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Marginalized Patients With Rheumatic Disease Experience Higher Rates of Psychological Distress

“Access to mental health services is a critical component of comprehensive care for patients suffering from rheumatologic disease,” investigators stated.

Immigrants with rheumatologic disease reported higher rates of severe psychological distress yet were less likely to receive mental health services (MHS) when compared with the general population, which may negatively impact musculoskeletal functional outcomes, according to a study published in Springer.1 Those least likely to receive MHS were male, Black, Asian, Hispanic, older, uninsured, and had a lower income.

“Access to MHS is a critical component of comprehensive care for patients suffering from rheumatologic disease,” investigators stated. “Mental health interventions have not only been shown to substantially improve overall musculoskeletal functional outcomes, but also improve biopsychosocial outcomes including coping, physical activity, and self-efficacy.”

The cross-sectional National Health Interview Survey (NHIS) was used to analyze patients with rheumatic disease from 2009 to 2018. Eligible participants answered “yes” to the question: “Were you ever told you had arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?” Assessment of MHS was evaluated by the question: “Have you seen or talked to a mental health professional such as a psychiatrist, psychologist, psychiatric nurse, or clinical social worker during the past twelve months?”Information included demographics, receipt of MHS, and severe psychological distress.

Psychological distress was determined using a 6-item Kessler Psychological Distress Score (K6), in which a score greater than 13 defined severe psychological distress.

Variables included race, ethnicity, age, income, sex, insurance status, birth status, geographical location, self-reported health, and education. Multivariable logistic regressions accounted for factors linked to a decrease in MHS and psychological distress.

Among respondents surveyed, 107,490 patients with rheumatic disease were identified. The majority (90.1%) were US-born (77.2% White, 12.6% Black, and 4.9% Hispanic). Among the immigrant population, 50.5% were Hispanic, 25.5% were White, and 16.3% were Asian. In both cohorts, roughly half of patients were over the age of 65 (42.2% for US-born and 46.1% for immigrants). When compared with the US-born population, immigrants were more likely to be below the poverty threshold (27.5% vs 15.5%, respectively), uninsured (11.0% vs 6.7%, respectively), less likely to finish high school (38% vs 16.3%, respectively), and self-reported poor or fair health (38.9% vs 29.3%, respectively).

Additionally, the immigrant cohort had higher rates of psychological distress when compared with patients born in the United States (7.7% vs. 6.5%, p < 0.001, respectively). However, they were less likely to have the ability to participate in MHS when compared with US-born participants (8.3% vs. 11.0%, p < 0.001, respectively). This was especially evident in those with severe psychological distress (immigrants: 29.0%, US born: 40.0%, p < 0.001).

In the multivariable logistic model analysis, higher rates of severe psychological distress were seen in females (AOR 1.39, 95% CI 1.29–1.49, p < 0.001), those who were uninsured (AOR 1.47, 95% CI 1.33–63, p < 0.001), and those who reported poor health (AOR 24.55, 95% CI 19.65–30.66, p < 0.001). Patients who had a lower MHS receipt were more likely to be an immigrant (AOR 0.70, 95% CI 0.63–0.79, p < 0.001), Black (AOR 0.74, 95% CI 0.68–0.80, p < 0.001), or Asian (AOR 0.57, 95% CI 0.45–0.72p < 0.001).

In the adjusted subgroup analysis, evaluating immigrant patients with rheumatic disease, lower MHS receipt was seen in patients who were Black (AOR 0.50, 95% CI 0.32–0.77, p = 0.002), Hispanic (AOR 0.80, 95% CI 0.30–1.00, p = 0.050), or Asian (AOR 0.44, 95% CI 0.31–0.63, p < 0.001). Other factors included being over 64 years of age (AOR 0.24, 95% CI 0.16–0.34, p < 0.001), uninsured (AOR 0.25, 95% CI 0.17–0.37, p < 0.001), reporting a lower income (AOR), and those who hadself-reported poor health (AOR 5.01, 95% CI 3.31–7.59, p < 0.001).

While the large and diverse sample size strengthens the study, the retrospective and self-reported data is limiting due to recall bias and answering questions differently due to varying cultural standpoints. However, this survey format may give insight into the individual patient’s experience.

“Future efforts to carefully screen for mental health diseases in these vulnerable patient populations should be made while exploring patient-specific cultural considerations of MHS receipt,” investigators concluded.


Amen TB, Chavez TJ, Dee EC, et al. Disparities in psychological distress and access to mental health services among immigrants with rheumatologic disease [published online ahead of print, 2022 Mar 9]. Clin Rheumatol. 2022;10.1007/s10067-022-06074-6. doi:10.1007/s10067-022-06074-6