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People with Rheumatoid Arthritis Should be Assessed for Anxiety, Depression as Pandemic Continues

April 2, 2021
Studies point to increased links between chronic illness and mental health balance.

with Don L. Goldenberg MD

While the ongoing COVID-19 pandemic continues to challenge the mental health of the population at large, providers should be especially attuned to patients with rheumatoid arthritis (RA) as new data shows they may be at increased risk for anxiety and depression.

“Patients with RA have a greater risk of infection due to immune dysregulation, immunosuppressive therapy, and older age on average,” and therefore may be more anxious about COVID-19 than the general population, wrote Takahiro Itaya, MD, lead author of a new study based at Kyoto University in Japan.

Patients with chronic diseases, such as rheumatoid arthritis, already have increased risk of mood disorders, so they are especially prone to increase in mood disorders during the pandemic. (Image: iStock)

In a Letter to the Editor published in Rheumatology,  Dr. Itaya’s team shared findings identified from 108 RA outpatients who had enrolled in a large cohort study between May 1, 2019, and August 31, 2020. Anxiety and depression were measured using the Hospital Anxiety and Depression Scale (HADS). The average age of the patients was 66 years and 87% were women. Their average disease duration was 15 years. In terms of prescribed medications for RA, 57 patients were using biologics, 71 were using methotrexate, and 25 were using glucocorticoids.

Overall, 9% of the participants reported definite anxiety before the pandemic in 2019, with an increase to 12% in 2020. In addition, 8% of the patients reported “doubtful anxiety” (suspected anxiety) in 2019, which increased to 15% in 2020. The prevalence of patients reporting definite depression remained constant at 10% before and after the start of the pandemic, although more patients reported doubtful (suspected) depression in 2020 than in 2019 (20% vs. 15%).

Higher anxiety scores during the pandemic were significantly associated with changes in the Health Assessment Questionnaire (P = 0.014), biologic drug use (P = 0.047), and previous anxiety points (P < 0.001).

Pointing to potential reasons behind these increases, the authors wrote that “psychological pressure might further increase due to the perplexing nature of information on the benefits and harms of rheumatic drugs against the COVID-19… Consequently, patients with high disease activity can become highly prone to psychological distress and should be offered focused care,” they suggested.

The study was limited by several factors including the small sample size, the researchers noted.

However, “As the pandemic continues, more patients are likely to experience anxiety and depression and healthcare professionals must remain vigilant for these psychological changes,” they concluded.

Counsel Patients with Rheumatoid Arthritis Regularly to Prevent Mental Health Care Challenges

The Japan-based study was important because, despite its small sample size, “it is good to have information about changes before, during, and after the pandemic,” according to Don L. Goldenberg, MD, a rheumatologist and affiliate faculty member at Oregon Health & Science University, Portland, and a member of the PPM Editorial Board.

In fact, Dr. Goldenberg said he was not surprised by the study findings. “Anxiety and depression in general population have increased during the pandemic, and patients with chronic diseases, such as RA, already have increased risk of mood disorders, so they are especially prone to increase in mood disorders at this time,” he said. “Also, you would expect patients with greater disease activity to be at greater risk for increased mood disturbances, which is what the researchers found.”

People living with rheumatoid arthritis may be concerned about their COVID-19 risk and how it relates to their medications, although data on this relationship are limited. “Rheumatologists must be proactive in detailed discussions regarding patient concerns during the pandemic,” advised Dr. Goldenberg. National and international guidelines have been updated monthly and should be discussed with patients, he said.

Clinicians also can help to manage anxiety and depression in patients with RA by being proactive in discussing coping strategies, said Dr. Goldenberg. “For example, patients should be asked how they are coping and reassured that increased stress during the pandemic will increase risk of anxiety and depression. Discuss problems with social isolation, missing medical appointments and lack of exercise,” he said, adding that,” It has been suggested that keeping active and exercising during the pandemic lessens risk of increase in mood disturbances.”

Encourage Physical Activity to Reduce Rheumatoid Arthritis Symptoms

Physical activity has been positively associated with the physical and mental health of people with RA prior to the pandemic. While social distancing due to COVID-19 has impacted opportunities for the physical activity, those who are able to engage in it enjoy its benefits, based on data from a British study of 345 adults with RA.

In that study, led by Sophia M. Brady, MD, of the University of Birmingham, patients diagnosed with rheumatoid arthritis completed online questionnaires about their sedentary time and physical activity during the pandemic. Respondents used the NIH-American Association of Retired Persons (NIH-AARP) Diet and Health Study questionnaire to note time spent in the past 7 days on light PA (housework), walking, and more vigorous exercise such as tennis or cycling. To measure sedentary behavior, they responded to the International Physical Activity Questionnaire-Short Form (IPAQ-SF) with how much time they spend sitting on a weekday and weekend day.

Anxiety and depression were measured using the Hospital Anxiety and Depression Scale (HADS). In regression analyses, light physical activity and walking were negatively associated with mental fatigue and depressive symptoms, and positively associated with vitality. Exercise was negatively associated with both physical and general fatigue, as well as depressive symptoms. However, sedentary time was positively associated with physical fatigue. All these associations were statistically significant.

Although physical activity and sedentary time were not associated with anxious symptoms, the researchers noted that being active can promote mental health during COVID-19 restrictions in several ways, ranging from distracting from negative thoughts to having an immediate positive effect on mood to, leading to overall improved wellbeing, they wrote.

Next Steps on RA and Mental Health

Larger data sets examining the impact of commonly prescribed medications to treat rheumatoid arthritis on COVID-19 risk are needed, suggested Dr. Goldenberg. However, “the good news is that rheumatologists established international registries early on during the pandemic, and we will have the information from these large, prospective studies shortly.”


Disclosures: The Kyoto University RA Management Alliance (KURAMA) cohort study was supported by Daiichi Sankyo and by the Japan Society for the Promotion of Science KAKENHI programme. The authors’ academic department of advanced medicine for rheumatic diseases is supported by supported by Nagahama City, Shiga, Japan, Toyooka City, Hyogo, Japan and five pharmaceutical companies (Mitsubishi Tanabe Pharma, Chugai Pharmaceutical, UCB Japan, AYUMI Pharmaceutical and Asahi Kasei Pharma). Lead author Dr. Itaya had no financial conflicts to disclose; several coauthors disclosed relationships with multiple companies including those that fund the department.


Last updated on: May 11, 2021
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How Clinicians Can Manage Rheumatic and Immune Diseases During COVID-19
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