Addressing depression may improve outcomes in psoriatic arthritis
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PHILADELPHIA — Patients with psoriatic arthritis who have depression may perceive their disease differently compared with patients without depression which may make achievement of low disease activity or remission more challenging.
The findings from the prospective study were presented at ACR Convergence 2022.
“In general, we know that depression is associated with higher levels of pain and reduced pain thresholds — meaning people feel pain at lower amounts. It’s associated with worse reports of physical function, worse outcomes after orthopedic surgeries, like joint replacement. We also know that in psoriatic arthritis, depression and anxiety are independently associated with higher pain scores despite their level of disease activity,” Rebecca Haberman, MD, assistant professor in the department of medicine and division of rheumatology at NYU Langone Health, told Healio. “So, from a couple of different directions, depression and anxiety do increase pain, but depression and anxiety can also reduce a patient’s ability to go into remission.”
For the study, Haberman and colleagues prospectively enrolled 537 consecutive adult patients who met Classification for Psoriatic Arthritis (CASPAR) criteria from the NYU Psoriatic Arthritis Center. Patients were followed for up to 2 years and all data was obtained from clinical visits using a standardized EPIC template, according to the poster. The first clinical interaction was defined as the baseline visit, regardless of each patient’s disease duration or treatment. Depression was categorized by patient-reported depression and/or use of anti-depressant medication.
The study population was 53% male, 79.7% white and had a mean age of 49 years. The researchers reported 23% of patients experienced depression, 18% anxiety and 4% ADHD. Among the patients with depression at the initial visit, more were likely to be female, older and have concomitant anxiety compared with patients without depression.
Patients with depression had similar swollen joint counts, tender joint counts, lower percent body surface area and Routine Assessment of Patient Index Data 3 (RAPID3) scores compared with patients without depression at the initial visit.
However, when analyzing subsequent timepoints, patients with depression had higher tender joint counts compared with patients without depression. However, all other outcomes remained similar between the groups, according to the poster.
“Patients who have psoriatic arthritis and depression, versus those who have psoriatic arthritis without depression, have higher levels of pain which we are reporting here as tender joints, but have similar amounts of inflammation, which is what we’re reporting here as swollen joints,” Haberman said. “So, patients with depression may be more likely to have pain and residual pain compared to those who do not have depression.”
At baseline, the rate ratio of tender swollen joints in patients with depression compared with patients without depression was 1.23 (95% CI, 0.78 – 1.94) when the researchers adjusted for age, sex, race, medication use, and comorbidities. At year 1, the rate ratio was higher at 1.47 (95% CI, 0.91 – 2.35) and at year 2, the rate ratio neared significance at 1.75 (95% CI, 0.97 – 3.14). However, the pattern was not observed in the adjusted models for swollen joint count, body surface area, and RAPID3.
“This is important is because often as rheumatologists, when we’re faced with patients who continue to have pain, our immediate reaction is to change their immunomodulatory medications,” Haberman said. “Often, if they have remaining pain, we increase or change their immunomodulating medications which comes with the possibility of side effects. But it may be that we are changing these immunomodulatory medications to try to address pain that isn’t from inflammation, which will not help our patients feel better and may actually be doing more harm than good.”
Haberman and colleagues highlighted the importance of not only addressing inflammatory systems but also depression among patients with PsA, particularly for those experiencing residual pain.
“We know that in patients who have seemingly good control over their inflammatory disease, meaning physicians think they are in very low disease activity, up to half of them continue to have residual pain and residual fatigue,” she said. “Not all of those are due to sub-clinical inflammation; there’s another component there. What we’re talking about is that some of that residual pain and fatigue may be coming from depression, rather than inflammation itself. Asking about depression, addressing depression, even just knowing that it's there, can help physicians make proper treatment decisions moving forward.”
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Haberman R, et al. Abstract 1021. Presented at: ACR Convergence 2022; November 11-14, 2022; Philadelphia (hybrid meeting).
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