Impact and Prevalence of Depression and Anxiety in Rheumatoid Arthritis—A Cross-Sectional Study with Self-Reported Questionnaires
Abstract
:1. Introduction
2. Materials and Methods
2.1. Patients
2.2. RA Evaluation
2.3. Depression Questionnaires
2.4. Statistics
3. Results
4. Discussion
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
Abbreviations
RA | Rheumatoid arthritis |
HADS | Hospital Anxiety and Depression Scale |
PHQ9 | Patient Health Questionnaire |
HADS-D | Hospital Anxiety and Depression Scale—Depression subscale |
HADS-A | Hospital Anxiety and Depression Scale—Anxiety subscale |
DAS28 | Disease Activity Score—28 joints count |
VAS | Visual analogue scale |
ESR | Erythrocyte sedimentation rate |
CRP | C reactive protein |
DSM | Diagnostic and Statistical Manual of Mental Disorders |
ICD | International Classification of Diseases |
IDD | Inventory to Diagnose Depression |
CESD | Center for Epidemiological Studies Depression Scale |
BDI | Beck Depression Inventory |
GDS | Geriatric Depression Scale |
cs/b/ts DMARD | Conventional synthetics/biologics/targeted synthetics Disease-modifying antirheumatic drugs |
ACPA | Anti-citrullinated protein antibodies |
TJC | Tender joint count |
SJC | Swollen joint count |
SRPC | Steinbrocker radiographic progression |
SFCC | Steinbrocker functional capacity class |
IQR | Interquartile range |
SD | Standard deviation |
PtGA | Patient global assessment |
References
- Smolen, J.S.; Aletaha, D.; McInnes, I.B. Rheumatoid arthritis. Lancet 2016, 388, 2023–2038. [Google Scholar] [CrossRef]
- Dougados, M.; Soubrier, M.; Antunez, A.; Balint, P.; Balsa, A.; Buch, M.H.; Casado, G.; Detert, J.; El-Zorkany, B.; Emery, P.; et al. Prevalence of comorbidities in rheumatoid arthritis and evaluation of their monitoring: Results of an international, cross-sectional study (COMORA). Ann. Rheum. Dis. 2014, 73, 62–68. [Google Scholar] [CrossRef]
- Matcham, F.; Rayner, L.; Steer, S.; Hotopf, M. The prevalence of depression in rheumatoid arthritis: A systematic review and meta-analysis. Rheumatology 2013, 52, 2136–2148. [Google Scholar] [CrossRef] [PubMed]
- Withers, M.H.; Gonzalez, L.T.; Karpouzas, G.A. Identification and Treatment Optimization of Comorbid Depression in Rheumatoid Arthritis. Rheumatol. Ther. 2017, 4, 281–291. [Google Scholar] [CrossRef] [PubMed]
- Morf, H.; da Rocha Castelar-Pinheiro, G.; Vargas-Santos, A.B.; Baerwald, C.; Seifert, O. Impact of clinical and psychological factors associated with depression in patients with rheumatoid arthritis: Comparative study between Germany and Brazil. Clin. Rheumatol. 2021, 40, 1779–1787. [Google Scholar] [CrossRef] [PubMed]
- Spitzer, R.L.; Kroenke, K.; Williams, J.B.; Löwe, B. A brief measure for assessing generalized anxiety disorder: The GAD-7. Arch. Intern. Med. 2006, 166, 1092–1097. [Google Scholar] [CrossRef]
- Rayner, L.; Matcham, F.; Hutton, J.; Stringer, C.; Dobson, J.; Steer, S.; Hotopf, M. Embedding integrated mental health assessment and management in general hospital settings: Feasibility, acceptability and the prevalence of common mental disorder. General. Hosp. Psychiatry 2014, 36, 318–324. [Google Scholar] [CrossRef]
- Javaid, S.F.; Hashim, I.J.; Hashim, M.J.; Stip, E.; Samad, M.A.; Ahbabi, A.A. Epidemiology of anxiety disorders: Global burden and sociodemographic associations. Middle East. Curr. Psychiatry 2023, 30, 44. [Google Scholar] [CrossRef]
- Yılmaz, V.; Umay, E.; Gündoğdu, İ.; Karaahmet, Z.; Öztürk, A.E. Rheumatoid Arthritis: Are psychological factors effective in disease flare? Eur. J. Rheumatol. 2017, 4, 127–132. [Google Scholar] [CrossRef]
- Matcham, F.; Norton, S.; Scott, D.L.; Steer, S.; Hotopf, M. Symptoms of depression and anxiety predict treatment response and long-term physical health outcomes in rheumatoid arthritis: Secondary analysis of a randomized controlled trial. Rheumatology 2016, 55, 268–278. [Google Scholar] [CrossRef] [PubMed]
- Ang, D.C.; Choi, H.; Kroenke, K.; Wolfe, F. Comorbid depression is an independent risk factor for mortality in patients with rheumatoid arthritis. J. Rheumatol. 2005, 32, 1013–1019. [Google Scholar]
- Joyce, A.T.; Smith, P.; Khandker, R.; Melin, J.M.; Singh, A. Hidden cost of rheumatoid arthritis (RA): Estimating cost of comorbid cardiovascular disease and depression among patients with RA. J. Rheumatol. 2009, 36, 743–752. [Google Scholar] [CrossRef] [PubMed]
- Kekow, J.; Moots, R.; Khandker, R.; Melin, J.; Freundlich, B.; Singh, A. Improvements in patient-reported outcomes, symptoms of depression and anxiety, and their association with clinical remission among patients with moderate-to-severe active early rheumatoid arthritis. Rheumatology 2011, 50, 401–409. [Google Scholar] [CrossRef]
- Qiu, X.J.; Zhang, X.L.; Cai, L.S.; Yan, C.; Yu, L.; Fan, J.; Zhang, R.W.; Huang, J.W.; Duan, X.W. Rheumatoid arthritis and risk of anxiety: A meta-analysis of cohort studies. Clin. Rheumatol. 2019, 38, 2053–2061. [Google Scholar] [CrossRef] [PubMed]
- Hotopf, M.; Chidgey, J.; Addington-Hall, J.; Ly, K.L. Depression in advanced disease: A systematic review Part 1. Prevalence and case finding. Palliat. Med. 2002, 16, 81–97. [Google Scholar] [CrossRef]
- Matcham, F.; Rayner, L.; Steer, S.; Hotopf, M. The prevalence of depression in rheumatoid arthritis: A systematic review and meta-analysis: Reply. Rheumatology 2014, 53, 578–579. [Google Scholar] [CrossRef]
- Aletaha, D.; Neogi, T.; Silman, A.J.; Funovits, J.; Felson, D.T.; Bingham, C.O., 3rd; Birnbaum, N.S.; Burmester, G.R.; Bykerk, V.P.; Cohen, M.D.; et al. 2010 Rheumatoid arthritis classification criteria: An American College of Rheumatology/European League Against Rheumatism collaborative initiative. Arthritis Rheum. 2010, 62, 2569–2581. [Google Scholar] [CrossRef]
- Steinbrocker, O.; Traeger, C.H.; Batterman, R.C. Therapeutic criteria in rheumatoid arthritis. J. Am. Med. Assoc. 1949, 140, 659–662. [Google Scholar] [CrossRef]
- Fransen, J.; van Riel, P.L. The Disease Activity Score and the EULAR response criteria. Rheum. Dis. Clin. N. Am. 2009, 35, 745–757, vii–viii. [Google Scholar] [CrossRef]
- Prevoo, M.L.; van ’t Hof, M.A.; Kuper, H.H.; van Leeuwen, M.A.; van de Putte, L.B.; van Riel, P.L. Modified disease activity scores that include twenty-eight-joint counts. Development and validation in a prospective longitudinal study of patients with rheumatoid arthritis. Arthritis Rheum. 1995, 38, 44–48. [Google Scholar] [CrossRef]
- Spitzer, R.L.; Kroenke, K.; Williams, J.B. Validation and utility of a self-report version of PRIME-MD: The PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire. JAMA 1999, 282, 1737–1744. [Google Scholar] [CrossRef]
- Zigmond, A.S.; Snaith, R.P. The hospital anxiety and depression scale. Acta Psychiatr. Scand. 1983, 67, 361–370. [Google Scholar] [CrossRef] [PubMed]
- Žagar, I.; Delimar, V.; Pap, M.; Perić, D.; Laktašić Žerjavić, N.; Perić, P. Prevalence and Correlation of Depressive Symptoms with Functional Scores, Therapy and Disease Activity among Croatian Patients with Rheumatoid Arthritis: A Preliminary Study. Psychiatr. Danub. 2018, 30, 452–458. [Google Scholar] [CrossRef] [PubMed]
- Overman, C.L.; Bossema, E.R.; van Middendorp, H.; Wijngaards-de Meij, L.; Verstappen, S.M.; Bulder, M.; Jacobs, J.W.; Bijlsma, J.W.; Geenen, R. The prospective association between psychological distress and disease activity in rheumatoid arthritis: A multilevel regression analysis. Ann. Rheum. Dis. 2012, 71, 192–197. [Google Scholar] [CrossRef] [PubMed]
- Kuriya, B.; Joshi, R.; Movahedi, M.; Rampakakis, E.; Sampalis, J.S.; Bombardier, C. High Disease Activity Is Associated with Self-reported Depression and Predicts Persistent Depression in Early Rheumatoid Arthritis: Results from the Ontario Best Practices Research Initiative. J. Rheumatol. 2018, 45, 1101–1108. [Google Scholar] [CrossRef]
- Fragoulis, G.E.; Cavanagh, J.; Tindell, A.; Derakhshan, M.; Paterson, C.; Porter, D.; McInnes, I.B.; Siebert, S. Depression and anxiety in an early rheumatoid arthritis inception cohort. associations with demographic, socioeconomic and disease features. RMD Open 2020, 6, e001376. [Google Scholar] [CrossRef]
- Machin, A.R.; Babatunde, O.; Haththotuwa, R.; Scott, I.; Blagojevic-Bucknall, M.; Corp, N.; Chew-Graham, C.A.; Hider, S.L. The association between anxiety and disease activity and quality of life in rheumatoid arthritis: A systematic review and meta-analysis. Clin. Rheumatol. 2020, 39, 1471–1482. [Google Scholar] [CrossRef]
- Manning-Bennett, A.T.; Hopkins, A.M.; Sorich, M.J.; Proudman, S.M.; Foster, D.J.R.; Abuhelwa, A.Y.; Wiese, M.D. The association of depression and anxiety with treatment outcomes in patients with rheumatoid arthritis—A pooled analysis of five randomised controlled trials. Ther. Adv. Musculoskelet. Dis. 2022, 14, 1759720X221111613. [Google Scholar] [CrossRef]
- Michelsen, B.; Kristianslund, E.K.; Sexton, J.; Hammer, H.B.; Fagerli, K.M.; Lie, E.; Wierod, A.; Kalstad, S.; Rodevand, E.; Kroll, F.; et al. Do depression and anxiety reduce the likelihood of remission in rheumatoid arthritis and psoriatic arthritis? Data from the prospective multicentre NOR-DMARD study. Ann. Rheum. Dis. 2017, 76, 1906–1910. [Google Scholar] [CrossRef]
- Matcham, F.; Ali, S.; Irving, K.; Hotopf, M.; Chalder, T. Are depression and anxiety associated with disease activity in rheumatoid arthritis? A prospective study. BMC Musculoskelet. Disord. 2016, 17, 155. [Google Scholar] [CrossRef] [PubMed]
- Boer, A.C.; Huizinga, T.W.J.; van der Helm-van Mil, A.H.M. Depression and anxiety associate with less remission after 1 year in rheumatoid arthritis. Ann. Rheum. Dis. 2019, 78, e1. [Google Scholar] [CrossRef] [PubMed]
- Lisitsyna, T.A.; Veltishchev, D.; Gerasimov, A.; Seravina, O.; Kovalevskaya, O.; Zeltyn, A.; Novikova, D.; Novikov, A.; Alexandrova, E.; Smirnov, A.; et al. AB0395 Depression as a Risk Factor for Joints Destruction in Rheumatoid Arthritis Patients. Ann. Rheum. Dis. 2015, 74, 1025. [Google Scholar] [CrossRef]
- Kronisch, C.; McLernon, D.J.; Dale, J.; Paterson, C.; Ralston, S.H.; Reid, D.M.; Tierney, A.; Harvie, J.; McKay, N.; Wilson, H.E.; et al. Brief Report: Predicting Functional Disability: One-Year Results From the Scottish Early Rheumatoid Arthritis Inception Cohort. Arthritis Rheumatol. 2016, 68, 1596–1602. [Google Scholar] [CrossRef] [PubMed]
- Kwiatkowska, B.; Kłak, A.; Maślińska, M.; Mańczak, M.; Raciborski, F. Factors of depression among patients with rheumatoid arthritis. Reumatologia 2018, 56, 219–227. [Google Scholar] [CrossRef]
women | 92.3% | CRP (mg/L) median (IQR) | 4.7 (9.3) |
age (y) mean (SD) | 62.1 (11.5) | ESR (mm/h) mean (SD) | 28.5 (20.1) |
RA duration (y) mean (SD) | 11.1 (9.9) | TJC28 median (IQR) | 3 (5) |
RF positive | 70.3% | SJC28 median (IQR) | 1 (3) |
ACPA positive | 75.6% | PtGA (mm) mean (SD) | 42 (25) |
RF and ACPA positive | 64.6% | DAS28 * mean (SD) | 3.5 (1.5) |
SRPC1 | 24.4% | DAS28 remission | 30.1% |
SRPC2 | 44.0% | DAS28 LDA | 17.7% |
SRPC3 | 18.2% | DAS28 MDA | 34.4% |
SRPC4 | 13.4% | DAS28 HDA | 17.7% |
SFCC1 | 21.5% | ≥1 csDMARDs | 90.9% |
SFCC2 | 58.4% | b/tsDMARD | 41.6% |
SFCC3 | 19.1% | glucocorticoids | 34.9% |
SFCC4 | 1.0% |
depression history | 10.0% | HADS-D mean (SD) | 6.3 (4.0) |
anxiety history | 8.1% | HADS-D > 10 | 14.8% |
antidepressants | 7.7% | HADS-D normal | 64.6% |
PHQ9 mean (SD) | 8.1 (4.9) | HADS-D borderline | 21.1% |
PHQ9 ≥ 10 | 34.4% | HADS-D abnormal | 14.4% |
PHQ9-DS: none/minimal | 27.3% | HADS-A | 8.6 (4.4) |
PHQ9-DS: mild | 38.3% | HADS-A > 10 | 32.5% |
PHQ9-DS: moderate | 25.4% | HADS-A normal | 40.2% |
PHQ9-DS: moderate-severe | 8.1% | HADS-A borderline | 26.8% |
PHQ9-DS: severe | 0.5% | HADS-A abnormal | 33.0% |
PHQ9<10 (n = 137) | PHQ9≥10 (n = 72) | p | HADS-D ≤10 (n = 178) | HADS-D >10 (n = 31) | p | HADS-A ≤10 (n = 141) | HADS-A >10 (n = 68) | p | |
---|---|---|---|---|---|---|---|---|---|
women | 90.5% | 95.8% | 0.169 | 91.6% | 96.8% | 0.315 | 88.7% | 100% | 0.004 |
age (y) mean (SD) | 61.5 (11.8) | 61.9 (11.0) | 0.646 | 61.2 (11.6) | 63.7 (11.0) | 0.339 | 61.0 (11.7) | 62.8 (11.2) | 0.289 |
RA duration (y) mean (SD) | 10.5 (8.9) | 11.5 (10.4) | 0.418 | 10.0 (8.4) | 15.2 (13.1) | 0.028 | 10.3 (8.6) | 11.9 (10.9) | 0.157 |
RF + | 71.3% | 70.4% | 0.892 | 70.5% | 74.2% | 0.672 | 70.5% | 72.1% | 0.817 |
ACPA + | 75.0% | 78.9% | 0.534 | 75.0% | 83.9% | 0.284 | 75.5% | 77.9% | 0.703 |
RF, ACPA + | 62.8% | 68.1% | 0.448 | 62.9% | 74.2% | 0.226 | 63.1% | 67.6% | 0.521 |
CRP (mg/L) median (IQR) | 4.4 (8.1) | 6.2 (14.1) | 0.094 | 4.6 (9.0) | 5.6 (21.8) | 0.119 | 4.3 (8.5) | 6.3 (11.7) | 0.183 |
ESR (mm/h) mean (SD) | 26.3 (18.9) | 31.9 (20.5) | 0.112 | 26.3 (22.5) | 38.7 (22.9) | 0.012 | 26.6 (18.6) | 31.4 (21.1) | 0.085 |
TJC median (IQR) | 2 (6) | 4 (7) | 0.000 | 2 (6) | 6 (6) | 0.000 | 2 (6) | 4 (6) | 0.025 |
SJC median (IQR) | 0 (3) | 2 (4) | 0.006 | 0 (3) | 3 (5) | 0.006 | 0 (3) | 1 (4) | 0.216 |
PtGA (mm) mean (SD) | 36 (24) | 54 (24) | 0.000 | 40 (26) | 57 (19) | 0.001 | 40 (26) | 46 (24) | 0.169 |
DAS28 * mean (SD) | 3.2 (1.4) | 4.1 (1.4) | 0.000 | 3.4 (1.4) | 4.5 (1.3) | 0.000 | 3.4 (1.5) | 3.8 (1.4) | 0.130 |
≥1 csDMARDs | 89.8% | 93.1% | 0.631 | 90.4% | 93.5% | 0.815 | 92.2% | 88.2% | 0.607 |
b/tsDMARD | 43.1% | 38.9% | 0.560 | 39.9% | 51.6% | 0.222 | 41.1% | 42.6% | 0.835 |
glucocorticoids | 29.9% | 44.4% | 0.036 | 33.7% | 41.9% | 0.375 | 31.9% | 41.2% | 0.188 |
PHQ9 | HADS-D | HADS-A | ||
---|---|---|---|---|
sex | women | 8.3 (4.9) | 6.3 (4.0) | 8.9 (4.5) |
men | 5.2 (3.5) | 5.6 (3.8) | 5.5 (2.8) | |
p | 0.013 | 0.466 | 0.003 | |
RF | negative | 8.1 (4.3) | 5.9 (3.7) | 8.6 (4.0) |
positive | 8.1 (5.1) | 6.4 (4.1) | 8.7 (4.6) | |
p | 0.973 | 0.419 | 0.888 | |
ACPA | negative | 7.6 (4.4) | 5.9 (3.6) | 8.5 (4.5) |
positive | 8.2 (5.0) | 6.4 (4.1) | 8.7 (4.4) | |
p | 0.461 | 0.434 | 0.789 | |
Steinbrocker radiographic stage | 1 | 5 (5) | 4 (4) | 7 (6) |
2 | 8 (8) | 6 (4) | 9 (8) | |
3 | 9 (6) | 8 (7) | 10 (7) | |
4 | 7 (6) | 8 (7) | 8 (8) | |
p | 0.011 | 0.009 | 0.045 | |
Steinbrocker functional stage | 1 | 5 (5) | 4 (5) | 6 (6) |
2 | 7 (8) | 6 (6) | 9 (7) | |
3 | 9 (7) | 9 (6) | 10 (8) | |
4 | 11 (5) | 9 (7) | 17 (4) | |
p | 0.001 | 0.000 | 0.005 | |
RA disease activity * | remission | 6 (5) | 4 (5) | 7 (7) |
low | 8 (9) | 5 (5) | 8 (8) | |
moderate | 8 (7) | 6 (6) | 9 (6) | |
high | 10 (9) | 9 (6) | 10 (6) | |
p | 0.000 | 0.000 | 0.058 | |
b/tsDMARD | no | 8.3 (4.8) | 6.2 (3.8) | 8.5 (4.3) |
yes | 7.8 (4.9) | 6.3 (4.2) | 8.8 (4.6) | |
p | 0.339 | 0.929 | 0.619 | |
glucocorticoids | no | 7.8 (5.1) | 5.8 (3.9) | 8.2 (4.5) |
yes | 8.6 (4.4) | 6.2 (4.0) | 9.4 (4.3) | |
p | 0.175 | 0.018 | 0.074 |
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Ionescu, C.-E.; Popescu, C.C.; Codreanu, C. Impact and Prevalence of Depression and Anxiety in Rheumatoid Arthritis—A Cross-Sectional Study with Self-Reported Questionnaires. J. Clin. Med. 2025, 14, 1718. https://doi.org/10.3390/jcm14051718
Ionescu C-E, Popescu CC, Codreanu C. Impact and Prevalence of Depression and Anxiety in Rheumatoid Arthritis—A Cross-Sectional Study with Self-Reported Questionnaires. Journal of Clinical Medicine. 2025; 14(5):1718. https://doi.org/10.3390/jcm14051718
Chicago/Turabian StyleIonescu, Cătălina-Elena, Claudiu C. Popescu, and Cătălin Codreanu. 2025. "Impact and Prevalence of Depression and Anxiety in Rheumatoid Arthritis—A Cross-Sectional Study with Self-Reported Questionnaires" Journal of Clinical Medicine 14, no. 5: 1718. https://doi.org/10.3390/jcm14051718
APA StyleIonescu, C.-E., Popescu, C. C., & Codreanu, C. (2025). Impact and Prevalence of Depression and Anxiety in Rheumatoid Arthritis—A Cross-Sectional Study with Self-Reported Questionnaires. Journal of Clinical Medicine, 14(5), 1718. https://doi.org/10.3390/jcm14051718