Risk factors associated with depressive symptoms in Venezuelan patients with rheumatoid arthritis.

R heumatoid arthritis (RA) is a common chronic inflammatory disease that can lead to significant disability and increased mortality. Depression is common but probably underrecognized in patients with RA, with a prevalence ranging from 13% to 42%, 2to 3-fold higher than that seen in the general population. The increased prevalence of depression in RA has been supported in a meta-analysis. Pain was the single most consistent variable associated with depression in RA patients. As a comorbid condition depression is a predictor of further disability and mortality in patients with RA. In addition, persistent depression may hamper the response to tumor necrosis factor antagonists. Depression in RA patients may vary among ethnicities, as suggested by a recent study showing lower prevalence in Asians. To our knowledge, data on the prevalence of depression in RA patients living in a Latin America country are scant. Cadena et al. showed high disease activity as a risk factor for depression and low quality of life (QoL) in Colombian patients with RA. Escalante et al. showed increased depression in Hispanic RA patients living in San Antonio, Tex, in a proportion inversely proportional to the level of acculturation. The main purpose of our study was to determine the prevalence of depressive symptoms and predisposing factors in a sample of Venezuelan patients with RA. This was a cross-sectional study in a cohort of Venezuelan patients with RA being followed at Hospital Universitario de Caracas. As most Latin American subjects, Venezuelans are a mestizo population with a variable admixture of Spanish, Native American, and African stock. Patients (N = 113) had a mean age of 51 years, were predominately female (89.4%), and were diagnosed following the American College of Rheumatology 1987 criteria. Mean disease duration was 6.79 (SD, 7.29) years. Data were acquired using the following instruments in their translated and validated-to-Spanish versions: the Center for Epidemiologic StudiesYDepression Scale (CES-D), the modified Health Assessment Questionnaire, and the Short-Form 36 Health Survey for assessment of QoL. The CES-D is not a diagnostic instrument for depression but measures the occurrence of depressive symptoms in the past week, and it has been shown to be a useful psychometric instrument in patients with arthritis. We established the presence of depressive symptoms when patients had a CES-D score of 16 or greater as previously reported. The clinical activity was measured using the Disease Activity Score for 28 Joints instrument. The socioeconomic status was assessed using the Graffar classification system as adapted to Venezuela by Méndez-Castellanos and Méndez. Statistical analysis was performed by W and Fisher exact tests for categorical variables, t test for continuous variable, and multivariate analysis using logistic regression modeling to examine the factors associated with depression. The study was approved by the bioethics committee of the hospital, and all patients signed an informed consent. Twenty-nine percent of patients (n = 33) fulfilled criteria for depressive symptoms. Being nonmarried or not living as a couple (P = 0.0118), the presence of extra-articular manifestations (P = 0.0004), the presence of comorbidities (P = 0.0094), having at least 1 painful joint at the moment of the physical examination (P = 0.0242), and a high mean erythrocyte sedimentation rate (P = 0.0008) were associated with depression. Multivariate analysis modeling using a logistic regression confirmed the impact of being unmarried, presence of extra-articular manifestations, and presence of comorbidities as independent predictor variables for depression. The multivariate analysis also identified a Disease Activity Score for 28 Joints score of greater than 2.5 and lower scores in the physical and mental components of the Short-Form 36 Health Survey instrument as independent predictor variables. The latter findings are consonant with the report by Cadena et al., showing depression as a predictor of low QoL in Colombian RA patients. Comorbidity was also an independent risk factor for depression in a national study of depression in American RA patients. Unlike previously reports, but consistent with the report by Margaretten et al., age was not associated to depression in our study. Unexpectedly, socioeconomic level was not a predictor variable for depression in our study. Our findings suggest a high prevalence of depression among Hispanic patients with RA living in a Latin American country. However, our prevalence of 29% is relatively lower as compared with previous studies showing 45% and 42% among Hispanic RA patients living in the United States. Limitations of our study were the relatively small sample, its cross-sectional design that precludes the assertion of newly (RA-related) versus previously acquired depression (nonYRA related), and the 1-center, hospital-based population that limits the generalizability of the results. Patients at a higher risk for depression were single, had a high disease activity, and were sicker, as suggested by the presence of extra-articular manifestations and comorbidities. Because depression seems to be frequent and may significantly add to increased disability and mortality in RA patients, an early diagnostic surveillance and opportune therapeutic intervention seem to be warranted.