OBJECTIVE: This systematic review and meta-analysis examined the strength of association between rheumatoid arthritis and depression. In addition, we investigated the extent to which sociodemographic characteristics, level of pain, and method of assessing depression might affect the degree of depression. METHODS: CD-ROM databases and bibliographies were searched to identify all studies comparing depression in patients with rheumatoid arthritis and control subjects using standardized assessments. Effect sizes (Pearson's r) and probabilities were combined across studies. We examined the extent to which the association between rheumatoid arthritis and depression could be attributed to level of pain (using contrasts), sociodemographic differences between groups (combining methodologically restricted studies), and methods of assessing depression (examining heterogeneity across studies). RESULTS: Twelve independent studies comparing depression in patients with rheumatoid arthritis with depression in healthy control subjects were found. Effect sizes for depression were small to moderate (r =.21, p <.0001; heterogeneous). This effect was not reduced in studies controlling for sociodemographic characteristics (r =.27, p <.0001). The effect sizes did vary in a linear manner in proportion to the effect size for pain (z = 2.67, p =.0064). The effect sizes produced by different measures of depression were heterogeneous (chi(2) for Fisher's Z = 24.6, p =.0002), with the Hospital Anxiety and Depression Scale giving effect sizes most dissimilar to those of other measures. CONCLUSIONS: Depression is more common in patients with rheumatoid arthritis than in healthy individuals. This difference is not due to sociodemographic differences between groups, but it may be attributable, in part, to the levels of pain experienced. Variation in the methods of assessing depression partly accounts for the differences among studies examining the levels of depression in patients with rheumatoid arthritis.

Depression in rheumatoid arthritis: a systematic review of the literature with meta-analysis.

Objective. To study, for the first time, service utilization and costs in fibromyalgia, a prevalent syndrome associated with high levels of pain, functional disability, and emotional distress.

Methods. Five hundred thirty-eight fibromyalgia patients from 6 rheumatology centers were enrolled in a 7-year prospective study of fibromyalgia outcome. Patients were assessed every 6 months with validated, mailed questionnaires which included questions regarding fibromyalgia symptoms and severity, utilization of services, and work disability.

Results. Fibromyalgia patients averaged almost 10 outpatient medical visits per year, and when nontraditional treatments were considered, this number increased to ∼1 visit per month. Patients were hospitalized at a rate of 1 hospitalization every 3 years. In each 6-month study period, patients used a mean of 2.7 fibromyalgia-related drugs. Costs increased over the course of the study. The mean yearly per-patient cost in 1996 dollars was $2,274. However, results were skewed by high utilizers, and many patients used few services and had limited costs. Total costs and utilization were independently associated with the number of selfreported comorbid or associated conditions, functional disability, and global disease severity. Compared with patients with other rheumatic disorders, those with fibromyalgia were more likely to have lifetime surgical interventions, including back or neck surgery, appendectomy, carpal tunnel surgery, gynecologic surgery, abdominal surgery, and tonsillectomy, and were more likely than other rheumatic disease patients to report comorbid or associated conditions. Almost 50% of hospitalizations occurring during the study were related to fibromyalgia-associated symptoms.

Conclusion. The average yearly cost for service utilization among fibromyalgia patients is $2,274. Fibromyalgia patients have high lifetime and current rates of utilization of all types of medical services. They report more symptoms and comorbid or associated conditions than patients with other rheumatic conditions, and symptom reporting is linked to service utilization and, to a lesser extent, functional disability and global disease severity.

A prospective, longitudinal, multicenter study of service utilization and costs in fibromyalgia

Objective

Although 2 recent studies have found associations between catastrophizing and poor medical outcomes in patients with fibromyalgia syndrome (FMS), neither assessed these findings in comparison with a similar group of patients with chronic pain. Our study examined the complex relationships between depression, catastrophizing, and the multidimensional aspects of pain in women with FMS and compared these relationships with those in women with rheumatoid arthritis (RA).



Methods

Sixty-four FMS patients and 30 RA patients completed the Coping Strategies Questionnaire (CSQ), the Beck Depression Inventory II (BDI-II), and the McGill Pain Questionnaire.



Results

Compared with subjects with RA, FMS subjects scored significantly higher on the catastrophizing subscale of the CSQ. FMS patients also earned higher scores on overall depression and on the cognitive subscale of the BDI-II. Furthermore, the relationship between catastrophizing and depression was significant in the FMS group only. Regression analyses revealed that in FMS, catastrophizing as a measure of coping predicted patients' perception of pain better than demographic variables such as age, duration of illness, and education.



Conclusion

Cognitive factors, such as catastrophizing and depressive self-statements, have a more pronounced role in the self-reported pain of patients with FMS than in patients with RA. Clinically, this indicates that treating pain and depression in FMS by adding cognitive therapy and coping skills components to a comprehensive treatment program may improve the outcomes obtained with pharmacologic interventions.

The role of catastrophizing in the pain and depression of women with fibromyalgia syndrome.

Fibromyalgia is a disorder that is part of a spectrum of syndromes that lack precise classification. It is often considered as part of the global overview of functional somatic syndromes that are otherwise medically unexplained or part of a somatization disorder. Patients with fibromyalgia share symptoms with other functional somatic problems, including issues of myalgias, arthralgias, fatigue and sleep disturbances. Indeed, there is often diagnostic and classification overlap for the case definitions of a variety of somatization disorders. Fibromyalgia, however, is a critically important syndrome for physicians and scientists to be aware of. Patients should be taken very seriously and provided optimal care. Although inflammatory, infectious, and autoimmune disorders have all been ascribed to be etiological events in the development of fibromyalgia, there is very little data to support such a thesis. Many of these disorders are associated with depression and anxiety and may even be part of what has been sometimes called affected spectrum disorders. There is no evidence that physical trauma, i.e., automobile accidents, is associated with the development or exacerbation of fibromyalgia. Treatment should be placed on education, patient support, physical therapy, nutrition, and exercise, including the use of drugs that are approved for the treatment of fibromyalgia. Treatment should not include opiates and patients should not become poly pharmacies in which the treatment itself can lead to significant morbidities. Patients with fibromyalgia are living and not dying of this disorder and positive outlooks and family support are key elements in the management of patients.

Fibromyalgia: A Critical and Comprehensive Review

Objective

To compare the momentary association between salivary cortisol levels and pain, fatigue, and stress symptoms in patients with fibromyalgia (FM), and to compare diurnal cycles of cortisol secretion in patients with FM and healthy control subjects in a naturalistic environment.



Methods

Twenty-eight patients with FM and 27 healthy control subjects completed assessments on salivary cortisol levels and pain, fatigue, and stress symptoms, 5 times a day for 2 consecutive days, while engaging in usual daily activities. Only those participants who adhered to the protocol (assessed via activity monitor) were included in the final analyses.



Results

Twenty FM patients and 16 healthy control subjects adhered to the protocol. There were no significant differences in cortisol levels or diurnal cortisol variation between FM patients and healthy controls. Among women with FM, a strong relationship between cortisol level and current pain symptoms was observed at the waking time point (t = 3.35, P = 0.008) and 1 hour after waking (t = 2.97, P = 0.011), but not at the later 3 time points. This association was not due to differences in age, number of symptoms of depression, or self-reported history of physical or sexual abuse. Cortisol levels alone explained 38% and 14% of the variation in pain at the waking and 1 hour time points, respectively. No relationship was observed between cortisol level and fatigue or stress symptoms at any of the 5 time points.



Conclusion

Among women with FM, pain symptoms early in the day are associated with variations in function of the hypothalamic–pituitary–adrenal axis.

/pdf/momentary-relationship-between-cortisol-secretion-and-4rxtydyne5.pdf

Momentary relationship between cortisol secretion and symptoms in patients with fibromyalgia

This study reports psychological symptoms assessed in 327 patients with fibromyalgia (FS) in a multicenter investigation. Two self-report scales, in their validated Italian translations, were used for screening: the CES-D (the Center of Epidemiologic Studies-Depression) developed at the NIMH for measuring depression and the Illness Behavior Questionnaire (IBQ) developed by Pilowsky and Spence. The cutoff point of 23 in the CES-D scores revealed about 49% of the fibromyalgic patients as depressed. In analyzing patterns of illness behavior patients with FS showed a high score on IBQ scales of disease conviction, psychological versus somatic focusing and denial. CES-D scores showed significant correlations with illness behavior scales. These results and their implications for the treatment of fibromyalgic patients are discussed.

Fibromyalgic Syndrome: Depression and Abnormal Illness Behavior

This study reports the psychological symptomatology assessed in 50 rheumatoid arthritis patients (RA) and 50 with primary fibromyalgic syndrome (PFS). Depression and illness behavior were investigated by two self-report scales in their validated Italian translations: the Center for Epidemiologic Studies Depression (CES-D) and Illness Behavior Questionnaire developed by Pilowsky and Spence (IBQ). Our results suggest that the average RA patients were not depressed to a clinically significant level at the time of the investigation. The mean scores of CES-D by RA patients do not differ from those found in Italian patients affected by other organic diseases. On the contrary, mean score in the CES-D depression scale obtained from PFS patients was significantly higher than the cut-off point. In analyzing the pattern of illness behavior the significant difference between RA and PFS patients in scale of denial of problems is relevant. This means the RA patients have a tendency to deny life stresses and to attribute all problems to the effects of their illness. Such a result is in line with a classic psychosomatic point of view, that defines RA patients as alexitimic ones, that is, with poor capacity to recognize and express emotions. Our data support both the hypothesis that depressive symptoms are more common among PFS patients than RA patients, and that psychological factors may play a significant role in most patients with PFS.

G Piergiacomi

Papers

Fibromyalgic Syndrome: Depression and Abnormal Illness Behavior

Personality pattern in rheumatoid arthritis and fibromyalgic syndrome. Psychological investigation.