The course of depression in recent onset rheumatoid arthritis: The predictive role of disability, illness perceptions, pain and coping

https://doi.org/10.1016/S0022-3999(01)00266-5Get rights and content

Abstract

Background: This study aimed to investigate the course of depression for patients with recently diagnosed rheumatoid arthritis (RA) and to investigate predictors of depression. Methods: Twenty-two patients with a history of recently diagnosed RA of less than 2 years were assessed on a variety of clinical outcome and process measures on six assessment occasions over a 21-month period. These 22 patients constituted the control group of a controlled trial and received standard outpatient clinic treatment during follow-up. Results: Patients became significantly more depressed over time. A set of five factors were found to consistently predict depression at the following assessment. These were initial level of depression, disability, pain, beliefs about the consequences of arthritis and coping strategies. Conclusions: The results confirm the importance of psychological factors in early RA and their relative independence from physical findings. This is the first study to document the importance of illness perceptions in recent onset RA.

Introduction

Rheumatoid arthritis (RA) is a chronic disease, which often leads to high levels of disability, impairment and handicap even early in the course of the illness [1]. Physical deterioration is often associated with changes in mood [2] and the fact that rates of depression are higher in samples of patients with RA than in the normal population is well documented [3], [4], [5]. It is also well documented that depression and other psychological factors are more highly associated with measures of disability than disease parameters themselves [6], [7], [8]. Associations between depression and disability have been demonstrated in both cross-sectional studies and longitudinal designs [6], [7], [8]. However, the bulk of research has been confined to patient samples with chronic RA.

There has recently been interest in investigating the course and determinants of distress early in the disease course. A number of studies have now documented that rates of depression are at least as high for patients recently diagnosed with RA compared to those with chronic RA [9], [10], [11], [12], [13]. The majority of studies have been cross-sectional in nature and confirmed similar associations between distress, pain and disability as reported in the literature on chronic RA [9], [10], [11], [12]. Two prospective studies have confirmed that there is little evidence of adaptation early in the disease and that those who are depressed early in the disease rarely adjust with medical intervention alone [13], [14]. Smedstad et al. [13] were unable to identify predictors of distress over a 3-year period where patients were assessed annually. Similarly, Evers et al. [14] found that depression and anxiety at Time 1 were highly predictive of subsequent deterioration in those measures. They also found that social support networks were predictive of changes in depressed mood but accounted for only a small proportion of the variance (3%).

In both studies cited above [13], [14], predictive analyses were conducted 1 year apart. Crotty et al. [15] have criticized studies that aim to predict variables over lengthy time frames. They suggested that research should concentrate on multiple assessments from cohorts over time to investigate more thoroughly the complex interrelationships that are likely to exist. They followed their sample of young women with early onset (<40 years) in the first 5 years of illness at 4-monthly intervals over 44 months. Unlike the other studies mentioned above, Crotty et al. [15] found that psychological factors, as well as physical parameters, improved over time. They found evidence to suggest that initial levels of pain and depression were predictive of subsequent levels of depression and disability. Indeed, they found that depression contributed at least as much as biological parameters (e.g., ESR) to the variance in levels of disability over time. However, they made no attempts to predict distress.

Although the results of these three studies do not provide a consistent picture, all studies report the relationship between pain, disability and depression to be important [13], [14]. While these studies have investigated a range of psychological measures, such as mood, coping, social support and self-efficacy, none have investigated the role of illness related attitudes. Only one study has yet to investigate illness beliefs in early RA [12]. They investigated the role of acceptance of illness in depression and anxiety in a cross-sectional design. Although they found that the recent onset group did not differ from the chronic group in terms of either depression or level of acceptance, level of acceptance was associated with depression. No study has yet to investigate the impact of illness beliefs on depression in early RA in a prospective design. However, theoretical interest has highlighted the importance of illness perceptions in adaptation to illness generally [16] and in chronic rheumatic diseases specifically [17], [18], [19], [20].

The aim of the current study was to investigate the occurrence and determinants of depression in a cohort of patients with recent onset RA. It was hypothesised that depression would be stable across time. Depression was hypothesised to be associated with coping and beliefs about the illness, both in cross-sectional and prospective analyses. Disease parameters were hypothesised to be less strongly associated with depression than measures of disability and pain.

Section snippets

Participants

The study sample was drawn from patients recruited into a randomized controlled trial of an adjunctive psychological treatment versus standard medical management for early RA. Results of this trial are reported elsewhere [21]. Participants were consecutive patients presenting to each of the three general hospital rheumatology clinics with an illness duration of less than 2 years. All participants had a diagnosis of classical or definite RA [22] and were seropositive for rheumatoid factor. All

Changes over time

Table 1 indicates the means of depression and the other clinical measures across the six assessments periods. Over time, mood deteriorated significantly [F(5,21)=4.867, P<.04], and the Ritchie Atricular Index showed significant improvements [F(5,21)=9.265, P<.007]. No other variables changed significantly. The proportion of participants who met ‘caseness’ criteria of “possible” depression is also worthy of consideration. At the first assessment, 15% of participants met criteria for “possible”

Discussion

The aim of the present study was to investigate the course and determinants of depression in a cohort of recently diagnosed patients with RA. Due to the limited sample size for the prospective design, the results need to be interpreted cautiously and should be regarded as largely hypothesis generating. However, the multiple assessment periods allow the replicability of the results to be tested. A combination of the same five variables contributed to the variance in measures over the six periods

Acknowledgements

This study was supported by a grant from North Thames Regional Research and Development Programme. We are grateful to Bridget Ryan for her help in the recruitment and administration of the outcome measures and to Sheila Davidson for her assistance in entering the data for this study. We also thank Diane Holmes, West Middlesex University Hospital, Dr. Rod Hughes and Maggie Carr, St. Peter's Hospital, Chertsey and the Rheumatology staff at Charing Cross Hospital for their help in recruiting

References (35)

  • T Pincus et al.

    Prevalence of self-reported depression in patients with rheumatoid arthritis

    J Br Rheumatol

    (1996)
  • AC McFarlance et al.

    Psychological predictors of disease course in rheumatoid arthritis

    J Psychosom Med

    (1987)
  • S Büchi et al.

    Sense of coherence—a protective factor of depression in rheumatoid arthritis

    J Rheumatol

    (1998)
  • A McFarlane et al.

    The determinants of disability in Rheumatoid Arthritis

    Br J Rheumatol

    (1988)
  • JM Chaney et al.

    Differential effects of age and illness duration on pain–depression and disability–depression relationships in rheumatoid arthritis

    Int J Rehab Health

    (1996)
  • RF Meenan et al.

    The clinical and health status of patients with recent-onset rheumatoid arthritis

    Arthritis Rheum

    (1991)
  • SP Newman et al.

    The origins of depressed mood in rheumatoid arthritis

    J Rheumatol

    (1989)
  • Cited by (133)

    • Depression in Saudi Patients with Rheumatoid Arthritis

      2023, Open Access Rheumatology: Research and Reviews
    View all citing articles on Scopus
    View full text