Background/Purpose:

Depression and anxiety have detrimental effects on quality-of-life, treatment response and disease outcomes. Whilst psychological morbidity has been described in individual rheumatic diseases, less is known about the comparative burden across the spectrum of rheumatic conditions. The prevalence of depression and anxiety in the general population is 3.8% and 5% respectively. We sought to quantify major depressive disorder (MDD), suicidal ideation, and generalised anxiety disorder (GAD), in a cross-section of rheumatology outpatients.

Methods:

All data were collected using electronic records from an inner city hospital in London, UK. MDD/GAD were identified using the Patient Health Questionnaire (PHQ9) and Generalised Anxiety Disorder questionnaire (GAD7) respectively. Suicidal ideation was identified using PHQ9 item 9: having “thoughts that you would be better off dead or of hurting yourself in some way”.

Results:

Between February 2013 and February 2015, 1281 patients with a confirmed diagnosis were screened (mean age 53.6 (SD15.8); 24.6% male). Overall, 29.7% of patients reported significant psychological morbidity: 21.9% screened positive for MDD; 6% of patients reported suicidal ideation. GAD was found in 23.1% of patients; 10% reported severe anxiety symptoms (GAD7≥15). Depression correlated with increased pain (rho = 0.46, p<0.001) and fatigue (rho = 0.44, p<0.001). Anxiety correlated with increased pain (rho = 0.38, p<0.001) and fatigue (rho = 0.33, p<0.001). MDD was most prevalent in early inflammatory arthritis (EIA) (29.7%), and least prevalent in patients with vasculitis (17.5%). Fewer AxSpa reported severe MDD (8%), whilst the highest levels were reported in CTD (10.9%), EIA (10.8%) and PsA (10.8%). Severe anxiety was not significantly different across the diseases however GAD was substantially more prevalent in EIA (35.1%). Patients with PsA reported the most suicidal ideation (10%).

Conclusion:

Psychological comorbidity is highly prevalent across rheumatic diseases. The slightly higher levels of MDD and GAD in EIA may relate to the recent diagnosis, reflecting a period of adjustment to chronic illness and lifestyle and medication changes. The high prevalence of suicidal ideation in PsA may reflect the impact of visible cutaneous disease upon self-esteem and mood. Reporting suicidal ideation within the PHQ9 can imply anything from a fleeting thought of suicide, to a detailed plan. There is a need for greater awareness of mental health comorbidities in patients attending rheumatology clinics. These findings help delineate the magnitude of the problem and inform departments of the likely level of provision that will be needed. Integrating mental health services into musculoskeletal clinics offers a unique opportunity to improve clinical care, and based upon the burden of disease in our population, this approach is justifiable.