To our knowledge, this is the first study involving
a sample of Iranian patients with RA that sought to
determine the frequency of depression and its severity
and evaluate the depressive symptoms to figure out whether they had any correlation with the disease. In
our study, the overall frequency of mild-to-moderate
and severe depression in the active RA group was
30.4% and 1.8%, respectively. These rates in the inactive
RA group were lower. In a similar study by Wolfe
and Michaud,
9 the cross-sectional prevalence of selfreported
depression was estimated to be 15.2%, with
an incidence rate of 5.5%. However, in their report, the
cumulative risk of self-reported depression in patients
with RA reached almost 40% at the nine-year followup.
9 In another study by Zung et al.,
14 the prevalence
of clinically significant depressive symptoms was found
to be 20.9%. Furthermore, Katz and Yelin
15 found
an annualized prevalence of depressive symptoms
between 15 and 17%, and the prevalence of clinically
significant depressive symptoms in a multiethnic
survey by Margaretten et al.
16 was reported as 40%.
Although our reported frequency is within the range of previously reported results (13-42%), the appearance
of severe depression based on our findings was notably
low. However, this low depression rate may be specified
as short-term. Thus, for appropriate judgment of the
psychological deterioration of RA patients, a long-term
follow-up seems to be necessary. Besides, the frequency
of depression is directly dependant on socioeconomic
and disease characteristics, such as the proportion
of females along with the severity and chronicity of
illness. Depression associated with RA contributes not
only to the heavy burden placed on the patients and
their families, but society as a whole is affected since
those who suffer from severe depression interact with
their families as well as with the general population.
These patients may have notable physical disabilities,
and a seven-fold increase in depression leads to a
10% reduction in their ability function normally.
17-19
Therefore, by estimating the long-term prevalence
of severe depression in RA patients and scheduling
beneficial treatment options, such as cognitive
behavioral therapy, they are actively encouraged, which
results in a decrease in disabilities and more social
interaction.
The present data from patients with RA demonstrates
a significant positive association between mild-tomoderate
depression and inflammatory markers, even
after adjusting for clinical and social covariates. In
similar studies in other nations, a wide variation in
determinants has been reported. In some previous
studies, pain extent and fatigue have been identified
as the primary dominant causes of RA-related
depression.6 A study by Dirik and Karanci20 revealed
that among the Turkish population, gender, a feeling
of helplessness, an inability to cope, and resource
loss were significant predictors of anxiety, whereas
arthritis self-efficacy and resource loss were significant
predictors of depression in RA patients. In a recent
study by Godha et al.21 the severity of RA played a
major role in predicting depression, and patients with
class III RA were 5.92 times more likely to have a high
tendency toward depression compared with class I RA
patients, and those with class II RA were 3.78 times
more likely. They also showed that advanced age
(≥68 years) and low physical activity were other
significant negative predictors of depression for this
chronic condition. Regarding the association between
inflammation and depression, multiple studies
have suggested there is a link. Moreover, Howren
et al.,22 Miller et al.23 and Kojima et al.24 studied
the relationship between CRP levels and depression
in a cross-sectional analysis of 218 patients with RA who were recruited from a Japanese academic
rheumatology clinic and found a mild but statistically
significant positive association between depression
index scores and elevated CRP levels. In addition, that
study showed that elevated depression scores and CRP
levels were independently associated with increased
pain scores. Those authors concluded that the
severity of depression and inflammation were related,
with each having an independent effect on patientreported
pain. There are also other studies that have
demonstrated decreased inflammation in depressed
patients who have been treated with antidepressants,
but Howren et al.22 believe that further studies are
needed to confirm this relationship.
In conclusion, it seems that inflammation was
effective in predicting the appearance of depression
in our RA patient population, and further study of its
role with other populations, particularly over the longterm,
is recommended.
Declaration of conflicting interests
The authors declared no conflicts of interest with
respect to the authorship and/or publication of this
article.
Funding
The authors received no financial support for the
research and/or authorship of this article.
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