Communication about depression during rheumatoid arthritis patient visits

Patient and healthcare team recommended medication adherence strategies for hydroxychloroquine: results of a qualitative study informing intervention development

OBJECTIVE

Patients identified as black and from disadvantaged backgrounds have a twofold higher hydroxychloroquine (HCQ) non-adherence, which contributes to worse lupus outcomes and disparities. Yet, most adherence interventions lack tailored strategies for racially and socioeconomically diverse patients who face unique challenges with HCQ. We aimed to examine a broadly representative group of patients with SLE and physician perspectives on HCQ adherence and adherence strategies to redesign an adherence intervention.

METHODS

We conducted four virtual focus groups (90 min each) with 11 racially and socioeconomically diverse patients with SLE recruited from two health systems. Additionally, we hosted two focus group meetings with nine healthcare advisors. In focus groups, patients: (1) shared their perspectives on using HCQ; (2) shared concerns leading to non-adherence; (3) discussed strategies to overcome concerns; (4) prioritised strategies from the most to least valuable to inform an adherence intervention. In two separate focus groups, healthcare advisors gave feedback to optimise an adherence intervention. Using content analysis, we analysed transcripts to redesign our adherence intervention.

RESULTS

Worry about side effects was the most common barrier phrase mentioned by patients. Key themes among patients' concerns about HCQ included: information gaps, logistical barriers, misbeliefs and medication burden. Finally, patients suggested adherence strategies and ranked those most valuable including co-pay assistance, personal reminders, etc. Patient and healthcare advisors informed designing a laminate version of an adherence intervention to link each barrier category with four to six patient-recommended adherence strategies.

CONCLUSION

We developed a patient stakeholder-informed and healthcare stakeholder-informed tailored intervention that will target non-adherence at the individual patient level.

Patient Perception of Depressive Symptoms in Rheumatic Diseases: A Cross-sectional Survey

OBJECTIVES

The presented study aimed to explore the presence and the self-identification of depressive symptoms among patients with rheumatic musculoskeletal diseases (RMDs) through the use of the Patient Health Questionnaire (PHQ-9).

METHODS

Between June and October 2019, patients from the regional association for people with RMDs in Lombardy, Italy (ALOMAR), were invited to participate in a cross-sectional online survey. Participants completed PHQ-9 along with a survey about their perception of depressive symptoms. Patients were stratified according to PHQ-9 score as follows: not depressed (<4), subclinical or mild depression (5-9), moderate depression (10-14), moderately severe depression (10-14), and severe depression (20-27). Descriptive statistics and analyses of variance were used to explore data.

RESULTS

Of the 192 RMD patients who completed PHQ-9, 35 (18.2%) were not depressed, 68 (35.4%) had subclinical or mild depression, 42 (21.9%) had moderate depression, 30 (15.6%) had moderately severe depression, and 17 (8.9%) had severe depression. Contrary to the above findings, only 16 respondents (8.3%) reported that they experienced depressive symptoms, and only 7 of the 16 were being followed by a psychiatrist. Respondents with higher PHQ-9 scores tended to have concomitant fibromyalgia, to be younger, and to be overweight.

CONCLUSIONS

The current results indicate the overall burden of depressive symptoms in RMD patients. While clinical depression (PHQ-9 >10) was detected in 41.2% of respondents, only 8.3% reported that they experience depressive symptoms. Routine screening of RMD patients for depression is therefore critical.

Clinical Significance of Monitoring Hydroxychloroquine Levels in Patients With Systemic Lupus Erythematosus: A Systematic Review and Meta-Analysis

OBJECTIVE

Despite the pivotal role that hydroxychloroquine (HCQ) plays in treating systemic lupus erythematosus (SLE), less than 50% of patients take HCQ as prescribed. Measurement of HCQ blood levels can help clinicians distinguish nonadherence versus lack of efficacy of HCQ. Our objective was to systematically review publications and perform a meta-analysis to examine the correlation between HCQ levels and 1) nonadherence and 2) Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) scores, in SLE.

METHODS

A comprehensive search was performed. We included observational and interventional studies that measured HCQ levels and assessed adherence or SLEDAI scores in adults with SLE. Forest plots compared pooled estimates of correlations between HCQ levels and reported nonadherence or SLEDAI scores.

RESULTS

Among 604 studies screened, 17 were reviewed. We found 3-times higher odds of reported nonadherence in patients with low HCQ levels (odds ratio 2.95 [95% confidence interval (95% CI) 1.63, 5.35], P < 0.001). The mean SLEDAI score was 3.14 points higher in groups with below-threshold HCQ levels on a priori analysis (δ = 3.14 [95% CI -0.05, 6.23], P = 0.053), and 1.4 points higher in groups with HCQ levels of <500 ng/ml (δ = 1.42 [95% CI 0.07, 2.76], P = 0.039). Among 1,223 patients, those with HCQ levels ≥750 ng/ml had a 58% lower risk of active disease, and their SLEDAI score was 3.2 points lower.

CONCLUSION

We found a strong association between low HCQ levels and reported nonadherence. Our results suggest that HCQ levels of ≥750 ng/ml might be a potential therapeutic target.

Beyond Rheumatoid Arthritis Evaluation: What are We Missing?

Rheumatoid Arthritis (RA) is a chronic inflammatory autoimmune systemic disease that preferentially affects small and large joints with a progressive course and can become deforming and disabling. In recent years, much progress has been made in the evaluation of inflammation and disease activity, however, there are other factors that have a high impact on the quality of life of these patients, such as depression, anxiety, fatigue, sleep disorders, suicidal behavior, fibromyalgia, sexual activity, sarcopenia, frailty, cachexia and obesity that are not always evaluated by rheumatologists. This review shows that the evaluation and timely detection of these aspects in patients with RA could interfere with the prognosis and improve their quality of life.

Relationship Between Depression and Disease Activity in United States Veterans With Early Rheumatoid Arthritis Receiving Methotrexate

OBJECTIVE

Depression is common in patients with rheumatoid arthritis (RA), exacerbates disease activity, and may decrease response to first-line disease-modifying antirheumatic drugs. This study aimed to determine if depression affects disease activity among veterans with early RA prescribed methotrexate (MTX).

METHODS

Participants included veterans enrolled in the Veterans Affairs Rheumatoid Arthritis (VARA) registry with early RA (onset < 2 yrs) prescribed MTX. Depression was assessed at enrollment using the International Classification of Diseases, 9th revision codes (296.2-296.39, 300.4, 311). Disease activity was measured using the Disease Activity Score in 28 joints (DAS28) and other core measures of RA disease activity. Propensity score weights were used to adjust depressed (n = 48) and nondepressed (n = 220) patients on baseline confounders within imputed datasets. Weighted estimating equations were used to assess standardized mean differences in disease activity between depressed and nondepressed patients at 6-month, 1-year, and 2-year follow-ups.

RESULTS

The analytic sample was composed of 268 veterans with early RA prescribed MTX who were predominantly male (n = 239, 89.2%) and older (62.7 yrs, SD 10.6) than patients with RA in the general population. Adjusted estimates indicated that depression was associated with significantly higher DAS28 at 6 months (β 0.35, 95% CI 0.01-0.68) but not at the 1- or 2-year follow-up. Also, depression was associated with significantly worse pain at 6 months (β 0.39, 95% CI 0.04-0.73) and 1 year (β 0.40, 95% CI 0.04-0.75).

CONCLUSION

In early RA, depression is associated with greater short-term disease activity during MTX treatment, as well as more persistent and severe pain.

Epidemiology of Depression and Anxiety in Gout: A Systematic Review and Metaanalysis

OBJECTIVE

To conduct a systematic review of depression and anxiety among patients with gout that specifically evaluates the prevalence, incidence, determinants, and effects of these mental health comorbidities.

METHODS

We conducted a literature search in Medline, Embase, Cochrane Database of Systematic Reviews, CINAHL, and PsycINFO using indexed terms and key words to identify studies reporting on depression/anxiety in patients with gout. This review included full-text articles published in English that reported on patients with gout, evaluated depression/anxiety using a routinely reported measure, and provided estimates or sufficient data on the prevalence, incidence, determinants, or effects of depression/anxiety. Metaanalyses were conducted using random effects models.

RESULTS

Twenty of 901 articles identified through the search strategy met our inclusion criteria. All 20 studies evaluated depression, while only 10 assessed anxiety (50%). Metaanalyses suggest a positive association between mental health disorders and gout, as resultant pooled OR were 1.29 (95% CI 1.07-1.56) for depression and 1.29 (95% CI 0.96-1.73) for anxiety. Findings from four studies reporting on the incidence of depression in patients with gout resulted in a pooled HR of 1.17 (95% CI 1.01-1.36). Significant determinants of depression included number of tophi, frequency of flares, and oligo/polyarticular gout.

CONCLUSION

Our systematic review suggests that depression and anxiety are significantly associated with gout, highlighting the need for future research to focus on the onset of mental disorders after gout diagnosis. We also identify potential targets for intervention.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The multifaceted impact of anxiety and depression on patients with rheumatoid arthritis

Background

The prevalence of mood disturbances such as anxiety and depression is greater in rheumatoid arthritis (RA) patients than in the general population. Given this association, the primary aim of this study was to assess the incremental impact of anxiety or depression on patients with RA from the United States of America (USA) and Europe, independent of the impact of the underlying RA disease.

Methods

Rheumatologists (n = 408) from the USA and 5 European countries completed patient record forms for a predetermined number of RA patients who consulted consecutively during the study period; these patients completed patient-reported questionnaires. Descriptive statistics and multivariate regression were used to investigate the relationship between anxiety and depression with treatment and economic outcomes in RA patients.

Results

Of 1015 physician and patient pairs who completed all relevant questionnaire sections, 390 (38.4%) patients self-reported anxiety or depression, while 180 (17.7%) patients were reported to have anxiety or depression by their physicians. Controlling for age, gender, body mass index and clinical factors (flaring and severity), multiple regression analyses suggested that patients with anxiety or depression more often experienced treatment dissatisfaction (odds ratio [OR] 2.28; P < .001), had greater impairment in work (coefficient [β] = 11.82; P = .001) and usual activity (β = 14.73; P < .001), greater disability (β = .35; P < .001), and more often reported unemployment (OR 1.74; P = .001). Multinomial logistic regression revealed discordance between physician and patient satisfaction with treatment. For patients reporting anxiety or depression, physicians were more often satisfied with achievement of current disease control than patients (relative risk ratio 2.19; P = .002).

Conclusion

Concomitant anxiety or depression was associated with a significant incremental impact on the health-related quality of life and economic aspects of life of patients with RA. In light of observed differences between physician recognition of patient anxiety and/or depression versus patient reporting of anxiety and/or depression symptoms, further research is warranted to develop optimal screening and management of depression and anxiety in patients with RA.

Association of use of rehabilitation services with development of osteoporosis among patients with rheumatoid arthritis: a nationwide population-based cohort study

This is the first study that has found that rehabilitation services (RS) intervention, following the onset of rheumatoid arthritis (RA), may significantly reduce the risk of osteoporosis in RA patients. Those patients who received more than five sessions of RS had the greatest benefit for the prevention of osteoporosis.

INTRODUCTION

People with rheumatoid arthritis have increased risk of developing osteoporosis (OP). It remains unclear whether use of rehabilitation services can reduce the risk of developing OP. We conducted a longitudinal cohort study to compare the effect of RS on the risk of OP in Taiwanese individuals with RA.

METHODS

A national health insurance database was used to identify 2693 newly diagnosed RA patients, 20-70 years old, between 1998 and 2007. Among them, 808 received RS after the onset of RA (RS users) and 1885 patients did not receive RS (non-RS users). All enrollees were followed until the end of 2012 to record incident cases of OP. A Cox proportional hazards regression model was used to compute adjusted hazard ratios (aHRs) for the relationship of use of RS with OP.

RESULTS

During the 15-year follow-up, 358 RS users and 1238 non-RS users developed OP, corresponding to incidence rates of 87.24 and 129.27 per 1000 person-years, respectively. Use of RS was significantly associated with a lower risk of OP (aHR 0.62; 95% confidence interval [CI] = 0.56-0.71). Those who received more than five sessions of RS had the greatest benefit (aHR 0.47; 95% CI = 0.38-0.56).

CONCLUSIONS

The integration of RS into the clinical management of patients with RA may decrease their risk of developing OP.

Cost of Depression in Japanese Patients with Rheumatoid Arthritis: Evidence from Administrative Data

INTRODUCTION

To determine the cost of depression comorbidity among Japanese adults with rheumatoid arthritis (RA).

METHODS

A retrospective database study of 8968 patients diagnosed with RA between 2010 and 2015 and treated with any RA medication was conducted. Health care utilization characteristics were compared between patients with and without a comorbidity of depression. Propensity score matching was applied to ensure a balanced comparison between the two cohorts.

RESULTS

The prevalence of a depression comorbidity was found for 5% of the total RA patients. This comorbidity was associated with 62% (56%) higher total outpatient visits and 66% (163%) higher rate of emergency room visits after 6 (12) months.

CONCLUSIONS

Burden of depression among RA patients in Japan is relatively high and awareness for depression as a comorbidity of RA needs to be reinforced.

FUNDING

Janssen Pharmaceutical KK.

Identification and Treatment Optimization of Comorbid Depression in Rheumatoid Arthritis

Patients with rheumatoid arthritis (RA) suffer from high rates of depression but depression often remains undiagnosed and untreated among RA patients. Because of its high prevalence and its profound impact on functional disability and health-related quality of life, prompt recognition and management of comorbid depression is urgently needed in patients with RA. Rheumatologists face the challenge of addressing depression in their clinical interactions with patients. The purpose of this paper is to present the prevalence of comorbid depression in RA, to delineate the consequences of depression among RA patients, to discuss the barriers to the identification of depression among RA patients, and to outline a set of recommendations to identify and treat comorbid depression that could be implemented within the rheumatology clinic setting. A comprehensive approach to the management of both physical and mental health needs of RA patients can aid in improving patient overall quality of life. New clinical protocols should be developed to include routine depression screening as part of the rheumatology visit. Patient education to address misconceptions, knowledge gaps, and destigmatize depression is also recommended. More counseling resources, including emotional support groups, are necessary to provide treatment for those suffering from depression. Such interventions could help mitigate disability, improve quality of life, patient function, and overall satisfaction.

The underrated prevalence of depression in Japanese patients with rheumatoid arthritis - evidence from a Nationwide survey in Japan

Background

To determine the prevalence of depression among Japanese people with rheumatoid arthritis (RA) and explore the relationships between depression and an array of variables.

Methods

Nation-wide, cross-sectional online survey (n = 500) of people with RA including the Patient Health Questionnaire (PHQ-9) to measure the presence and severity of depressive symptoms were performed.

Results

While only 5% of the population studied had been officially diagnosed with depression, 35% had PHQ-9 scores indicating depression was present. People with RA are more likely to experience depression if they are younger, have greater functional impairment, or whose treatment regimen includes pain medications not biologic agents.

Conclusions

It is a potential risk of under-diagnosis and under-reporting of depression in Japanese people with RA. People with RA are more likely to experience depression if they are younger, have greater functional impairment, or whose treatment regimen includes pain medications without biologic drugs.

Electronic supplementary material

The online version of this article (10.1186/s41927-017-0003-6) contains supplementary material, which is available to authorized users.

[The specific features of the psycho-emotional status and the application of psychotherapy for the rehabilitative treatment of the patients presenting with rheumatoid arthritis]

The relevance of the problem of rheumatoid arthritis arises from the influence of such factors as its prevalence rate, unpredictability, tendency towards the transition to the chronic form, severe pain syndrome, high levels of disability, and long-term loss of working ability, as well as the accompanying psycho-emotional disorders. The present reviews article was designed to analyze the premorbid personality characteristics, the specifics features of mental health, and the response to the disease in the patients presenting with rheumatoid arthritis. Special emphasis is placed on the discusses of the relationship between the intensity of the pain syndrome and psycho-emotional disorders. The factors responsible for the development of the depressive states associated with rheumatoid arthritis are distinguished; they are shown to be related to both pathogenesis and the clinical symptoms of the underlying pathology as well as the general course of the disease and the specific features of the patients' psychological condition. The most extensively applied psychodiagnostics techniques are described, and the commonest psychotherapeutic approaches to the combined therapy and rehabilitation of the patients presenting with rheumatoid arthritis are overviewed.

Does depression increase the risk of stroke in patients with rheumatoid arthritis? A population-based cohort study

OBJECTIVES

Comorbid depression is common and undertreated in patients with rheumatoid arthritis (RA). It remains uncertain whether comorbid depression provoked the risk of poor clinical outcome, stroke in particular, among patients with RA. This work aimed to determine if depression onset during the treatment process increases stroke risk for patients with RA as compared with those with (1) neither RA nor depression, (2) RA only and (3) depression only.

DESIGN

A nationwide, population-based cohort study.

SETTING

Taiwan's Longitudinal Health Insurance Database.

PARTICIPANTS

We identified 8045 subjects with a newly diagnosed RA between 1997 and 2010, together with 32 600 subjects without RA matched by age, gender and index date. All subjects were further divided into four groups based on whether they were diagnosed with comorbid depression during the follow-up period.

MAIN OUTCOME MEASURE

The incidence rate and HR for incident stroke were estimated by the end of 2012 using Cox proportional hazard regression.

RESULTS

We discovered that patients with RA with the comorbid depression exhibited the highest risk of stroke, with an adjusted HR of 2.18 (95% CI 1.87 to 2.54). Those with RA only or those with depression only still had the higher risk of stroke by 43% and 57% as compared with subjects without either condition. Multivariate analysis showed RA subjects who were male or older, incurred the onset of depression, or had comorbidities such as hypertension, diabetes as well as heart disease, had a greater risk of stroke.

CONCLUSIONS

This study cleared up the significant association between RA and the subsequent risk of stroke, and further highlighted that the onset of depression within the treatment process may increase stroke risk for RA subjects. Findings could assist healthcare providers to pinpoint individuals with RA with a higher predisposition of stroke, which could facilitate the provision of appropriate rehabilitation.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Healthcare burden of depression in adults with arthritis

INTRODUCTION

Arthritis and depression are two of the top disabling conditions. When arthritis and depression exist in the same individual, they can interact with each other negatively and pose a significant healthcare burden on the patients, their families, payers, healthcare systems, and society as a whole. Areas covered: The primary objective of this review is to summarize, identify knowledge gaps and discuss the challenges in estimating the healthcare burden of depression among individuals with arthritis. Electronic literature searches were performed on PubMed, Embase, EBSCOhost, Scopus, the Cochrane Library, and Google Scholar to identify relevant studies. Expert Commentary: Our review revealed that the prevalence of depression varied depending on the definition of depression, type of arthritis, tools and threshold points used to identify depression, and the country of residence. Depression exacerbated arthritis-related complications as well as pain and was associated with poor health-related quality of life, disability, mortality, and high financial burden. There were significant knowledge gaps in estimates of incident depression rates, depression attributable disability, and healthcare utilization, direct and indirect healthcare costs among individuals with arthritis.

Patients' Perspectives on the Psychological Impact of Inflammatory Arthritis and Meeting the Associated Support Needs: Open-Ended Responses in a Multi-Centre Survey

OBJECTIVES

Psychological support for inflammatory arthritis is recommended in rheumatology treatment guidelines. Previous research found that high numbers of patients would access such support but that provision is often inconsistent and inadequate. The present study explored patients' perspectives on the nature of the psychological impact of inflammatory arthritis and how to meet the associated support needs.

METHODS

A cross-sectional survey was conducted, using questionnaires which included three open-ended questions about helpful and unhelpful psychological support. The questionnaires were administered to 1,080 patients at six regional rheumatology units across England, and 1,200 members of a national patient charity.

RESULTS

A total of 1,210 (53%) patients completed the questionnaire, with 779 (64%) responding to the open-ended questions: 80% female; mean age 59 years (12.6); disease duration <5 years (40%), 5-10 years (20%), >10 years (40%). Data were analysed using a hybrid content analysis. Four categories emerged: challenges of an altered life course (negative emotions, isolation and loneliness, a dysfunctional body, loss, strained relationships, and fears for the future); poor communication (feeling unheard, clinicians' reluctance to address psychological issues, a lack of help to manage pain and fatigue, and struggling to ask for help); understood by others (sharing with people who have arthritis, supportive family and friends, whole team support, and understanding from clinicians); and acquiring strategies (ways of coping).

CONCLUSIONS

Psychological distress was commonplace, and often attributed to fatigue and pain. In addition to peers and family, patients looked to the rheumatology team for validation and support. Further research will address the skills training needs of rheumatology teams to meet patients' psychological support requirements.

Depression risk in patients with late-onset rheumatoid arthritis in Germany

GOAL

The goal of this study was to determine the prevalence of depression and its risk factors in patients with late-onset rheumatoid arthritis (RA) treated in German primary care practices.

METHODS

Longitudinal data from general practices (n=1072) throughout Germany were analyzed. Individuals initially diagnosed with RA (2009-2013) were identified, and 7301 patients were included and matched (1:1) to 7301 controls. The primary outcome measure was the initial diagnosis of depression within 5 years after the index date in patients with and without RA. Cox proportional hazards models were used to adjust for confounders.

RESULTS

The mean age was 72.2 years (SD: 7.6 years). A total of 34.9 % of patients were men. Depression diagnoses were present in 22.0 % of the RA group and 14.3 % of the control group after a 5-year follow-up period (p < 0.001). In the multivariate regression model, RA was a strong risk factor for the development of depression (HR: 1.55, p < 0.001). There was significant interaction of RA and diagnosed inflammatory polyarthropathies (IP) (RA*IP interaction: p < 0.001). Furthermore, dementia, cancer, osteoporosis, hypertension, and diabetes were associated with a higher risk of developing depression (p values <0.001).

CONCLUSION

The risk of depression is significantly higher in patients with late-onset RA than in patients without RA for subjects treated in primary care practices in Germany. RA patients should be screened routinely for depression in order to ensure improved treatment and management.

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.

Pain Predicts Function One Year Later: A Comparison across Pain Measures in a Rheumatoid Arthritis Sample

Background. Guidance is limited on best measures and time periods to reference when measuring pain in order to predict future function. Objective. To examine how different measures of pain predict functional limitations a year later in a sample of rheumatoid arthritis patients. Methods. Logistic regression analyses were conducted using baseline and one-year data (n = 262). Pain intensity in the last 24 hours was measured on a 0–10 numerical rating scale and in the last month using an item from the Arthritis Impact Measurement Scale 2 (AIMS2). AIMS2 also provided frequency of severe pain, pain composite scores, and patient-reported limitations. Physician-rated function was also examined. Results. Composite AIMS2 pain scale performed best, predicting every functional outcome with the greatest magnitude, a one-point increase in pain score predicting 21% increased odds of limitations (combined patient and physician report). However, its constituent item—frequency of severe pain in the last month—performed nearly as well (19% increased odds). Pain intensity measures in last month and last 24 hours yielded inconsistent findings. Conclusion. Although all measures of pain predicted some functional limitations, predictive consistency varied by measure. Frequency of severe pain in the last month provided a good balance of brevity and predictive power.

Health-related quality of life and its predictors among patients with rheumatoid arthritis

BACKGROUND

Limited studies have examined the predictors of HRQoL among patients with rheumatoid arthritis. This study helped to ascertain the predictors of HRQoL from the pool of influencing factors identified by previous studies.

AIM

This study investigated the health-related quality of life (HRQoL) of adult patients with rheumatoid arthritis and its predictors.

METHODS

Using a descriptive correlational design, this study explored the relationship between HRQoL and pain, functional disability, anxiety, depression, medication adherence and social support. Eligible outpatients (n=108) were recruited via their attending doctors who were co-investigators of this study. Informed consent forms were distributed and questionnaires administered in a teaching hub by the main researcher.

RESULTS

Significant correlations were found between HRQoL and all of the study variables. Pain, functional disability and depression were main predictors of HRQoL.

CONCLUSIONS

Future evidence-based interventions focusing on pain relief, delaying disability or improving functional ability and reducing depressive symptoms are required to enhance the HRQoL of patients with rheumatoid arthritis.

Perspectives of vulnerable U.S Hispanics with rheumatoid arthritis on depression: awareness, barriers to disclosure, and treatment options

OBJECTIVE

Despite the high prevalence of depression among vulnerable Hispanics with rheumatoid arthritis (RA), many do not disclose it or seek treatment. This study explored patient perceptions of depression, its association with their primary disease, barriers to disclosure, reasons for low utilization of mental health care resources, and culturally acceptable intervention approaches.

METHODS

Semistructured interviews were conducted with 46 participants with RA. Depression was evaluated using Patient Health Questionnaire 9 (PHQ-9).

RESULTS

Thirty-three percent of participants were moderately depressed at the time of the interview, based on PHQ-9 score ≥10; 12 of 46 patients (26%) stated they were depressed regardless of PHQ-9 score. Depression was perceived as a long-term, severe problem leading to suicide. It was associated with weakness and character flaws, contributing to stigma and reduced likelihood of disclosure. Antidepressants were not acceptable; self-reliance and interventions incorporating interpersonal connections were preferred. Systems-related barriers to disclosure included lack of verbal screening, language barriers, limited clinic visit time, and lack of continuity of care, restricting trust with providers.

CONCLUSION

Rectifying misconceptions, as well as providing education regarding the association between RA and depression, the continuum of symptoms, and the range of experiences incurred are needed to facilitate earlier recognition and reduce stigma. Use, duration, and goals of antidepressant therapy should be clarified. Providers should strive to establish trust and conduct in-person depression screening to facilitate disclosure. Interventions with an interpersonal component, such as support groups or patient navigators, were preferred. Themes emphasizing coping strategies, stress reduction, positive thinking, self-efficacy, and resiliency are likely to be most acceptable.

Increased risk of depression in patients with rheumatoid arthritis: a seven-year population-based cohort study

OBJECTIVE

Rheumatoid arthritis (RA) is a costly and crippling autoimmune disease that can lead to the development of depression, contributing to suboptimal clinical outcomes. However, no longitudinal studies have identified an association between rheumatoid arthritis and subsequent depression. This study aimed to investigate the incidence and risk factors of depression among RA patients in Taiwan.

METHODS

Using Taiwan's National Health Insurance Research Database, we identified 3,698 newly diagnosed RA patients aged 18 years or older, together with 7,396 subjects without RA matched by sex, age and index date, between 2000 and 2004. The incidence of depression and the risk factors among RA cases were evaluated using Cox proportional-hazard regression.

RESULTS

The incidence of depression was 1.74-fold greater in the RA cohort than in the non-RA cohort (11.80 versus 6.89 per 1,000 person-years; p<0.01). Multivariate analysis showed that RA subjects who were female, were older, or had comorbidities such as stroke, chronic kidney disease, or cancer had a significantly greater risk of depression compared with those without these conditions.

CONCLUSION

This population-based cohort study showed a strong relationship between RA and a subsequent risk of depression. The findings could be beneficial to healthcare providers for identifying individuals with a higher predisposition for depression, thereby possibly facilitating the provision of an appropriate rehabilitation intervention after RA onset to support the patient's adaptation.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Impact of psychological factors on subjective disease activity assessments in patients with severe rheumatoid arthritis

OBJECTIVE

The Disease Activity Score in 28 joints (DAS28), used to assess disease activity in rheumatoid arthritis (RA), is a composite score comprising clinical, biochemical, and patient self-report measures. We hypothesized that psychological factors (cognitions and mood) would be more strongly associated with patient-reported components of the DAS28 than clinical or biochemical components.

METHODS

A cross-sectional, observational study of 322 RA patients with active disease (mean DAS28 6.0) awaiting therapy with a biologic agent was undertaken. Patients' illness beliefs, treatment beliefs, and mood were measured using the Brief Illness Perception Questionnaire (IPQ), the Beliefs about Medicines Questionnaire (BMQ), and the Hospital Anxiety and Depression Scale (HADS), respectively. Relationships between psychological factors and 1) total DAS28 and 2) individual components of the DAS28 were analyzed using linear regression.

RESULTS

Total DAS28 produced significant but weak associations with 2 of the Brief IPQ items, but no associations with BMQ or HADS scores. There were larger significant associations between the patient-reported visual analog scale (VAS) with 5 items of the Brief IPQ and with HADS depression. Low illness coherence was associated with higher tender joint count. Three Brief IPQ items and HADS anxiety scores were significantly associated with C-reactive protein level or erythrocyte sedimentation rate. No psychological factors were associated with the swollen joint count.

CONCLUSION

One of the subjective components of the DAS28, patient VAS, was highly correlated with cognitive factors and depression in those with severe RA. By reporting individual DAS28 components, clinicians may be better able to assess the impact of therapies on each component, adjusting approaches according to patients' needs.

Mental health status can reflect disease activity in rheumatoid arthritis

OBJECTIVE

A significant number of patients with rheumatoid arthritis (RA) link the start of illness with psychological trauma or severe stress. Impaired mental health (IMH), defined as depression and anxiety with psychoneuroimmunological factors, can play a significant role in RA. The main objective of this research was to investigate the mutual correlation of IMH and RA activity, estimated by the laboratory and clinical parameters in RA patients.

MATERIAL AND METHODS

An open clinical prospective study that lasted for 6 months was designed. There were 72 patients included, 58 women and 14 men, aged 34 to 80 years and screened for mental health status. The study population was randomized following the Brief Symptoms Inventory (BSI) scale, comprised of 53 questions with a range from 0 (no symptoms) to 4 (severe). This mental test was done only once during the study. Following the results from the BSI scale, RA patients were divided into mentally stable and mentally unstable patients to investigate the influence of RA activity on mental health. The following laboratory and clinical parameters were analyzed: sex, age, erythrocyte sedimentation rate (ESR), rheumatoid factor (RF), C-reactive protein (CRP), anti-cyclic citrullinated peptide (anti-CCP) antibody, and disease activity score (DAS28). All RA patients did not express extra-articular manifestations or Sjögren's syndrome. The chi-square test, ANOVA, Pearson's coefficient, and IBM Statistics - SPSS v19 were used.

RESULTS

From a total of 72 RA patients, there were 44 mentally stable and 28 mentally unstable patients. All patients had either moderate or severe active disease. The only significant correlation of IMH and activity of RA was found in CRP and DAS28, but no significance was observed in ESR, RF, and anti-CCP. The DAS28 showed high disease activity with an average of 5.3 and CRP of 20.9 mg/L in patients with unstable mental health compared to stable mental health patients, where RA was associated with a moderate DAS average value of 4.35 and CRP of 14.1 mg/L. Depression and anxiety were found in all 28 (39%) RA patients.

CONCLUSION

Mentally unstable RA patients correlate more with severe disease activity, while mentally stable patients express moderate disease activity.

Missed opportunities for depression screening in patients with arthritis in the United States

BACKGROUND

Arthritis affects 20 % of the adult US population and is associated with comorbid depression. Depression screening guidelines have been endorsed for high-risk groups, including persons with arthritis, in the hopes that screening will increase recognition and use of appropriate interventions.

OBJECTIVE

To examine national rates of depression and depression screening for patients with arthritis between 2006 and 2010.

PARTICIPANTS AND DESIGN

We used nationally representative cross-sections of ambulatory visits in the United States from the National Ambulatory Medical Care Survey from 2006 to 2010, which included 18,507 visits with a diagnosis of arthritis. When weighted to the US population, this total represents approximately 644 million visits.

MEASUREMENTS

Visits where arthritis was listed among diagnoses. Outcomes were survey-weighted estimates of depression and prevalence of depression screening among patients with arthritis across patient and physician characteristics.

KEY RESULTS

Of the 644,419,374 visits with arthritis listed, 83,574,127 (13 %) were associated with a comorbid diagnosis of depression. The odds ratio for comorbid depression with arthritis was 1.42 (95 % CI 1.3, 1.5). Depression screening occurred at 3,835,000 (1 %) visits associated with arthritis. When examining the rates of depression screening between ambulatory visits with and without arthritis listed, there was no difference in depression screening rates; both were approximately 1 %. There was no difference in screening rates by provider type. Compared to visits with other common, chronic conditions, the prevalence of depression at arthritis visits was high (13 per 100 visits), although the prevalence of depression screening at arthritis visits was low (0.68 per 100 visits).

CONCLUSIONS

Despite the high prevalence of depression with arthritis, screening for depression was performed at few arthritis visits, representing missed opportunities to detect a common, serious comorbidity. Improved depression screening by providers would identify affected patients, and may lead to appropriate interventions such as mental health referrals and/or treatment with anti-depressants.

An acceptance-oriented cognitive-behavioral therapy in multimodal rehabilitation: a pre-post test evaluation in highly distressed patients with rheumatic diseases

OBJECTIVE

To examine the potential effectiveness of a multimodal rehabilitation program including an acceptance-oriented cognitive-behavioral therapy for highly distressed patients with rheumatic diseases.

METHODS

An observational study employing a one-group pre-post test design (N=25). The primary outcome was psychological distress. Secondary outcomes were quality of life, illness acceptance, and coping flexibility. Group pre-to-post and pre-to-12 months follow-up treatment changes were evaluated by paired-samples t-tests and Cohen's effect sizes (d). Individual changes were evaluated by the reliable change index (RCI) and clinically significant change (CSC) parameters.

RESULTS

Significant effects were found post-treatment and maintained at 12 months in psychological distress (d>0.80), illness acceptance (d=1.48) and the SF-36 subscales role physical, vitality, and mental health (d ≥ 0.65). No significant effects were found for coping flexibility and the SF-36 subscales physical functioning, bodily pain, social functioning, and role emotional. Both a reliable (RCI) and clinically significant (CSC) improvement was observed for almost half of the highly distressed patients.

CONCLUSION

The patients enrolled in the multimodal rehabilitation program showed improved psychological health status from pre to post-treatment.

PRACTICE IMPLICATIONS

A randomized clinical trial is needed to confirm or refute the added value of an acceptance-oriented cognitive-behavioral therapy for highly distressed patients in rehabilitation.

Development of a quality of patient-health care provider communication scale from the perspective of patients with rheumatoid arthritis

OBJECTIVES

To devise a patient-perspective driven measure of the quality of patient-health care provider communication and to evaluate the psychometric properties of this scale in a sample of 150 patients with rheumatoid arthritis.

METHODS

Items were developed from interviews with 15 patients with rheumatoid arthritis. Two rheumatologists, a behavioral scientist, and a nurse researcher provided item feedback. Exploratory factor analysis with Oblimin rotation was used to examine the dimensionality of the newly developed Patient-Health Care Provider Communication Scale (PHCPCS). Cronbach's alpha was computed to assess internal consistency. Test-retest reliability was determined using the intraclass correlation coefficient. Construct validity was tested by comparing the PHCPCS with the Perceived Involvement in Care Scale (PICS) using correlation analysis.

RESULTS

The PHCPCS measured two dimensions of the quality of patient-health care provider communication [Quality Communication (α = 0.94) and Negative Patient-Health Care Provider Communication (α = 0.73)]. The total PHCPCS score and its Quality Communication Subscale were positively correlated with the total score on the PICS and with the doctor facilitation subscale of the PICS.

DISCUSSION

This new measure of the quality of patient-health care provider communication has the potential for use in clinical practice, provider education, and further studies to improve health care to patients with rheumatoid arthritis.

Psychological interventions for patients with rheumatic diseases and anxiety or depression

The prevalence of clinical anxiety and clinical depression in rheumatic diseases is about twice the prevalence seen in the general population. At a milder level, the occurrence of psychological distress that does not fulfil diagnostic criteria of anxiety and depression is even higher. Evidence indicates that this high prevalence is multifactorial. Correlational studies suggest that possible factors for anxiety and depression include the suffering accompanying somatic symptoms, functional limitations, pro-inflammatory cytokines, helplessness due to the uncontrollable, unpredictable and progressive nature of the disease, and other factors associated with having a chronic disease. This article reviews the prevalence and diagnosis of anxiety and depression in rheumatic diseases and it examines the contents and the impact of psychological interventions to address these difficulties for patients.

Suicidal ideation among adults with arthritis: prevalence and subgroups at highest risk. Data from the 2007-2008 National Health and Nutrition Examination Survey

OBJECTIVE

To evaluate the prevalence, correlates, and subgroups at highest risk for suicidal ideation among adults with arthritis.

METHODS

We used data on US adults with arthritis, ages ≥40 years, participating in the 2007-2008 National Health and Nutrition Examination Survey. Suicidal ideation was assessed by item 9 of the Patient Health Questionnaire 9 (PHQ-9). Sociodemographic factors, health behaviors, and comorbid conditions were examined as potential correlates. Depression was measured by the PHQ-8 score (range 1-24). We used random forests to identify subgroups at highest risk for suicidal ideation. To determine if any correlates were unique to arthritis, we compared results to those for persons with diabetes mellitus and cancer.

RESULTS

The prevalence ± SEM of suicidal ideation was 5.6% ± 0.8% among persons with arthritis and 2.4% ± 0.4% among those without. The most important correlates for suicidal ideation in adults with arthritis were depression, anxiety, duration of arthritis, age, income:poverty ratio, number of close friends, pain, alcohol, excessive daytime sleepiness, and comorbidities. Eleven of the 16 most important contributors for suicidal ideation among adults with arthritis were also important for people with diabetes mellitus and cancer. Among persons with arthritis, subgroups at highest risk for suicidal ideation were those with a PHQ-8 score between 18 and 24 and less than 4.5 years of arthritis (96.5%), and those with a PHQ-8 score between 7 and 17, ≥1.24 days of binges/month, and either an income of ≥$45,000/year (85.4%) or an income of <$45,000/year and >3 comorbidities (70.8%).

CONCLUSION

Depression, short duration of arthritis, binge drinking, income, and >3 comorbidities identified subgroups of adults with arthritis at greatest risk for suicidal ideation.

Fatigue and depression predict physician visits and work disability in women with primary Sjögren's syndrome: results from a cohort study

OBJECTIVES

Patients with primary SS (pSS) are frequently suffering from multiple enduring disorders that raise the risk of work disability and require treatment by various health-care specialists. We aimed at determining predictors of physician visits and work disability in pSS patients.

METHODS

Physician visits within the past 6 months, employment status and sick leave were compared among 176 female pSS patients and 115 age-matched controls. Dryness, pain, fatigue and depression were assessed by rating scales of the EULAR Sjögren's Syndrome Patient Reported Index (ESSPRI), the Profile of Fatigue and Discomfort (PROFAD) and Patient Health Questionnaire depression measurements (PHQ-9). Factors associated with an increased number of physician visits and inability to work were determined by multivariate logistic regression analysis.

RESULTS

Patients and controls were comparable in age and education, but differed significantly in the prevalence of depression (38.1 vs 7.9%, P < 0.001), the number of physician visits [17.0 (10.0) vs 6.5 (4.5); P < 0.001] and gainful employment (≤64 years: 52.8 vs 77.1% P < 0.001). Multivariate regression analyses revealed that depression (PHQ-9) and/or fatigue, particularly lack of stamina, but not dryness, were significantly associated with physician visits and working status in pSS patients. Patients with high ratings for the statement 'I have had difficulties to keep going, was easily worn out or lacking in energy' had a highly increased risk of not being gainfully employed (adjusted OR 4.1; 95% CI 1.5, 11.2; P < 0.001).

CONCLUSION

In pSS, lack of stamina and/or depression cause a higher level of individual and societal burden than dry eyes and mouth. Fatigue and depression deserve more recognition as treatment targets in pSS.

Potential role of FRAX analysis in postmenopausal women with osteopenia

Early diagnosis of osteoporosis and estimation of subjects that are at high risk for fracture, is neccesary for osteoporosis treatment. Dual-energy X-ray absorptometry (DXA) is a modern method for bone mineral density (BMD) evaluation. However, along BMD, clinical risk factors may significantly influence fracture development. Therefore, FRAX algorithm was designed for the assessment of a ten-year risk for serious osteoporotic fractures (SOF), as well as hip fractures. In the current study, we tried to evaluate the possible lumbal spine and hip BMD influence on ten year risk for SOF and hip fractures and potential role of FRAX in predicting the therapy in postmenopausal women with osteopenia. We performed the study on 385 postmenopausal women. According to the DXA measurements, at the lumbal (L) spine (L1–L4) and hip (femor neck), patients were then classified as normal, osteopenic, or osteoporotic. BMD evaluation included the L spine and the hip (subgroup 1), and only on the L spine (subgroup 2). By filling up the FRAX questionnaire, a ten-year risk for SOF fracture and hip fracture was calculated. BMD evaluation, in complete patient’s group and in subgroup 1, resulted in the highest number of osteoporosis (61.04%, 48.08%, retrospectively), while ospeopenia was a main finding in subgroup 2. In the subgroup 1, a high risk for SOF and hip fracture was detected in 16.45% and with high risk for hip fracture in 11.38% subjects. In subgroup 2, only high risk for hip fracture was observed in 3.16% subjects, indicating the active medicament treatment. Simultaneously, correlation of BMD results with FRAX values for SOF and hip fracture, showed significant negative correlation (p<0.001). Obtained results showed significant role of femur neck BMD evaluation in predicting the future factors, which may, together with FRAX analysis, improve the therapy approach in postmenopausal women with ospeopenia.

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.

Predictors of rheumatoid arthritis patient-physician communication about medication costs during visits to rheumatologists

OBJECTIVE

To examine the frequency with which medication costs are discussed, and the predictors of these discussions, during visits between rheumatologists and their patients with rheumatoid arthritis (RA).

METHODS

Audiotapes of medical visits, patient questionnaires, medical records, and physician questionnaires were collected from March 2003 to December 2005. Data were collected from 200 RA patients from 4 rheumatology clinics. Audiotapes were coded for the presence of communication about medication costs using a detailed coding instrument. The final analysis sample included 193 patients and 8 rheumatologists. Stepwise multivariable logistic regression was used to examine the role of patient, physician, medication, and relationship characteristics on discussions of medication costs.

RESULTS

Despite medication changes being made in more than 50% of the visits, only 34% of those visits included discussions of medication-related costs; 48% of these discussions were initiated by patients. In multivariable logistic regression models, communication about medication costs occurred more often when patients were white (compared with nonwhite) and reported an annual income of $20,000-$59,999 (compared with those earning > or =$60,000). Discussions about medication costs also were more common when physicians were white.

CONCLUSION

Although medication changes were common, medication costs were only discussed in one-third of the visits. Communication about medication costs was more common among patients who were white and in a middle income category. Disparities in communication about medication costs have the potential to negatively impact prescribing and subsequent medication use. Further research should examine potential disparities in communication about medication costs.

Depression, inflammation, and pain in patients with rheumatoid arthritis

OBJECTIVE

An association between depression and inflammation has been suggested. In patients with rheumatoid arthritis (RA), pain is a major symptom associated with depression and inflammation. We examined the independent associations between depression, the inflammation marker C-reactive protein (CRP) level, and pain in patients with RA.

METHODS

In total, 218 RA outpatients completed self-administered questionnaires, using the Beck Depression Inventory II to measure depressive symptoms and a visual analog scale to quantify their perceived pain. Functional disability and CRP level were also measured.

RESULTS

Depression scores were mildly and positively correlated with the CRP level (r = 0.46, P < 0.001). Both the depression score (standardized beta = 0.35, P < 0.001) and the CRP level (standardized beta = 0.35, P < 0.001) were significantly associated with pain, even after adjustment for clinical covariates in regression analysis. In logistic analysis, the combined effects on the risk of severe pain (pain score in the upper tertile) increased with depression scores and CRP levels linearly.

CONCLUSION

Depression severity and inflammation were associated with each other and appeared to have independent effects on perceived pain. Therefore, a clinical approach that takes into account both the body and the mind could have benefits and could enable optimal pain control.

Prevalence of mood and anxiety disorders in women with systemic lupus erythematosus

OBJECTIVE

To examine the lifetime prevalence of mood and anxiety disorders in patients with systemic lupus erythematosus (SLE). Demographic and disease-related variables were examined for association with lifetime major depressive disorder (MDD) and the presence of any mood or anxiety disorder.

METHODS

Three hundred twenty-six white women with SLE completed the Composite International Diagnostic Interview and the Systemic Lupus Activity Questionnaire, a self-report measure of SLE disease activity. The binomial test was used to compare the prevalence of psychiatric diagnoses in patients with SLE with a population sample of white women.

RESULTS

Sixty-five percent of the participants received a lifetime mood or anxiety diagnosis. MDD (47%), specific phobia (24%), panic disorder (16%), obsessive-compulsive disorder (9%), and bipolar I disorder (6%) were more common among patients with SLE than among other white women (P = 0.00009 for specific phobia; for all other values P = 0.00001). Although most patients with histories of mood disorders reported their psychiatric symptoms to a medical provider, a substantial number of patients with anxiety disorders did not. Self-reported disease activity was associated with a lifetime history of MDD (P = 0.001) and presence of a mood or anxiety disorder (P = 0.001), after controlling for demographic and clinical characteristics.

CONCLUSION

Several mood and anxiety disorders were more common in women with SLE compared with the general population, and disease activity may contribute to this higher risk. Brief self-report questionnaires may help providers identify patients with these conditions, particularly when patients are reluctant to disclose their symptoms.

Fatigue communication at the out-patient clinic of Rheumatology

OBJECTIVE

To describe nurse-patient and rheumatologist-patient interaction in fatigue communication at the rheumatology out-patient clinic.

METHODS

Consultations of 20 rheumatoid arthritis (RA) patients with the nurse specialist and the rheumatologist were videotaped and analysed using the Medical Interview Aural Rating Scale (MIARS). Subsequently, patients were asked to fill out a concern questionnaire asking how worried they felt and how satisfied they were with attention given by both healthcare professionals. Finally, patients were interviewed on reasons for being not or not completely satisfied with the care received.

RESULTS

Fatigue was discussed in 42% of the rheumatologists' consultations and 83% of the nurse specialists' consultations. RA patients more often used implicit cues instead of explicit concerns related to fatigue. Almost 72% of the patients felt worried about fatigue and in general they were more satisfied with the nurse specialist's attention to fatigue than with the attention from the rheumatologist.

CONCLUSION

Fatigue is not structurally communicated at the rheumatology out-patient clinic and exploring and acknowledging communication techniques can help patients to express their concerns about fatigue.

PRACTICE IMPLICATIONS

Healthcare professionals must recognise fatigue as a severe problem for RA patients and start the conversation on fatigue instead of waiting for the patient to mention fatigue spontaneously.

The challenges of assessing fidelity to physician-driven HIV prevention interventions: lessons learned implementing Partnership for Health in a Los Angeles HIV clinic

Documenting fidelity to HIV prevention interventions is critical to ensure consistency in intervention implementation and necessary for measuring intervention exposure and, ultimately, outcomes. Significant variation from prescribed protocols or inconsistent implementation can jeopardize the integrity of evaluation research and render outcomes uninterpretable. There is increasing support for HIV prevention models targeting seropositive individuals designed to be delivered by physicians during clinic visits. Assessing fidelity to physician-delivered interventions that occur during clinical exams present unique challenges. This paper presents findings from various data sources designed to track intervention fidelity and exposure to the Partnership for Health intervention, a physician-delivered HIV prevention intervention implemented in an urban community HIV clinic. We present findings from chart abstraction data, patient surveys and exit interviews, and provider qualitative interviews. Lessons learned and recommendations for maximizing the accuracy and validity of fidelity assessment in future evaluations of HIV prevention interventions in primary care settings are considered.