Depression and Mortality Associated with Rheumatoid Arthritis

Washington, DC—Identifying and managing depression in people with rheumatoid arthritis (RA), particularly men, is important based on the results of a study showing an increase in all-cause mortality associated with depression in RA patients.

Although rates of depression are increased among people with RA, and studies of elderly people and cardiovascular disease show depression as a risk factor for mortality, little attention has been given to the potential risk of mortality in RA patients with depression.

To fill this gap, investigators at the University of California, San Francisco conducted a longitudinal cohort study of people with RA recruited from community rheumatology practices in Northern California. Using annual telephone surveys, the investigators collected data from 530 people with RA to assess symptoms of depression as well as the potential impact of the disease. Mean age of the participants was 60 years, with a mean disease duration of 19 years. Most were female (84%), and 46% reported at least 1 cardiovascular disease risk factor.

All people included in the survey were required to score ≥5 on the Geriatric Depression Scale (GDS), a standardized measurement tool for depression, as well as to have undergone a telephone interview in either 2002 or 2003 with at least 1 follow-up interview, and to have been followed until 2009.

Using Cox regression models, the investigators estimated the association between depression and all-cause mortality based on 2 analyses. One analysis examined all-cause mortality risk associated with depression as defined as GDS >5 in the last interview prior to death or censorship. The second analysis examined all-cause mortality risk associated with a 2-point increase in GDS score from the penultimate to the last interview prior to death or censorship. Both analyses controlled for sex, age, disease duration, and presence of cardiovascular disease risk.

At a mean follow-up of 4.9 years until death or censorship, the study found that 63 of the 530 (12%) participants died. Under both analyses, the study found that depression was associated with an increased risk of death (hazard ratio [HR], 3.5; 95% confidence interval [CI], 2.1-5.8). Mortality risk was also associated with depression when looking at a worsening of GDS score by >2 points (HR, 2.5; 95% CI, 1.5-4.2). This increased mortality risk associated with depression remained when controlling for age, disease duration, and cardiovascular risk factors.

In separate analyses that examined the effects of both gender and depression on increased mortality risk, the study found that men without depression had 5 times the risk of death compared with women without depression (HR, 5.1; 95% CI, 2.2-11.8 vs HR, 1, respectively, based on worsening of GDS score by >2 points; and HR, 5.9; 95% CI, 2,7-13.1 vs HR, 1, respectively, based on baseline GDS >5).

After controlling for covariates, a greater mortality risk was still seen in men without depression compared with women without depression.

According to Patricia Katz, PhD, a study co-investigator and professor in residence of Medicine and Health Policy in the Division of Rheumatology at the University of California, San Francisco, who presented the results at the ACR meeting, healthcare providers need to be aware of the problem of depression. She also emphasized the need for strategies to motivate men in particular to seek treatment for their depression, including regular monitoring of depression, providing information on manifestations of depressive symptoms, and incorporating motivational interviewing techniques that may help to handle resistance to treatment and downplaying symptoms.