Depression Rates Among Patients With Fibromyalgia Increased During COVID-19

Approximately one-third of patients with concomitant fibromyalgia and rheumatoid arthritis (RA) experienced depression during the COVID-19 pandemic, which was significantly higher when compared with pre-COVID-19 times. Investigators encouraged the incorporation of a mental health assessment in routine management of patients with RA, according to a study published in BMJ Open.¹

Sundeep Kumar Upadhyaya, MD, MBBS, DM

Credit: AskApollo.com

A concomitant diagnosis of RA and fibromyalgia is common, as noted by several previous studies. Fibromyalgia is also associated with concomitant systemic lupus erythematosus, psoriatic arthritis, and other autoimmune inflammatory rheumatic diseases. Changes among revised diagnosis criteria have included a transition from a mono-dimensional, pain-centric definition to a multisystem, and multidimensional syndrome, allowing for evaluation in the clinic as well as the community.²

“To our knowledge, only 1 study in India evaluated fibromyalgia prevalence in patients with RA by the American of Rheumatology (ACR) 1990 criteria,” wrote Sundeep Kumar Upadhyaya, MD, MBBS, DM, Rheumatology, Indraprastha Apollo Hospital, New Delhi, India, and colleagues. “In addition, it evaluated clinically significant depression and anxiety in the same subset. Still, no such study was undertaken during the COVID-19 pandemic. We know that depression is an important comorbidity associated with RA, but very few studies have evaluated fibromyalgia and depression simultaneously in patients with RA.”

The prevalence of fibromyalgia, depression, and anxiety in patients with adult patients with RA, along with controls, were analyzed in the cross-sectional, outpatient clinic, observational, non-interventional study between June 2020 and June 2021. Effects on the clinical parameters of RA during the COVID-19 pandemic were evaluated. The study was conducted in a single-center tertiary care, multispecialty, service and research hospital setting in north-central India.

The study included 200 patients with RA diagnosed by the American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) 2010 criteria. Multiple Disease Activity Scores were used to assess disease activity, functional disability, and quality of life, including the Simplified Disease Activity Index (SDAI) and the Clinical Disease Activity Index (CDAI). Depression and anxiety were evaluated using the Hospital Anxiety and Depression Scale (HADS).

Among patients with RA, fibromyalgia was present in 31% of patients, compared with 4% of controls. Those with concomitant RA and fibromyalgia were predominantly female, older, had longer disease duration, and were more likely to be treated with steroids. This patient population also had higher disease duration and none of these patients were in remission.

According to a multivariable analysis, fibromyalgia was deemed an independent predictor of the Simplified Disease Activity Index for RA. Those with concomitant RA and fibromyalgia reported worse functional ability and a poorer quality of life. Patients with RA and fibromyalgia had significantly higher rates of anxiety and depression (12.5% and 30%, respectively).

Investigators noted the study was strengthened by including patients without limitations regarding treatment status and activity measures, which helped to represent the real-world setting and increase generalizability. However, the study was not representative of all ethnicities, even within the Indian subcontinent. Another limitation was that investigators didn’t follow up with patients longitudinally, so they could not determine the effects the treatment prescriptions may have had on fibromyalgia and depression status.

“The assessment of fibromyalgia and mental health should be incorporated into the routine management of patients with RA, not only in extraordinary circumstances but also in everyday clinical practice and randomized controlled trials, since these conditions may represent the tail-ends of the spectrum of a ‘somatic pain—inflammatory arthritis—depression/fatigue continuum,’” investigators concluded.

References

1. ^{Upadhyaya SK, Malgutte DR, Handa R, Gupta S, Kumar A, Budumuru S. Fibromyalgia and mental health in rheumatoid arthritis: a cross-sectional prevalence study from the COVID-19 pandemic. BMJ Open. 2023;13(6):e069014. Published 2023 Jun 15. doi:10.1136/bmjopen-2022-069014}
2. ^{Wolfe F, Clauw DJ, Fitzcharles M-A, et al. Revisions to the 2010/2011 Fibromyalgia diagnostic criteria. Semin Arthritis Rheum 2016;46:319–29. doi:10.1016/j.semarthrit.2016.08.012}