Major Depressive Disorder Is the Most Observed Psychiatric Comorbidity in RA

Ajaz Kariem Khan, MD, FACR, FRCM

Credit: Arthritis & Rheumatology, Clinic of Kashmir

In a recent study, major depressive disorder (MDD) was the most observed comorbidity in patients with rheumatoid arthritis (RA), followed by somatoform disorder and generalized anxiety disorder (GAD).¹

“It was surprising that almost 80% of participants reported some degree of psychological distress in the form of major depression, somatoform disorders, and generalized anxiety disorder, which is one and half times more than reported in the literature,” wrote investigators, led by Ajaz Kariem Khan, MD, FACR, FRCM, from the center for rheumatic diseases at Shifa Superspeciality Hospital in India.

The symptoms of RA—inflammation and pain in the joints—affect not only an individual’s physical but also emotional well-being, and the discomfort puts people with RA at a high risk of developing psychiatric morbidity. Chronic pain, inflammation, medications, and the burden of managing a chronic illness all impact the relationship between psychiatric symptoms and RA.

Previous research found patients had high levels of anxiety if they viewed RA as an illness with serious negative consequences and depressive symptoms if they experienced more primary symptoms of the disease.^2,3 Literature reported patients with RA have a high prevalence of MDD, social phobia, panic disorder, and anxiety.⁴ Prior studies evaluating the psychiatry comorbidity in RA took place in Western countries, but a lack of research on the relationship existed among Indian patients with RA.

Investigators sought to analyze the prevalence of psychiatric morbidly among Indian patients with RA.¹ Specifically, they aimed to identify the common mental health conditions in patients with RA and how the relationship between RA and comorbid psychiatric conditions can provide insight for improved holistic patient care.

The team conducted a prospective, observational cross-sectional study in patients with RA at Shifa Hospital and V care super specialty clinic in Srinagar, India over 3 years (January 2019 – January 2022). They assessed psychiatric morbidity (International Classification of Diseases-10 criteria and Mini-International Neuropsychiatric Interview Schedule PLUS) RA (2010 American College of Rheumatology/European Alliance of Associations for Rheumatology (ACR/EULAR) diagnostic criteria), and disease activity (Disease Activity Score with 28-joint count using the calculator from the RheumaHelper application).

The study included 1000 patients with RA on treatment, aged ≥ 17 years. Of the sample, nearly two-thirds were female (64.8%), more than half (53.2% with moderate disease activity, and most belonged to the age group of 41 – 54 years. Slightly less than of patients were unemployed (47.5%), followed by patients who were salaried (27%), businessmen (19%), and students (6.5%).

MDD was the most common comorbidity (41%), followed by somatoform disorder (28.5%) and GAD (13.5%). A total of 17% of patients did not have comorbid psychiatric symptoms. Patients < 55 years old had a greater prevalence of MDD (47%) than patients > 55 years old (21.3%).

“The low prevalence of major depression in aged patients may not necessarily be a good thing; it is possible that those patients with depression and RA have high mortality and may not reach this advanced age,” investigators wrote. “…or it could simply be that patients stop worrying about the illness and get adapted to the illness.”

The prevalence of depression increased with the severity of disease activity; the prevalence of depression was 63.8% (123 patients out of 210) in patients with high disease activity, 36.8% (196 patients out of 5232) in patients with moderate disease activity, and 31.7% (82 patients out of 258) in patients with low disease activity.

Investigators pointed out 3 limitations: the clinic-based data preventing the results from being extrapolated to a wider Indian population, the study not recording management of the depressive morbidities, and being unable to rule out recall bias.

“In view of high psychiatric morbidity associated with RA, there is enough scope for psychiatric services to be made available to these patients,” investigators concluded. “In addition, personnel involved in the treatment of these patients should be trained for early detection of psychiatric symptoms for better treatment outcomes.”

References

1. ^{Khan AK, Nabi J, Parrey AH, Rath PD, Lone S. Patterns and prevalence of psychiatric morbidity among individuals with rheumatoid arthritis. Reumatologia. 2024;62(2):115-120. doi:10.5114/reum/186975}
2. ^{Graves H, Scott DL, Lempp H, Weinman J. Illness beliefs predict disability in rheumatoid arthritis. J Psychosom Res 2009; 67: 417–423, DOI: 10.1016/j.jpsychores.2009.01.006.}
3. ^{Murphy S, Creed F, Jayson MI. Psychiatric disorder and illness behaviour in rheumatoid arthritis. Br J Rheumatol 1988; 27: 357–363, DOI: 10.1093/rheumatology/27.5.357.}
4. ^{Bekhuis E, Boschloo L, Rosmalen JG, Schoevers RA. Differential associations of specific depressive and anxiety disorders with somatic symptoms. J Psychosom Res 2015; 78: 116–122, DOI: 10.1016/j.jpsychores.2014.11.007.}