Temporal Effect of Depressive Symptoms on the Longitudinal Evolution of Rheumatoid Arthritis Disease Activity

Abstract

Objective Depression is common in the rheumatoid arthritis (RA) population, yet little is known of its effect on the course of disease activity. The aim of our study was to determine if prevalent and incident depressive symptoms influenced longitudinal changes in RA disease activity. Methods RA patients with and without depressive symptoms were identified using single-item questions from an existing registry sample. Mixed-effects models were used to examine changes in disease activity over 2 years in those with and without prevalent and incident depressive symptoms. Outcome variables included composite disease activity, joint counts, global assessments, pain, function, and acute-phase reactants. Model-based outcome estimations at the index dates and corresponding 1- and 2-year changes were calculated. Results Rates of disease activity change were significantly different in patients with a lifetime prevalence of symptomology, but not incident depressive symptoms, when compared to controls. Prior symptoms were associated with slower rates of disease activity decline, evidenced by the estimated 1-year Clinical Disease Activity Index changes: −3.0 (−3.3, −2.6) and −4.0 (−4.3, −3.6) in patients with and without lifetime prevalence, respectively. Analogous results were obtained for most of the other disease activity outcomes; although, there was no temporal effect of prevalent symptoms of depression on swollen joints and acute-phase reactants. Conclusion Depressive symptoms temporally influence the evolution of RA disease activity, and the magnitude is dependent on the time of symptomatic onset. However, the effect is limited to patient-reported pain, global assessment, and function, as well as physician-reported global assessment and tender joints.

A Prospective Evaluation of the Effects of Prevalent Depressive Symptoms on Disease Activity in Rheumatoid Arthritis Patients Treated With Biologic Response Modifiers

“…That is, depressed patients had slightly larger adjusted decreases in their SJC and TJC ratings; and conversely, smaller declines in global assessments. The depressive effect was greatest in magnitude for the PGA at 6 months, but larger for the EGA at 12 months, which is in contrast to prior evidence showing a larger impact of depressive symptoms on patient-reported disease activity measures (22,29). These results imply that depressive symptomology was associated with a greater response as measured using joint counts, and the lower likelihood of remission at 6 months was related to subjective assessments of RA disease activity, particularly the PGA.…”

“…These results imply that depressive symptomology was associated with a greater response as measured using joint counts, and the lower likelihood of remission at 6 months was related to subjective assessments of RA disease activity, particularly the PGA. The attenuated association at 12 months after adjustment indicates that depressed patients were subsequently more likely to achieve remission, which is supported by prior research demonstrating that depression's effect on RA disease activity decreases as time progress (22). Depressive symptoms at treatment initiation that are an aftereffect of increased disease activity could have a time dependent effect on how patients and rheumatologists interpret and perceive disease status during the course treatment (14,15,22,29).…”

“…The unadjusted estimates were similar to previous studies assessing depression as a moderator of biologic DMARD treatment; yet, after controlling for possible confounders any differences in LDA response were attenuated to the null (18-20). Prior studies have shown that depressive symptoms do not temporally influence every metric of RA disease activity and are highly correlated with global assessment scales among patients being treated with biologic agents (14,15,22). The CDAI incorporates the crude value of each component measure, and unlike remission, achieving LDA does not require all constituent values to be low (15,31).…”

“…Nonetheless, self-reported depressive symptoms, which include questions about being “depressed,” are routinely used to evaluate depression in clinical practice and have been developed and validated in patients with chronic physical disease (24-26). Moreover, patient-reported comorbidity has been well validated and is more reliable than physician-reported information, particularly for depression (6,7,27,28), and several studies have used these measures to assess the impact of depression in RA patients (7,20,22,29). Given the burden of longer screening instruments in busy practice sites, these measures are feasible alternatives that provide valuable clinical information (24,30).…”

“…As prevalent depressive symptoms have been demonstrated to impact the trajectory of RA disease activity, our objective was to evaluate the moderating effects of prevalent depressive symptoms on response to biologic agents using a large national RA registry (22). …”