Rheumatoid arthritis and risk of anxiety: a meta-analysis of cohort studies

Prevalence and correlates of generalized anxiety disorder and subthreshold anxiety symptoms in south China: A network perspective

AIMS

To investigate the prevalence of generalized anxiety disorder (GAD) and subthreshold anxiety symptoms (SAS) in Guangdong province of China, and to identify the central anxiety symptoms, while further exploring their associations with sociodemographic characteristics, lifestyle factors, and somatic diseases.

METHODS

This survey was conducted in 21 administrative regions of Guangdong province with multistage-stratified cluster random sampling method. Multivariate logistic regression analyses were performed to estimate the adjusted odds ratios (ORs) and their 95 % confidence intervals (CIs). Network analyses were conducted to explore the centrality of anxiety symptoms.

RESULTS

A total of 16,377 individuals were included in this study. The weight 12-month prevalence rates for GAD and SAS were 3.5 % and 10.0 %, respectively. Multivariable logistic regression analysis identified several factors significantly associated with increased risks of GAD and SAS, including younger age, female, no spouse, current alcohol consumption, never exercising, comorbidities, sleep duration of less than 7 h. Notably, the factors related to GAD and SAS largely overlapped, with urban residency and napping correlating specifically with SAS, and mental health literacy correlating specifically with GAD. Network analysis identified "Trouble relaxing" (GAD4) as the most central symptom of anxiety.

CONCLUSIONS

GAD and SAS were prevalent among residents in south China. More attention and assistance should be prioritized to individuals with younger age, female, no spouse, current alcohol consumption, sleep less than 7 h, and comorbid with somatic diseases. Taking regular exercise and improving mental health literacy may be beneficial in preventing and controlling anxiety.

Beyond rheumatoid arthritis: A meta-analysis of the prevalence of anxiety and depressive disorders in rheumatoid arthritis

BACKGROUND

The prevalence of anxiety and depressive disorders in patients with rheumatoid arthritis (RA) is heterogenous with reports from 2.4 % to 85.2 % and 15 %-73.2 %, respectively. The present study provides meta-analytic current, and lifetime estimates of anxiety and depressive disorders amongst those living with RA.

METHOD

An online search of PubMed, PsycINFO, CINAHL, and WoS was conducted. Of the 3801 articles identified, 13 and 22 studies were coded for anxiety or depressive disorder prevalence in RA, respectively. Studies were included if they prospectively examined individuals (age >16) with RA, used semi-structured diagnostic interviews, and reported lifetime or current anxiety or depressive disorder comorbidity.

RESULTS

Data were analyzed using a Bayesian multilevel modelling approach, revealing current and lifetime prevalence of anxiety disorders to be 13.5 % CI95 % (9.2-17.3) and 22.2 %, CI95 % (15.9-29.1), respectively. Models also demonstrated the current and lifetime prevalence of depressive disorders to be 17.9 % CI95 % (10.1-27.1) and 32.4 %, CI95 % (18.3-47.6), respectively. Moderator analyses revealed numerically greater rates of GAD and MDD than other anxiety or depressive disorders.

LIMITATIONS

There were too few estimates to extensively model several moderators or to conduct exhaustive comparisons of demographic populations requiring greater representation such as males, non-White participants, and people with young adult RA onset.

CONCLUSIONS

The prevalence and risk for comorbid anxiety and depressive disorders in RA is extremely high. Routine screening and ongoing monitoring of individuals with RA for comorbid anxiety and depressive disorders is important to support improved prognosis.

Impact and Prevalence of Depression and Anxiety in Rheumatoid Arthritis-A Cross-Sectional Study with Self-Reported Questionnaires

Objective: This study aims to screen for depression and anxiety in a real-life sample of rheumatoid arthritis (RA) patients and to observe whether RA phenotype characteristics and RA disease activity measures are associated with depression and anxiety. Methods: This cross-sectional study from a tertiary rheumatology hospital in Romania screened all patients with diagnosed RA that came for their one month disease follow-up for depression and anxiety using the Patient Health Questionnaire-9 (PHQ9) and Hospital Anxiety and Depression Scale (HADS), self-reported questionnaires. The follow-up captured the date of RA diagnosis, pharmacological treatment, clinical examination, blood sampling, and functional and radiographic assessment. The cut-off for positive screening of depression was a PHQ9 of 10 or more and a HADS-depression (D) of over 10, and the positive cut-off for anxiety was a HADS-anxiety (A) of over 10. Results: According to the medical histories, the prevalence of depression and anxiety in the 209 patients included was 10% and 8.1%, respectively, while the likely depression diagnosis according to PHQ was 34.4% and that according to HADS-D was 14.8%, while the likely anxiety diagnosis using the HADS-A was 32.5%. The subgroup of patients that positively screened for depression using the self-reported questionnaires PHQ9 and HADS-D had significantly higher DAS28, disease activity class, tender joint count, swollen joint count, patient global assessment, and functional stage, with some particularities regarding ESR and radiographic stage, which were higher just in the HADS-D of more than 10 subgroup, and glucocorticoid use, which was higher just in the PHQ9 over 10 subgroup. Regarding patients with a HADS-A of more than 10, they were more frequently women and had higher tender joint count and functional stage. Conclusions: Depression and anxiety are highly prevalent and underreported in the RA population and are associated with higher levels of pain, physical disability, and disease activity.

Trends in Anxiety and Depression Among Individuals With Rheumatoid Arthritis: A Population-Based Study

OBJECTIVE

To investigate trends in depression and anxiety over 3 decades among individuals with rheumatoid arthritis (RA).

METHODS

Patients with incident RA (age ≥ 18 years, meeting 1987 American College of Rheumatology criteria between 1985 and 2014) were identified using the Rochester Epidemiology Project. Individuals with RA were matched 1:1 with non-RA comparators on age, sex, and calendar year of RA incidence. Patients were followed until death, migration, or December 31, 2020. Depression and anxiety were defined using established International Classification of Diseases, 9th and 10th revision code sets. Cox models were used to compare trends in the occurrence of depression and anxiety diagnoses and cooccurring anxiety and depression by decade and RA status, adjusted for potential confounders.

RESULTS

The study included 1012 individuals with RA and 1012 matched controls (mean age 55.9 years, 68.38% female). Hazard ratios (HRs) demonstrated a temporal increase in anxiety and cooccurring anxiety and depression from 2005-2014 compared to 1985-1994 for individuals both with and without RA. Persons with RA exhibited a rising occurrence of anxiety (HR 1.27, 95% CI 0.86-1.88) and concomitant anxiety and depression (HR 1.49, 95% CI 0.96-2.33) compared to controls. Trends were most pronounced in seropositive patients with RA (anxiety: HR 4.01, 95% CI 2.21-7.30).

CONCLUSION

Anxiety and concomitant anxiety and depression diagnoses are elevated in individuals with RA. The increasing occurrence of anxiety and cooccurring anxiety and depression suggests rising awareness and diagnosis of these disorders. Adding to stable but high rates of depression diagnoses, individuals with RA now have evidence of a widening gap in mental health diagnoses that clinicians should address.

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

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

Higher levels of physical activity are associated with less evasive coping, better physical function and quality of life in patients with axial spondyloarthritis

OBJECTIVE

To evaluate daily physical activity (PA) in relation to psychosocial factors, such as anxiety, depression and different types of coping strategies, as well as patient- and disease-related factors in patients with axial spondyloarthritis (axSpA).

METHODS

Consecutive outpatients from the Groningen Leeuwarden AxSpA (GLAS) cohort completed the modified Short Questionnaire to assess health-enhancing PA (mSQUASH), Hospital Anxiety and Depression Scale (HADS) and Coping with Rheumatic Stressors (CORS) questionnaires, as well as standardized patient- and disease-related assessments. Univariable and multivariable linear regression analyses and comparison of lowest and highest PA tertiles were performed to explore associations between the HADS, CORS, patient- and disease-related factors and PA.

RESULTS

In total, 84 axSpA patients were included; 60% male, mean age 49 (SD ±14) years, median symptom duration 20 (25th-75th percentiles: 12-31) years, mean ASDAS 2.1 (±1.0). Higher PA levels were significantly associated with better scores on patient-reported disease activity (BASDAI), physical function (BASFI) and quality of life (ASQoL). Furthermore, higher levels of PA were associated with less impact of axSpA on wellbeing and lower HADS depression scores. In the multivariable linear regression model, less use of the coping strategy 'decreasing activities' (β: -376.4; p 0.003) and lower BMI (β:-235.5; p: 0.030) were independently associated with higher level of PA. Comparison of patients from the lowest and highest PA tertiles showed results similar to those found in the regression analyses.

CONCLUSION

In this cohort of axSpA patients, higher levels of daily PA were associated with better patient-reported outcomes and lower depression scores. Additionally, the passive coping strategy "decreasing activities" and lifestyle factor BMI were independently associated with PA. Besides anti-inflammatory treatment, coping strategies and lifestyle should be taken into account in the management of individual axSpA patients. Incorporating these aspects into patient education could increase patient awareness and self-efficacy. In the future, longitudinal studies are needed to better understand the complex relationship between patient-, disease- and psychosocial factors associated with daily PA.

The prevalence and correlation of depression and anxiety with disease activity in rheumatoid arthritis

INTRODUCTION

Depression and anxiety share similar symptoms with rheumatoid arthritis (RA) and these conditions are often not diagnosed or overlooked in RA. This study aimed to determine the prevalence of depression/anxiety in RA and their correlation with RA activity.

MATERIAL AND METHODS

Rheumatoid arthritis patients who presented at a rheumatology clinic were selected consecutively. The diagnosis of RA was confirmed by the ACR/EULAR criteria, disease activity was assessed by Disease Activity Score based on the 28-joint count (DAS28) and patients with DAS28 > 2.6 were considered to have active RA. The diagnosis of depression and anxiety was made by the Hospital Anxiety and Depression Scale (HADS). The Pearson test was used to determine the correlation between DAS28 and HADS scores.

RESULTS

Two-hundred patients (female, 82%) with a mean age of 53.5 ±10.1 years and mean disease duration of 6.6 ±6.8 years were studied. Depression was diagnosed in 27 (13.5%) patients and anxiety in 38 (19%) patients. The DAS28 score correlated positively with depression (r = 0.173, p = 0.014) and anxiety score (r = 0.229, p = 0.001). In multiple logistic regression analysis after adjustment for all covariates, age < 40 years and female sex were independently associated with RA activity in patients with depression, with OR = 4.21 (p = 0.002) and OR = 3.56 (p = 0.028) respectively.

CONCLUSIONS

These findings indicate that depression and anxiety are prevalent in RA and correlate positively with active disease in particular in depressive female patients aged < 40 years.

Assessment of Bidirectional Relationships between Mental Illness and Rheumatoid Arthritis: A Two-Sample Mendelian Randomization Study

A correlation between mental illness and systemic rheumatoid arthritis (RA) has been observed in several prior investigations. However, little is known about the causative relationship between them. The present study aimed to systematically investigate the potential association between genetically determined mental illness and RA. Two-sample bidirectional Mendelian randomization (MR) analysis was performed using publicly released genome-wide association studies (GWAS). We selected independent genetic variants associated with four mental illnesses (bipolar disorder, broad depression, major depression, and anxiety) as instrumental variables. The inverse variance weighted (IVW) method was used as the primary analysis to assess the causal relationship between mental illness and RA. Results of the IVW analysis suggested that genetic predisposition to bipolar disorder was associated with a decreased risk of RA (odds ratio [OR] = 0.825, 95% CI = 0.716 to 0.95, p = 0.007). Furthermore, we did not find a significant causal effect of RA on bipolar disorder in the reverse MR analysis (p > 0.05). In addition, our study found no evidence of a bidirectional causal relationship between genetically predicted broad depression, major depression, anxiety, and RA (p > 0.05). The genetically proxied bipolar disorder population has a lower RA risk, which may indicate that there is a hidden mechanism for inhibiting the pathogenesis of RA in bipolar disorder. However, results do not support a causal connection between depression, anxiety, and RA.

From Low-Grade Inflammation in Osteoarthritis to Neuropsychiatric Sequelae: A Narrative Review

Nowadays, osteoarthritis (OA), a common, multifactorial musculoskeletal disease, is considered to have a low-grade inflammatory pathogenetic component. Lately, neuropsychiatric sequelae of the disease have gained recognition. However, a link between the peripheral inflammatory process of OA and the development of neuropsychiatric pathology is not completely understood. In this review, we provide a narrative that explores the development of neuropsychiatric disease in the presence of chronic peripheral low-grade inflammation with a focus on its signaling to the brain. We describe the development of a pro-inflammatory environment in the OA-affected joint. We discuss inflammation-signaling pathways that link the affected joint to the central nervous system, mainly using primary sensory afferents and blood circulation via circumventricular organs and cerebral endothelium. The review describes molecular and cellular changes in the brain, recognized in the presence of chronic peripheral inflammation. In addition, changes in the volume of gray matter and alterations of connectivity important for the assessment of the efficacy of treatment in OA are discussed in the given review. Finally, the narrative considers the importance of the use of neuropsychiatric diagnostic tools for a disease with an inflammatory component in the clinical setting.

Pathway Phenotypes Underpinning Depression, Anxiety, and Chronic Fatigue Symptoms Due to Acute Rheumatoid Arthritis: A Precision Nomothetic Psychiatry Analysis

Rheumatoid arthritis (RA) is a chronic inflammatory and autoimmune disorder which affects the joints in the wrists, fingers, and knees. RA is often associated with depressive and anxiety symptoms as well as chronic fatigue syndrome (CFS)-like symptoms. This paper examines the association between depressive symptoms (measured with the Beck Depression Inventory, BDI), anxiety (Hamilton Anxiety Rating Scale, HAMA), CFS-like (Fibro-fatigue Scale) symptoms and immune-inflammatory, autoimmune, and endogenous opioid system (EOS) markers, and lactosylcer-amide (CD17) in RA. The serum biomarkers were assayed in 118 RA and 50 healthy controls. Results were analyzed using the new precision nomothetic psychiatry approach. We found significant correlations between the BDI, FF, and HAMA scores and severity of RA, as assessed with the DAS28-4, clinical and disease activity indices, the number of tender and swollen joints, and patient and evaluator global assessment scores. Partial least squares analysis showed that 69.7% of the variance in this common core underpinning psychopathology and RA symptoms was explained by immune-inflammatory pathways, rheumatoid factor, anti-citrullinated protein antibodies, CD17, and mu-opioid receptor levels. We constructed a new endophenotype class comprising patients with very high immune-inflammatory markers, CD17, RA, affective and CF-like symptoms, and tobacco use disorder. We extracted a reliable and replicable latent vector (pathway phenotype) from immune data, psychopathology, and RA-severity scales. Depression, anxiety, and CFS-like symptoms due to RA are manifestations of the phenome of RA and are mediated by the effects of the same immune-inflammatory, autoimmune, and other pathways that underpin the pathophysiology of RA.

Quality of life and life-space mobility after total knee arthroplasty in patients with rheumatoid arthritis: a pilot case-controlled study

[Purpose] The purpose of this study was to identify factors inhibiting improvement in the quality of life after total knee arthroplasty in patients with rheumatoid arthritis. [Participants and Methods] This was a pilot case-control study. The sample comprised of five participants with rheumatoid arthritis and 11 participants with osteoarthritis, who underwent total knee arthroplasty. We compared the groups in terms of physical function, walking ability, Japanese Knee Osteoarthritis Measure, and Life-Space Assessment. Measurements were taken before surgery and at four weeks and five months post-surgery. All patients underwent rehabilitation for five months postoperatively, first as inpatients, and then as outpatients after discharge. [Results] In the period from 4 weeks to 5 months post-surgery, physical function improved similarly in both groups in terms of muscle strength and walking ability. Despite the patients with rheumatoid arthritis being younger, their self-health assessment score by the Japanese Knee Osteoarthritis Measure and measures of life-space mobility by Life-Space Assessment were lower. [Conclusion] It is important to consider exercise therapy, and gait instruction to alleviate anxiety about health status and improve the quality of life and life-space mobility in patients with rheumatoid arthritis who undergo total knee arthroplasty.

Psychological Backgrounds of Medically Compromised Patients and Its Implication in Dentistry: A Narrative Review

The number of medically compromised dental patients is increasing every year with the increase in the super-aged population. Many of these patients have underlying psychiatric problems and diseases, which need to be recognized by dental professionals for better treatment outcomes. The aim of this narrative review article is to summarize the psychological and psychiatric backgrounds of medically compromised patients who are frequently visited and taken care of by dentists using findings from recent systematic reviews and meta-analyses. Anxiety and symptoms of depression, post-traumatic stress disorders, panic disorders, poor cognitive functions, and poor quality of life were some of the common psychological backgrounds in medically compromised patients. Additionally, the consequences of these psychological problems and the considerations that need to be taken by the dentist while treating these patients have been discussed. Dental professionals should be aware of and recognize the different psychological backgrounds of medically compromised dental patients in order to provide appropriate dental treatment and to prevent oral conditions from worsening.

Ideational Fluency in Patients with Rheumatoid Arthritis

BACKGROUND

Neuropsychiatric symptoms have been well documented in several systemic inflammatory conditions, for example, systemic lupus erythematosus (SLE). Increased prevalence of cognitive decline and psychiatric issues has been reported in patients with rheumatoid arthritis (RA). However, there is limited evidence of which exact cognitive domains are affected and to what degree.

AIM

To test the performance of cognition in the domain of ideational fluency (Thing Categories Test in particular) in patients with RA and compare the results with the general population and to the results with cognitive and depression screening scores in both groups.

METHODS

Patient Health Questionnaire 9 (PHQ-9), Generalized Anxiety Disorder 7 (GAD-7) assessment, Montreal Cognitive Assessment (MoCA), and Thing Categories Test (TCT) were used to evaluate patients with RA, as well as the control group.

RESULTS

Twenty patients with RA and 20 controls were tested, with 7 and 4 men, and 13 and 16 women in the study and control group, respectively. Average scores in TCT at three minutes were 7.50 (IQR6.0-10.0) and 6.0 (IQR3.0-8.0) for category "blue"; 17.50 (IQR15.0-19.0) and 16.0 (10.0-18.0) for category "round" in the control and study group, respectively. A statistically significant difference was established between the study and the control group in TCT for the category "blue" (p<0.025). The average score for GAD7 was 2.0 (IQR 0.0-5.75) and 3.0 (IQR0.50-6.00) in the control and study group, respectively. The average score for PHQ-9 was 2.0 (IQR0.25-4.75) and 4.0 (IQR2.00-5.50) in the control and study group, respectively. Finally, the average score for the MoCA scale was 27.0 (IQR25.25-28.00) and 26.0 (IQR23.50-28.00) in the control and study group, respectively.

CONCLUSION

Preliminary evidence suggests that RA at least partially affects the cognitive domain of ideational fluency. However, further research with larger experimental groups is needed to provide more conclusive evidence.

Mapping publication status and exploring hotspots in a research field: Rheumatoid arthritis with depression

AIM

To make a bibliometric analysis of the current research status and hot spots in the field of rheumatoid arthritis (RA) -related depression.

DESIGN

Systematic review.

METHODS

Based on the Web of Science database, studies in the past 5 years from 1 January 2015-5 November 2019 have been included. Data were analysed from annual number of published papers, main research institutions, core authors, core teams and research topics by using bibliometric approaches.

RESULTS

Related papers (N = 1,073) were obtained. The field of RA-related depression is in a stable development stage, forming core authors and core teams. The epidemiological characteristics, influencing factors, prediction effect and the intervention of RA-related depression are common research directions and themes. The common role of auto-antibodies and inflammatory factors in the development of RA and depression, the risk of cardiovascular events and disease burden caused by RA-related depression are newly emerging research topics.

CONCLUSION

The RA-related depression has been widely concerned by scholars and the research field is gradually mature. However, the research on the prevention and intervention of RA-related depression is still wanting, which needs to be strengthened. WHERE AND ON WHOM WILL THE RESEARCH HAVE AN IMPACT?: The research revealed the most popular institutions, authors, research teams, emerging issues and 'hot topics' in the RA-related depression field, which might suggest avenues for future research in this field.

The association between anxiety and disease activity and quality of life in rheumatoid arthritis: a systematic review and meta-analysis

OBJECTIVES

In people with rheumatoid arthritis (RA), mental health problems are common, but often not recognized or treated, contributing to increased morbidity and mortality. Most studies examining the impact of mental health problems in RA have focused on depression. We aimed to determine the association between anxiety, and disease activity and quality of life (QoL) in people with RA.

METHODS

A systematic review and meta-analysis were performed. A protocol was registered with PROSPERO (CRD2-17062580). Databases (Web of Science, PsycINFO, CINAHL, Embase, Medline) were searched for studies examining the association between anxiety and disease activity and QoL, in adults with RA, from inception to February 2019. Primary outcome measures were DAS28 and SF-36. Eligibility screening and data extraction were completed by two reviewers. Disagreements were resolved by discussion or a third reviewer. Quality assessment was carried out using the Newcastle-Ottawa Scale.

RESULTS

From 7712 unique citations, 60 articles were assessed for eligibility. The final review included 20 studies involving 7452 people with RA (14 cross-sectional, 6 cohort). Eleven examined disease activity, 6 reported QoL outcome measures and 3 included both. Anxiety was associated with increased disease activity and worse QoL. Meta-analysis showed anxiety to be correlated with increased DAS28 scores (r = 0.23, CI 0.14, 0.31) and reduced physical (r = - 0.39, CI - 0.57, - 0.20) and mental QoL (- 0.50, CI - 0.57, - 0.43).

CONCLUSIONS

Anxiety in people with RA is associated with increased disease activity and worse QoL. Improved recognition and management of comorbid anxiety may help to improve outcomes for people with RA.Key Points• This is the first systematic review and meta-analysis to examine the relationship between anxiety and disease activity and QoL in people with RA.• Anxiety was associated with higher disease activity both cross-sectionally and at up to 12-month follow-up.• Anxiety may have a more significant impact on disease activity in early RA, highlighting the importance of early recognition and management of comorbid anxiety.• People with anxiety had poorer self-reported physical and mental QoL, although there was some heterogeneity in study findings, particularly for physical QoL (I² = 78.5%).