Research Article: New insights into the prevalence of depressive symptoms and depression in rheumatoid arthritis – Implications from the prospective multicenter VADERA II study

Date Published: May 28, 2019

Publisher: Public Library of Science

Author(s): Matthias Englbrecht, Rieke Alten, Martin Aringer, Christoph G. Baerwald, Harald Burkhardt, Nancy Eby, Jan-Paul Flacke, Gerhard Fliedner, Ulf Henkemeier, Michael W. Hofmann, Stefan Kleinert, Christian Kneitz, Klaus Krüger, Christoph Pohl, Georg Schett, Marc Schmalzing, Anne-Kathrin Tausche, Hans-Peter Tony, Jörg Wendler, Peter M. ten Klooster.


To investigate the prevalence of depressive symptoms in rheumatoid arthritis (RA) patients using two previously validated questionnaires in a large patient sample, and to evaluate depressive symptoms in the context of clinical characteristics (e.g. remission of disease) and patient-reported impact of disease.

In this cross-sectional study, the previously validated Patient Health Questionnaire (PHQ-9) and Beck-Depression Inventory II (BDI-II) were used to assess the extent of depressive symptoms in RA patients. Demographic background, RA disease activity score (DAS28), RA impact of disease (RAID) score, comorbidities, anti-rheumatic therapy and antidepressive treatment, were recorded. Cut-off values for depressive symptomatology were PHQ-9 ≥5 or BDI-II ≥14 for mild depressive symptoms or worse and PHQ-9 ≥ 10 or BDI-II ≥ 20 for moderate depressive symptoms or worse. Prevalence of depressive symptomatology was derived by frequency analysis while factors independently associated with depressive symptomatology were investigated by using multiple logistic regression analyses. Ethics committee approval was obtained, and all patients provided written informed consent before participation.

In 1004 RA-patients (75.1% female, mean±SD age: 61.0±12.9 years, mean disease duration: 12.2±9.9 years, DAS28 (ESR): 2.5±1.2), the prevalence of depressive symptoms was 55.4% (mild or worse) and 22.8% (moderate or worse). Characteristics independently associated with depressive symptomatology were: age <60 years (OR = 1.78), RAID score >2 (OR = 10.54) and presence of chronic pain (OR = 3.25). Of patients classified as having depressive symptoms, only 11.7% were receiving anti-depressive therapy.

Mild and moderate depressive symptoms were common in RA patients according to validated tools. In routine clinical practice, screening for depression with corresponding follow-up procedures is as relevant as incorporating these results with patient-reported outcomes (e.g. symptom state), because the mere assessment of clinical disease activity does not sufficiently reflect the prevalence of depressive symptoms.

This study is registered in the Deutsches Register Klinischer Studien (DRKS00003231) and (NCT02485483).

Partial Text

Rheumatoid arthritis (RA) is a chronic inflammatory disease of the musculoskeletal system that leads to pain, swelling and progressive joint destruction via increased activity of pro-inflammatory cytokines [1]. Although a variety of conventional and biological disease modifying anti-rheumatic drugs are available to control disease activity in RA, the disease is still challenging and usually requires life-long treatment. Furthermore, it is associated with a substantial reduction of overall physical and emotional well-being not only due to articular symptoms including pain and loss of physical function but also as a result of fatigue and impaired quality of sleep [1, 2]. This disease burden can affect the patient’s quality of life and socioeconomic outcomes including workplace absenteeism and presenteeism (low workplace productivity) [3–5]. For patients with RA, a greater loss of workplace productivity has been associated not only with functional disability but also with depressive symptoms [6]. Moreover, depression has also been associated with high costs of absenteeism and presenteeism in a wide range of countries across a variety of socioeconomic statuses [7]. Against this background, the challenge of depression as a comorbidity of RA becomes evident: in combination, these disorders pose an even more considerable burden for patients and are likely to result in more frequent and longer periods of absence. In clinical practice, depressive symptoms and affective disorders are common in RA [8–10] with a recent meta-analysis reporting 16.8% of RA patients as having a major depressive disorder [11]. Furthermore, Dougados et al. found depression to be the most frequent comorbidity in RA (15%) [12]. Thus, detecting and addressing depression in patients with RA needs to be a part of patient care. This means, applying standardized procedures to screen for depression and in the case of positive screening results, a follow-up with a full diagnostic assessment [13].

To the best of our knowledge, this is the first time the RAID questionnaire and its PASS criterion have been applied to a study addressing depressive symptoms in RA. Furthermore, this is the first time depression questionnaires that were previously validated specifically in RA patients have been used in a prevalence study.