Because Drs. Yelin and Katz are Editors of Arthritis Care & Research, review of this article was handled by the Editor of Arthritis & Rheumatism.
Predictors of depression in a multiethnic cohort of patients with rheumatoid arthritis†
Article first published online: 29 OCT 2009
Copyright © 2009 by the American College of Rheumatology
Arthritis Care & Research
Volume 61, Issue 11, pages 1586–1591, 15 November 2009
How to Cite
Margaretten, M., Yelin, E., Imboden, J., Graf, J., Barton, J., Katz, P. and Julian, L. (2009), Predictors of depression in a multiethnic cohort of patients with rheumatoid arthritis. Arthritis & Rheumatism, 61: 1586–1591. doi: 10.1002/art.24822
- Issue published online: 29 OCT 2009
- Article first published online: 29 OCT 2009
- Manuscript Accepted: 1 JUL 2009
- Manuscript Received: 27 MAR 2009
- Arthritis Foundation
- American College of Rheumatology Research and Education Foundation “Within our Reach” Grant
- National Institute of Arthritis and Musculoskeletal and Skin Diseases. Grant Number: grant P60-AR-053308
- Rosalind Russell Medical Research Center for Arthritis
- University of California, San Francisco
- University of California
- San Francisco School of Medicine Research Evaluation & Allocation Committee
Patients with rheumatoid arthritis (RA) who experience depression have worse health outcomes. This study identifies predictors of depression in an ethnically and racially diverse population of patients with RA.
Patients with RA in a prospective cohort at the San Francisco General Hospital outpatient rheumatology clinic were included if they were age ≥18 years, met the American College of Rheumatology classification criteria for RA, had a Health Assessment Questionnaire (HAQ) score collected, and had the RA-specific Disease Activity Score performed by a rheumatologist. The outcome variable was a depression score measured by the Patient Health Questionnaire 9 (PHQ-9), a self-report questionnaire validated to correlate with a diagnosis of major depression.
Three hundred forty-nine clinical visits for 172 patients were included in the analysis. Forty percent of patients scored ≥10 on the PHQ-9 during at least one clinic visit, which corresponds to a symptom severity of at least moderate depression. The mean PHQ-9 score was 7, corresponding to a symptom severity of mild depression. In the multivariate analysis, higher HAQ scores were associated with depression, and Asians had lower depression scores compared with Hispanic, white, and African American subjects.
Identifying associated predictors of depression in a diverse population of patients with RA can help guide treatment, which should include preventing disability and decreased function as well as targeting depressive symptoms more specifically in patients with RA.
Of the 1.3 million adults in the US (0.6%) with rheumatoid arthritis (RA) (1, 2), most will develop progressive functional limitation and physical disability (3). Depression, a frequent disorder among patients with RA, is often unrecognized or undertreated (4, 5). The prevalence of major depressive disorder is 13–42% in patients with RA (6–13), which is at least double that in the general population.
In patients with RA, poor clinical characteristics and function are associated with subsequent depression. There are more RA-related physician visits and hospitalizations in patients with depression, as well as negative health and functional outcomes and increased health service use (14). Patients with rheumatic diseases and depression are less likely to be adherent with their medications (15) and more likely to discontinue anti–tumor necrosis factor α (anti-TNFα) therapy when compared with patients without depression (16), which may then have a negative effect on their health status. Furthermore, comorbid depression is an independent risk factor for death in patients with RA, with a hazard ratio of 2.2 (95% confidence interval [95% CI] 1.2, 3.9; P = 0.01) (17, 18).
Studies have shown that disability and decreased function as measured by the Health Assessment Questionnaire (HAQ) are associated with depression in white populations (19–22), but have not addressed potential predictors of depression in an ethnically diverse group of patients with RA. A recent study identified Hispanics with RA as more likely to have symptoms of depression than non-Hispanic subjects (23); however, important covariates such as disease activity and disease duration were not taken into account. Furthermore, patients of other races/ethnicities (African Americans, Asians) were not included in this study for comparison. Since concomitant depressive symptoms are known to worsen health outcomes and confer independent risk for mortality in RA, it would be useful to discover associations between depression and RA in diverse populations.
Our objective was to identify demographic and disease-related predictors of depressive symptoms in a socioeconomically and ethnically distinct population of patients with RA at an urban public hospital. The independent effects of race/ethnicity on depressive symptoms were of special interest in this multiethnic cohort of patients with RA.
SUBJECTS AND METHODS
The study subjects were patients from the University of California, San Francisco (UCSF) RA cohort at the San Francisco General Hospital (SFGH) outpatient rheumatology clinic. The SFGH is the major provider to the poor, minority population of the City and County of San Francisco. Patients were consecutively enrolled when they presented for their initial or return visit between November 2006 and December 2008, and the data were gathered at regular clinical visits. Patients were included in the analysis if they were age ≥18 years, met the American College of Rheumatology (formerly the American Rheumatism Association) classification criteria for RA (24), had a depression score measured by the Patient Health Questionnaire 9 (PHQ-9), had the RA-specific Disease Activity Score in 28 joints (DAS28) performed by a rheumatologist at the same clinical visit, and had a HAQ score collected within 6 months before or after the depression measure. The UCSF Committee on Human Research approved the study. Written informed consent was obtained and patients were interviewed in the language of their choice (English, Cantonese, Mandarin, or Spanish).
Assessment of clinical data.
In addition to sociodemographic characteristics (age, sex, self-reported ethnicity) and disease duration, a wide range of clinical data was collected at enrollment and at regular intervals thereafter during routine clinical encounters. Disease activity was assessed with the DAS28, calculated at each clinic visit. The DAS28 includes scores of tender and swollen joint counts, patient global disease activity rating scale, and erythrocyte sedimentation rate (ESR) (25, 26). Functional limitation was evaluated with the 20-item HAQ score (27), which is a reliable and valid assessment of functional limitations in RA. HAQ scores collected within 6 months of the depression scores were included, since HAQ scores are generally stable over a 1-year period among patients with RA (28–30). The HAQ has been translated and validated in Mandarin/Cantonese (31) and Spanish (32). Treatment-related variables were prednisone use and other disease-modifying antirheumatic drugs (DMARDs) such as methotrexate, hydroxychloroquine, sulfasalazine, azathioprine, leflunomide, anti-TNFα medications, or other biologic medications.
Ascertainment of depression.
The outcome variable was depressive symptoms measured by the PHQ-9. This self-report depression questionnaire yields a 27-point scale that correlates with a diagnosis of major depression (33, 34). The PHQ-9 is composed of 10 items corresponding to the 9 diagnostic criteria of major depressive disorder, plus 1 item to assess functional impairment secondary to depression. A score of 5–9 is consistent with mild depressive symptoms, 10–14 with moderate depressive symptoms, 15–19 with moderate to severe depressive symptoms, and ≥20 with severe depressive symptoms. The PHQ-9 has established reliability and validity in white, African American, Asian, and Hispanic populations (35, 36). To classify patients with at least moderate symptoms of depression, we used a clinically useful cut point of 10, which distinguishes between no/mild and moderate/severe depressive symptoms for the univariate analysis. The term “depressed” will be used from this point forward to refer to participants meeting this threshold of symptom severity.
Study research staff who were not the patient's physician administered standardized questionnaires (PHQ-9, HAQ) and interviews in English, Spanish, or Chinese. Research staff and treating physicians were blind to PHQ-9 scores and HAQ scores because scores were tabulated independently.
The analysis accommodated the repeated measures from an individual's multiple clinical encounters and was conducted using STATA, version 10.0 (StataCorp, College Station, TX). The unit of analysis was a subject's clinical visit, in which the patient had a PHQ-9 score collected. A total of 46 visits (12%) involving 22 patients were excluded because of incomplete information. Most of these visits were dropped because a component of the DAS28 was not collected and therefore could not be calculated.
Differences in baseline characteristics between depressed and non-depressed subjects were assessed using a 2-sided t-test with equal variance or the Pearson's chi-square test, as appropriate. For the multivariate analysis, we used generalized estimating equations (GEEs) with robust standard errors of the estimate (SEEs) to assess associations with depression scores, while taking into account within-subject correlations between measurements over time and to account for the influence of potential confounding covariates (37). The PHQ-9 score was used as a continuous outcome for the multivariate analysis. For the multivariate analysis, independent variables were determined a priori with a forward inclusion strategy. Variables were selected based on face validity and biologic plausibility to obtain a minimally confounded estimate of their effect and identify important independent predictors of depression in patients with RA. Given the modestly sized data set and the number of predictors, bootstrapping (re-sampling of subjects, not observations) was employed to check the reliability of the SEEs and CIs.
Three hundred forty-nine clinical visits for 172 patients were included in the analysis. The average number of outpatient rheumatology clinic visits per patient was 2 (range 1–5). In this study, 89% of included patients were women, with a mean age of 52 years (Table 1). In regard to race/ethnicity, 54% of the patients were Latino/Hispanic, 34% were Asian/Pacific Islander, 7% were African American, and 4% were white. Eighty-four percent of the patients were rheumatoid factor positive and 81% were anti–cyclic citrullinated peptide (anti-CCP) positive. Eighty-three percent of patients were taking a DMARD, 24% were taking anti-TNFα medications, and 62% of patients were taking prednisone, with a mean dose of 4 mg. Fifteen percent of patients were prescribed an antidepressant medication. The mean HAQ score was 1.25 and the mean DAS28 was 4.1, which is indicative of fairly high levels of functional impairment and disease activity, respectively.
|All subjects (n = 172)||PHQ-9 score <10 at any visit (n = 103)||PHQ-9 score ≥10 at any visit (n = 69)||P|
|Women||153 (89)||92 (89)||61 (88)|
|Men||19 (11)||11 (11)||8 (12)|
|Age, mean ± SD years||52 ± 13||51 ± 14||53 ± 13||0.26|
|Latino/Hispanic||93 (54)||54 (52)||37 (54)|
|African American||12 (7)||8 (8)||4 (6)|
|Asian/Pacific Islander||58 (34)||35 (34)||25 (36)|
|White||7 (4)||6 (6)||1 (1)|
|American Indian/other||2 (1)||0 (0)||2 (3)|
|DAS28, mean ± SD†||4.1 ± 1.4||4.0 ± 1.3||4.3 ± 1.6||0.04|
|Disease duration, mean ± SD years||7.5 ± 8.0||6.9 ± 7.5||8.4 ± 8.9||0.08|
|HAQ score, mean ± SD||1.25 ± 0.81||1.1 ± 0.68||1.4 ± 0.92||<0.0001|
|Rheumatoid factor||144 (84)||87 (84)||57 (83)||0.92|
|Anti-CCP||139 (81)||83 (81)||56 (82)||0.66|
|DMARDs‡||143 (83)||89 (86)||54 (78)||0.03|
|Methotrexate||105 (61)||66 (64)||39 (56)||0.11|
|Prednisone||107 (62)||66 (64)||41 (60)||0.65|
|Prednisone dose, mean ± SD mg||4 ± 4.8||4.1 ± 4.4||4.3 ± 5.3||0.76|
|Anti-TNFα||41 (24)||24 (23)||17 (25)||0.84|
With regard to the prevalence of depressive symptoms in our cohort, 40% of patients scored ≥10 on the PHQ-9 during at least one clinic visit (n = 138 clinic visits), which corresponds to a symptom severity of at least moderate depression. The mean PHQ-9 score was 7, corresponding to symptom severity of mild depression.
In univariate analyses of baseline data, there were no statistically significant differences between depressed and non-depressed patients with regard to age, ethnicity, disease duration, antibody status, or prednisone treatment and dose. However, depressed participants had higher HAQ and DAS28 scores, and were less likely to be treated with a DMARD (Table 1).
After adjusting for age, sex, race/ethnicity, disease duration and activity, prednisone treatment, and RA disease-modifying medications in a GEE model (Table 2), higher HAQ scores were significantly associated with higher PHQ-9 scores. A clinically meaningful change in HAQ score is 0.24 (38), so the GEE coefficient, which represents associations with a 1-point difference in HAQ score, was divided by 4. With each 0.24-unit increase in the HAQ score, there was an increase in the PHQ-9 score of 0.98 (95% CI 0.73, 1.3). Asian ethnicity was associated with lower depression scores, specifically a decrease in PHQ-9 score of 1.6 (95% CI −3.0, −0.28) as compared with the reference group, Latinos/Hispanics (Table 2). The CIs from this multivariate model remained similar when bootstrapping was employed. The effects of HAQ score and race/ethnicity on PHQ-9 scores did not differ when modeled for possible interactions.
|Characteristic||GEE coefficient (95% CI)||P|
|Female sex||−0.41 (−2.6, 1.7)||0.70|
|Age, years||−0.31 (−0.09, −0.02)||0.27|
|African American||−0.20 (−2.7, 2.4)||0.88|
|Asian/Pacific Islander||−1.6 (−3.0, −0.28)||0.02|
|White||0.37 (−2.1, 2.8)||0.77|
|American Indian/other||−1.8 (−6.1, 2.6)||0.43|
|DAS28†||0.08 (−0.31, 0.45)||0.70|
|Disease duration, years||−0.02 (−0.10, 0.05)||0.50|
|HAQ score||0.98 (0.73, 1.3)||<0.0001|
|DMARDs‡||−0.76 (−2.6, 1.1)||0.43|
|Prednisone||−0.42 (−1.7, 0.83)||0.51|
To our knowledge, this is the first study evaluating the predictors of depressive symptoms in an underserved, ethnically diverse cohort of patients with rigorously defined RA that includes measures of functional disability and disease status as measured by the DAS28. Several conclusions stem from our data.
First, the prevalence of clinically significant depressive symptoms in an urban, multiethnic sample of patients with RA is 40%. Although this is within the range of previously reported results (13–42%), it is on the higher end of the spectrum compared with white populations with RA and depression.
Second, those with more disability are at greater risk for depression. These findings in a previously unstudied population corroborate with the literature. Given the high prevalence of depression in our subjects and the strong association with decreased function, this raises the question of whether depression is a product of increased disability as measured by the HAQ. A mean HAQ score of 1.25 is well above the previously reported mean HAQ score of 0.71 in a population-based cohort of patients with RA (28). Why is there a higher mean HAQ score in our study sample? The most obvious answer is that health disparities in the RA cohort at the SFGH associated with race/ethnicity and socioeconomic status lead to worse outcomes (39); in this case, a higher mean HAQ score. Identifying pathways and mechanisms by which socioeconomic status and race/ethnicity affect HAQ scores would provide more options for intervention to eliminate disability and subsequent depression in patients with RA.
Third, it is surprising that disease activity as measured by swollen, tender joints, patient global disease activity scale, and the ESR is not associated with higher depression scores, given previous research in this area (40, 41). In the multivariate analysis, the upper limit for the GEE coefficient of the DAS28 is 0.45. The SD for the DAS28 in the cohort is 1.4, and a 2-point change in the DAS28 would be quite large clinically. Therefore, the maximum change in the depression score associated with a 2-point increase in DAS28 is only 0.9, which is quite a small clinical change. This suggests that it is not the acute pain or clinical manifestations of RA disease activity, but more the long-term disability and joint damage associated with arthritis that lead to depression in patients with RA.
Finally, Asians in the SFGH RA cohort had lower depression scores compared with Latino/Hispanic, white, and African American subjects. To our knowledge, this is the first study to find an association between depressive symptoms and Asian race/ethnicity in patients with RA. This finding is supported by previous literature other than that specific to RA, which substantiates that there is a low level of reporting depressive symptoms in Asians (42), owing to the stigma of mental illness, implications of weakness of character, and factors that may protect against depression such as stoicism and cultural support systems (43).
There are limitations to this study. Like other chronic conditions, assessing depressive symptoms in patients with RA can be difficult. It is well understood that somatic symptoms of depression (e.g., fatigue or decreased energy) overlap with symptoms of RA. Consequently, there is a risk that depression in RA may be overestimated (44). Conversely, there is also some evidence to suggest that using conventional assessments of depression does not overestimate depression in similar chronic conditions (45). In our approach to the assessment of depressive symptoms, we chose the PHQ-9 as a measure for depression because it was developed for primary care, is in widespread use for a range of acute and chronic medical conditions, and was developed to closely parallel the diagnostic symptoms of major depressive disorder (33, 34, 46).
Our study design was cross-sectional, and therefore causality between greater HAQ scores and the associated increased depressive symptoms cannot be established. Future studies should examine this relationship in a prospective manner. Also, as a cross-sectional study, there is a limit to the information that can be produced about the waxing and waning nature of depressive symptoms over time. The high prevalence of depressive symptoms in this cohort is either because they occur more frequently or because the depressive symptoms last longer.
Another potential limitation to this study is that detection bias or medical surveillance bias could influence the association between depressive symptoms and clinical predictors if depressed patients with RA were less likely to attend clinical appointments. To investigate this possibility, we compared the mean number of clinical visits of patients with and without depressive symptoms and found no significant difference.
Finally, the question of how applicable our results are to other RA patients must be asked. The high percentage of subjects with positive anti-CCP (81%), which portends a poor prognosis, is greater than reported in other clinical cohorts. Furthermore, our study population has relatively high disease activity, with a mean DAS28 of 4.1 and a mean HAQ score of 1.25. The fact that our study population has more erosive and disabling disease is likely a reflection of referral practices to a public urban hospital clinic as well as our precise definition of RA for entry into the study. Although our cohort was skewed toward more severe disease and included an ethnically diverse patient population, we believe that the heterogeneity of our cohort is a benefit and not a limitation.
Given that patients in this cohort are comprised of minorities who struggle with poverty and often have poor education, future studies should directly compare this population with those with higher socioeconomic status to determine associations between depression, disease activity, disability, and health disparities in patients with RA. Since depression is known to confer risk of poor health outcomes, identifying associated predictors of depression in all patients with RA, not just whites, is useful. The above findings can help guide treatment to include preventing disability and decreased function as well as targeting depressive symptoms more specifically in a vulnerable population of patients with RA.
All authors were involved in drafting the article or revising it critically for important intellectual content, and all authors approved the final version to be submitted for publication. Dr. Margaretten had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study conception and design. Margaretten, Yelin, Imboden, Graf, Julian.
Acquisition of data. Margaretten, Yelin, Imboden, Graf, Barton, Julian.
Analysis and interpretation of data. Margaretten, Yelin, Imboden, Katz.
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