Symptoms of Depression and Disability among Rheumatoid Arthritis Patients

Introduction

Rheumatoid arthritis (RA) is a chronic systemic inflammatory autoimmune disease characterized by proliferative inflammation of synovial joints (Kuo et al., 2020). It is common among adults around the world with prevalence rate about 1% of general population and commonly starts between the ages of 30-50 years (Vallerand et al., 2019), theoccurrence in Women is two to three times more than men. There is no definite cause of RA; it is thought to involve a variety of factors mainly genetic in addition to environmental factors. RA cannot be cured and its management aimed to achieving remission" few or no symptoms" and maintaining good quality of life (Arthritis Foundation., 2019). Depressive symptoms is known in the rheumatology field as ‘comorbidity’ of RA (Vallerand et al., 2019) that occurs in about 16.8 (10-23%) of patients and this is considered greater than prevalence in general population (Alan et al., 2016).

Depressive symptoms in RA may occur as a result of pain and disability which associated with impaired activity, organ dysfunction and altered role performance (Cunha et al., 2016). Also, there is a great evidence that joint pain, fatigue and disability result in physical and psychological stress which lead to disturbance in balance of brain neurotransmitters and hormones like serotonin, norepinephrine and this lead to negative impact on mood, behavior and cognition, that finally increasing the risk of depression (Arthritis Foundation, 2016; Zelman, 2018). According to a different model, depression in RA occur as a result of chronic inflammation from pro-inflammatory cytokine present in RA (Arthritis Foundation., 2016), The presence of depression in the case of RA results in different problems more than the burden of the emotional problem alone (Dures et al., 2014). It is linked with higher incidence of cardiovascular problems, heart attack, suicidal ideation (Tektonidou et al., 2011) increase health service use, impaired quality of life and higher mortality (Matcham, et al., 2016*).

RA also, has a great negative effects on patient's quality-of-life (QoL), including physical, mental, social and occupational aspects (Matchamet al., 2014; Qorolli et al., 2019). Health-related quality of life (HRQL) involve physical, emotional, , social and particular feelings of wellbeing  which represent the person's  evaluation and response to his disease (Fontaine, 2011; Malm et al., 2017).  RA is affecting quality of life directly and indirectly, and accounted as the major cause of health service consuming, the main cause of handicap, the first reason for impaired work productivity and early retirement. Pain and physical disability that present in RA accompanied with limited activity, organ deterioration, and impaired social and functional roles resulting, a negative effect on different aspects of patient life (Cunhaa et al., 2016). Poor quality of life in patients with RA is accompanied with increased healthcare resources usage and high risk of depression (Gaber et al., 2013; Gheita et al., 2014).

Significance of the study

Symptoms of depression has been listed as the most common symptom among psychological problems that negatively impacts patient's life and adversely affects multiple outcomes in RA beyond the burden of mental illness itself (Margaretten et al., 2011). Also RA has a considerable impact on patient's physical health and lead to great limitation in physical activity. Assessing both the physical and psychological symptoms of RA is very important to investigate the association between depression and disability, which considered a useful target for interventions aimed at improving physical and mental health status.

Aim of the study

This study aimed to assess prevalence of symptoms of depression and disability among RA patients.

Subjects and Methods

Research design

A descriptive correlational research design was utilized in this study.

Setting

This study was conducted on a cohort of RA patients' recruited from out-patient clinic of Rheumatology and Rehabilitation Department at Minia university hospital. The Hospital serves as central hospital in Minia Governorate and its suburb areas.

Subjects                                                          

A purposive sample established diagnosed 80 RA patients by rheumatologist which equal to 30% from total population size, and the total population size at a previous year was (270) (Mohamed.,2002; Roscoe., 1975).

Inclusion Criteria

• Patients aged ≥18 years (Adult RA).

• Disease duration ≥ one year.

• The patient should be adherent to follow up outpatient clinic.

Tools of Data Collection

A well-designed questionnaire was used to collect the data of the recruited patients. Patient data were obtained from patient's record sheet in Rheumatology outpatient clinic and includes; demographic information: age, gender, educational level, marital status, occupation and clinical data (duration of illness).

Tool (I): Beck Depression Inventory (BDI):

(BDI) version I developed by Beck (1961), is a 21-question multiple-choice self-report inventory measuring the severity of depressive symptoms The questionnaire contains 21 questions about how the subject has been feeling in the last week; each question has a set of at least four possible answer choices, ranging from 0 to 3, indicating the severity of the symptom. Items 1 to 13 assess symptoms that are psychological in nature, while items 14 to 21 assess more physical symptoms (Beck. 1961). The questionnaire back translated to Arabic by Abdel- khalek, (1998), the translated questionnaire had shown a strong validity and reliability. Internal consistency showed a high value for standardized alpha (Cronbach’s) = 0.98 (Damati et al., 2000).

Tool (II): The Health Assessment Questionnaire- Disability Index (HAQ-DI):

Originally was developed in 1978 by James F. Fries and colleagues at Stanford University as a functional assessment tool measure disease-related disability and discomfort in patients with RA. The questionnaire contains 20 questions grouped into eight subscales as dressing and grooming, arising, eating, walking, hygiene, reach, grip and activities (Fries et al., 1982).The Arabic version of El-miedany was used. The translated questionnaire had shown a strong validity and reliability.

 Internal consistency showed a high value for standardized alpha (Cronbach’s): 0.979(El Miedany et al., 2003).The HAQ disability index was calculated as the sum of the scores for various subscales, divided by the number of subscales responded to, and results in a score between (0 and 3). Scores of 0 to 1 is generally represent mild to moderate difficulty, 1 to 2 represents moderate to severe disability, and 2 to 3 indicates severe to very severe disability (Fries et al., 1982).

Pilot study

Pilot Study was conducted on 10% from the total number which equal 8 patients of study sample to test the study process and to evaluate the efficiency, clarity, of tools that was used in the study. Subjects who participated in the pilot study were excluded from the actual study.

Field work

Each patient interviewed to collect the necessary data, the researcher went to Minia university hospital for two days per week (Sunday, and Wednesday from 9 am to 11 am). The questionnaires filled out by the researcher and also the researcher clarified the meaning of the questions to the patient facilitate understanding the meaning of the statements.

Administrative Design

An official letter was obtained from the dean of the Faculty of Nursing, Minia University, as well as the Head of rheumatology and rehabilitation department, asking for permission to collect data and carry out the program. Oral consent was obtained from the patients after explaining the nature and purpose of the study through direct personal communication to gain their acceptance and cooperation.

Ethical Consideration

A written initial approval obtained from the Research Ethical Committee of the Faculty of Nursing, Minia University, there was no risk for studied subject during application of this research, the study followed the common ethical rules in clinical research, and privacy was provided during data collection. Anonymity and confidentiality were assured through coding the data; and a patient had the right to refuse to participate in the study and without any rationale.

Statistical Analysis

Recorded data were analyzed using the statistical package for social sciences; version 24.0 Quantitative data were expressed as mean± standard deviation (SD). Qualitative data were expressed as frequency and percentage

Results

Table (1): Descriptive statistic of demographic and clinical data of the studied sample (N= 80).

_{Frequency   %                                                      Mean ± SD                       Median}

Table 1 showed the descriptive statistics of the 80 participants included in the study. In total, 71 (88.7) % of participants were female, and the median age was 42.5 (20-65) y. The majority of participants were married 59 (73.8 %) and 46 (57.5%) of them were primary educated. About one third of the studied sample had moderate activity and the median disease duration was 8 (1-20) y.

Figure (1): Frequency distribution of levels of symptom of Depression among the studied sample (N=80)

Figure (2): Frequency distribution of disability levels among the studied sample (N=80)

Figure1, 2 showed the frequency distribution of depressive symptoms and disability levels. It can be noted from figure 1 that 59 (73.8%) of the studied sample had moderate symptoms of depression, while figure 2 showed that 67 (83.8%) had moderate level of disability.

Table (2).  Comparison between levels of symptom of Depression relation to levels of disability among the studied sample (N=80).

Chi-square test                                                           *p-value <0.05 S; **p-value <0.001 HS

Table 2 revealed that there was statistically significant differences between levels of depressive symptoms in relation to levels of disability with p= .04.

There was significant positive correlation between symptom of Depressionand disability with total score r = .81 at P= .0001 which shown in Figure 3.