Anxiety and depression among US adults with arthritis: Prevalence and correlates

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DOI: 10.1002/acr.21685 · Source: PubMed
Abstract
There has been limited characterization of the burden of anxiety and depression, especially the former, among US adults with arthritis in the general population. The study objective was to estimate the prevalence and correlates of anxiety and depression among US adults with doctor-diagnosed arthritis. The study sample comprised US adults ages ≥ 45 years with doctor-diagnosed arthritis (n = 1,793) from the Arthritis Conditions Health Effects Survey (a cross-sectional, population-based, random-digit-dialed telephone interview survey). Anxiety and depression were measured using separate and validated subscales of the Arthritis Impact Measurement Scales. Prevalence was estimated for the sample overall and stratified by subgroups. Associations between correlates and each condition were estimated with prevalence ratios and 95% confidence intervals using logistic regression models. Anxiety was more common than depression (31% and 18%, respectively); overall, one-third of respondents reported at least 1 of the 2 conditions. Most (84%) of those with depression also had anxiety. Multivariable logistic regression modeling failed to identify a distinct profile of characteristics of those with anxiety and/or depression. Only half of the respondents with anxiety and/or depression had sought help for their mental health condition in the past year. Despite the clinical focus on depression among people with arthritis, anxiety was almost twice as common as depression. Given their high prevalence, their profound impact on quality of life, and the range of effective treatments available, we encourage health care providers to screen all people with arthritis for both anxiety and depression.

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Anxiety and Depression Among US Adults With
Arthritis: Prevalence and Correlates
LOUISE B. MURPHY,
1
JEFFREY J. SACKS,
2
TERESA J. BRADY,
1
JENNIFER M. HOOTMAN,
1
AND
DANIEL P. CHAPMAN
1
Objective. There has been limited characterization of the burden of anxiety and depression, especially the former,
among US adults with arthritis in the general population. The study objective was to estimate the prevalence and
correlates of anxiety and depression among US adults with doctor-diagnosed arthritis.
Methods. The study sample comprised US adults ages >45 years with doctor-diagnosed arthritis (n 1,793) from the
Arthritis Conditions Health Effects Survey (a cross-sectional, population-based, random-digit–dialed telephone interview
survey). Anxiety and depression were measured using separate and validated subscales of the Arthritis Impact Mea-
surement Scales. Prevalence was estimated for the sample overall and stratified by subgroups. Associations between
correlates and each condition were estimated with prevalence ratios and 95% confidence intervals using logistic
regression models.
Results. Anxiety was more common than depression (31% and 18%, respectively); overall, one-third of respondents
reported at least 1 of the 2 conditions. Most (84%) of those with depression also had anxiety. Multivariable logistic
regression modeling failed to identify a distinct profile of characteristics of those with anxiety and/or depression. Only
half of the respondents with anxiety and/or depression had sought help for their mental health condition in the past year.
Conclusion. Despite the clinical focus on depression among people with arthritis, anxiety was almost twice as common
as depression. Given their high prevalence, their profound impact on quality of life, and the range of effective treatments
available, we encourage health care providers to screen all people with arthritis for both anxiety and depression.
INTRODUCTION
Depression, a well-documented comorbidity among peo-
ple with chronic diseases, including arthritis (1–6), can
exacerbate functional disabilities (1), affect adherence to
treatment (2), and be a barrier to self-care and self-man-
agement behaviors (3,4). Despite its high prevalence in the
general population and equal or stronger incapacitating
effects on physical function (5), anxiety is often underrec-
ognized and undertreated (6). Until recently, anxiety has
been regarded largely as a comorbidity of depression, but
its independent effects, including its role as a potential
risk factor for depression, are increasingly recognized (7).
Anxiety and depression are generally more common
among people with arthritis than in the general population
(8,9), and interplay independently and synergistically
with clinical outcomes such as pain and disability (10,11).
Many studies examining the occurrence of these condi-
tions among people with arthritis have studied depression
only, have studied people with one type of arthritis (e.g.,
rheumatoid arthritis), or were clinic-based, not popula-
tion-based, samples (4,12–17). International population-
based studies identifying major depression using the
World Health Organization Composite International Diag-
nostic Interview (WHO-CIDI) indicate prevalences ranging
from 2.2% (Japan) to 19% (Ukraine; in the US, age 18
years 7–9% and age 54 65 years 11%) (9,18,19). The
prevalence of anxiety disorders among people with arthri-
tis also varies internationally; a survey of 18 countries in
the early 2000s found that people with arthritis were con-
sistently more likely than those without arthritis to have
anxiety disorders. Additionally, across the countries sur-
veyed, US adults with arthritis had the first or second
highest prevalence of each of the 4 specific anxiety disor-
ders examined (generalized anxiety disorder [6%], social
phobia [8%], agoraphobia/panic disorder [3%], and post-
traumatic stress disorder [5%] [18]). The 2001–2003 US
National Comorbidity Study Replication found that each
The findings and conclusions in this report are those of
the authors and do not necessarily represent the official
position of the Centers for Disease Control and Prevention.
1
Louise B. Murphy, PhD, Teresa J. Brady, PhD, Jennifer M.
Hootman, PhD, Daniel P. Chapman, PhD: CDC, Atlanta,
Georgia;
2
Jeffrey J. Sacks, MD, MPH: Sue Binder Consulting,
Inc., Atlanta, Georgia.
Address correspondence to Louise B. Murphy, PhD, Ar-
thritis Program, Division of Population Health, CDC, 4770
Buford Highway NE, Mailstop K-51, Atlanta, GA 30341.
E-mail: lmurphy1@cdc.gov.
Submitted for publication October 11, 2011; accepted in
revised form March 20, 2012.
Arthritis Care & Research
Vol. 64, No. 7, July 2012, pp 968–976
DOI 10.1002/acr.21685
© 2012, American College of Rheumatology
ORIGINAL ARTICLE
968
of the 6 anxiety disorders measured was more common
among people with arthritis (the prevalence among people
with arthritis ranged from 1% for agoraphobia to 6% for
social phobia; 10% reported a specific phobia) (9). All
anxiety disorders were measured using the WHO-CIDI. A
study of Australians ages 18 years with arthritis indi-
cated that one-quarter had experienced an anxiety disor-
der in the past 12 months (19). A comparable estimate for
the US is lacking.
To better characterize the burden of anxiety and depres-
sion among US adults with arthritis, we estimated the
prevalence of each in a national sample of adults ages 45
years with self-reported doctor-diagnosed arthritis. As de-
pression and anxiety can be highly responsive to clinical
treatment (20), better recognition and detection of these
conditions is a necessary first step to reducing the burden
of these mental health conditions among people with ar-
thritis. Therefore, we also examined the correlates of each
condition to identify the sociodemographic, clinical, and
other characteristics that can help health care providers
(HCPs) identify those who are likely to have anxiety
and/or depression.
MATERIALS AND METHODS
Study sample. We analyzed data from the Arthritis Con-
ditions Health Effects Survey (ACHES), a cross-sectional,
random-digit–dialed telephone survey. ACHES, con-
ducted by the Centers for Disease Control and Prevention
(CDC), was designed to be representative of the civilian
noninstitutionalized US population of adults ages 45
years with arthritis and/or chronic joint symptoms (21).
Telephone numbers were selected from a proprietary list
linking phone numbers to US Census blocks. These num-
bers were first partitioned into 7 strata based on census-
estimated percentages of Hispanics and non-Hispanic
blacks associated with each block. To ensure geographic
representation and reduce sample variation, the numbers
were then sorted by census division and metropolitan
status (i.e., urban versus rural counties) in each stratum.
Numbers were then selected with equal probability within
each of the 7 strata, with oversampling in those strata with
high percentages of Hispanics and non-Hispanic blacks
(21).
To maximize response rates, letters were mailed to the
addresses associated with potential residential phone
numbers at least 2 weeks prior to the first call. Trained
interviewers called each number to identify 1) residential
numbers and 2) household members who were ages 45
years and had doctor-diagnosed arthritis or chronic joint
symptoms. We restricted our analysis to respondents with
doctor-diagnosed arthritis (n 1,793), who were identi-
fied with a response of “yes” to: “Have you ever been told
by a doctor or other health professional that you have some
form of arthritis, rheumatoid arthritis, gout, lupus, or fi-
bromyalgia?” Given this method of case ascertainment, in
this article, arthritis refers to people with arthritis and
other rheumatic conditions. Interviews were conducted in
English (or Spanish as needed) from June 2005 to April
2006. All residents in each household who met the inclu-
sion criteria were eligible. Participants were compensated
with a 100-minute prepaid long-distance phone card or a
$5 donation to the Arthritis Foundation. Among eligible
households, Council on American Survey Research Orga-
nizations response and completion rates were 51% and
86%, respectively (i.e., those with at least 1 age-eligible
resident). Response and completion rates for eligible peo-
ple in the household were 31% and 75% for the first
household participant identified as eligible and 16% and
80% among other eligible respondents in the same house-
hold, respectively (21). The ACHES protocol was ap-
proved by the CDC Institutional Review Board.
Using a standardized questionnaire, interviewers col-
lected information on sociodemographic characteristics
and medical and psychosocial aspects of arthritis, includ-
ing physical functioning and limitations, work effects,
knowledge and attitudes about arthritis, self-management
and self-care behaviors, and mental health. ACHES meth-
ods are described in detail elsewhere (21–23).
Study outcomes. Anxiety and depression were assessed
using the Arthritis Impact Measurement Scales (AIMS).
Originally developed for use in longitudinal trials of rheu-
matoid arthritis to detect changes over time (24), AIMS
was subsequently validated for use in studies of other
arthritis types (25).
The AIMS anxiety and depression module comprises 12
questions (6 for anxiety and 6 for depression) and mea-
sures the frequency of symptoms (rating of 06; see Sup-
plementary Appendix A, available in the online version of
this article at http://onlinelibrary.wiley.com/journal/
10.1002/(ISSN)1529-0131a) in the past month. Following a
validation study that reported that an AIMS depression
subscale score of 4 was comparable to the Center for
Epidemiologic Studies Depression Scale (CES-D) score
cutoff for probable depression (16), multiple subsequent
studies using AIMS to quantify the occurrence of anxiety
Significance & Innovations
One-third of US adults with arthritis ages 45
years reported having at least one of anxiety
and/or depression.
Although there is considerable clinical and re-
search focus on depression among people with
arthritis, anxiety was more common than depres-
sion (31% and 18%, respectively).
A distinct profile of those with anxiety and/or
depression did not emerge in the multivariable
models, indicating that all people with arthritis
should be screened for anxiety and depression.
Only half of the respondents with anxiety and/or
depression had sought help for their mental health
condition in the past year, suggesting there is an
unmet need for treatment of mental health condi-
tions among people with arthritis.
Anxiety and Depression in US Adults With Arthritis 969
and depression among people with arthritis have used 4
as the threshold for both conditions (4,14,16). Consistent
with this, for each condition, we calculated the average
subscale value and defined the presence of the condition
as a mean value of 4.
Following the series of AIMS questions, respondents
reported help-seeking behaviors (“During the past 12
months, have you sought help for stress, depression, or
problems with emotions?”) and from whom this help was
sought (i.e., “Did you seek help from any of the following:
Family or friends? A self-help group or support group? A
priest, minister, rabbi, or other religious counselor? A ther-
apist or counselor? A physician?”).
Independent variables. We examined variables repre-
senting 3 domains of interest: 1) sociodemographic char-
acteristics (i.e., age, sex, race/ethnicity, highest educa-
tional attainment, and current employment status) to
develop a profile of affected individuals, 2) arthritis symp-
toms and physical function that can increase the likeli-
hood of arthritis and depression, and 3) potentially mod-
ifiable health and self-management behaviors that are
associated with arthritis symptoms and mental and phys-
ical function.
Respondents reported the severity of each of 3 symp-
toms (i.e., joint pain or aching, stiffness, and fatigue) in the
past 7 days using a 0–10 scale (where 0 no symptoms
and 10 most severe) and the number of days that they
had experienced joint pain or aching in the past 7 days.
The survey included the Short Form 36 (SF-36) physical
functioning subscales and a series of questions about the
degree to which arthritis interfered with routine activities
(e.g., spending time with family and friends, errands/shop-
ping, and household chores) (21,26). The SF-36 and inter-
ference variables were measured using Likert-style re-
sponse scales (a lot, a little, or not at all), which we
dichotomized (a lot versus a little/not at all). We analyzed
individual items rather than the SF-36 score, since these
individual items correspond to questions clinicians might
use when asking about patients’ physical function. Initial
analysis showed moderate to strong correlations among
the function (r 0.40.8) and interference variables (r
0.5–0.8). Therefore, we restricted analyses to 3 function
variables (difficulty in walking several hundred feet, wash-
ing or bathing, and bending, kneeling, or stooping) and 1
interference variable (difficulty with errands and shop-
ping). These physical function and interference variables
have been associated with loss of independence among
people with arthritis (27) and loss of independence has
been correlated with depression in at least one previous
study (4).
Physical activity was measured with 6 validated ques-
tions on frequency and duration of participation in leisure-
time activities of moderate or vigorous intensity (28). Cat-
egories were based on the total number of minutes of
physical activity each week, where 1 minute of vigorous
exercise was equivalent to 2 minutes of moderate activity:
recommended (150 minutes), insufficient (10 –149 min-
utes), or inactive (10 minutes) (29). Using a 0 –10 scale
(where 0 no confidence and 10 highest confidence),
the participants rated their confidence on 3 aspects of
self-management: belief that self-management education
(SME) courses would help to manage arthritis or joint
symptoms, ability to manage arthritis or joint symptoms,
and ability to engage in moderate physical activity at least
3 times/week.
Statistical analysis. We examined the prevalence of
anxiety and depression (to estimate the public health bur-
den) and then stratified by independent variables to iden-
tify potential correlates for logistic regression models. For
each outcome, we estimated the associations with inde-
pendent variables with unadjusted and multivariable ad-
justed prevalence ratios (PRs) and 95% confidence inter-
vals (95% CIs) (30). Last, we determined the proportion of
respondents with anxiety and/or depression who had
sought help for mental health conditions in the past 12
months and estimated the likelihood, with PRs and 95%
CIs, of help seeking for anxiety, depression, and both con-
ditions.
Sampling weights, based on the distribution of US
adults ages 45 years with arthritis in the 2003–2005
National Health Interview Survey (NHIS) (21), were ap-
plied in all analyses to infer estimates to the national
population of civilian noninstitutionalized adults ages
45 years with doctor-diagnosed arthritis. Statistical sig-
nificance was defined using 2 criteria: nonoverlapping
95% CIs and a Wald’s test (test of statistical significance of
variable overall in the model) P value of less than or equal
to 0.05. Analyses conducted in SAS, version 9.1 and
SUDAAN, version 10 (Research Triangle Institute) ac-
counted for the complex survey design.
RESULTS
Among adults with arthritis, 30.5% (11.5 million) reported
anxiety, 17.5% (6.6 million) reported depression, and
14.7% (5.5 million) reported both. Most respondents with
depression also had anxiety (84%), whereas half of those
with anxiety also had depression (49.5%) (Figure 1).
Anxiety Only
6.0 million
Anxiety & Depression
5.5 million
Depression Only
1.0 million
Figure 1. Number of US adults ages 45 years with arthritis who
have anxiety and/or depression, 2005–2006, Arthritis Conditions
Health Effects Survey.
970 Murphy et al
Prevalence and correlates of anxiety. At least half of
the people in the following 6 subgroups reported anxi-
ety: unemployed, unable to work, or disabled (62%);
respondents who reported “a lot” of difficulty with bath-
ing or dressing (63%), “a lot” of interference with er-
rands or household chores in the past 7 days (51%), or
that their arthritis or joint symptoms affected whether
they worked for pay (52%); severe fatigue in the past 7
days (50.2%); and no confidence in their ability to engage
in moderate physical activity at least 3 times/week (56%)
(Table 1).
Almost all of the independent variables were signifi-
cantly associated with anxiety in unadjusted models (Ta-
ble 1). In the multivariable model, anxiety was signifi-
cantly higher among respondents who were ages 45– 64
years (PR 1.7; referent: age 65 years), reported severe
joint pain in the past week (PR 1.9; referent: no pain), and
reported good (PR 1.4) or poor/fair self-rated health (PR
1.6; referent for self-rated health: excellent/very good) (Ta-
ble 2). Anxiety was also higher among respondents who
had no or moderate confidence in their ability to engage in
moderate physical activity at least 3 times/week (PRs 1.5
and 1.3, respectively; referent: high confidence) (Table 2).
After multivariable adjustment, respondents who were
overweight or obese were 20% less probable to report
anxiety (PR 0.8) (Table 2).
Prevalence and correlates of depression. Depression
prevalence was highest among those who reported “a lot”
of difficulties bathing or dressing themselves (48%) (Table
1). At least one-third of people in the following subgroups
reported depression: unemployed, unable to work, or dis-
abled (45%); Hispanics (37%); severe fatigue in the past 7
days (36.3%); and respondents whose arthritis or joint
symptoms affected whether they worked for pay (33%),
who had “a lot” of interference with errands or household
chores in the past 7 days (36%), who had no or a low level
of confidence in their ability to manage their arthritis or
joint symptoms (34% and 45%, respectively), or who had
no confidence in their ability to engage in moderate phys-
ical activity at least 3 times/week (42%).
Several correlates of depression were observed in unad-
justed models (Table 1). In multivariable models, depres-
sion was significantly more common among those who
were ages 45– 64 years (PR 1.6; referent: age 65 years),
reported low confidence in their ability to manage their
arthritis or joint symptoms (PR 2.3), and had only moder-
ate confidence in their ability to engage in moderate phys-
ical activity at least 3 times/week (PR 1.5) (Table 2).
Prevalence of help seeking for anxiety and depression
in the past year. Help seeking was highest among people
with both conditions (57.1%) and lowest among those
with anxiety only (45.1%; people with depression
51.3%) (data not shown). Respondents were most likely to
have sought help from their doctor (82–83%), followed by
family and friends (45– 46%); therapist/counselor (43–
46%); priest, minister, rabbi, or other religious counselor
(15–16%); and self-help or support groups (11–13%; sum
exceeds 100% because respondents sought help from mul-
tiple sources).
Among those with anxiety, depression, or both, more
than half (55%) of all respondents had not sought help in
the past year. This was only slightly improved when lim-
ited to those who were currently seeing a doctor or HCP for
their arthritis or joint symptoms (46%) (Table 3). Across
all sociodemographic groups, 3666% of respondents had
not sought help (Table 3), and among those who were
currently seeing a doctor or HCP for their arthritis or joint
symptoms, the range was 21– 61%. Similar patterns were
observed among those with each of anxiety, depression,
and both conditions (data not shown).
DISCUSSION
One-third of respondents with arthritis had anxiety, de-
pression, or both. Anxiety was almost twice as common as
depression (31% and 18%, respectively), and virtually all
respondents with depression also had anxiety. Approxi-
mately half of the respondents with anxiety and/or depres-
sion had sought help for their mental health condition in
the past year. Most of the statistically significant associa-
tions observed in the multivariable analysis were moder-
ately strong; nevertheless, a distinct profile of characteris-
tics of those with anxiety and depression did not emerge.
We found that anxiety was more common than depres-
sion in this population-based sample of people with ar-
thritis, a pattern that has been observed in clinic-based
samples (4,12–14,16). Anxiety can elicit independent and
at least equally debilitating effects as depression (5,31,32).
Despite this and the high prevalence of anxiety in previous
studies, few influential rheumatology texts (33) mention anx-
iety, suggesting that the magnitude and impact of this prob-
lem among people with arthritis are underrecognized (31).
The US Preventive Services Task Force recommends
screening of all adults for depression when systems are in
place to ensure accurate diagnosis, effective treatment, and
appropriate followup; there is insufficient evidence sup-
porting universal screening when effective treatment and
followup are unavailable (34). HCPs do not appear to rou-
tinely and systematically screen for anxiety or depression
(35). We believe that screening of all people with arthritis
for anxiety and depression is indicated when the same
conditions (e.g., effective treatment) are met. Although
there are differences in the treatment for depression and
anxiety, pharmacotherapy and cognitive–behavioral ther-
apy are considered effective methods of treating depres-
sion and many forms of anxiety (20). Furthermore, the
appropriate treatment of depression among people with
arthritis can lead to clinically significant reductions in
pain, improved functional outcomes, and continued com-
pliance with antidepressant use for at least 1 year follow-
ing treatment (36). For this reason, treating existent mental
health conditions should be regarded as a fundamental
part of managing arthritis symptoms. Both anxiety and
depression were common among respondents who were
currently being seen by an HCP for their arthritis and joint
symptoms, but approximately half of those reporting anx-
iety or depression had not sought help for their mental
health conditions in the past year. HCP visits for manage-
ment of arthritis symptoms may be an opportunity to
screen for and treat anxiety and depression.
Anxiety and Depression in US Adults With Arthritis 971
Table 1. Associations of sociodemographic, disease, and physical function and health behaviors, self-management, and self-
efficacy with each of anxiety and depression: prevalence and unadjusted PRs*
Anxiety Depression
Prevalence
(95% CI)
Unadjusted
PR (95% CI)
Prevalence
(95% CI)
Unadjusted
PR (95% CI)
Sociodemographic
Age, years
45–64 39.3 (35.7–42.9) 1.9 (1.6–2.3) 21.8 (18.9–24.8) 1.7 (1.4–2.2)
65 20.6 (17.5–23.6) 1.0 12.6 (10.0–15.2) 1.0
Sex
Men 26.2 (22.1–30.4) 1.0 15.0 (11.7–18.2) 1.0
Women 33.5 (30.6–36.3) 1.3 (1.1–1.5) 19.1 (16.7–21.4) 1.3 (1.0–1.6)
Race/ethnicity
Non-Hispanic white 28.8 (26.1–31.5) 1.0 22.5 (16.2–28.8) 1.0
Hispanic 45.6 (33.9–57.3) 1.6 (1.2–2.1) 37.3 (25.9–48.8) 2.4 (1.7–3.4)
Non-Hispanic black 32.7 (25.7–39.8) 1.1 (0.9–1.4) 16.8 (7.4–26.1) 1.5 (1.1–2.0)
Non-Hispanic other† 40.1 (27.1–53.1) 1.4 (1.0–2.0) 15.4 (13.3–17.5) 1.1 (0.6–1.9)
Education
Less than high school 44.1 (37.6–50.5) 2.3 (1.8–2.9) 31.5 (25.4–37.6) 3.8 (2.6–5.6)
High school or some college 32.2 (29.0–35.4) 1.7 (1.3–2.1) 17.9 (15.3–20.5) 2.2 (1.5–3.1)
Completed college or greater 19.3 (15.4–23.1) 1.0 8.1 (5.4–10.8) 1.0
Employment status
Employed 28.4 (24.1–32.7) 1.0 12.5 (9.4–15.5) 1.0
Unemployed, unable to work, or disabled‡ 62.4 (56.6–68.1) 2.2 (1.8–2.6) 44.8 (38.6–51.0) 3.5 (2.7–4.6)
Retired 31.1 (23.7–38.5) 0.7 (0.6–0.9) 11.1 (8.7–13.6) 0.9 (0.6–1.2)
Other§ 19.6 (16.5–22.6) 1.1 (0.8–1.5) 14.1 (8.7–19.6) 1.1 (0.7–1.7)
Disease and physical function
No. of days in the past week with pain, aching, or
stiffness
None 11.5 (7.2–17.8) 1.0 4.5 (2.4–8.3) 1.0
1 or 2 19.8 (14.7–26.2) 1.7 (1.0–3.0) 9.2 (5.9–14.0) 2.1 (1.0–4.4)
3 or 4 30.7 (24.3–37.9) 2.7 (1.6–4.4) 12.9 (8.7–18.9) 2.9 (1.4–6.0)
5 35.8 (32.7–38.9) 3.1 (2.0–4.9) 21.8 (19.3–24.5) 4.9 (2.6–9.2)
Severity of joint pain in the past 7 days
None (0) 9.0 (5.2–15.1) 1.0 5.4 (2.6–11.0) 1.0
Low (1–3) 19.7 (15.6–24.7) 2.2 (1.2–4.0) 7.6 (5.1–11.1) 1.4 (0.6–3.2)
Moderate (4–6) 28.8 (25.3–32.5) 3.2 (1.9–5.6) 15.6 (13.0–18.7) 2.9 (1.4–6.1)
Severe (7–10) 46.9 (42.2–51.7) 5.2 (3.0–9.0) 31.1 (26.9–35.7) 5.7 (2.7–12.0)
Severity of joint stiffness in the past 7 days
None (0) 14.3 (9.5–19.0) 1.0 6.9 (3.6–10.1) 1.0
Low (1–3) 20.1 (15.3–24.8) 1.4 (0.9–2.1) 9.2 (5.6–12.8) 1.3 (0.7–2.5)
Moderate (4–6) 29.7 (25.8–33.7) 2.1 (1.5–3.0) 16.6 (13.4–19.7) 2.4 (1.4–4.1)
Severe (7–10) 48.2 (43.4–52.9) 3.4 (2.4–4.8) 30.4 (26.1–34.7) 4.4 (2.7–7.3)
Severity of fatigue in the past 7 days
None (0) 12.4 (8.7–16.0) 1.0 6.0 (3.3–8.7) 1.0
Low (1–3) 18.9 (14.1–23.7) 1.5 (1.0–2.3) 7.9 (4.6–11.2) 1.3 (0.7–2.4)
Moderate (4–6) 34.0 (29.5–38.6) 2.8 (2.0–3.8) 14.9 (11.6–18.2) 2.5 (1.5–4.1)
Severe (7–10) 50.2 (45.5–55.0) 4.1 (3.0–5.6) 36.3 (31.8–40.9) 6.0 (3.8–9.6)
Self-reported general health status in the past 7 days
Very good/excellent 16.5 (13.1–19.9) 1.0 7.1 (4.8–9.4) 1.0
Good 27.0 (22.9–31.0) 1.6 (1.3–2.1) 13.8 (10.7–16.9) 2.0 (1.3–2.9)
Poor/fair 48.3 (44.0–52.7) 2.9 (2.3–3.6) 31.0 (27.0–35.1) 4.4 (3.1–6.2)
Limited in any way because of arthritis or joint
symptoms
No 20.5 (17.5–23.6) 1.0 10.4 (8.2–12.6) 1.0
Yes 39.8 (36.3–43.3) 1.9 (1.6–2.3) 23.8 (20.7–26.8) 2.2 (1.8–2.9)
Difficulty bathing or dressing yourself?
A little/none 27.9 (25.4–30.3) 1.0 14.9 (12.9–16.8) 1.0
A lot 62.8 (54.3–71.2) 2.2 (1.9–2.6) 47.7 (38.7–56.7) 3.2 (2.5–4.0)
Difficulty walking several hundred feet
A little/none 25.2 (22.5–27.9) 1.0 12.1 (10.2–14.1) 1.0
A lot 46.0 (41.0–50.9) 1.8 (1.6–2.1) 32.4 (27.8–37.1) 2.7 (2.1–3.3)
(continued)
972 Murphy et al
The relationship across anxiety, depression, and pain is
complex, with evidence that each condition acts indepen-
dently and synergistically as a risk factor and outcome for
each other (10,11,37). Furthermore, each is an indepen-
Table 1. (Cont’d)
Anxiety Depression
Prevalence
(95% CI)
Unadjusted
PR (95% CI)
Prevalence
(95% CI)
Unadjusted
PR (95% CI)
Difficulty bending, kneeling, or stooping
A little/none 21.6 (18.6–24.5) 1.0 10.4 (8.2–12.6) 1.0
A lot 41.0 (37.3–44.6) 1.9 (1.6–2.2) 25.4 (22.3–28.6) 2.4 (1.9–3.1)
Do arthritis or joint symptoms now affect whether
you work for pay or not?
No 21.5 (18.9–24.1) 1.0 10.3 (8.4–12.2) 1.0
Yes 51.8 (47.2–56.4) 2.4 (2.1–2.8) 33.0 (28.6–37.3) 3.2 (2.5–4.0)
Did arthritis or joint symptoms interfere with
errands or shopping in the past 7 days?
A little/none 24.8 (22.2–27.3) 1.0 12.2 (10.4–14.1) 1.0
A lot 51.1 (45.8–56.4) 2.0 (1.8–2.4) 36.4 (31.2–41.5) 3.0 (2.4–3.6)
Satisfaction with current ability to do usual
activities
Somewhat satisfied/very satisfied 20.0 (17.3–22.6) 1.0 9.4 (7.5–11.3) 1.0
Neutral 39.0 (28.3–49.7) 2.0 (1.4–2.7) 20.2 (11.5–28.9) 2.1 (1.3–3.4)
Somewhat dissatisfied/very dissatisfied 48.1 (43.6–52.5) 2.4 (2.0–2.8) 31.4 (27.3–35.5) 3.3 (2.6–4.2)
Health and self-management behaviors
Body mass index, kg/m
2
Under- and normal weight (25) 31.1 (26.8–35.5) 1.0 14.7 (11.4–18.0) 1.0
Overweight (25 to 30) 25.5 (21.6–29.4) 0.8 (0.7–1.0) 13.5 (10.5–16.5) 0.9 (0.7–1.3)
Obese (30) 36.0 (31.7–40.3) 1.2 (1.0–1.4) 23.6 (19.8–27.4) 1.6 (1.2–2.1)
Physical activity level¶
Meets recommendations 26.4 (23.4–29.6) 1.0 12.8 (10.7–15.3) 1.0
Insufficient 29.8 (25.3–34.8) 1.1 (0.9–1.4) 17.2 (13.7–21.3) 1.3 (1.0–1.8)
Inactive 42.8 (37.4–48.4) 1.6 (1.4–1.9) 30.6 (25.7–36.1) 2.4 (1.9–3.1)
Have you ever taken a self-management education
course?
No 30.2 (27.7–32.8) 1.0 17.0 (15.0–19.0) 1.0
Yes 34.7 (26.8–42.5) 1.1 (0.9–1.5) 21.9 (15.2–28.6) 1.3 (0.9–1.8)
Confidence that a self-management education course
would help manage symptoms
No confidence 25.4 (19.8–31.1) 0.9 (0.7–1.1) 17.0 (12.2–21.9) 1.1 (0.7–1.5)
Low (1–3) 30.8 (24.8–36.8) 1.1 (0.8–1.3) 16.9 (12.1–21.7) 1.1 (0.8–1.5)
Moderate (4–6) 34.4 (29.9–38.9) 1.2 (1.0–1.4) 18.6 (15.1–22.1) 1.2 (0.9–1.6)
High (7–10) 29.2 (25.0–33.3) 1.0 16.1 (12.8–19.4) 1.0
Confidence in ability to manage arthritis or joint
symptoms
No confidence 45.7 (32.5–59.0) 2.0 (1.4–2.7) 34.3 (21.5–47.2) 3.0 (2.0–4.5)
Low (1–3) 49.3 (38.4–60.2) 2.1 (1.6–2.7) 44.7 (33.9–55.6) 3.9 (2.9–5.3)
Moderate (4–6) 40.6 (35.6–45.6) 1.7 (1.5–2.1) 22.3 (18.2–26.4) 1.9 (1.5–2.5)
High (7–10) 23.4 (20.5–26.2) 1.0 11.5 (9.4–13.5) 1.0
Confidence in ability to engage in moderate physical
activity at least 3 times/week
No confidence 55.8 (45.5–66.2) 2.5 (2.0–3.1) 42.4 (31.8–53.0) 4.1 (3.0–5.6)
Low (1–3) 48.0 (38.7–57.3) 2.1 (1.7–2.6) 30.5 (22.2–38.9) 3.1 (2.2–4.2)
Moderate (4–6) 40.2 (34.9–45.5) 1.8 (1.5–2.1) 25.6 (20.9–30.3) 2.5 (1.9–3.2)
High (7–10) 22.7 (20.0–25.4) 1.0 10.3 (8.4–12.2) 1.0
Currently being treated by doctor or HCP for
arthritis or chronic joint symptoms?
No 26.0 (22.9–29.2) 1.0 13.5 (11.0–15.9) 1.0
Yes 35.5 (31.9–39.2) 1.4 (1.2–1.6) 21.8 (18.7–24.8) 1.6 (1.3–2.0)
*PR prevalence ratio; 95% CI 95% confidence interval; HCP health care provider.
Alaska Native/American Indian, Asian, and Native Hawaiian or other Pacific Islander.
Disabled and unable to work were combined because of small sample sizes.
§ Homemakers and students were combined because of small sample sizes.
Categories were: recommended (150 minutes), insufficient (10 –149 minutes), or inactive (10 minutes), where 1 minute of vigorous exercise was
equivalent to 2 minutes of moderate activity.
Anxiety and Depression in US Adults With Arthritis 973
dent determinant of disability, further complicating this
interrelationship. Similar to depression, anxiety can per-
sist and worsen if untreated (7); the importance of ad-
dressing anxiety is emerging only now (18). Kessler et al
propose that anxiety may be underrecognized and under-
treated because it can be an appropriate response to stress-
ful life events and circumstances, and therefore treatment
may not seem indicated (7). In fact, psychosocial distress
among people with arthritis may signal the presence of
other threats to their well-being, such as economic insecu-
rity (the prevalence of each of anxiety and depression in
our study was higher among those who were unemployed,
disabled, or unable to work) (38). In at least one study,
anxiety was an even stronger predictor of functional lim-
itations than depression among people with arthritis (5),
and it can be an obstacle to the behavioral changes asso-
ciated with reducing pain and depression, such as physi-
cal activity. Minor and Brown examined the efficacy of an
exercise program for people with arthritis, and both high
baseline anxiety and depression scores were indepen-
dently associated with an increased risk of not exercising
at 3, 9, and 18 months postintervention (32).
Ideally, treatment and management of anxiety and de-
pression include simultaneous clinical and self-manage-
ment interventions. There are multiple inexpensive,
convenient, and evidence-based self-management inter-
ventions for anxiety and depression that complement clin-
ical care. Aerobic exercise is an effective treatment for
mild to moderate depression and is associated with reduc-
tions in anxiety (39); some strength training activities may
Table 3. Percentage with anxiety, depression, or both in
the past month who have not sought help in the past 12
months for “stress, depression, or problems
with emotions”
Overall
Currently
being treated
for arthritis or
joint symptoms
Overall 55 46
Age, years
45–64 50 43
65 65 56
Sex
Men 60 53
Women 53 43
Race/ethnicity
Hispanic 40 40
Non-Hispanic black 63 21
Non-Hispanic other* 53 53
Non-Hispanic white 56 48
Highest level of education
Less than high school 60 57
High school or some college 53 46
Completed college or greater 55 51
Employment status
Employed 66 61
Unemployed, unable to work,
or disabled†
37 32
Retired 66 57
Other‡ 55 39
* Alaska Native/American Indian, Asian, and Native Hawaiian or
other Pacific Islander.
Disabled and unable to work were combined because of insuffi-
cient sample sizes.
Homemakers and students were combined because of insufficient
sample sizes.
Table 2. Sociodemographic, physical, and psychosocial
characteristics associated with anxiety and depression:
statistically significant multivariable adjusted PRs*
Anxiety,
PR (95% CI)
Depression,
PR (95% CI)
Sociodemographics
Age, years
45–64 1.7 (1.3–2.1) 1.6 (1.1–2.2)
65 1.0 1.0
Arthritis symptoms and physical
health and function
Severity of joint pain in the
past 7 days†
No pain (0) 1.0 1.0
Low (1–3) 1.6 (1.0–2.5) 1.3 (0.6–2.7)
Moderate (4–6) 1.6 (1.0–2.5) 1.6 (0.8–3.2)
Severe (7–10) 1.9 (1.2–3.0) 1.8 (0.9–3.6)
Self-reported general health
status
Very good/excellent 1.0 1.0
Good 1.4 (1.1–1.7) 1.4 (1.0–2.0)
Poor/fair 1.6 (1.2–2.1) 1.5 (1.0–2.3)
Health and self-management
behaviors
Body mass index, kg/m
2
1.0
Under- and normal weight
(25)
0.8 (0.7–1.0)
Overweight (25 to 30) 0.8 (0.7–0.9)
Obese (30) 1.0
Confidence in ability to
manage arthritis or joint
symptoms
No confidence 1.1 (0.6–1.9)
Low (1–3) 2.3 (1.6–3.3)
Moderate (4–6) 1.2 (0.9–1.6)
High (7–10) 1.0
Confidence in ability to engage
in moderate physical
activity at least 3 times/
week
No confidence 1.5 (1.1–2.1) 1.5 (1.0–2.3)
Low (1–3) 1.2 (1.0–1.6) 1.1 (0.8–1.7)
Moderate (4–6) 1.3 (1.1–1.6) 1.5 (1.2–2.1)
High (7–10) 1.0 1.0
* The multivariable adjusted model comprised all but 1 variable
examined in unadjusted models. This table shows statistically sig-
nificant associations only; PRs for all variables examined in this
multivariable model are shown in Supplementary Table 1 (available
in the online version of this article at http://onlinelibrary.wiley.
com/journal/10.1002/(ISSN)2151-4658). PR prevalence ratio;
95% CI 95% confidence interval.
Severity of each of fatigue, joint stiffness, and joint pain was
highly correlated (r 0.7). To reduce collinearity, only the latter
was included in the multivariable models; joint pain was selected
because it is generally the most modifiable symptom among people
with arthritis, and was also strongly associated with both anxiety
and depression (see Table 1). Because severity of pain was highly
correlated with number of days in the past week with pain, aching,
or stiffness (r 0.6), only severity of pain was included in the
multivariable models.
974 Murphy et al
also elicit the same effects for depression (29). For those
wanting guidance on safely exercising, community-based
physical activity programs (e.g., Walk With Ease, Enhance-
Fitness) teach people with arthritis strategies to reach
recommended levels of physical activity without exac-
erbating symptoms or worsening disease (40). SME inter-
ventions (e.g., Chronic Disease Self-Management Program,
Arthritis Self-Management Program) have been proven to
lead to reductions in anxiety and depression (40). There-
fore, another strategy for HCPs is recommending par-
ticipation in physical activity and evidence-based SME
interventions (http://www.cdc.gov/arthritis/interventions.
htm). Recommendation from an HCP is key; ACHES re-
spondents who had received a recommendation from their
HCP to attend an SME class were 18.5 times more likely to
report attending one than those without a recommenda-
tion (41).
AIMS anxiety and depression subscales were used to
define these conditions. AIMS is one of the most com-
monly used and reported instruments for the study of
anxiety and depression among people with rheumatic con-
ditions (4,13–16). As mentioned previously, although
AIMS subscales have not been validated directly in pop-
ulation-based studies, the AIMS depression subscale is
strongly correlated (r 0.81) with the CES-D (42), a pop-
ulation measure of depression symptoms. Increasing lev-
els of AIMS depression and anxiety scores are also asso-
ciated with lower levels of physical function (measured
with the Health Assessment Questionnaire [HAQ]) (4,13),
suggesting construct validity. To our knowledge, the AIMS
anxiety subscale has not been validated against any other
population-based measure of anxiety. We believe there is
construct validity to the anxiety subscale because of the
association between anxiety and HAQ physical function
scores (4,13). Also, we found that having sought help in
the past 12 months for mental health conditions was
strongly associated with both anxiety (PR 3.5, 95% CI
2.94.2) and depression (PR 3.4, 95% CI 2.9 4.0) (data
not shown), suggesting that the subscales detect mental
distress.
The types of anxiety disorders (e.g., generalized anxiety
disorder, panic disorder) detected by the AIMS anxiety
subscale have not been characterized. Also, because symp-
toms of anxiety can be a manifestation of depression (43),
the proportion of anxiety among respondents attributable
to depression is unknown.
Our estimates indicate that the population burden of
anxiety and depression among adults with arthritis is sub-
stantial, but may be underestimated for several reasons.
We used a conservative definition of depression (i.e., the
AIMS depression subscale cutoff of “probable” rather than
“probable and possible”) (16,42) that would exclude what
a provider might detect and treat. Further, there may be
underreporting of the presence and frequency of symp-
toms if ACHES respondents did not disclose information
about symptoms of anxiety and depression because of
social stigma concerns.
This study has the following limitations. First, people
with arthritis were ascertained by a question on self-
reported doctor-diagnosed arthritis and not by examina-
tion. A clinic-based validation study found that this ques-
tion had a high positive predictive value (44). Second,
ACHES is a cross-sectional study and it is not known
whether the correlates studied are predictors or sequelae
of anxiety and depression. Third, several 95% CIs in both
unadjusted and multivariable analyses bordered on statis-
tical significance, especially for depression, for which
there were fewer people affected. This suggests that there
was insufficient power to detect modest statistically sig-
nificant associations. Last, despite multiple strategies to
maximize survey participation, response rates were low,
particularly among blacks and Hispanics. A previous ana-
lysis indicated that the sociodemographic characteristics
of ACHES respondents are similar to adults with arthritis
ages 45 years in the nationally representative NHIS (22),
suggesting that ACHES results are generalizable to the US
population.
ACHES is the most comprehensive population-based
national survey of US adults with arthritis to date. We
found that both anxiety and depression are common
among people with arthritis and the prevalence of anxiety
was higher than the prevalence of depression. A distinct
profile of people with these conditions was not evident
because the prevalence of these conditions was relatively
high across all of the subgroups. Approximately half of the
affected respondents whose arthritis was being treated by
an HCP had not sought treatment in the past year for their
mental health condition, indicating a missed opportunity
for HCP intervention. This is important because HCPs can
have a significant impact on reducing the burden of anxi-
ety and depression among people with arthritis through
systematic screening for both conditions, treatment based
on current standards of care, and their strong influence in
recommending physical activity and SME programs to
their patients.
ACKNOWLEDGMENTS
The authors would like to thank the Battelle staff for co-
ordinating all aspects of ACHES, the ACHES steering
group’s expertise and time in development of the survey,
and the ACHES respondents for their participation in this
study.
AUTHOR CONTRIBUTIONS
All authors were involved in drafting the article or revising it
critically for important intellectual content, and all authors ap-
proved the final version to be published. Dr. Murphy had full
access to all of the data in the study and takes responsibility for
the integrity of the data and the accuracy of the data analysis.
Study conception and design. Murphy, Sacks, Brady, Hootman,
Chapman.
Acquisition of data. Sacks.
Analysis and interpretation of data. Murphy, Hootman, Chapman.
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976 Murphy et al
    • "Furthermore, analyses of longitudinal study subsets supported the status of pain beliefs risk factors for later problems in functioning in these groups. Keywords Meta-analysis Á Pain beliefs Á Arthritis Á Impairment Á Pain severity Á Affective distress Arthritis is the leading cause of disability for people over age 15 in the United States (e.g., O'Donnell et al., 2010) as well as a common source of emotional distress among the affected (Margaretten et al., 2011; Murphy et al., 2012). Osteoarthritis (OA), a disease characterized by degeneration of cartilage in joints, is the most common subtype with a lifetime prevalence of about 9 % in the U.S. (Johannes et al., 2010; Neogi, 2013) and an estimated annual cost of $185.5 billion in healthcare expenditures alone (Kotlarz et al., 2009; White et al., 2007 ). "
    [Show abstract] [Hide abstract] ABSTRACT: In this meta-analysis, we evaluated overall strengths of relation between beliefs about pain, health, or illness and problems in functioning (i.e., functional impairment, affective distress, pain severity) in osteoarthritis and rheumatoid arthritis samples as well as moderators of these associations. In sum, 111 samples (N = 17,365 patients) met inclusion criteria. On average, highly significant, medium effect sizes were observed for associations between beliefs and problems in functioning but heterogeneity was also inflated. Effect sizes were not affected by arthritis subtype, gender, or age. However, pain belief content emerged as a significant moderator, with larger effect sizes for studies in which personal incapacity or ineffectiveness in controlling pain was a content theme of belief indices (i.e., pain catastrophizing, helplessness, self-efficacy) compared to those examining locus of control and fear/threat/harm beliefs. Furthermore, analyses of longitudinal study subsets supported the status of pain beliefs risk factors for later problems in functioning in these groups.
    Article · Aug 2016
    • "Previous studies suggest that the relationship may be largely accounted for by mental health factors [1, 37, 38] . The comorbidity of depression among individuals with arthritis is high having been reported to be 40 % or above [39, 40], while anxiety is reported to be 31 % [41]. Although our study also shows that the arthritis–suicide attempt association was substantially reduced when lifetime depression and anxiety disorders were accounted for, the relationship remained statistically significant. "
    [Show abstract] [Hide abstract] ABSTRACT: The objectives of this study were (1) to determine the odds of suicide attempts among those with arthritis compared with those without and to see what factors attenuate this association and (2) to identify which factors are associated with suicide attempts among adults with arthritis. Secondary data analysis of the nationally representative 2012 Canadian Community Health Survey-Mental Health (CCHS-MH) was performed. For objective 1, those with and without arthritis were included (n = 21,744). For objective 2, only individuals who had arthritis (n = 4885) were included. A series of binary logistic regression analyses of suicide attempts were conducted for each objective, with adjustments for socio-demographics, childhood adversities, lifetime mental health and chronic pain. After full adjustment for the above listed variables, the odds of suicide attempts among adults with arthritis were 1.46. Among those with arthritis, early adversities alone explained 24 % of the variability in suicide attempts. After full adjustment, the odds of suicide attempts among those with arthritis were significantly higher among those who had experienced childhood sexual abuse (OR = 3.77), chronic parental domestic violence (OR = 3.97) or childhood physical abuse (1.82), those who had ever been addicted to drugs or alcohol (OR = 1.76) and ever had a depressive disorder (OR = 3.22) or an anxiety disorder (OR = 2.34) and those who were currently in chronic pain (OR = 1.50). Younger adults with arthritis were more likely to report having attempted suicide. Future prospective research is needed to uncover plausible mechanisms through which arthritis and suicide attempts are linked.
    Article · Jun 2016
    • "The functional limitations and unpredictable nature of arthritis symptoms can also contribute to stress by making daily planning difficult and creating dependency upon others for routine daily activities (Gignac, Cott, & Badley, 2000). Together these disease-related and psychosocial stressors can take a toll on psychological well-being (e.g., Murphy, Sacks, Brady, Hootman, & Chapman, 2012). Given that stress has been implicated in the etiology, maintenance, and exacerbation of rheumatic diseases (Cohen et al., 2012; Evers et al., 2013), and that adaptive coping is linked to better adjustment to arthritis over time (Pinto-Gouveia, Costa, & Marôco, 2013; Sirois & Hirsch, 2013), understanding the factors and processes that impact how people with arthritis perceive and respond to disease-related stressors can have important implications for disease management and adjustment. "
    [Show abstract] [Hide abstract] ABSTRACT: Guided by pain-related attachment models and coping theory, we used structural equation modeling (SEM) to test an appraisal-based coping model of how insecure attachment was linked to arthritis adjustment in a sample of 365 people with arthritis. The SEM analyses revealed indirect and direct associations of anxious and avoidant attachment with greater appraisals of disease-related threat, less perceived social support to deal with this threat, and less coping efficacy. There was evidence of reappraisal processes for avoidant but not anxious attachment. Findings highlight the importance of considering attachment style when assessing how people cope with the daily challenges of arthritis.
    Full-text · Article · May 2016
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