NORTH STAFFORDSHIRE, United Kingdom—Clinicians fail to recognize and treat depression in 43% of rheumatoid arthritis (RA) patients taking TNF inhibitors, and that might be leading to inappropriate discontinuation of treatment in some cases, according to research reported early online in Rheumatology.1
According to Samantha L. Hider, PhD, and colleagues, depression is associated with lower responses to TNF inhibitors, as assessed with the 28-point Disease Activity Score (DAS28), and a significant reduction in DAS28 “is a requirement for continuing therapy” in patients treated within the UK National Health Service. Dr. Hider is at Staffordshire Rheumatology Centre, University Hospitals of North Staffordshire, Stoke on Trent, UK.
“We hope that this paper will serve to highlight this issue to clinicians so that perhaps more will ask about symptoms of depression and treat accordingly,” Dr. Hider told Musculoskeletal Report.
Depression improves in most after beginning TNF inhibitors
These authors found that many patients with severe RA who are depressed do not receive treatment for their depression. The current study also suggested that recognition and appropriate management of depression may improve objective and subjective ratings of the effectiveness of anti-TNF medications.
In this retrospective chart study the researchers examined the depression scores (measured by Hospital Anxiety and Depression Scale, HADS-D) and disease activity scores (DAS28) of 160 patients with severe longstanding RA who were beginning anti-TNF therapy. Probable depression was defined as HADS-D of ≥ 8; severe depression was defined as HADS-D of ≥11. For patients who remained persistently depressed at 4 months, the researchers reviewed clinical case notes to determine whether their depression had been recognized and managed with either antidepressant therapy or referral.
“This cut-off of 4 months for persistent depression was deliberately chosen, as we hypothesized that if anti-TNF therapy is effective and leads to an improvement in disease activity and pain, there may be an associated improvement in mood, and therefore, we did not wish to be prematurely treating patients with low mood who may have improved without additional management,” the authors wrote.
But those who stay depressed are often not diagnosed and treated
At baseline before initiation of TNF inhibitor treatment 47.5% (76/160) of the RA patients in the sample were depressed. The researchers found that 87% of patients continued anti-TNF therapy at 4 months, at which point 19% still reported depression, as did 15% of those who continued anti-TNF therapy at 12 months.
According to the case records, only 57% (13/23) of those with persistent depression had been treated for this mood disorder, despite frequent attendance at the clinic.
Translating research into practice: RA, depression, and TNF inhibitors
The researchers also found that patients’ level of depression influenced treatment outcome. Those with persistent depression had smaller decreases in DAS28 than individuals without depression. Depressed patients also had persistently higher swollen joint counts and tender joints, despite having similar levels of RA disease activity at baseline.
“In summary, depression is common in patients starting anti-TNF therapy and tends to improve after anti-TNF exposure. However, depression is significantly under-recognized and treated within the rheumatology clinic. Given that depression is treatable and is associated with poorer responses to anti-TNF, recognition and appropriate management of depression may improve TNF effectiveness,” the authors conclude.
Reference
a great deal of positive can come from good thoughts... we are unable to have those positive thoughts when we are so depressed and feeling so badly....... it's a vicious circle! Yes, a vicious circle describes "it" perfectly. And as perfectly as the description is, a companion article Lynn posted >>HERE<< perfectly restates how important mental well being is in relationship to physical well being.1. Hider SL, Tanveer W, Brownfield A, et al. Depression in RA patients treated with anti-TNF is common and under-recognized in the rheumatology clinic. Rheumatology. 2009. [epub ahead of print July 16, 2009]. doi:10.1093/rheumatology/kep170.
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