The presence of depression or anxiety among patients with psoriatic arthritis was associated with a diminished likelihood of achieving a state of minimal disease activity, regardless of the method used to diagnose depression/anxiety, researchers reported.
When depression/anxiety was defined as a score of 38 or lower on the Mental Component Summary of the Short Form (SF)-36 Health Survey (definition 1), the odds ratio for reaching sustained minimal disease activity was only 0.30 (95% CI 0.22-0.39, P<0.0001), according to Vinod Chandran, MD, PhD, of the University of Toronto, and colleagues.
And if the definition was a score of 56 or lower on the Mental Health Subscale of the SF-36 (definition 2), the odds ratio was 0.34 (95% CI 0.26-0.45, P<0.0001), while when the definition was a physician diagnosis of depression/anxiety (definition 3), the odds ratio was 0.47 (95% CI 0.35-0.65, P<0.0001).
As the researchers explained in their study online in Arthritis Care & Research, patients with psoriatic arthritis commonly experience various comorbidities, not the least of which is depression/anxiety, which can have a substantial impact on emotional well-being. Previous studies have suggested that the presence of depression/anxiety was associated with higher disease activity, and a suicide signal was reported for a monoclonal antibody that blocks interleukin 17 receptor A in patients with psoriatic disease.
The aim of treatment in psoriatic arthritis is the attainment of remission or at least minimal disease activity. To clarify the potential impact of depression/anxiety on the achievement of that goal, Chandran and colleagues analyzed data for patients enrolled in the University of Toronto Psoriatic Arthritis Clinic during 2008 to 2017.
Minimal disease activity was defined as achievement of at least five of the following seven criteria:
- Tender joint count of 1 or less
- Swollen joint count of 1 or less
- Tender enthesial points of 1 or less
- Psoriasis Activity and Severity Index (PASI) of 1 or less or body surface area of 3 or less
- Pain scores of 15 or less
- Patient global disease activity of 20 or less
- Health Assessment Questionnaire (HAQ) of 0.5 or lower
Minimal disease activity was considered sustained if achieved for at least two consecutive 6-month visits.
The analysis included 743 patients whose mean age was 50. More than half were men. The mean number of active joints at baseline was 5.8, enthesitis was present in 18%, mean PASI was 4, pain score was 32.9, and mean score on the HAQ was 0.5.
A total of 44.54% of patients were considered to have depression/anxiety according to definition 1, 48.99% according to definition 2, and 28.4% according to definition 3.
On a univariate analysis, depression/anxiety by all three definitions lowered the likelihood of achieving minimal disease activity by approximately 60-75%, the researchers found. This analysis adjusted for multiple factors, including the Charlson Comorbidity Index, fibromyalgia, treatment with disease-modifying anti-rheumatic drugs (DMARDs) or biologics, daily alcohol intake, damaged joint count, smoking, and obesity.
Other factors that were found on the univariate analysis to be associated with non-achievement of minimal disease activity included the presence of fibromyalgia, higher scores on the Charlson Comorbidity Index, treatment with DMARDs, and the presence of axial involvement. A higher likelihood of minimal disease activity was seen for daily alcohol intake.
Factors other than depression/anxiety that remained significant for a reduced probability of minimal disease activity in a multivariate analysis included the Charlson Comorbidity Index (OR 0.74, 95% CI 0.64-0.87, P=0.0002) and fibromyalgia (OR 0.19, 95% CI 0.08-0.44, P<0.0001, both according to definition 1).
As in the univariate analysis, daily alcohol use was associated with a higher probability (OR 1.68, 95% CI 1.12-2.52, P=0.012), and similar results were observed for definitions 2 and 3.
“Our study demonstrated that the presence of symptoms or a diagnosis of depression/anxiety significantly reduced the probability of achieving sustained minimal disease activity in psoriatic arthritis patients, and this was independent of disease severity as measured by number of damaged joints or medications used,” the researchers wrote.
Potential reasons for the consistent association of depression/anxiety and inability to attain low disease activity including a heightened sensitivity to pain, which may “lead to avoidance, inactivity, deconditioning, and social isolation,” Chandran and co-authors continued, adding that the association with fibromyalgia “may be due to persistent pain that contributes to both the tender joint count and the patient-reported pain and disease activity scores.”
And as to the daily alcohol consumption and greater achievement of minimal disease activity, this may reflect an overall heightened state of well-being, the investigators speculated.
They said the study findings suggest that comprehensive management of psoriatic arthritis should include assessment and measures for the alleviation of depression/anxiety.
A limitation of the study, the team said, was the lack of formal psychiatric assessment for depression/anxiety.
Disclosures
Several of the researchers are affiliated with the Psoriatic Disease Program of the Krembil Research Institute of University Health Network in Toronto, which is supported by the Krembil Foundation.
Chandran reported support from a Pfizer Chair Rheumatology Research Award from the Department of Medicine, University of Toronto, and a co-author received a Krembil Psoriatic Arthritis Fellowship.