RA patients with persistent or recurrent depression have double the risk of death

Comorbid depression increases the risk of death for patients with rheumatoid arthritis (RA), Dr Dennis C Ang (Indiana University School of Medicine, Indianapolis) and colleagues report in the June 2005 Journal of Rheumatology.

“Depression screening should be performed for RA patients with significant pain and functional impairment that are out of proportion to the objective findings. Patients with mild depression should be encouraged to participate in mutual support groups to learn more about their pain and RA, in general. Psychosocial support provided through regular telephone contact with an office nurse can help promote self-care. If depression is more than mild, antidepressant medications should be considered in addition to supportive therapy. Alternatively, referral to a mental-health specialist is warranted for patients who continue to have substantial depression after 12 weeks of psychosocial support,” Ang tells rheumawire.1290 RA patients followed over 18 yearsAng and colleagues followed 1290 consecutive outpatients with RA for an 18-year observation period. The primary independent variable was the mean of the Arthritis Impact Measurement Scales (AIMS) depression scores during the first four years (the average four-year depression). The investigators found that the hazard ratio (HR) for each unit increase in the average four-year depression score was 1.14 (p<0.0001). After a median follow up of 4.9 years, the depressed patients were 2.2 times more likely to die than the nondepressed RA patients (p=0.01).RA patients with persistent or recurrent depression during the first four years of entry into the cohort were at least twice as likely to die as patients with no depression. "RA patients with persistent or recurrent depression during the first four years of entry into the cohort were at least twice as likely to die as patients with no depression. After a median five-year follow-up period, clinical depression, as defined by an AIMS depression score >4, was associated with higher mortality risk, independent of comorbid medical disorders and RA disease activity. Moreover, the effect of depression persists beyond the early years of the observation period, which suggests a true depression-mortality association rather than confounding from the presence of other chronic illnesses,” the researchers report.Ang also points out that patients with RA “are twice as likely to suffer from depression as members of the general population.” In this study, 17.6% of RA patients had clinical depression.The investigators acknowledge that clinical trials will be needed to determine whether treating depression can reduce mortality in RA, but they think it is worth a try.A single sensitive screening question ‘Have you been bothered by feeling down or depressed?’ may be used to identify depressive states. “A variety of instruments have been developed to screen for the presence of affective disorder. In my clinic practice, I use the PHQ-9 questionnaire. The PHQ-9 is a nine-item depression scale from the newly validated Patient Health Questionnaire based on the DSM-IV criteria for the diagnoses of depressive disorders,” Ang says. “In addition to its utility as a diagnostic instrument, the PHQ-9 may be used to assess the severity of depressive symptoms. Cut points of 5, 10, 15, and 20 represent mild, moderate, moderately severe, and severe depression, respectively. Alternatively, a single sensitive screening question’Have you been bothered by feeling down or depressed?’ may be used to identify depressive states. Patients who answer affirmatively can then be questioned about additional features for major depression.”(Source: Rheumawire Joint and Bone: Ang DC, Choi H, Kroenke KI, Wolfe F. Comorbid depression is an independent risk factor for mortality in patients with rheumatoid arthritis. J Rheumatol 2005; 32:1013-1019: June 2005.)