An innovative method to identify educational need regarding depression and anxiety as an under-recognised side effect of anti-TNF medicines
Authors: Rosembert D , Eldridge F , Raine T , St Clair-Jones A 
Published: November 2023

Abstract

Introduction
Depression and anxiety (D&A) in chronic autoimmune conditions such as Inflammatory Bowel Disease (IBD), Rheumatoid arthritis (RA), Psoriatic arthritis (PsA), and Psoriasis (PsO) is common, with patients twice as likely to suffer from it.1 Biologic medicines are increasingly used in autoimmune conditions and are prescribed only by secondary care. Patients initiated on biologic medicines, specifically anti-TNF, can report depression and anxiety as related side effects listed as common in the summary of product characteristics2,3 and may not get investigated for this side effect when visiting GP practices and hospital reviews. This could lead to unnecessary use of psychological or psychopharmacological treatment and a poor patient experience of biologics therapies.

Aim
To explore healthcare professionals’ understanding of the potential adverse effects of anti-TNF medicines including D&A symptoms in patients who present to primary care.

Methods
A Twitter poll was used on the social media platform Twitter to raise the question; ‘GP’s, practice nurses and pharmacists, if your patient with IBD, RA, PsA, PsO etc. presents with symptoms of depression, do you check if they are prescribed a hospital only biologic such as anti-TNF (depression listed as a common side effect) as a possible cause?’. The Likert scale, Always, Sometimes, Never, Didn’t occur to me was used to elicit answers. The question was open for a 3 day window in May 2021, and then repeated in February 2022. A national webinar (advertised for anyone to attend) was held to present these results, and two further questions were asked of the participants using Slido; ‘are you surprised at this figure of 60%?’ and ‘do you think that something needs to be done about this?’ with a yes or no response option. Ethical approval was not required for this service evaluation.

Results
The results from the Twitter poll in May 2021, had 38 votes, the summary of the responses were 2(5%) [Always], 5 (13%) [Sometimes], 8 (21%) [Never] and 23 (61%) [Didn’t occur to me]. Results from the second poll in February 2022 had 217 votes and responses were 27(12%) [Always], 33(15%) [Sometimes], 23(10%) [Never] and 134(63%) [Didn’t occur to me]. Of the 150 people who attended the webinar, 99 (66%) were not surprised and 100% thought something needs to be done about it.

Discussion/Conclusion
This innovative if not scientific method (Twitter and Slido) of surveying HCPs, identified a considerable lack of awareness of the D&A side effects of biologics and uncovered a gap in monitoring of vulnerable patients. This suggests the need for education of HCPs about this issue. Awareness can also be increased through patient education, appropriate counselling, and patient information leaflets. Empowering patients to ask if the hospital prescribed medication is on their GP medication list and a potential cause. Twitter is a novel way to gain insight from colleagues, however responses from HCPs only are not guaranteed. This approach is a model to scope feasibility of projects, but only captures users of Twitter and is dependent on the size of the individual’s network and level of engagement by retweeting.

References
1. Wells KB, Golding JM, Burnam MA. Psychiatric disorder in a sample of the general population with and without chronic medical conditions. Am J Psychiatry. 1988 Aug;145(8):976-81
2. Amgevita 40mg solution for injection pre-filled pen. Electronic medicines compendium. Search Results - (emc) (medicines.org.uk) 2022. (accessed May 2023)
3. Eldridge F, Raine T, Understanding and addressing the psychological burden of IBD, Journal of Crohn’s and colitis, 2021, 1-2