Serious Psychological Distress in U.S. Adults with Arthritis
From: Journal of General Internal Medicine. 2006 November; 21(11): 1160–1166
Arthritis and mental health disorders are leading causes of disability commonly seen by health care providers. Several studies demonstrate a higher prevalence of anxiety and depression in persons with arthritis versus those without arthritis.
In this study, we found the national prevalence of both serious psychological distress and frequent anxiety or depression to be significantly higher in adults with arthritis than in those without arthritis, with serious psychological distress prevalence 3 times higher and frequent anxiety or depression prevalence 2.5 times higher. Frequent anxiety and depression in the past year (frequent anxiety or depression) was common, with 1 in 4 adults with arthritis reporting frequent anxiety or depression. After adjustment for covariates, serious psychological distress in the past 30 days was significantly associated with younger age, lower socioeconomic status, being divorced or separated, having recurrent pain, being physically inactive, and having more limitations or medical comorbidities in adults with arthritis.
These findings are consistent with other smaller studies of specialized populations that have found higher rates of anxiety, major depression, and depressive symptoms in persons with arthritis. One large community-based study found the prevalence of frequent mental distress mentally unhealthy days in the past 30 days to be 13.4% among adults with arthritis who were 45 years and older. Although the results of that study are not directly comparable because different definitions of mental health and arthritis and a state-based data source were used, it corroborates the higher prevalence of mental distress in adults with arthritis compared with adults without arthritis.
Higher rates of depression and depressive symptoms in younger adults relative to older adults with arthritis have also been shown in previous studies. Although the reasons for this association remain unclear, studies in patients with rheumatoid arthritis suggest that depressive symptoms in younger adults and adolescents with arthritis are related to less effective coping strategies and higher perceived stress and pain. Because arthritis is a nonnormative event in younger adults, these higher rates of depression and depressive symptoms may be related to a greater perceived impact on family life, work, and leisure activities. Also, adults 18 to 44 years of age may be developing more systemic forms of arthritis, such as rheumatoid arthritis and systemic lupus erythematosus, which can have more severe manifestations. Finally, more recent birth cohorts have been found to be at increased risk for major depression. Longitudinal studies of mental health in persons with specific types of arthritis are needed to help discriminate between the roles of age versus birth cohort and to elucidate the relationship of age to psychological distress in specific types of arthritis.
Previous research has consistently shown depression to be associated with pain, functional impairment, and loss of valued activities in persons with arthritis and suggests that the relationship of pain and loss of function to depression is closely linked and bi-directional. Improvement of depression has been associated with improved functional status, and at least 1 randomized-controlled trial has shown that enhancing depression care in older adults with arthritis results in less pain and better function and quality of life. Furthermore, pain appears to be undertreated in depressed older adults with pain related functional impairment. Improving pain management may not only directly benefit mental health and physical functioning but may also assist with increasing physical activity levels.
Lack of physical activity, which has been associated with depression and depressive symptoms in this and other studies, is another important modifiable risk factor in persons with arthritis that can mediate multiple contributing factors to mental well-being, including decreasing pain, improving function, delaying disability, and decreasing the risk of obesity and other chronic diseases that may further add to depressive symptoms. Several studies have shown exercise to be similarly effective to medication or cognitive behavioral therapy in treating major depression, but 1 meta-analysis, which was restricted to randomized-controlled trials of clinically depressed patients, cautions that although exercise appears to be effective in reducing depressive symptoms in the short term, studies with long-term follow-up are lacking. In persons with arthritis, increased physical activity has been shown to have significant mental health benefits and to be associated with fewer physically and mentally unhealthy days. Unfortunately, the prevalence of adults with arthritis who are not physically active remains high, while arthritis-related physical activity counseling by health care providers remains low and represents a missed opportunity to help our patients and to meet Healthy People 2010 objectives. Existing evidence-based interventions such as the Arthritis Foundation Arthritis Self-Help Course, which is a group self-management education program, and the Arthritis Foundation Exercise Program, which is a community-based exercise program, have been shown to reduce pain and symptoms of anxiety and depression while improving function and activity levels. Efforts to expand access to these programs should be continued.
There are several limitations of the present study. One important limitation was that the data source did not contain information on what type of arthritis the respondent had, so we were not able to examine serious psychological distress or frequent anxiety or depression in relation to specific rheumatic conditions. Second, due to the self-report nature of the data, which is subject to recall bias, patients with serious psychological distress or frequent anxiety or depression may be more likely to recall being told by a health care provider that they have arthritis, resulting in misclassification bias. While data are not available to directly address this issue, 2 validation studies have shown the case definition used to be valid for public health surveillance and suggest that this is not a significant issue. Third, the use of cross-sectional survey data cannot be used to infer causation, and while we attempted to adjust for potential confounders as the data allowed, some confounders may not have been taken into account. Another limitation is that some of the K6 items, particularly the question asking whether “everything is an effort,” may overlap with somatic symptoms of arthritis; however, the pattern of responses across individual items appeared similar in persons with and without arthritis. Finally, the survey population included only noninstitutionalized persons, so some adults with severe arthritis or depression may have been missed.
This study has several important strengths. We provide the first national prevalence estimates for serious psychological distress and frequent anxiety or depression in persons with arthritis, using a nationally representative sample of U.S. adults. Also, we were able to adjust for potential confounders in evaluating factors associated with serious psychological distress, including comorbid medical conditions, which is not possible with some data sources. Future research should focus on longitudinal studies of specific types of mental health problems, including depression and anxiety, in adults with different types of arthritis, specifically looking at the effects of age and physical activity. Younger adults with arthritis should be included in programs designed to help people with arthritis of all ages.
Mental health disorders remain underdiagnosed and undertreated in persons with arthritis, contributing to treatment noncompliance, poor response to treatment, higher disability rates, poor quality of life, and increased health care utilization among persons who seek medical care. There are many brief screening tools available for use in the clinical setting to facilitate diagnosis. Mental health impairment should be recognized, addressed, and followed-up by health care providers who care for adults with arthritis, especially among patients who are younger, have recurrent pain, or report limitations in either functional or social activities. Additional emphasis should be placed on physical activity counseling and pain management because these interventions may foster better mental health in addition to delaying physical disability.
