A comparison of self-reports of distress and affective disorder diagnoses in rheumatoid arthritis: a receiver operator characteristic analysis

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.

Associations of Rheumatoid Arthritis and Depressive Symptoms Over Time: Are There Differences by Education, Race/Ethnicity, and Gender?

OBJECTIVE

To examine associations between changes in rheumatoid arthritis (RA) symptoms and depressive symptoms adjusted for other time-varying characteristics, and to test if these associations differed by education, race/ethnicity, or gender.

METHODS

Data from the 1988-1998 US National Rheumatoid Arthritis Study were analyzed (n = 854). Time-varying covariates included year of the study, pain, functional ability, household work disability, parental status, marital status, employment status, and social support. The time-invariant covariates included years since diagnosis, education, race/ethnicity, and gender. Multivariate multilevel-model analyses were used to estimate associations within people over time.

RESULTS

Patients with RA experience considerable change in depressive symptoms, pain, functional disability, and household work disability over the study period. Depressive symptoms were driven more by differences between people compared to changes within people over time. Findings show that patients experienced increases in depressive symptoms over the study period. The rate of change in depressive symptoms did not differ by education, race/ethnicity, or gender. Times of worse pain, functional disability, and household disability were associated with worse depressive symptoms. The association of functional disability and depressive symptoms was stronger for men than women.

CONCLUSION

Increases in pain and disability were associated with worse depressive symptoms, adjusted for covariates. It is important to monitor and treat both mental and physical health symptoms. Future research efforts should focus on collecting data reflecting the educational, gender, and racial/ethnic diversity of individuals with RA.

Subjective wellbeing and longevity: Findings from a 22-year cohort study

OBJECTIVE

The health implications of positive affect (PA) are still a matter of debate. The present study examined the longitudinal relationships between subjective wellbeing (SWB) components (i.e., Life satisfaction, PA and negative affect (NA)) and all-cause mortality in older adults.

METHODS

Discrete-time survival analysis within the structural equation modeling framework was applied to data from the PAQUID Cohort (n=3777, baseline age 62-101years) including ten time periods spanning 22years. Time-invariant (age, gender, baseline life satisfaction, diabetes mellitus and hypercholesterolemia status) and lagged time-varying (PA, NA, dementia, functional status and self-rated health) predictors were included sequentially in the analyses.

RESULTS

When included together in the model, only PA among the SWB components showed a significant association with longevity, which persisted (OR=.962, 95% CI=.938, .986) even after adjustment for the interaction between PA and NA, and after additional adjustment for prior medical conditions, functional status and self-rated health.

CONCLUSIONS

In congruence with positive psychology, PA proved to be an independent protective factor regardless of variations in NA, which did not seem to be a mortality risk factor.

Caregiving appraisal and disease activity in early inflammatory arthritis

OBJECTIVE

The caregiving process accompanying inflammatory arthritis can be stressful to both caregivers and care recipients. In this study, we examined how caregiving involvement and caregiving appraisal as perceived by both patients and their caregiving spouses relate to disease activity and mental health of patients in early inflammatory arthritis.

METHODS

Patients in the early phase (> 6 weeks, <18 months duration) of inflammatory arthritis were recruited from a larger early inflammatory arthritis registry, which recorded sociodemographic data and disease characteristics. Disease activity was measured with the Disease Activity Score in 28 joints (DAS28). Current depressive symptoms were measured using the Center for Epidemiologic Studies - Depression Mood Scale. Patient and spouse perceived caregiving involvement and caregiving appraisal were assessed using the Caregiving Involvement Questionnaire and Caregiving Appraisal Scale, respectively.

RESULTS

The study sample consisted of 73 patients living with spouse. Mean age was 54 years, 64.4% were women and mean illness duration was 7.48 months. Patients' positive caregiving appraisal was associated with less disease activity (DAS28) (p = 0.003) and less total depressive mood (p < 0.001). In multivariate analysis, patients' appraisal of the caregiving context was negatively associated with disease activity (DAS28) after controlling for caregiving involvement and depression (p = 0.035).

CONCLUSION

This study indicates that, in early inflammatory arthritis, patients' caregiving appraisal might be important to consider when assessing disease activity. Clinicians are encouraged to include both patients and their spouse caregivers in interventions.

Differences in depression, anxiety, and quality of life between women with and without breast pain prior to breast cancer surgery

PURPOSE OF THE RESEARCH

Little is known about the relationships between pain, anxiety, and depression in women prior to breast cancer surgery. The purpose of this study was to evaluate for differences in anxiety, depression, and quality of life (QOL) in women who did and did not report the occurrence of breast pain prior to breast cancer surgery. We hypothesized that women with pain would report higher levels of anxiety and depression as well as poorer QOL than women without pain.

METHODS AND SAMPLE

A total of 390 women completed self-report measures of pain, anxiety depression, and QOL prior to surgery.

KEY RESULTS

Women with preoperative breast pain (28%) were significantly younger, had a lower functional status score, were more likely to be Non-white and to have gone through menopause. Over 37% of the sample reported clinically meaningful levels of depressive symptoms. Almost 70% of the sample reported clinically meaningful levels of anxiety. Patients with preoperative breast pain reported significantly higher depression scores and significantly lower physical well-being scores. No between group differences were found for patients' ratings of state and trait anxiety or total QOL scores.

CONCLUSIONS

Our a priori hypotheses were only partially supported. Findings from this study suggest that, regardless of pain status, anxiety and depression are common problems in women prior to breast cancer surgery.

Case identification of depression in patients with chronic physical health problems: a diagnostic accuracy meta-analysis of 113 studies

BACKGROUND

Depression is more likely in patients with chronic physical illness, and is associated with increased rates of disability and mortality. Effective treatment of depression may reduce morbidity and mortality. The use of two stem questions for case finding in diabetes and coronary heart disease is advocated in the Quality and Outcomes Framework, and has become normalised into primary care.

AIM

To define the most effective tool for use in consultations to detect depression in people with chronic physical illness.

DESIGN

Meta-analysis.

METHOD

The following data sources were searched: CENTRAL, CINAHL, Embase, HMIC, MEDLINE, PsycINFO, Web of Knowledge, from inception to July 2009. Three authors selected studies that examined identification tools and used an interview-based ICD (International Classification of Diseases) or DSM (Diagnostic and statistical Manual of Mental Disorders) diagnosis of depression as reference standard. At least two authors independently extracted study characteristics and outcome data and assessed methodological quality.

RESULTS

A total of 113 studies met the eligibility criteria, providing data on 20,826 participants. It was found that two stem questions, PHQ-9 (Patient Health Questionnaire), the Zung, and GHQ-28 (General Health Questionnaire) were the optimal measures for case identification, but no method was sufficiently accurate to recommend as a definitive case-finding tool. Limitations were the moderate-to-high heterogeneity for most scales and the facts that few studies used ICD diagnoses as the reference standard, and that a variety of methods were used to determine DSM diagnoses.

CONCLUSION

Assessing both validity and ease of use, the two stem questions are the preferred method. However, clinicians should not rely on the two-questions approach alone, but should be confident to engage in a more detailed clinical assessment of patients who score positively.

History of depressive episodes as a risk factor for illness severity in early inflammatory arthritis

OBJECTIVE

Psychosocial research in arthritis consistently demonstrates a relationship between depression and disease characteristics such as severity of illness and physical disability. In this study, we examine how a history of clinical depression identified through diagnostic interviews influences disease outcome measures in patients with early inflammatory arthritis (EIA) in the absence of current depression.

METHODS

Patients in the early phase (more than 6-weeks, less than 1-year duration) of inflammatory arthritis were recruited from a larger EIA registry, which recorded sociodemographic data, current depressive symptoms and measures of disease severity. Current and history of major depression was assessed by a structured clinical interview. Eighty-one patients without current major depression were divided into two groups: 28 with and 53 without a history of depression.

RESULTS

There were no significant differences between the two groups in age, sex, education, income, or level of current depressive symptoms. Compared with patients with no history of major depression, those with a history of depressive episodes had higher self-ratings of disease activity and were assessed as having more severe disease and poorer physical functioning by their physicians.

CONCLUSION

This study indicates that a history of major depression represents a risk factor for disease severity in EIA. This may reflect an enduring physiological effect of depression that influences subsequent inflammatory arthritis or an underlying shared process between these two disease entities.

Reliability Generalization

The assessment of positive affect (PA) and negative affect (NA) by means of the Positive Affect and Negative Affect Schedule has received a remarkable popularity in the social sciences. Using a meta-analytic tool—namely, reliability generalization (RG)—population reliability scores of both scales have been investigated on the basis of a random effects model in 147 studies. Correcting for measurement errors, the results demonstrate moderate to high internal consistency coefficients and variations of the PA and NA reliability scores with regard to time frame instructions, language of items, and sample characteristics. The percentage of PA and NA true score variance differs in subpopulations up to 11%. RG analysis of test–retest coefficients illustrates state-like fluctuations and trait-like stability of both scales. Calculations of the fail-safe number point at the robustness of the results. Applications of RG coefficients compared to single-study coefficients highlight the relevance of population coefficients for research and assessment situations.

Depressive symptoms in rheumatoid arthritis

OBJECTIVE

To determine the prevalence of depressive and anxiety symptoms in patients with rheumatoid arthritis (a chronic inflammatory disease) in comparison to a control group with osteoarthritis (a chronic non-inflammatory degenerative disease) and to identify the sociodemographic and clinical variables associated with depressive symptoms in these patients.

METHOD

Sixty-two rheumatoid arthritis patients and 60 osteoarthritis patients participated in the study. Sociodemographic and clinical data were collected and the Hospital Anxiety and Depression Scale and the Disability Index of the Health Assessment Questionnaire were applied.

RESULTS

The prevalence of depressive symptoms was of 53.2% in rheumatoid arthritis and 28.3% in osteoarthritis (p = 0.005). The prevalence of anxiety symptoms was of 48.4% in rheumatoid arthritis and 50.0% in osteoarthritis (p = 0.859). The mean (and standard deviation) scores in the Disability Index of the Health Assessment Questionnaire were 1.4 (0.8) in rheumatoid arthritis and 1.4 (0.6) in osteoarthritis (p = 0.864). Rheumatoid arthritis patients with depressive symptoms had lower education and higher disease activity and functional disability.

CONCLUSION

Although these two rheumatic diseases are similar in terms of the pain and functional disability that they cause, a significantly higher prevalence of depressive symptoms was found in rheumatoid arthritis patients. This difference might be explained by the hypothesis of a neuroimmunobiological mechanism related to cytokines in inflammatory diseases, which has been considered as a candidate to the development of depressive symptoms.

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.

Sociodemographic risk indicators for depressive symptoms among persons with oral cancer or oral epithelial dysplasia

PURPOSE

We report findings from a study that measured associations between sociodemographic risk indicators and depressive symptoms among individuals diagnosed with either oral cancer or a premalignant lesion.

MATERIALS AND METHODS

Incident cases of oral cancer and oral epithelial dysplasia (OED) were identified by reviewing pathology reports generated by 3 oral pathology laboratories serving primarily community-based oral and maxillofacial surgeons. Subjects were interviewed by telephone to collect information on sociodemographic characteristics, depressive symptoms using the Center for Epidemiologic Studies-Depression (CES-D) Scale, and social support using the Berkman Social Network Inventory.

RESULTS

The analysis included 167 oral cancer and 234 OED cases. Nineteen percent of the subjects had a CES-D score indicative of clinical depression (CES-D > or =16). Forward and backward stepwise logistic regression identified diagnosis (cancer/OED), age, social support, employment status, and gender as sociodemographic indicators of CES-D scores of 16+. In the final model, which also controlled for smoking and drinking, the odds of having elevated CES-D scores (16+) were 79% higher among oral cancer relative to OED cases. The odds of high CES-D scores were significantly reduced in persons over the age of 50 compared with those aged 50 years and younger as well as in persons with higher, relative to low, levels of social support and in persons employed outside the home compared with those who were not. Although not statistically significant, men were more likely to have CES-D scores indicative of clinical depression.

CONCLUSIONS

Knowledge of sociodemographic characteristics may assist the clinician in identifying those individuals with an elevated risk of concomitant depressive symptoms.