3.5 Correlation between RA disease parameters and psychological manifestations
Table 3 shows that depressive symptoms (P = .002), recurrent depression (P = .02), and somatic manifestation (P = .002) were mostly associated with moderate to severe disease activity; anxiety was also only reported among RA patients with elevated DAS28 scores, but correlation did not reach statistical significance (P = .09). Patients who were in remission reported no psychological manifestations. CRP levels did not correlate with any of the psychological factors; ESR was used to calculate DAS28, and was not correlated with any psychological factor neither.
This table also shows that all patients with complete impairment had severe depression (P = .08), recurrent depression (P = .37), and somatic symptoms (P = .01).
All patients with severe pain, as evaluated by the VAS, had severe depression (P = .01), recurrent depressive episodes (P = .02), and most of them had anxiety (3 out of 4 patients [75%]) though not to a significant extent.
The present study aimed primarily at evaluating prevalence of psychological affection in RA patients, in a specialized center in Upper Egypt.
It included 23 female (92%) and 2 male (8%) patients who had had RA for 3.68 ± 2.32 years and 25 healthy subjects. Though the sample size was quite limited with a total of 50 participants, it compares to a recent study performed on RA patients in the same Egyptian region of Minya. The large prevalence of RA among women in our study also matched the gender imbalance reported by the same study on RA patients in Minya. This overrepresentation of women was also underlined in a 2009 review, which discussed the potential involvement of sex hormones in RA onset and evolution. In this study, patients were relatively young, with an average age of 41 years; which also could explain female gender prevalence, in accordance with a 2006 study which reported than below the age of 50, females have a 4 to 5 times higher incidence rate of RA than their male counterparts, while the female/male ratio above the age of 60 to 70 years goes to only about 2.
The vast majority of patients (80%) had depression, whether mild (2 patients), moderate (4 patients), or severe (16 patients), classified according to ICD-10 classification of Mental and Behavioral Disorders.
Findings demonstrated a highly significant correlation between occurrence of depressive symptoms, recurrent depressive episodes, and somatic manifestation (marked loss of interest in regular activities, appetite, libido, and lack of emotional reaction) with severity of disease activity in RA patients as assessed by the DAS28 tool.
The results of the present study were in agreement with Muhammad et al who studied 102 RA patients diagnosed according to the 1987 ACR criteria. Though disease duration reported in that study was longer than reports of the present study, gender distribution, and average age of patients were closely comparable. Importantly, over 70% of RA patients were found to have depression (over 40% reported moderate-to-severe cases), significantly correlated with the severity of disease.
In addition, the study by Mostafa et al on 170 RA patients found a positive significant correlation between depressive symptoms and disease activity of patients.
There is in disagreement with Cordingley et al who studied 322 RA patients with active disease (mean DAS28 = 6.0) and found that there was no significant correlation between depression and disease activity; this discrepancy may be due to the use of hospital anxiety and depression scale in assessing depression instead of the ICD-10international classification of Mental and Behavioral Disorders.
On the other hand and comparing with the same study, our data also showed no significant correlation between anxiety symptoms and disease activity of RA patients assessed by DAS28, also matching findings by Khedr et al.
In our study, we found that the frequency of psychological disorders in RA patients was 80%, compared with 20% in controls. Specifically, RA patients displayed a significantly higher frequency of psychological disorders (depression: P = .0001 and somatic manifestations: P = .0006), when compared to their RA-free counterparts. These results were in agreement with Khedr et al where frequency of psychological disorders in RA patients was 60.8%, compared with 12% in controls (anxiety, somatoform disorder, and depression). The present study found a significant correlation between somatic manifestations and HAQ-DI score of RA patients (P = .01), in accordance with Muhammad et al, but no significant correlation existed between depressive symptoms, recurrent depressive episodes and anxiety symptoms, and extent of impairment among RA patients.
In our study, depression correlated significantly with VAS pain score (P = .01), matching results by 2 studies.[17,18]
This work explores a small sample of patients and control subjects; in fact, no sample size calculation was performed, and this study serves as an exploratory investigation of the problem, which warrants a larger study and follow-up over time.
Psychological manifestations are common in RA and they positively correlate with severity of disease activity.
Psychological examination should be routinely undertaken in patients with rheumatic diseases, and special attention should be given to depression and anxiety, given their strong relationship to severity of the disease.
As psychological affectation in RA patients affects disease outcome and increases morbidity psychological evaluation would provide a more accurate and earlier diagnosis, which would lead to better clinical care and preventing debilitating changes and subsequent physical dysfunctions and impairment of the quality of life of RA patients.
Amal Ali Hassan, Mona Hamdy Nasr, and Ahmed Mustafa Kamal designed the study. Alyaa Diaa Elmoghazy, Mona Hamdy Nasr, and Ahmed Lotfi Mohamed were responsible for proposal/study protocol writing. Aliya Diaa Elmoghazy also collected data and performed the statistical analyses. Ahmed Lotfi Mohamed wrote the manuscript, which was read and approved by all authors.
Conceptualization: Amal Ali Hassan, Mona Hamdy Nasr, Ahmed Lotfi Mohamed, Ahmed Mustafa Kamal.
Data curation: Alyaa Diaa Elmoghazy.
Formal analysis: Alyaa Diaa Elmoghazy.
Methodology: Amal Ali Hassan, Mona Hamdy Nasr, Ahmed Lotfi Mohamed, Ahmed Mustafa Kamal.
Software: Alyaa Diaa Elmoghazy.
Supervision: Mona Hamdy Nasr, Ahmed Lotfi Mohamed.
Writing – original draft: Ahmed Lotfi Mohamed.
Writing – review and editing: Amal Ali Hassan, Mona Hamdy Nasr, Ahmed Mustafa Kamal, Alyaa Diaa Elmoghazy.
Ahmed Lotfi Mohamed orcid: 0000-0001-9422-6841.
. Majithia V, Geraci SA. Rheumatoid arthritis
: diagnosis and management. Am J Med 2007;120:936–9.
. Prevoo M, van’t Hof MA, Kuper H, et al. 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;38:44–8.
. Isik A, Koca SS, Ozturk A, et al. Anxiety
in patients with rheumatoid arthritis
. Clin Rheumatol 2007;26:872–8.
. Kessler R, Berglund P, Demler O, et al. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA 2003;289:3095–105.
. Zyrianova Y, Kelly B, Gallagher C, et al. Depression
in rheumatoid arthritis
: the role of perceived social support. Ir J Med Sci 2006;175:32–6.
. Ang D, Choi H, Kroenke K, et al. Comorbid depression
is an independent risk factor for mortality in patients with rheumatoid arthritis
. J Rheumatol 2005;32:1013–9.
. Aletaha D, Neogi T, Silman AJ, et al. 2010 Rheumatoid arthritis
classification criteria: an American College of Rheumatology/European League against rheumatism collaborative initiative. Arthritis Rheum 2010;62:2569–81.
. Oxford University Press, Inc, Portenoy RK, Tanner RM. Visual Analog Scale and Verbal Pain Intensity Scale: Pain Management: Theory and Practice. 1996.
. World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders Tenth Revision (ICD-10). International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Edition 2010, World Health Organization, Geneva. Available at: http://www.who.int/classifications/icd/ICD10Volume2_en_2010.pdf
. Accessed August 14, 2018.
. Kamel SR. Using rheumatoid arthritis disease activity
index-5 questionnaire in the assessment of disease activity
in patients with rheumatoid arthritis
: correlation with quality of life, pain, and functional status. Egypt Rheumatol Rehabil 2018;45:43–8.
. van Vollenhoven RF. Sex differences in rheumatoid arthritis
: more than meets the eye. BMC Med 2009;7:12.
. Kvien TK, Uhlig T, Ødegård S, et al. Epidemiological aspects of rheumatoid arthritis
: the sex ratio. Ann N Y Acad Sci 2006;1069:212–22.
. Imran MY, Saira Khan EA, Ahmad NM, et al. Depression
in rheumatoid arthritis
and its relation to disease activity
. Pak J Med Sci 2015;31:393–7.
. Mostafa H, Abdullah Radwan A. The relationship between disease activity
in Egyptian patients with rheumatoid arthritis
. Egypt Rheumatol 2015;35:193–9.
. Cordingley L, Prajapati R, Plant D, et al. Impact of psychological factors on subjective disease activity
assessments in patients with severe rheumatoid arthritis
. Arthritis Care Res (Hoboken) 2014;66:861–8.
. Khedr EM, Abo El Fetoh N, Herdan O, et al. Clinical and subclinical neuropsychiatric abnormalities in rheumatoid arthritis
patients. Egypt Rheumatol Rehabil 2015;42:11–8.
. Solomon A, Christian BF, Woodiwiss AJ, et al. Burden of depression
symptoms in South African public healthcare patients with established rheumatoid arthritis
: a case-control study. Clin Exp Rheumatol 2011;29:506–12.
Keywords:Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.
anxiety; depression; disease activity; disease severity; rheumatoid arthritis