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Rheumatoid Arthritis May Have Strong, Early Links to Depression and Anxiety

Monitoring newly diagnosed RA patients for psychiatric comorbidities may help reduce any situational or long-term anxiety and depression.

with Kevin Byram, MD

Depression and anxiety are common comorbidities in people living with rheumatoid arthritis (RA), with perhaps as many as 16.8% of people with RA experiencing major depressive disorder (MDD) and 25 to 46% living with anxiety.1,2 In addition, depression in this population is associated with poorer outcomes.1

To explore these associations, a group of UK researchers examined a cohort of patients with early RA, tracking the course of the disease and mental health status for 1 year from baseline.

In the study cohort of individuals with rheumatoid arthritis, the prevalence of depression was 13% and the prevalence of anxiety was 19%.

Tracking Depression and Anxiety in People with Rheumatoid Arthritis

The study, published in RMD Open in October 2020, recruited patients from the Scottish Early Rheumatoid Arthritis (SERA) inception cohort.2 The cohort included patients with new-onset RA who were treated in secondary-care rheumatology clinics in Scotland between 2011 and 2015. Assessments were recorded from the baseline visit, and again at 6-month and 12-month follow-ups.

At each visit, participants completed the Hospital Anxiety and Depression scale (HADS). (Researchers analyzed data on anxiety and depression separately.) Disease activity scores were measured using Disease Activity Score-18 (DAS28) and the Patient Global Assessment Visual Analog Scale (PGA-VAS). The Health Assessment Questionnaire (HAQ) was used to measure functional status.

Disease activity was recorded using C-reactive protein (CRP) levels, erythrocyte sedimentation (ERS) rate, and rheumatoid factor (RF) status. The analysis included 848 subjects at baseline, 70% of whom were female. At 6-month follow-up, 691 patients remained; at 12 months, 618 patients remained. Researchers looked at the difference between baseline and final scores and compared depression scores with disease activity scores.

Anxiety and Depression at Highest in Patients with Early Rheumatoid Arthritis

In this cohort, the prevalence of depression was 13% – which is toward the low end of averages in published studies on RA and depression, although the team pointed out in their paper that different methods of assessing depression make comparisons difficult.2 The prevalence of anxiety was 19%, also a bit lower than in other published studies, which, as noted, average from 25 to 46%.

The UK team reported that depression and anxiety scores decreased over the 12-month study period. While their study offered no clues as to the reason for the decrease, the researchers did speculate that it may have to do with better control of the disease and less inflammation. Indeed, they determined that depression was correlated with disease activity, although the correlation with anxiety was weaker. For example, CRP was associated with depression (but not anxiety) at all points in the study. The researchers thus suggested “a close relationship between inflammation and depression.”2

They also pointed to a “complex interplay between depression and RA,” noting that prior studies have suggested “shared inflammatory pathways.” In addition to recommending further studies, they noted that “clinicians should be alert to neuro-psychiatric comorbidity in RA from the earliest stages of the disease when the prevalence and levels of depression and anxiety appear to be highest.”2

Practical Takeaways

Consider that Pain and Function Loss May Lead to Situational Anxiety and Depression

Kevin Byram, MD, assistant professor of medicine in the Division of Rheumatology and Immunology, and associate director of the Rheumatology Training Program at Vanderbilt University Medical Center, agrees that the relationship between depression and rheumatoid arthritis is complex.

“It’s difficult to pin down whether some of these inflammatory cytokines like C-reactive protein might contribute to some anxiety and depression in and of themselves,” he told PPM. “It’s a very tough thing to sort out scientifically, and I think we're in the infancy of understanding that.” However, Dr. Byram also points out that there is likely some situational anxiety and depression related to the loss of function and chronic pain.

Shoot for Baseline

Whether the depression is situational or due to a not yet fully understood relationship between inflammation and depression, this study indicates that the best approach for now is to treat the RA aggressively. “The goal in an early patient with rheumatoid arthritis is to get them back to baseline,” he suggests. “Zero swollen joints, zero tender joints, baseline function…Many times if you can do that, the patient clearly feels better, lives a more fulfilling life, and can cope a little bit better.”



Last updated on: February 19, 2021
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