.

Effect of etanercept on fatigue in patients with recent or established rheumatoid arthritis

OBJECTIVE

To assess the long-term impact of etanercept on fatigue in patients with recent-onset (mean duration 11 months) or established (mean duration 12 years) rheumatoid arthritis (RA).

METHODS

Patients participating in either of 2 multicenter, randomized, double-blind clinical trials were included. In one trial, patients with recent-onset RA received either etanercept 25 mg twice weekly or methotrexate in a double-blind fashion for 12 months, then open label for 12 months. All patients then received open-label etanercept. In the second trial, patients with established RA received etanercept 25 mg or placebo twice weekly for 6 months in a double-blinded fashion, then open-label etanercept. Up to 46 months of followup data were included. Fatigue was measured regularly using the Health Assessment Questionnaire vitality domain.

RESULTS

Patients with recent-onset RA who received etanercept had a significantly faster improvement in fatigue than those receiving methotrexate in the first 2 months. Subsequently, patients receiving etanercept and methotrexate had 23-29% and 17-24% reductions in fatigue scores, respectively. In the group with established RA, patients who received etanercept had significantly greater reductions in fatigue than those receiving placebo during the blinded period. Patients initially receiving etanercept sustained a mean fatigue reduction of 25-36% for the entire followup. Patients achieving clinically meaningful improvement in fatigue were more likely to meet the American College of Rheumatology improvement criteria.

CONCLUSION

Etanercept therapy reduces fatigue in patients with recent-onset or established RA. Improvement in fatigue was sustained for up to 46 months, and correlated with other RA-relevant outcomes.

Fatigue in rheumatoid arthritis reflects pain, not disease activity

OBJECTIVE

We determined the amount of fatigue experienced by patients with RA, and its relationship to synovitis, pain and other common clinical features. We also examined to what extent RA fatigue is improved by disease-modifying antirheumatic drugs (DMARDs) and anti-tumour necrosis factor (TNF) therapy.

METHODS

We studied two cohorts of 238 and 274 RA patients cross-sectionally and examined treatment responses in 30 RA patients starting anti-TNF and 54 starting DMARDs followed for 3 and 6 months. We measured fatigue using visual analogue scores (VAS) and Medical Outcomes Study Short Form 36 (SF-36) vitality scores. We recorded the disease activity score for 28 joints and its components (tender/swollen joint counts, patient global assessment, ESR), morning stiffness, health assessment questionnaire, physician global assessment, erosive disease, nodules, rheumatoid factor, concomitant medications and illnesses, and the SF-36 questionnaire.

RESULTS

Fatigue was common in RA patients; over 80% had clinically relevant fatigue (VAS > or =20 mm), over 50% had high levels (VAS > or =50 mm). It was associated with pain and changes in mental health, particularly depression. In each of the two cross-sectional cohorts, this relationship was similar whichever measures of fatigue and mental health were used. Fatigue fell with DMARDs and anti-TNF: before treatment, 87% of patients had high fatigue, after treatment this fell to 50%. These treatment effects were mainly linked to improvements in pain.

CONCLUSIONS

High fatigue levels characterize RA and are mainly linked to pain and depression. The association with disease activity is secondary. Fatigue falls with DMARD and anti-TNF therapy. The balance of evidence suggests that fatigue is centrally mediated in established RA.

Mental health status and leisure-time physical activity contribute to fatigue intensity in patients with spondylarthropathy

OBJECTIVE

To examine the relationship between disease-related variables, leisure-time physical activity (LTPA), and mental health status with fatigue severity in patients with spondylarthropathy (SpA).

METHODS

Sixty-six SpA patients completed questionnaires assessing disease activity (Bath Ankylosing Spondylitis Disease Activity Index [BASDAI]), functional ability (Bath Ankylosing Spondylitis Functional Index), and health-related quality of life (Short Form 36). LTPA patterns, demographics, and disease-related data were obtained by interview. A clinical examination determined tender point count. Fatigue was assessed with the BASDAI fatigue item.

RESULTS

The mean BASDAI fatigue score was 5.5 (SD=2.7) with 59% of the sample obtaining a score > or =5. Disease activity, functional disability, and worse mental health contributed to greater fatigue (R2=0.56). The relationship between exercise duration and fatigue intensity was moderated by mental health status. For patients with poorer mental health scores, exercise did not influence fatigue severity. However, for patients reporting better mental health status, engaging in more LTPA decreased fatigue severity.

CONCLUSION

In addition to increased disease activity and functional disability, greater fatigue severity in SpA is associated with poorer mental health status. Integrating regular leisure physical activity into the comprehensive treatment of SpA may be useful for modulating fatigue.

History of affective disorder and the experience of fatigue in rheumatoid arthritis

OBJECTIVE

To evaluate how a prior affective disorder (major depression or generalized anxiety disorder) affects current fatigue among individuals with rheumatoid arthritis (RA). To determine whether that relationship is mediated by self-efficacy expectations.

METHODS

Forty-eight RA patients with a prior affective disorder and 74 without a history of affective disorder completed a mailed questionnaire that included the Multidimensional Assessment of Fatigue and indicators of neuroticism and self efficacy.

RESULTS

RA patients with a history of affective disorder reported higher levels of fatigue than those with no previous affective disturbance. Controlling for neuroticism and self efficacy, affective disorder history continued to predict current fatigue. Mediational analyses revealed both direct and indirect effects (via self efficacy) of history of affective disorder on the experience of fatigue in RA.

CONCLUSION

History of affective disorder independently predicts higher levels of fatigue in RA patients, and self efficacy plays a mediating role in this relationship.

Epidemiology and burden of illness of rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic, generally progressive autoimmune disease that causes functional disability, significant pain and joint destruction, and leads to premature mortality. It is estimated to affect between 0.5 and 1.0% of the adult population worldwide, increases in prevalence with age and affects more women than men. The magnitude of the severe long-term economic consequences of RA has been underestimated in the past. Most patients with the disease require continuous treatment to retard or stop progression and to control disease flares. Many also require surgery, such as total hip or knee replacement. In addition to these direct costs, work disability leads to reduced productivity and early retirement, and as a result, substantial indirect costs. The individual and his or her family must cope with the feeling of loss of contribution to society combined with redefined social roles, and the effects of pain, fatigue, low self-esteem, mental distress and depression. A number of countries in North America and Europe have reported a decline in the incidence of RA in recent years, although geographical differences remain that may be associated with genetic, environmental or cultural factors. Nevertheless, patients with RA have not shared the improvements in survival rates seen with other diseases over the last 40 years, and have a mean reduction in life expectancy of between 5 and 10 years. Disease severity, activity and disability are strongly linked to premature mortality in patients with RA. The high direct and indirect costs associated with RA, together with the substantial morbidity and mortality affecting millions of people worldwide, underline the potential benefits of improved treatments for this chronic disease to patients, their families and society.

Patient-reported outcomes and their role in the assessment of rheumatoid arthritis

Patients with rheumatoid arthritis (RA) face considerable physical, social and emotional disabilities. In this chronic disease, for which a cure is not yet available, improving patients' health-related quality of life (HRQoL) is of the utmost concern, particularly as the use of long-term and potentially toxic therapy increases. Early HRQoL outcome measures in RA focused on physical functioning, but the social and emotional aspects of the disease are now increasingly important. Thus, several generic and RA-specific HRQoL instruments have been developed, but no one tool covers all areas of HRQoL that affect the patient with RA. For this reason, a combination of generic and disease-specific tools is currently recommended for RA clinical trials.

Central nervous system mechanisms of pain in fibromyalgia and other musculoskeletal disorders: behavioral and psychologic treatment approaches

Pain is one of the most important and challenging consequences of musculoskeletal disorders. This article examines the role of central nervous system structures in the physiology of pain. It also describes the neuromatrix, a construct that provides a framework for understanding the interaction between physiologic mechanisms and psychosocial factors in the development and maintenance of chronic pain. This construct suggests that behavioral and psychologic interventions may alter the pain experience primarily through their effects on emotional states and cognitive processes. The literature on cognitive-behavioral interventions for patients with rheumatoid arthritis and osteoarthritis indicates that they are well-established treatments for these disorders. However, the efficacy of these interventions for patients with fibromyalgia has not been established. It is anticipated that the development of valid measures of readiness for behavioral change may allow investigators to identify the patients with musculoskeletal disorders who are most likely to benefit from cognitive-behavioral intervention.