Karen L. Smarr

Measures of depression and depressive symptoms: Beck Depression Inventory-II (BDI-II), Center for Epidemiologic Studies Depression Scale (CES-D), Geriatric Depression Scale (GDS), Hospital Anxiety and Depression Scale (HADS), and Patient Health Questionnaire-9 (PHQ-9).

This article presents a summary of self-report adult measures that are considered to be most relevant for the assessment of depression in the context of rheumatology clinical and/or research practice. This piece represents an update of the special issue article that appeared in Arthritis Care & Research in 2003; the current review followed similar selection criteria for inclusion of assessment tools. Specifically, measures were selected based on several considerations, including ease of administration, interpretation, and adoption by arthritis health professionals from varying backgrounds and training perspectives; self-report measures providing data from the patient or research participant’s perspective; availability of adequate psychometric literature and data involving rheumatology populations; and frequent use in both clinical and research practice with adult rheumatology populations. This study was not intended to be exhaustive. Clinicianadministered, semistructured depression interviews requiring specialized training such as the Hamilton Rating Scale for Depression and Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition were not included. Additionally, measures without sufficient use within rheumatology populations, such as the World Health Organization Composite International Diagnostic Interview depression module and the National Institutes of Health Patient-Reported Outcomes Measurement Information System, were also not included in this review. Self-report measures that have been included in this review are as follows: Beck Depression Inventory-II, Center for Epidemiologic Studies Depression Scale, Geriatric Depression Scale, Hospital Anxiety and Depression Scale, and Patient Health Questionnaire-9. Some of these measures have become integrated into routine clinical practice (as screening tools) in large managed-care organizations, and these specifics have been included in this article. Included within each measure review are “additional references” that, while not cited within the review itself, may be of interest to the arthritis health professional who intends to use this instrument in their clinical practice or as part of a research study. As a general comment regarding any assessment of depression, while care was taken to include measures that require little training to administer and interpret, users without psychological background/experience in the management of clinical issues related to depression and crisis situations may need contingency plans for clinical supervision and/or referral sources. Any individual meeting or close to meeting the diagnostic criteria for depressive disorders needs appropriate management and/or referral, including being provided with referral options for different treatment approaches (pharmacologic and/or psychological). Additionally, suicide risk associated with depression must be taken seriously and promptly addressed. Clinicians should have existing plans to immediately deal with anyone who is an imminent danger to self or others (including mandated reporting). Researchers and clinicians ought to identify behavioral health experts (e.g., psychologists, psychiatrists, social workers) who can assist with appropriately handling these types of crisis situations should they be identified in the context of rheumatology clinical or research environments.

Predictors of subjective fatigue among individuals with rheumatoid arthritis.

OBJECTIVEnTo examine a range of variables potentially associated with rheumatoid arthritis (RA)-related fatigue and to determine which variables best predict subjective fatigue.nnnMETHODSnMeasures of fatigue, disease activity, pain, and various psychosocial factors were gathered from 73 individuals with RA. Correlations between fatigue and other variables were examined, and the best predictors of fatigue were determined with multiple regression analyses.nnnRESULTSnMany of the variables that were significantly correlated with fatigue had a psychosocial character. Moreover, the best predictors of increased fatigue were higher levels of pain, more depressive symptoms, and female sex. Longer symptom duration, less perceived adequacy of social support, and less disease activity were significant predictors of fatigue, over and above the best model.nnnCONCLUSIONnRA-related fatigue appears to be strongly associated with psychosocial variables, apart from disease activity per se. Correspondingly, treatment of fatigue may be enhanced by interventions that address relevant cognitive and behavioral dimensions.

Age, depressive symptoms, and rheumatoid arthritis

OBJECTIVEnTo examine the relationship between age and depression in persons with rheumatoid arthritis (RA).nnnMETHODSnTwo separate outpatient cohorts of persons with RA were studied. In both studies, the Center for Epidemiological Studies Depression Scale was administered to all subjects, and the prevalence of depressive symptoms was determined by age group. In the second study, data on additional measures of disease activity, pain, life stress, and coping were collected for use in multiple linear regression analyses.nnnRESULTSnIn both samples, a significant correlation between age and depression was found; younger persons (age < or = 45 years) with RA were significantly more depressed, even after controlling for potentially confounding variables such as sex, marital status, antidepressant medication, arthritis medication, functional class, and disease duration.nnnCONCLUSIONnThe findings show that younger persons with RA are at higher risk for depressive symptoms than their older counterparts.

A biopsychosocial model of disability in rheumatoid arthritis

OBJECTIVEnTo test and cross-validate a model using disease activity, pain, and helplessness to predict future psychological and physical disability in persons with rheumatoid arthritis (RA) across time.nnnMETHODSnMeasures of disease activity, pain, helplessness, psychological function, and physical function were collected from 63 males with RA at baseline, 3 months, and 6 months. Path analytic methods were used to examine longitudinal relationships among these variables.nnnRESULTSnPath analysis revealed that pain and helplessness were significant mediators of the relationship between disease activity and future disability in RA; the predictive model withstood two cross-validations.nnnCONCLUSIONnThe findings suggest that pain and helplessness are key biopsychosocial variables that affect the development of disability in RA.

Risk factors for depression in rheumatoid arthritis

OBJECTIVEnTo identify risk factors for the development of depression in persons with rheumatoid arthritis (RA).nnnMETHODSnSubjects were divided into depressed versus nondepressed groups on the basis of the Center for Epidemiologic Studies-Depression Scale; a range of psychological, pain-related, disease-related, and demographic variables were analyzed to predict depression. Both cross-sectional and longitudinal predictive models were examined.nnnRESULTSnA series of analyses, including multiple logistic regression, found that the optimal predictors of depression in RA were average daily stressors, confidence in ones ability to cope, and degree of physical disability. The model was successfully cross-validated on separate data sets (i.e., same subjects at different time points).nnnCONCLUSIONnAll of the identified risk factors for depression in RA are preventable to some extent and, therefore, should be addressed in comprehensive, rheumatology team care.

Stress Management in Rheumatoid Arthritis: What Is the Underlying Mechanism?

OBJECTIVEnTo test whether change in cognitive-behavioral variables (such as self-efficacy, coping strategies, and helplessness) is a mediator in the relation between cognitive behavior therapy and reduced pain and depression in persons with rheumatoid arthritis (RA).nnnMETHODSnA sample of patients with RA who completed a stress management training program (n = 47) was compared to a standard care control group (n = 45). A path analysis testing a model including direct effects of comprehensive stress management training on pain and depression and indirect effects via change in cognitive-behavioral variables was conducted.nnnRESULTSnThe path coefficients for the indirect effects of stress management training on pain and depression via change in cognitive-behavioral variables were statistically significant, whereas the path coefficients for the direct effects were found not to be statistically significant.nnnCONCLUSIONnDecreases in pain and depression following stress management training are due to beneficial changes in the arenas of self-efficacy (the belief that one can perform a specific behavior or task in the future), coping strategies (an individuals confidence in his or her ability to manage pain), and helplessness (perceptions of control regarding arthritis). There is little evidence of additional direct effects of stress management training on pain and depression.

A confirmatory factor analysis of the center for epidemiologic studies depression scale in rheumatoid arthritis patients: Additional evidence for a four‐factor model

OBJECTIVEnTo examine the factor structure of the Center for Epidemiologic Studies Depression Scale (CES-D) in a sample of patients with rheumatoid arthritis (RA), testing all of the alternative models suggested by the previous evidence.nnnMETHODSnThe CES-D was administered to a group of RA patients (n = 685) during a structured telephone interview. The telephone interview was repeated 6 months later (n = 537) and 12 months later (n = 453). Confirmatory factor analyses were conducted to test alternative models.nnnRESULTSnThe correlated 4-factor model and the second-order 4-factor model were the best fitting models.nnnCONCLUSIONnThe factor structure of the CES-D previously found in the general population was replicated in an RA sample. The results are consistent with previous evidence of criterion contamination in the CES-D when used in an RA sample and provide support for the view that a single summary score may not be the most informative index of the CES-D.

Social interactions in an online self-management program for rheumatoid arthritis

Objective: To evaluate social interactions among individuals with rheumatoid arthritis (RA), participating in an empirically based, cognitive-behavioural, self-management (SM), and peer-support program, delivered in an online format. Methods: Thirty individuals with RA were recruited online. Subjects were a subset of participants in the treatment arm of a waiting-list controlled study testing the effectiveness of a 10-week, online, SM education and peer support program. Primary outcomes were process variables describing social activity in the online environment during active treatment. Qualitative review of discussion board posts was undertaken to gain insight into participants perceptions of social interactions. Results: Participants spent a large proportion of logged-in time accessing educational materials and community-level activity was vibrant, with members utilizing the discussion board and e-mail. The Chat feature was less well-used. Discussion board posts regarding RAHelp were very positive, especially in regard to perceived supportiveness and bonding among participants, and a sense of feeling uniquely understood by others who have RA. Concern arose in response to periods in which the discussion board was `too quiet. Discussion: Our work complements the emerging literature supporting acceptance and utility of Internet-based programming as a venue for SM education and social interaction among individuals with chronic illness.

RAHelp: An Online Intervention for Individuals With Rheumatoid Arthritis

To test an intervention for improving self‐management in rheumatoid arthritis (RA) using an online, cognitive–behavioral, self‐management group program (RAHelp), with weekly telephone support.

Online Self-Management in Rheumatoid Arthritis: A Patient-Centered Model Application

OBJECTIVEnThe aim of this study was to describe the online transformation of an empirically validated, clinic-based, self-management (SM) program for rheumatoid arthritis.nnnMATERIALS AND METHODSnA cognitive-behavioral framework served as the theoretical basis for the intervention. As with the clinic-based approach, the psychoeducational program included educational modules, weekly homework assignments, and self-evaluation. The dynamic online environment included secure communication tools to support a virtual community for the participants to garner peer support. In addition to peer support, weekly follow-up support was provided by a trained clinician via telephone. We describe the process and structure of the online self-management (OSM) intervention. Administrative issues including clinical monitoring and management, data collection, and security safeguards are considered. Utilization and management data are provided and explored for 33 initial subjects.nnnRESULTSnIndividuals who volunteer to participate in an online modality are eager to receive this home-based programming. They readily engaged with all aspects of the OSM program and experienced few difficulties navigating the environment.nnnCONCLUSIONnAn OSM site provides a convenient, effective, and securely maintained health service, once restricted to clinic settings. The OSM application can be used to extend the benefits of SM programs to broad target audiences and serves as a model for the emerging generation of Internet-based clinical management/delivery systems.