The Impact of Psychiatric-Rheumatic Comorbidity

Mar 14, 2018

Are you prepared to recognize and treat anxiety, depression, and other comorbid psychiatric disorders when they arise in your patients?

References1. Liew J, Lucas Williams J, Dobscha S, Barton JL. Posttraumatic stress disorder and correlates of disease activity among veterans with ankylosing spondylitis. Rheumatol Int. 2017;37:1765-1769.2. Marrie RA, Hitchon CA, Walld R, et al. Increased burden of psychiatric disorders in rheumatoid arthritis. Arthritis Care Res. 2018 Feb 13. doi:10.1002/acr.23539.3. Tiosano S, Nir Z, Gendelman O, et al. The association between systemic lupus erythematosus and bipolar disorder-a big data analysis. Eur Psychiatry. 2017;43:116-119.

Three recent studies looked at comorbid psychiatric disorders in patients with rheumatic/inflammatory disease. What can be gleaned from the findings? These key points:
• PTSD is linked to higher pain and disease activity scores in young veterans with ankylosing spondylitis.¹
• The risk of depression, anxiety disorders, and bipolar disorder is increased in patients with rheumatoid arthritis.²
• Lupus is independently associated with bipolar disorder.³

Scroll through the slides for the details of the studies and the clinical implications.

A retrospective observational study included 113 veterans with ankylosing spondylitis (AS); 18% had a diagnosis of PTSD.¹

Average pain intensity scores were higher for veterans with AS and PTSD than for those without PTSD (4.9 ± 2.4 vs 3.6 ± 2.8, P = .06). Veterans with PTSD had higher mean Bath AS Disease Activity Index (BASDAI) scores than those without PTSD (5.7 ± 2.7 vs 4.0 ± 1.8, P = .06). Those with and without PTSD received disease-modifying antirheumatic drugs (10% vs 15%), biologics (60% vs 52%), and opioids (15% vs 24%). More veterans with PTSD received NSAIDs compared with those who did not have PTSD (70% vs 42%, P = .03).

“This study underscores the importance of identifying PTSD in patients with AS who report higher pain and disease activity,”¹ wrote Liew and colleagues at Oregon Health and Science University in Portland.

A retrospective matched cohort study of residents in Manitoba, Canada, included 10,206 patients with rheumatoid arthritis (RA) and 50,960 matched controls.² Among the findings:
• The incidence of depression per 1000 persons in the RA cohort was 15.0 (95% confidence interval [CI]: 11.9-18.9) vs 9.09 (95% CI: 8.03-10.3) in the matched cohort.
• The incidence of anxiety per 1000 persons in the RA cohort was 16.7 (95% CI: 13.2-21.2) vs 15.6 (95% CI: 14.1-17.3) in the matched cohort.
• The incidence of bipolar disorder was 2.6 per 1000 persons (95% CI: 2.3-3.0) in the RA cohort vs 1.8 (95%CI: 1.7-2.0) in the matched cohort.
• The incidence of schizophrenia was 0.48 per 1000 persons (95% CI: 0.35-0.68) in the RA cohort vs 0.41 (95%CI: 0.34-0.50) in the matched cohort.

Patients with RA have higher rates of depression, anxiety disorder, and bipolar disorder. The consistent risk over the 20-year study period indicates that better control and management of RA has not lead to less psychiatric comorbidity.

“Clinicians should be aware that women, and those of lower socioeconomic status are at particularly increased risk of these disorders,”² wrote Marrie and colleagues in Manitoba, Canada.

A big data cross-sectional data mining study in Israel included 5018 patients with systemic lupus erythematosus (SLE) and 25,090 matched controls.³ Both groups were mostly women. The prevalence of bipolar disorder (BD) was 0.62% in subjects with SLE vs 0.26% in controls (P < .001). After multivariate analysis, SLE and smoking were found to be independent predictors of bipolar disorder: (odds ratio [OR], 1.74; P = .012) and (OR, 4.8; P < .001), respectively.

Based on these findings, inflammation as the etiology for psychiatric comorbidities in SLE should be a focus of research, note the researchers.

Note that the data suggest that the treatment of rheumatologic disorders may not help psychiatric comorbidities.