Rheumatoid arthritis and anxiety, depression during the COVID pandemic

Studies indicate increased links between chronic disease and balanced mental health.

with Don L. Goldenberg MD

As the ongoing COVID-19 pandemic continues to challenge the mental health of the population as a whole, providers should be especially mindful of patients with rheumatoid arthritis (RA), as new data shows they can be at increased risk for anxiety and depression.

“Patients with RA have a greater risk of infection due to immune deregulation, immunosuppressive therapy and older age on average”, and therefore may be more anxious about COVID-19 than the general population, wrote Takahiro Itaya, MD, lead author of a new study based at Kyoto University in Japan.

Patients with chronic diseases, such as rheumatoid arthritis, already have an increased risk of mood disorders, so they are particularly prone to an increase in mood disorders during the pandemic. (Image: iStock)

In a letter to the editor published in Rheumatology, Dr. Itaya’s team shared the results identified from 108 outpatients with RA who enrolled in a large cohort study between May 1, 2019 and August 31, 2020. Anxiety and depression have were measured using the Hospital Anxiety and Depression Scale (HADS). The mean age of the patients was 66 years and 87% were women. Their average duration of illness was 15 years. In terms of medications prescribed for RA, 57 patients were using biologics, 71 were using methotrexate, and 25 were using glucocorticoids.

Overall, 9% of participants reported definite anxiety before the pandemic in 2019, with an increase to 12% in 2020. Additionally, 8% of patients reported “questionable anxiety” (suspected anxiety) in 2019, which rose to 15% in 2020. The prevalence of patients reporting definitive depression remained constant at 10% before and after the onset of the pandemic, although more patients reported dubious (suspected) depression in 2020 than ” in 2019 (20% against 15%).

Higher anxiety scores during the pandemic were significantly associated with changes in the health assessment questionnaire (P = 0.014), use of biological drugs (P = 0.047) and the previous anxiety points (P <0.001).

Highlighting the potential reasons for these increases, the authors wrote that “psychological pressure could increase further due to the confusing nature of the information on the pros and cons of rheumatic drugs for COVID-19 … to psychological distress and should be offered targeted care, ”they suggested.

The study was limited by several factors, including the small sample size, the researchers noted.

However, “as the pandemic continues, more and more patients are susceptible to anxiety and depression and healthcare professionals must remain vigilant in the face of these psychological changes,” they concluded.

Regularly counsel rheumatoid arthritis patients to prevent mental health problems

The Japan-based study was important because, despite its small sample size, “it’s good to have information about the changes before, during and after the pandemic,” according to Don L. Goldenberg, MD, rheumatologist and member. faculty affiliated with Oregon Health & Science University, Portland, and member of the PPMEditorial committee.

In fact, Dr Goldenberg said he was not surprised by the results of the study. “Anxiety and depression in the general population have increased during the pandemic, and patients with chronic diseases, such as RA, already have an increased risk of mood disorders, so they are particularly prone to an increase in mood disorders at this time, ”he said. “Additionally, patients with greater disease activity are expected to be at greater risk for increased mood disturbances, which the researchers found.”

People with rheumatoid arthritis may be concerned about their risk of COVID-19 and its link to their medications, although data on this relationship is limited. “Rheumatologists need to be proactive in discussing detailed patient concerns during the pandemic,” said Dr. Goldenberg. National and international guidelines have been updated monthly and should be discussed with patients, he said.

Clinicians can also help manage anxiety and depression in RA patients by proactively discussing coping strategies, said Dr Goldenberg. “For example, ask patients how they are doing and be reassured that increased stress during the pandemic will increase the risk of anxiety and depression. Discuss issues related to social isolation, missed medical appointments and lack of exercise, ”he said, adding:“ It has been suggested that staying active and exercising during the pandemic reduces the risk of increased mood disorders.

Encourage physical activity to reduce symptoms of rheumatoid arthritis

Physical activity was positively associated with the physical and mental health of people with RA before the pandemic. While social distancing from COVID-19 has impacted opportunities for physical activity, those able to engage in it are reaping its benefits, based on data from a UK study of 345 adults with RA.

In this study, led by Sophia M. Brady, MD, of the University of Birmingham, rheumatoid arthritis patients filled out online questionnaires about their sedentary time and physical activity during the pandemic. Respondents used the NIH-American Association of Retired Persons (NIH-AARP) Diet and Health Study questionnaire to record time spent in the past 7 days doing light PA (housework). ), walking and more vigorous exercise such as tennis or cycling. To measure sedentary behavior, they responded to the International Physical Activity Questionnaire-Short Form (IPAQ-SF) indicating how much time they spend sitting on weekdays and weekends.

Anxiety and depression were measured using the Hospital Anxiety and Depression Scale (HADS). In regression analyzes, light physical activity and walking were negatively associated with mental fatigue and depressive symptoms, and positively associated with vitality. Exercise was negatively associated with physical and general fatigue, as well as depressive symptoms. However, sedentary time was positively associated with physical fatigue. All of these associations were statistically significant.

While physical activity and sedentary time are not associated with anxiety symptoms, researchers noted that being active can promote mental health during COVID-19 restrictions in a number of ways, ranging from distracting negative thoughts to an immediate positive effect on mood, leading to overall improved well-being, they wrote.

Next Steps on RA and Mental Health

Larger data sets examining the impact of drugs commonly prescribed to treat rheumatoid arthritis on the risk of COVID-19 are needed, Dr. Goldenberg suggested. However, “the good news is that rheumatologists established international registries early in the pandemic, and we will soon have information from these large prospective studies.”

Disclosures: The Kyoto University AR Management Alliance (KURAMA) cohort study was supported by Daiichi Sankyo and the Japanese Society for the Promotion of Science KAKENHI program. The authors’ University Department of Advanced Medicine for Rheumatic Diseases is supported by Nagahama City, Shiga, Japan, Toyooka City, Hyogo, Japan and five pharmaceutical companies (Mitsubishi Tanabe Pharma, Chugai Pharmaceutical, UCB Japan, AYUMI Pharmaceutical and Asahi Kasei Pharma) . The lead author, Dr. Itaya, had no financial conflicts to disclose; several co-authors have disclosed relationships with several companies, including those that fund the department.

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