Gender, paid work, and symptoms of emotional distress in rheumatoid arthritis patients

Decreased IL-4 is the risk factor of depression in patients with Takayasu arteritis

Objective

Depression is a common complication in Takayasu arteritis (TA). Disorders of the immune system play an important role in both diseases. This study aimed to clarify the feature of cytokines in TA patients with depression.

Methods

In this cross-sectional study, serum cytokines were tested in 40 TA patients and 11 healthy controls using the Bio-Plex Magpix System (Bio-Rad®). The state of depression was measured by the Zung Self-Rating Depression Scale (SDS) in TA patients. Logistic regression analysis was performed to find the risk factors of depression in patients with TA.

Results

TA patients with depression had higher ESR, hsCRP, NIH, and ITAS.A than patients without depression (16.00 [10.00, 58.50]mm/H vs. 7.50 [4.50, 17.75]mm/H, p = 0.013; 7.60 [2.32, 46.52]mg/L vs. 0.71 [0.32, 4.37]mg/L, p = 0.001; 2.00 [2.00, 3.00] vs. 1.00 [0.00, 2.00], p = 0.007; 7.00 [4.00, 9.50] vs. 1.50 [0.00, 5.75], p = 0.012, respectively). Additionally, the lower age of onset and levels of IL-4, IL-13, eotaxin, and IP-10 were observed in the depressed group compared with the non-depressed (23.50 [19.25, 32.50]pg./ml vs. 37.00 [23.25, 42.50]pg./ml, p = 0.017; 2.80 [2.17, 3.18]pg./ml vs. 3.51 [3.22, 4.66]pg./ml, p < 0.001; 0.66 [0.60, 1.12]pg./ml vs. 1.04 [0.82, 1.25]pg./ml, p = 0.008; 46.48 [37.06, 61.75]pg./ml vs. 69.14 [59.30, 92.80]pg./ml, p = 0.001; 184.50 [138.23, 257.25]pg./ml vs. 322.32 [241.98, 412.60]pg./ml, p = 0.005, respectively). The lower level of IL-4 and age of onset were the independent risk factors for depression in TA patients (OR [95% CI] 0.124 [0.018, 0.827], p = 0.031; 0.870 [0.765, 0.990], p = 0.035, respectively).

Conclusion

Our data suggested that lower cytokine levels, especially IL-4, might be involved in the development of TA patients with depression. Clinicians can probably use serum IL-4 level testing as a potential indicator of depression in TA.

Tailoring Rheumatoid Arthritis Treatment through a Sex and Gender Lens

Rheumatoid arthritis (RA) occurs more frequently in women than in men, and the studies that have addressed clinical and prognostic differences between the sexes are scarce and have contradictory results and methodological problems. The present work aims to evaluate sex- and gender-related differences in the clinical expression and prognosis of RA as well as on the impact on psychosocial variables, coping behavior, and healthcare use and access. By identifying between sex differences and gender-related outcomes in RA, it may be possible to design tailored therapeutic strategies that consider the differences and unmet needs. Being that sex, together with age, is the most relevant biomarker and health determinant, a so-called personalized medicine approach to RA must include clear guidance on what to do in case of differences.

Employment of patients with rheumatoid arthritis - a systematic review and meta-analysis

BACKGROUND

Patients with rheumatoid arthritis (RA) have difficulties maintaining employment due to the impact of the disease on their work ability. This review aims to investigate the employment rates at different stages of disease and to identify predictors of employment among individuals with RA.

METHODS

The study was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines focusing on studies reporting employment rate in adults with diagnosed RA. The literature review included cross-sectional and cohort studies published in the English language between January 1966 and January 2023 in the PubMed, Embase and Cochrane Library databases. Data encompassing employment rates, study demographics (age, gender, educational level), disease-related parameters (disease activity, disease duration, treatment), occupational factors, and comorbidities were extracted. Quality assessment was performed employing Newcastle-Ottawa Scale. Meta-analysis was conducted to ascertain predictors for employment with odds ratios and confidence intervals, and test for heterogeneity, using chi-square and I2-statistics were calculated. This review was registered with PROSPERO (CRD42020189057).

RESULTS

Ninety-one studies, comprising of a total of 101,831 participants, were included in the analyses. The mean age of participants was 51 years and 75.9% were women. Disease duration varied between less than one year to more than 18 years on average. Employment rates were 78.8% (weighted mean, range 45.4-100) at disease onset; 47.0% (range 18.5-100) at study entry, and 40.0% (range 4-88.2) at follow-up. Employment rates showed limited variations across continents and over time. Predictors for sustained employment included younger age, male gender, higher education, low disease activity, shorter disease duration, absence of medical treatment, and the absence of comorbidities. Notably, only some of the studies in this review met the requirements for high quality studies. Both older and newer studies had methodological deficiencies in the study design, analysis, and results reporting.

CONCLUSIONS

The findings in this review highlight the prevalence of low employment rates among patients with RA, which increases with prolonged disease duration and higher disease activity. A comprehensive approach combining clinical and social interventions is imperative, particularly in early stages of the disease, to facilitate sustained employment among this patient cohort.

Elucidating a bidirectional association between rheumatoid arthritis and depression: A systematic review and meta-analysis

BACKGROUND

Rheumatoid arthritis (RA) and depression are conditions which commonly co-exist. Recent longitudinal studies now suggest a bidirectional association between these disorders, with inconsistent results. We conducted a systematic review and meta-analysis to examine this relationship.

METHODS

Three electronic databases (PubMed, Embase and PsycINFO) were searched from inception to September 4, 2021 for cohort studies evaluating either the risk of depression in RA patients or the risk of RA in patients with depression, as well as the secondary outcome of all-cause mortality risk in RA patients with depression. A random effects model was used to summarize the included studies.

RESULTS

Eleven cohort studies were included, comprising a total of 39,130 RA patients, 550,782 patients with depression and 7,802,230 controls. RA patients had a 47% greater risk of incident depression compared to controls, while patients with depression had a 34% greater risk of developing RA. Subgroup analysis by age was only significant in the ≥60 years old age group. RA patients with depression had an 80% increased risk of all-cause mortality compared to those without depression.

LIMITATIONS

The results may have been confounded by factors such as differing methods of depression ascertainment across studies and overlap in presentation between the two conditions.

CONCLUSION

There exists a bidirectional association between RA and depression especially in the elderly which increases mortality risk. This invites the need for clinicians to screen and be vigilant for the presence of these conditions.

Depression is associated with increased disease activity and higher disability in a large Italian cohort of patients with rheumatoid arthritis

INTRODUCTION

Depression is a quite common comorbidity in patients with rheumatoid arthritis (RA) and is thought to influence its severity. This study aims to estimate, in a large cohort of Italian patients with RA, the prevalence of depression and to investigate the clinical correlates of depression in terms of disease activity and disability.

METHODS

This is a cross-sectional study enrolling 490 outpatients with RA (80% female, mean age 59.5). The Hospital Anxiety and Depression Scale (HADS) was used to assess the presence of depression with a cut-off of 11. We collected data about disease activity and disability with DAS28, TJC-68, PhGA, PGA, VAS, DAS28, SDAI, CDAI and HAQ.

RESULTS

Prevalence of depression was 14.3% (95% CI: 11-17%). Depressed patients, when compared with not depressed ones, were found to have higher scores for TJC-68 (p = 0.011), PhGA (p = 0.001), PGA (p = 0.001), VAS (p = 0.001), DAS28 (p = 0.007), SDAI (p = 0.001), CDAI (p = 0.001) and HAQ (p = 0.001). Out of the 70 depressed patients, 30 subjects, already known to be depressed in the past, were still depressed at the time of the assessment, with only 11 (15.7%) under antidepressants. A multivariate analysis showed that male sex, higher PGA score, use of antidepressants and higher HAQ score were significantly associated with an increased risk of depression.

CONCLUSIONS

Our study shows that depression is common in RA and may affect its activity mainly via an alteration in the perception of the disease. Although its important implications, depression is still under-diagnosed and its management is inadequate.

'Everyone assumes a man to be quite strong': Men, masculinity and rheumatoid arthritis: A case-study approach

Current literature has overlooked the impact of chronic illness on masculine identity. We therefore aimed to investigate the impact of rheumatoid arthritis (a long term condition, affecting more women than men) on masculine identity. Six focus groups with 22 men with rheumatoid arthritis (RA) (data reported elsewhere) followed by five one-to-one interviews with men (English, mean age: 59 years) sampled to reflect a heterogeneous experience of life with RA based on knowledge gained from the focus groups. Transcripts were analysed using thematic analysis and are presented as individual case studies. Whilst the case studies provide five distinct experiences, common themes can be drawn across them, such as the importance of paid work. The men needed to renegotiate their masculine identity to deal with their RA. Two dealt with this by pushing through pain to retain masculine activities, two replaced masculine roles they could no longer do with other roles, and one rejected masculinity completely. Men with long term conditions may need to re-write their masculinity scripts to enable them to accept and adapt to their condition. However, some men struggle with this, which should be taken into consideration when designing self-management services for men with long term conditions.

Men, rheumatoid arthritis, psychosocial impact and self-management: A narrative review

Rheumatoid arthritis is a chronic disease affecting fewer men than women. We systematically reviewed the literature on impact and self-management of rheumatoid arthritis in men. A total of 28 papers were included and grouped into two categories: psychosocial impact of rheumatoid arthritis, and coping and self-management. This review finds gender differences relating to quality of life, work, distress, self-management, coping and support. We conclude that there is a dearth of literature focussing on rheumatoid arthritis in men only, and mixed gender studies include insufficient men to draw strong conclusions about men. Thus, further research is needed to understand the support needs of men with rheumatoid arthritis in depth.

Depression in Autoimmune Diseases

Up to 50% of patients with autoimmune diseases show an impairment of health-related quality of life and exhibit depression-like symptoms. The immune system not only leads to inflammation in affected organs, but also mediates behavior abnormalities including fatigue and depression-like symptoms. This review focuses on the different pathways involved in the communication of the immune system with the neuronal network and the body's timing system. The latter is built up by a hierarchically organized expression of clock genes. As discussed here, the activation of the immune system interferes with high amplitude expression of clock genes, an effect which may play a pivotal role in depression-like behavior in autoimmune diseases.

Depression in patients with rheumatoid arthritis: description, causes and mechanisms

Two sets of contributory factors to depression among patients with rheumatoid arthritis (RA) are generally examined - the social context of the individual and the biologic disease state of that person's RA. This article will review the evidence for both. RA affects patients both physically and psychologically. Comorbid depression is common with RA and leads to worse health outcomes. Low socioeconomic status, gender, age, race/ethnicity, functional limitation, pain and poor clinical status have all been linked to depression among persons with RA. Systemic inflammation may also be associated with, cause, or contribute to depression in RA. Understanding the socioeconomic factors, individual patient characteristics and biologic causes of depression in RA can lead to a more comprehensive paradigm for targeting interventions to eliminate depression in RA.

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.

Societal cost of rheumatoid arthritis patients in the US

OBJECTIVE

To estimate comprehensive cost of rheumatoid arthritis (RA) patients to society and individual stakeholders, including patients/employees, employers, family members/caregivers, and government.

RESEARCH DESIGN AND METHODS

Administrative claims databases covering privately insured and Medicare and Medicaid beneficiaries in the US were used to compute the excess payer and beneficiary-paid costs per patient with RA compared with matched controls. Similarly, per-person excess costs for caregivers and uninsured patients with RA were estimated. Costs were estimated for other burdens, including costs of work-loss to employers, adaptations to home and work environments, lost on-the-job productivity, informal and hired care/household help, and job turnover costs. Intangible costs associated with quality-of-life deterioration were estimated based on legal system jury awards, whereas costs for premature mortality were based on lifetime earnings data. Per-capita cost estimates were weighted by the relevant population to estimate societal costs. Because data were incomplete, several assumptions were required; these assumptions could lead to an over- or under-estimation of cost burdens.

RESULTS

Annual excess health care costs of RA patients were $8.4 billion, and costs of other RA consequences were $10.9 billion. These costs translate to a total annual cost of $19.3 billion. From a stakeholder perspective, 33% of the total cost was allocated to employers, 28% to patients, 20% to the government, and 19% to caregivers. Adding intangible costs of quality-of-life deterioration ($10.3 billion) and premature mortality ($9.6 billion), total annual societal costs of RA (direct, indirect, and intangible) increased to $39.2 billion.

CONCLUSIONS

Societal costs of RA in the US are $19.3 billion and $39.2 billion (in 2005 dollars) without and with intangible costs, respectively. This study was one of the first to attempt to quantify the comprehensive burdens of RA. Despite several assumptions made in areas in which few data exist, the findings generate useful insights into the full burden of RA.

Reactions to disability in patients with early versus established rheumatoid arthritis

OBJECTIVES

This study examined differences in reactions to disability between early and established rheumatoid arthritis (RA) patients, and whether these reactions were related to age, physical functioning, acceptance of illness, or self-efficacy.

METHODS

Thirty-four patients with early RA (< 2 years since diagnosis) and 84 patients with established RA (> 4 years since diagnosis) completed the Reactions to Impairment and Disability Inventory (RIDI), and measures of anxiety, depression, acceptance of illness, self-efficacy, and physical functioning.

RESULTS

Early RA patients reported greater future denial than established RA patients. Younger patients reported more hostility than older patients. Accepting the illness was uniquely related to less anger and hostility. Higher self-efficacy for pain specifically related to greater shock, while patients with poorer self-efficacy for other symptoms reported worse anxiety, depression, shock, and anger.

CONCLUSIONS

Denial may be a coping strategy in the early stages of RA: anxiety, depression, shock, and anger appear to persist. Longitudinal studies of RA patients from diagnosis are required to plan interventions timed to maximize patient benefit and optimize healthcare resource utilization.

A two‐year follow‐up of work capacity in early rheumatoid arthritis: a study of multidisciplinary team care with emphasis on vocational support

OBJECTIVE

To explore changes in sick leave patterns and work ability in patients with early rheumatoid arthritis (RA). The patients received active team support focusing on vocational rehabilitation, in addition to treatment with disease-modifying anti-rheumatic drugs (DMARDs).

METHODS

This is an observational study of 110 patients with early RA aged 18-60 years and not permanently disabled. All patients were monitored regularly during a 2-year period by a team comprising a nurse, an occupational therapist, a physiotherapist, a rheumatologist, and a social worker. Intervention included work-site visits and rehabilitation meetings with the employer and the official from the local social insurance office in addition to DMARD treatment and different individual treatments, and support from the team members.

RESULTS

The number of patients working full-time increased from 65 to 74 (14%), those with full-time work disability decreased from 37 to 13 (65%), and patients working part-time increased from 8 to 23 (65%). This change was already evident during the first year.

CONCLUSION

Active vocational support in addition to DMARD treatment may prevent or delay work disability in patients with early RA.

Comparison of work disability and health-related quality of life between males and females with rheumatoid arthritis below the age of 45 years

OBJECTIVES

To compare work disability (WD) and health status between males and females with rheumatoid arthritis (RA) in the age group 18-45 years, and to compare health status between patients with and without WD within each gender, and finally to identify factors independently associated with WD in this age group.

METHODS

A cross-sectional study of RA patients at the time starting with disease-modifying antirheumatic drug (DMARD) therapy and/or biological treatment. Patients receiving a permanent, national WD pension corresponding to >or= 50% were defined as work disabled. We examined gender differences with regard to disease characteristics, health status and WD. The Mann-Whitney U-test and Pearson's chi(2)-test were applied for group comparisons. Multiple logistic regression analyses with adjustments for duration of education, disease duration, age, erosive disease, disability score [using the Modified Health Assessment Questionnaire (MHAQ)], Disease Activity Score-28 (DAS-28), the Short Form Health Survey (SF-36) mental health score and gender were used to identify variables associated with WD.

RESULTS

Out of 474 (372 females) patients, the number (%) of work-disabled females/males was 91 (24.7)/8 (8.1) (p<0.001). WD was associated with worse health status in both genders. The odds ratio (95% confidence interval) [OR (95% CI)] for WD in females vs. males was 4.84 (1.85-12.65) in the multivariate analyses. Other factors independently associated with WD were worse mental health, disease duration and low level of education.

CONCLUSION

Females with RA had a fourfold increased risk of WD compared to men. Low level of education, disease duration and worse mental health were also independently associated with WD.

Workplace impacts of anti-TNF therapies in rheumatoid arthritis: review of the literature

BACKGROUND

Rheumatoid arthritis (RA) causes pain and serious functional impacts and substantially affects patients' daily lives, including their ability to work.

OBJECTIVE

This review examines recent studies of patients with RA treated with TNF antagonists and the impacts these therapies have on the workplace.

METHODS

A total of 133 articles and 14 poster abstracts were reviewed that matched specific criteria.

RESULTS/CONCLUSION

The results of early studies of TNF antagonists varied regarding their effects on patients with RA in the workplace. However, recent studies of adalimumab showed positive impacts across a range of workplace burdens. Treatments such as adalimumab may help employees with RA to remain in the workforce and lead to reduced workplace costs to the employers and employees.

Variability in depression prevalence in early rheumatoid arthritis: a comparison of the CES-D and HAD-D Scales

Background

Depression is common in rheumatoid arthritis (RA), however reported prevalence varies considerably. Two frequently used instruments to identify depression are the Center for Epidemiological Studies Depression (CES-D) scale, and the Hospital Anxiety and Depression Scale (HADS). The objectives of this study were to test if the CES-D and HADS-D (a) satisfy current modern psychometric standards for unidimensional measurement in an early RA sample; (b) measure the same construct (i.e. depression); and (c) identify similar levels of depression.

Methods

Data from the two scales completed by patients with early RA were fitted to the Rasch measurement model to show that (a) each scale satisfies the criteria of fit to the model, including strict unidimensionality; (b) that the scales can be co-calibrated onto a single underlying continuum of depression and to (c) examine the location of the cut points on the underlying continuum as indication of the prevalence of depression.

Results

Ninety-two patients with early RA (62% female; mean age = 56.3, SD = 13.7) gave 141 sets of paired CES-D and HAD-D data. Fit of the data from the CES-D was found to be poor, and the scale had to be reduced to 13 items to satisfy Rasch measurement criteria whereas the HADS-D met model expectations from the outset. The 20 items combined (CES-D13 and HADS-D) satisfied Rasch model expectations. The CES-D gave a much higher prevalence of depression than the HADS-D.

Conclusion

The CES-D in its present form is unsuitable for use in patients with early RA, and needs to be reduced to a 13-item scale. The HADS-D is valid for early RA and the two scales measure the same underlying construct but their cut points lead to different estimates of the level of depression. Revised cut points on the CES-D13 provide comparative prevalence rates.

Reexamining the arthritis-employment interface: Perceptions of arthritis-work spillover among employed adults

OBJECTIVE

To examine employed individuals' perceptions of arthritis-work spillover (AWS), the reciprocal influence of arthritis on work and work on arthritis, and the demographic, illness, and work context factors associated with AWS.

METHODS

The study group comprised 492 employed individuals with osteoarthritis or inflammatory arthritis. Participants completed an interview-administered, structured questionnaire assessing AWS, demographic (e.g., age, sex), illness (e.g., disease type, pain, activity limitations), and work context (e.g., workplace control, hours of work) variables. Principal components analysis, reliability analysis, and multiple linear regression were used to analyze the data.

RESULTS

A single factor solution emerged for AWS. The scale had an internal reliability of 0.88. Respondents were more likely to report that work interfered with caring for their arthritis than they were to report that their disease affected their work performance. Younger respondents, those with more fatigue and workplace activity limitations, and those working in trades and transportation reported more AWS. Individuals with more control over their work schedules reported less AWS.

CONCLUSION

The results of this study extend research on arthritis by reexamining the interface between arthritis and employment. This study introduces a new measure of AWS that enhances the range of tools available to researchers and clinicians examining the impact of arthritis in individuals' lives.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Longitudinal study of negative workplace events among employed rheumatoid arthritis patients and healthy controls

OBJECTIVE

Most studies of employment in patients with rheumatoid arthritis (RA) have focused on job loss. Less is known about workplace events in patients who continued to work. The goal of this longitudinal study was to compare the incidence of negative workplace events between employed patients with RA and healthy controls.

METHODS

Participants completed the work domains of the Psychiatric Epidemiology Research Interview Life Events Scale and the Inventory of Small Life Events Scale measuring major and minor workplace events. Events were compared between groups according to psychosocial, clinical, and job characteristics.

RESULTS

A total of 122 patients with RA and 122 healthy controls were enrolled with similar demographic and occupational characteristics. There were no differences in percentages of patients and controls who had at least 1 major (35% versus 31%) or 1 minor (48% versus 55%) negative event. For patients with RA, negative events were associated with having more pain, more fatigue, more social stress, and less job autonomy (P < or = 0.05). For controls, in addition to social stress, negative events were associated with job characteristics, functional status, and social support (P < or = 0.05).

CONCLUSION

A comparable number of patients with RA and controls had negative workplace events. In addition to the well-known contributions of job autonomy and pain, social stress and fatigue also were found to be important variables related to negative events in patients with RA. These potentially modifiable variables have not been fully evaluated with respect to long-term employment in these patients.

Predictive factors of work disability in rheumatoid arthritis: a systematic literature review

BACKGROUND

Work disability-a common outcome of rheumatoid arthritis (RA)-is a societal (for example, financial costs) and individual problem (for example, loss of status, income, social support, and distraction from pain and distress). Until now, factors that predict work disability in RA have not been systematically reviewed.

OBJECTIVE

To determine predictive factors of work disability in RA as reported in the literature.

METHODS

A systematic literature search in Cinahl (1988-2004), Embase (1988-2004), and Medline (1989-2004) was followed by the application of two sets of criteria related to: (a) methodological quality, and (b) measurement of the predictive factor. Based on the quality and the consistency of the findings, a rating system was used to assess the level of evidence for each predictive factor.

RESULTS

Nineteen publications (17 cohorts) were identified, of which 13 met the general methodological quality criteria. Results provided strong evidence that physical job demands, low functional capacity, old age, and low education predict work disability in RA. Remarkably, biomedical variables did not consistently predict work disability. Moreover, owing to the lack of high quality studies no evidence was found for personal factors such as coping style, and work environmental factors such as work autonomy, support, work adjustments that are presumed crucial in the work disablement process.

CONCLUSIONS

The results indicate that work disability in RA is a biopsychosocially determined misfit between individual capability and work demands.

Psychosocial contributions to sex-correlated differences in pain

Sex-correlated differences in pain perception and behavior have been reported in several studies. Where such differences are found, they are most often in the direction of girls and women reporting more pain than is reported by boys and men. Although biologic, psychologic, and sociocultural factors act interdependently to influence pain responding, most efforts to explain sex-correlated differences in pain have focused on first-order biologic differences between the sexes. The current paper discusses empirical and theoretical literature addressing gender role socialization, cognitive factors, and affective factors associated with sex-correlated differences in pain. We affirm that there is convincing evidence that such psychosocial factors must be taken into account in research on sex-correlated differences in pain. We contend that the use of the dichotomous variable sex as a proxy for presumed biologic aspects of being female or male may obscure the contribution to sex-correlated differences that could be ascribed to the ways in which women and men are socialized with respect to pain perception and pain reporting.

Testing a theory of chronic pain

BACKGROUND

Chronic pain is highly prevalent among older people with arthritis, with depression as its major outcome. The psychopathological process of chronic pain and its outcomes in older people with arthritis have not been the subject of extensive research. The purpose of this study was to test a middle-range theory of chronic pain derived from the Roy Adaptation Model, a nursing theory whose validity has not been tested in the context of chronic pain.

METHODS

The study used a convenience sample of 71 older people with arthritis. Two subscales of the Arthritis Impact Measurement Scales were used to measure pain and physical disability. Social support was measured by Part II of the Personal Resource Questionnaire, and the Elderly Daily Stress scale was used to measure daily stress. Participants also completed the 10-item Center for Epidemiological Studies of Depression scale. Univariate analysis, correlation, and path analysis were used to analyse the data.

RESULTS

Overall, the data supported the hypothesized model in which pain, disability, social support, age, and gender are predictors of daily stress and daily stress further predicts depression. The direct effects of chronic pain, disability, and social support accounted for 37% of the variance of daily stress, which in turn predicted 35% of the variance of depression. Age and gender had no influence on daily stress. The chi-square index suggested a fit between the data and the model, and therefore the current model is temporarily accepted. Other fit indices also showed a good fit of the model to the data. To simplify the model, a revised version was developed.

CONCLUSIONS

This study validated a middle-range theory to explain the effects of chronic pain in older people with arthritis and highlights the importance of chronic pain in the development of depression.

Stage of life course and social support as a mediator of mood state among persons with disability

OBJECTIVE

This research seeks to determine which aspects of social support are most effective in mediating mood state among working-age and elderly adults with disability (N = 442).

METHODS

Participants were identified through random-digit dialing of telephone exchanges and administration of a disability screen. Multiple regression was used to model multiple aspects of social support while holding sociodemographic and disability indicators constant.

RESULTS

Analyses revealed that network size and confidence in the reliability of helping networks are significantly and negatively related to depressed mood. Confidant support was related to lower levels of depressed mood for younger respondents only. Neither marital status, advisor support, nor social integration were related to mood.

DISCUSSION

Both instrumental and emotional support are key in mediating depressed mood among this population. We conclude that all types of social support are not equally effective in mediating mood among people with disability.

Symptoms of depression and psychological distress among hispanics with rheumatoid arthritis

OBJECTIVE

To explore the roles played by Hispanic ethnic background and acculturation to the mainstream English language culture of the United States in the depressive symptoms and mental health of rheumatoid arthritis (RA) patients.

METHODS

Members of a consecutive cohort of patients with RA were studied cross-sectionally. All underwent a comprehensive clinical and psychosocial evaluation. Depressive symptoms were measured with the Center for Epidemiologic Studies Depression Scale (CES-D), and psychological distress was measured with the Medical Outcomes Study Short Form 36 (SF-36) mental health scale.

RESULTS

Two hundred thirty-six patients were studied. Women had significantly higher median CES-D scores than men (19 versus 14, P = 0.0004), Hispanics scored higher than non-Hispanics (14 versus 8, P = 0.0002), and foreign-born scored higher than US-born patients (14 versus 10, P = 0.009). Compared with those who were fully acculturated, patients who were partially acculturated were more likely to have a score > or = 16 on the RA-adjusted CES-D (odds ratio [OR] = 1.79, 95% confidence interval [95% CI] 1.37 to 2.35, P < or = 0.001). Among unacculturated patients, the likelihood of a score > or = 16 increased 6-fold (OR = 6.68; 95% CI 3.50 to 12.72; P < or = 0.001). A similar, inverse pattern was observed for the SF-36 mental health scale. In multivariate models accounting for age, sex, education, income, articular pain, deformity, and the level of disability, low acculturation was independently associated with high depressive symptoms, and a Hispanic background was independently associated with lower SF-36 mental health.

CONCLUSIONS

In this consecutive series of RA patients, Hispanics, particularly those who are not fully acculturated to the mainstream Anglo society, had more depressive symptoms and psychological distress than did non-Hispanics.

Differences by sex in correlates of work status in rheumatoid arthritis patients

OBJECTIVE

To examine differences by sex in correlates of work status in rheumatoid arthritis (RA) patients seen in rheumatology clinical settings.

METHODS

Associations of demographic factors, occupation, duration of RA, and scores for disease and psychological scales with work status according to sex were examined in a cross-sectional study of 960 RA patients, aged 18-64 years, of whom 451 were working and 254 were work-disabled. Comparisons of characteristics were conducted by logistic regression between working and work-disabled, and between working and not working subjects.

RESULTS

For both men and women, the odds of work disability increased with age, duration of RA, nonwhite race, and scores indicating high levels of functional disability, pain, and helplessness. Work-disabled women were more likely than working women to have less than a high school education or a nonprofessional occupation, compared with little association of these variables with work disability in men. Unmarried men were more likely to be work-disabled than working, while marital status was not associated with work disability in women. Differences by sex in the associations of pain and helplessness scores with work disability were also observed. Similar results were observed in associations of these characteristics when the outcome was coded as working versus not working.

CONCLUSIONS

These findings indicate some differences between men and women with RA in correlates of work disability that may help to more effectively target interventions. A patient's sex should be an important consideration in studies of work disability due to arthritis.

Psychological and behavioral approaches to pain management for patients with rheumatic disease

This article reviews the efficacy of the psychological and behavioral pain management interventions that have been evaluated among adult patients with rheumatoid arthritis (RA), osteoarthritis (OA), and fibromyalgia (FM). Using published criteria for empirically validated interventions, it is concluded that cognitive-behavioral therapies and the Arthritis Self-Management Program represent well-established treatments for pain among patients with RA and OA. These interventions involve education, training in relaxation and other coping skills, and rehearsal of these skills in patients' home and work environments. There currently are no psychological or behavioral interventions for pain among FM patients that can be considered as well-established treatments. Future intervention research should use clinically meaningful change measures in addition to conventional tests of statistical significance, attend to the pain management needs of children, and assess whether outcomes produced in university-based treatment centers generalize to those in local treatment settings.

Gender and psychological well-being of persons with rheumatoid arthritis

OBJECTIVE

This study examined the relationship of gender and psychological well-being (PWB) in community-dwelling persons with rheumatoid arthritis (RA).

METHOD

Data from the first wave of two longitudinal panel studies of persons with RA were examined (93 men and 276 women in panel 1; 60 men and 147 women in panel 2). Subjects completed self-report questionnaires on behavioral aspects of RA. Psychological well-being was assessed in both panels by the Center for Epidemiologic Studies-Depression Scale, using its 4 subcomponents, including positive and negative affect. Panel 2 had additional measures of PWB, namely the Positive and Negative Affect Schedule and the Satisfaction With Life Scale. Potential explanatory variables were then examined in an attempt to account for the observed gender differences.

RESULTS

Gender differences were found for negative indicators of PWB, while positive indicators of PWB showed no significant differences by gender. As with other community samples, women reported higher levels of depressive symptoms and negative mood than men. Quality of emotional support, passive pain coping, and physical functional impairment could only partially explain the observed gender differences in this study.

CONCLUSION

The relationship of gender to negative indicators of PWB cannot easily be diminished or dismissed. The mechanisms by which gender differentially affects PWB need to be further explored in order to intervene appropriately to help men and women with RA achieve an optimal quality of life.