Patients with arthritis, depression more likely to be unemployed
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Depression symptoms were associated with unemployment among working-age adults with arthritis, with middle-aged adults most affected, according to data published in Arthritis Care & Research.
“Arthritis is one of the most common causes of work disability in the United States,” Arif Jetha, PhD, of the Institute for Work and Health and the University of Toronto, and colleagues wrote. “Research of working-age (18-64 years) adults indicates that arthritis is consistently associated with challenges in finding and sustaining employment and remaining productive at work.”
“Emerging evidence also indicates that working-age adults with arthritis are also more likely to live with depression when compared with those without arthritis,” they added. “Few studies have examined the role of depression in the employment participation of those living with arthritis, and whether differences exist across young (18-34 years), middle-age (35-54 years), and older (55-64 years) working-age adults.”
To analyze the relationship between depression, arthritis and employment status, as well as to determine if this link varies by age, Jetha and colleagues studied data from the U.S. National Health Interview Survey. Focusing on the period from 2013 to 2017, the researchers examined data from 11,380 adults with some form of arthritis — including rheumatoid arthritis, gout, lupus and fibromyalgia — aged 18 to 64 years. Included patients were also required to have complete data on depression symptoms.
Covariates included sociodemographic information, health and health system use. The researchers compared employment prevalence to self-reported depressive symptoms. They then estimated percentages, as well as univariable and multivariable logistic regression models, to examine the relationship between depression and employment among young (aged 18-34 years), middle-aged (aged 35-54 years) and older adults (aged55-64 years).
According to the researchers, the overall prevalence of depression symptoms was 13%. Among those who reported depressive symptoms, 60% demonstrated a prevalence of fair or poor health, and 70% had arthritis-attributable activity limitations, compared with 23% and 39%, respectively, among those without depression.
Respondents with depression also reported significantly lower employment prevalence — 30%, compared with 66% among those not reporting depressive symptoms — and a lower multivariable-adjusted association with employment (PR = 0.88; 95% CI, 0.83-0.93). Middle-aged adults who reported depression were significantly less likely to be employed compared with their counterparts without depression (PR = 0.83; 95% CI, 0.77-0.9).
Additionally, the researchers noted similar, but borderline statistically significant, relationships for both younger (PR = 0.86; 95% CI, 0.74-0.99) and older adults (PR = 0.94; 95% CI, 0.86-1.03).
“In an analysis of the U.S. population living with arthritis, our study shows that depression can contribute to work disability,” Jetha told Healio Rheumatology. “We provide support for the importance of the diagnosis and treatment of depression as a strategy to promote the employment engagement of people living with arthritis. The relationship between depression and employment may be most significant for middle-aged adults with arthritis who are in the prime of their working lives and may also have a greater number of personal responsibilities, like parenting or caring for an elderly relative.”
Perspective
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David A. McLain, MD, FACP, FACR
This report, from Jetha and colleagues, shows that patients with arthritis who are on disability are more depressed than those who are employed. I do not know how many rheumatologists are screening their patients for depression. I think we know that depression is a major issue in rheumatology, and we see depression commonly with fibromyalgia, lupus and other connective tissue diseases. Chronic pain is a major issue in rheumatology and is independently associated with depression.
In 2012, Serge Perrot and colleagues published a literature review in the European Journal of Pain on the use of antidepressants in painful rheumatic conditions in rheumatology. Their review found that antidepressants helped the pain in rheumatic conditions, but also helped sleep disorders and fatigue. Such agents like tricyclic antidepressants – amitriptyline and nortriptyline (Pamelor, Mallinckrodt) – and selective serotonin reuptake inhibitors (SNRIs) – duloxetine (Cymbalta, Eli Lilly) and milnacipran (Savella, Allergan) – treat both depression and chronic pain.
Major depressive disorder is thought to be an independent risk factor for both work disability and mortality in those with RA, as noted by Dennis Ang and colleagues in the Journal of Rheumatology. Clinical associations between medical illnesses and major depressive disorder are not solely attributable to illness-induced disability or pain. For example, inflammatory mediators like proinflammatory cytokines are thought to have a direct impact on biologic substrates implicated in the pathophysiology of mood, particularly the serotonergic system, and conversely, serotonergic pathways are thought to be important in mediating both inflammation and mood.
Studies have also shown that inflammation upregulates the serotonin transporter – increasing clearance of serotonin or 5-HT from the synaptic cleft and terminating the effect of serotonin – and the kynurenine pathway – shunting away from 5-HT and forming substances that are NMDA agonists. In prior studies, depression has been correlated with levels of CRP, IL-1, and Il-6.
The present study looked at self-reported depression, self-reported “arthritis” and work status. It is interesting that depression and work disability was higher in the younger age groups, suggesting the “arthritis” was inflammatory rather than degenerative, which would fit with the observations that inflammation and depression are interconnected.
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