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Psychology, Health & Medicine
ISSN: 1354-8506 (Print) 1465-3966 (Online) Journal homepage: http://www.tandfonline.com/loi/cphm20
The prevalence of depression and insomnia
symptoms among patients with rheumatoid
arthritis and osteoarthritis in Poland: a case
control study
Brygida Kwiatkowska, Anna Kłak, Filip Raciborski & Maria Maślińska
To cite this article: Brygida Kwiatkowska, Anna Kłak, Filip Raciborski & Maria Maślińska
(2018): The prevalence of depression and insomnia symptoms among patients with rheumatoid
arthritis and osteoarthritis in Poland: a case control study, Psychology, Health & Medicine, DOI:
10.1080/13548506.2018.1529325
To link to this article: https://doi.org/10.1080/13548506.2018.1529325
Published online: 04 Oct 2018.
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The prevalence of depression and insomnia symptoms
among patients with rheumatoid arthritis and osteoarthritis
in Poland: a case control study
Brygida Kwiatkowska
a
, Anna Kłak
b
, Filip Raciborski
c
and Maria Maślińska
a
a
Clinic of Early Arthritis, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland;
b
Department of Gerontology, Public Health and Didactics, National Institute of Geriatrics, Rheumatology
and Rehabilitation, Warsaw, Poland;
c
Department of Prevention of Environmental Hazards and Allergology,
Medical University of Warsaw, Warsaw, Poland
ABSTRACT
The objective of the study was to assess the prevalence of symp-
toms of depression and insomnia among patients with rheuma-
toid arthritis and osteoarthritis in comparison with individuals
without chronic diseases. The study was carried out at National
Institute of Geriatrics, Rheumatology and Rehabilitation, included
229 persons. The participants were divided into the following
groups: group I –120 patients with rheumatoid arthritis, group II
–58 patients with osteoarthritis, group III –51 healthy individuals
no confirmed depression (control group). Symptoms of depression
were confirmed by a multiple-choice self-reported Beck
Depression Inventory questionnaire. Symptoms of depression con-
firmed with depression inventory≥10 occurred as follows: patients
with rheumatoid arthritis –75.83%, patients with osteoarthritis –
50%, control group –23.53% (p<0.0001), with the prevalence of
insomnia (AIS≥6) at: 71%, 32% and 33%, respectively (p<0.001). In
group I mean values of FIRST and AIS were 23.06 and 8.36 respec-
tively, with group II: 21.71 and 7.84, respectively. In all subjects
with AIS≥6, the depression inventory was statistically significantly
(p<0.005) higher than in the subjects with AIS<6 (respectively:
17.02 vs 12.13; 15.6 vs 8.05; 5.45 vs 1.81). Patients with rheumatoid
arthritis find it difficult to cope with stress. Insomnia as a reaction
to stress occurs more often in this group.
ARTICLE HISTORY
Received 30 December 2017
Accepted 21 September 2018
KEYWORDS
Rheumatoid arthritis;
osteoarthritis; depression;
insomnia
1. Background
Depression that occurs in chronic somatic diseases has been frequently discussed in
numerous scientific contributions for the last years. It is already known that in all
chronic conditions depression occurs 2–3 times more often than in individuals not
suffering from these diseases and has an impact on the course and treatment of the
disease. Depression increases mortality rates in almost all somatic conditions and causes
a number of somatic symptoms that are solely its result. The symptoms can overlap,
CONTACT Anna Kłak klak.anna2@gmail.com Department of Gerontology, Public Health and Didactics,
National Institute of Geriatrics, Rheumatology and Rehabilitation, Spartańska 1, 02-637 Warsaw, Poland
PSYCHOLOGY, HEALTH & MEDICINE
https://doi.org/10.1080/13548506.2018.1529325
© 2018 Informa UK Limited, trading as Taylor & Francis Group
exacerbate and sometimes make it difficult to determine their origin (Hegeman et al.,
2016).
The pathogenesis of a chronic somatic disease such as rheumatoid arthritis includes
immunological processes that cause an increase in proinflammatory cytokines and,
among others, disorders of the hypothalamo-pituitary axis resulting from the chronic
stressor –the disease (Li, Han, Li, & Lu, 2013). The following factors contribute to the
development of depression: genetic and individual characteristics, individual responses
to stress that manifest at first through insomnia due to stressors and behavioural
disorders resulting from adolescent experience (Hegeman et al., 2016). Patients with
rheumatoid arthritis can develop different types of depression which overlap, starting
with so-called endogenous depression up to reactive depression (caused by the so-called
losses that the patient experiences from the onset of the disease and during its course),
somatic depression (e.g. due to large doses of glucocorticosteroids). Insomnia is often
the first sign of depression in chronic somatic disorders such as rheumatoid arthritis
(Westhovens, Van der Elst, Matthys, Tran, & Gilloteau, 2014).
Basic criteria in diagnosing depression are a medical interview and compliance with
diagnostic criteria. International diagnostic criteria for depression that are currently in
force specify that 2 out of 10 symptoms lasting at least 2 weeks need to be determined
for a confirmed diagnosis (Whooley, Avins, Miranda, & Browner, 1997). The symptoms
are as follows: low mood, loss of interests and pleasures, low energy, fatigue, apathy,
pessimism towards future, disturbed sleep, poor appetite, poor concentration, low self-
esteem, guilt or self-blame and suicidal thoughts.
In the Polish population the prevalence of depression among adults has amounted to
12%, and increased to 15% among elderly people (Wojnar et al., 2002). Depression is
also diagnosed in 12.5% of patients who see their primary care physician; however,
antidepressants are prescribed to only 20% of patients, out of whom every eighth
patient is referred to a psychiatrist (Wojnar et al., 2002). Masked depression is char-
acterized by a diversity of clinical symptoms which hamper a correct diagnosis, and is
seen in 10% of patients who see their primary care physician (Wojnar et al., 2002). The
prevalence of depression in somatic diseases increases up to 55% (Veerman, Dowrick,
Ayuso-Mateos, Dunn, & Barendregt, 2009). Depression occurs more often in rheumatic
diseases due to chronic stress caused by the disease and chronic inflammation.
Regardless of the ethiopathogenesis of an inflammatory rheumatic disease the preva-
lence of depression is similar and ranges from 40% to 80%. Depression is also diag-
nosed more often during osteoarthritis (40%) in comparison with the general
population (Axford et al., 2010; McDonough et al., 2014; Meesters et al., 2014; Moll,
Gormsen, & Pfeiffer-Jensen, 2011; Palagini et al., 2013; Rathbun, Reed, & Harrold, 2013;
Thombs, Taillefer, Hudson, & Baron, 2007).
Depending on the intensity of symptoms, depression can be differentiated to mild
(masked), moderate or severe (Goldberg & Lecrubier, 1995). Screening measures
used to assess the risk of depression and its intensity are based on questionnaires
which are usually completed by the patient. Most frequently the questionnaires used
include: Beck Depression Inventory –version I and II, Hamilton Rating Scale for
Depression, Jung Self-Test Depression Scale, Montgomery–Åsberg Depression Rating
Scale, Geriatric Depression Scale, Center for Epidemiological Studies-Depression
2B. KWIATKOWSKA ET AL.
scale (CES-D) and Hospital Anxiety and Depression Scale (HADS-D) (Goldberg &
Lecrubier, 1995).
Recent estimates (Cross et al., 2014) indicate that the prevalence of rheumatoid
arthritis in developed countries amounted to 0.24% (95% CI: 0.23%–0.25%). Global
prevalence of rheumatoid arthritis (in the group of individuals 5 to 100 years of age)
was 0.24% (95% CI: 0.23–0.25%). In the group of women this factor is almost 3-times
higher than in the group of men –0.35% (0.34–0.37%) vs 0.13% (0.12–0.13%). In
Eastern Europe the prevalence was 0.14% (0.08–0.22%) for men and 0.38% (0.24–
0.57%) for women. In Central Europe the prevalence was 0.15% (0.11–0.19%) for
men and 0.41% (0.31–0.52%) for women. In Western Europe the prevalence was
0.24% (0.21–0.28%) for men and 0.63% (0.55–0.75%) for women (Cross et al., 2014).
Radiological changes in joints caused by osteoarthritis occur in nearly half of indivi-
duals at the age of 65 years and more, and rising in 80% of individuals aged over
75 years (Arden & Nevitt, 2006).
The objective of the present study was to assess the prevalence of depression
symptoms and sleep disorders such as insomnia in patients with rheumatoid arthritis
(RA) and osteoarthritis (OA) in comparison with individuals without either but with
complaints suggestive of depression.
2. Materials and methods
2.1. Study group
The study was carried out at the Clinic and Polyclinic of Rheumatology of the National
Institute of Geriatrics, Rheumatology and Rehabilitation in Warsaw. The participants
n = 229 were divided into three groups: group I –120 patients with rheumatoid arthritis
(RA), group II –58 patients with osteoarthritis (OA), group III –51 healthy individuals
(control group). Group I and II consisted of patients hospitalized at the Clinic and
Polyclinic of Rheumatology. Group III comprised medical personnel of the Clinic as
well as their families.
This study lasted 6 months. Inclusion criteria for the study in the patient groups:
diagnosed RA or OA, age over 18 years, no severe mental and somatic disorders,
depression not confirmed by a physician. Exclusion criteria for patients with RA or
OA: less than 18 years of age, severe mental and somatic disorders, depression con-
firmed by a physician. Inclusion criteria for the control group: no diagnosed RA or OA,
age over 18 years, no severe mental and somatic disorders, no confirmed depression.
Group I (with RA, n = 120) comprised patients with stage I radiological changes
according to Steinbrocker method (11%), patients with stage II (38%), 28% with stage
III and 23% with stage IV. Group II patients (with OA, n = 58) comprised 17 patients
(29.31%) with generalized osteoarthritis, 26 (44.83%) with osteoarthritis of the hand, 37
(63.79%) with osteoarthritis of the knee, 27 (46.55%) with osteoarthritis of the hip, and
52 (89.65%) with osteoarthritis of the spine. Characteristics of the study group are
presented in Table 1.
PSYCHOLOGY, HEALTH & MEDICINE 3
2.2. Questionnaire tools
Patients in all groups completed a questionnaire developed by the researchers which was
distributed by the medical practitioners. In the group of patients with RA the questionnaire
was completed twice at intervals of minimum 3 months and maximum 5 months. The
questionnaire consisted of demographic and socio-economic data (residence, living con-
ditions, education, professional activity, economic conditions). Additionally the patients
Table 1. Characteristics of the study group.
Variable
Group I
RA*
Group II
OA**
Group III
Healthy individuals with symptoms of
depression
Number, N 120 58 51
% (N)
Gender
Women 86.67 (104) 74.14 (43) 66.77 (34)
Men 13.33 (16) 25.86 (15) 33.33 (17)
Age, mean (min; max): 56.81 (19.01; 85) 64.56 (40;
93)
42.80 (22; 68)
Residence
Town 79.17 (95) 86.21 (50) 94.12 (48)
Countryside 20.83 (25) 13.79 (8) 5.88 (3)
Marital status
Single: maiden/bachelor 12.5 (15) 12.07 (7) 19.61 (10)
Single: widow/widower 20 (24) 31.03 (18) 3.92 (2)
Married 67.5 (81) 56.90 (33) 76.47 (39)
Education
Primary 7.5 (9) 5.17 (3) 0
Basic vocational 20 (24) 17.24 (10) 5.88 (3)
Secondary 54.17 (65) 43.10 (25) 41.18 (21)
Tertiary 17.5 (21) 34.48 (20) 52.94 (27)
Other 0.83 (1) 0 0
Professional activity
Employed 18.33 (22) 25.86 (15) 84.31 (43)
Unemployed 81.67 (98) 72.41 (42) 15.69 (8)
Disability pension yes 45.83 (55) 12.07 (7) 0
Disability pension no 54.17 (65) 86.21 (50) 0
Pension yes 34.17 (41) 65.52 (38) 11.76 (6)
Pension no 63.33 (76) 34.48 (20) 88.23 (45)
No answer 2.5 (3) 1.72 (1) 0
Children
Yes 85 (102) 84.48 (49) 74.51 (38)
No 15 (18) 15.52 (9) 25.49 (13)
Living conditions
Alone 18.33 (22) 29.31 (17) 7.84 (4)
With a spouse 43.33 (52) 55.17 (32) 72.55 (37)
With children 11.67 (14) 13.79 (8) 15.69 (8)
With parents/family 0.83 (1) 1.72 (1) 1.96 (1)
Other (e.g. concubinage) 25.83 (31) 0 1.96 (1)
Duration of the disease (years) mean (min; max): 11.2
(0.5; 40)
No data Not applicable
Coexisting diseases
Coexisting diseases in total 51.67 (62) 48.27 (28) Not applicable
Hypothyroidism 15.13 (18) 8.6 (5)
Diabetes 10.83 (13) 20.69 (12)
Ischaemic heart disease 16.67 (20) 20.69 (12)
Epilepsy or other mental illness before
the disease
8.33 (10) 0
Positive family history for mental
illnesses
5 (6) 6.9 (4)
* Rheumatoid arthritis, ** osteoarthritis.
4B. KWIATKOWSKA ET AL.
completed the following standardized questionnaires: Beck Depression Inventory –version
I (BDI I), Polish adaptation of Ford Insomnia Response to Stress Test (FIRST) and Athens
Insomnia Scale (AIS). Among the questionnaires which related to the occurrence of
insomnia and depression symptoms, only these questionnaires were validated into Polish
(Fornal-Pawłowska & Szelenberger, 2013; Fornal-Pawłowska, Wołyńczyk-Gmaj, &
Szelenberger, 2011,2007). BDI are psychometric tests with a multiple-choice self-reported
inventory composed of 21 questions, which measures the level (severity) of depression. In
the present study we used test BDI-IA (a revision of the original instrument developed by
Beck during the 1970s, Polish version). Results of 1–10 points is considered a norm,
between 11–16 –mild mood disturbance, 17–20 clinical depression, 21–30 moderate
depression, 31–40 severe depression, over 40 extreme depression. The Ford Insomnia
Response to Stress Test (FIRST), a diagnostic tool used to identify individuals predisposed
to insomnia, is a nine-item self-reported instrument that tests the likelihood that an
individual will get sleep disturbances following various stressful events. The Athens
Insomnia Scale (AIS) confirms insomnia symptoms by assessing eight factors that related
to nocturnal sleep and daytime dysfunction, with a rating of 0–3 for each point and an
evaluation used in conjunction. A result above 6 is a diagnosis of insomnia.
The questionnaire dedicated to patients with RA also included clinical data of the
disease such as medical history, treatment used to date and currently, as well as
coexisting diseases such as hypothyroidism, hyperthyroidism, hypertension, ischaemic
heart disease, diabetes, episodes of epilepsy occurring before the diagnosis of rheuma-
toid arthritis, and/or the occurrence of depression in the family. This part of the
questionnaire was completed partly by the physician and partly by the patient.
Disease activity was assessed on the number of painful and swollen joints (in the
assessment of 28 joints), Visual Analogy Scale (VAS) (pain and disease activity as
assessed by the patient), inflammatory parameters such as erythrocyte sedimentation
rate (ESR), and concluded as a Disease Activity Score 28 (DAS 28). Also evaluated were
the duration of morning stiffness (patients assessment) and disease activity as assessed
by the physician (Physician Global Activity –PGA). Patients with RA also completed
the Health Assessment Questionnaire (HAQ) –data not shown.
The questionnaire used in the OA group (group II) consisted of demographic and socio-
economic data, treatments used, as well as coexisting diseases such as hypothyroidism and
hyperthyroidism, hypertension, ischaemic heart disease, diabetes, episodes of epilepsy
occurring before the diagnosis of osteoarthritis and/or the occurrence of depression in
the family. The assessment of pain by the patient (VAS), the assessment of disease activity
by the patient (VAS), HAQ, BDI I, FIRST and Athens Insomnia Scale were also evaluated.
In the control group the questionnaire included demographic and socio-economic data,
the history of an episode of depression in a medical interview, and the history of depression
occurrence in the family. BDI, FIRST and Athens Insomnia Scale were also evaluated.
The study was approved by the Bioethics Committee of the National Institute of
Geriatrics, Rheumatology and Rehabilitation.
2.3. Statistical analysis
The level of statistical significance for all the tests carried out within the study was
defined at p < 0.05. Within descriptive statistics, continuous variables were
PSYCHOLOGY, HEALTH & MEDICINE 5
characterized by classic measures (mean, standard deviation) as well as positional
measures (minimum, maximum, median and quartiles). In the case of ordinal variables,
of a small number of categories and of nominal variables, the structure of particular
answers was calculated. Hypotheses about the relations between nominal variables were
tested with the use of Chi-squared test and Fisher’s Exact Test (for 2 × 2 tables and
small number of observations). The differences between the values of continuous
variables in the two study groups were examined with the use of Student’s t-test with
independent variance estimation. In the case of comparisons of more than the two
groups, variance analysis was used and additional post-hoc tests with least significant
difference test (LSD) were performed. If the size of the group was too small, the results
were additionally verified with the use of nonparametric Mann–Whitney U test. The
relation between continuous variables was measured with Pearson product-moment
correlation coefficient and nonparametric Spearman’s rank correlation coefficient.
Calculations were carried out using Statistica and GRETL software.
3. Results
3.1. Prevalence of depression symptoms (BDI≥10) in groups I and II in
comparison with group III
The assessment of depression symptoms in the three groups (I, II, III) revealed
statistically significant differences between the RA and OA groups compared to group
III (p < 0.0001). In group III (n = 51), confirmed symptoms suggestive for depression
based on the BDI questionnaire (≥10) were evaluated in 12 (23.53%) investigated
subjects. The data is shown in Table 2.
3.2. Prevalence of insomnia (AIS≥6) in group i (RA) and group II (OA) in
comparison with group III (control group)
Assessment of insomnia (AIS ≥6) in the three analysed groups (I, II, III) showed
statistically significant differences between groups I and II (RA and OA patients)
compared to the control group (III) of healthy individuals (Table 3).
3.3. Mean values of AIS and FIRST in the RA and OA groups
Post hoc analysis confirmed that the difference between the group of patients with RA
and those with OA was not statistically significant (Table 4).
Table 2. The prevalence of symptoms of depression (BDI≥10) in the three groups.
Group
BDI < 10
N (%)
BDI ≥10
N (%)
Group I –Rheumatoid arthritis (n = 120) 29 (24.17) 91 (75.83)*
Group II –Osteoarthritis (n = 58) 29 (50) 29 (50)*
Group III –Control group (n = 51) 39 (76.47) 12 (23.53) *
Total (n = 229) 97 (42.36) 132 (57.64)
*p < 0.0001 (Chi-squared test ^2 Pearson’s test, Chi-squared test ^2 NW).
6B. KWIATKOWSKA ET AL.
Group I (RA) mean values of FIRST and AIS were 23.06 and 8.36 respectively and
group II (OA) were 21.71 and 7.84, respectively. In the group of patients with RA,
statistically significant differences were demonstrated in mean BDI values between the
patients with a low (< 6) AIS value: 12.13 (p = 0.011694, Mann–Whitney U test) and a
high (≥6) AIS value, 17.02 (p = 0.004836, Student’s t-test). Similar statistically significant
differences were demonstrated in patients with osteoarthritis (group II) at 8.05 and 15.16,
respectively (p = 0.002303, Student’s t-test; p = 0.007984, Mann–Whitney U test).
A test for linear correlation between FIRST and BDI variables was carried out within
groups (RA) and II (OA) with a statistically significant positive correlation demonstrated
for each group. Nonparametric analysis was also carried out by calculating Spearman’srank
correlation coefficient, which confirmed the results. Pearson product-moment correlation
coefficient and critical values of the correlation test are presented in Table 5.
4. Discussion
The prevalence of depression in chronic somatic disorders is more frequent than in the
population of healthy individuals, with approximately 20% of the general population
Table 3. The prevalence of insomnia (AIS≥6) in the analysed groups (n = 212).
Group
AIS < 6
N (%)
AIS ≥6
N (%)
Group I –Rheumatoid arthritis (n = 103) 30 (29.13) 73 (70.87)*
Group II –Osteoarthritis (n = 58) 21 (36.21) 37 (31.51)*
Group III –Control group (n = 51) 34 (42.86) 17 (33.33) *
* p = 0.00004 (Chi-squared test^2 Pearson’s test, Chi-squared test^2 NW).
Table 5. Pearson product-moment correlation coefficient, Spearman’s rank correlation coefficient
and critical values of the correlation test in two analysed groups (RA*, OA**).
FIRST
and BDI variables
Group I
RA*
Group II
OA**
Pearson product-moment correlation coefficient (p) 0.2439 (p = 0,038) 0.5995 (p < 0,001)
Spearman’s rank correlation coefficient 0.264224 (p < 0,05) 0.544433 (p < 0,05)
* rheumatoid arthritis, ** osteoarthritis.
Table 4. Mean values of AIS and FIRST in the analysed groups of patients: RA^ (n = 120), OA^^
(n = 58).
Athens Insomnia Scale (AIS)
Ford Insomnia Response to Stress Test
(FIRST)
AIS
total AIS total
Group I (RA)
M = 8.863
Group II (OA)
M = 7.844
FIRST
value FIRST value
Group I
(RA)
M = 23.6
Group II
(OA)
M = 21.70
Group mean
standard
deviation P values mean
standard
deviation P values
Group I
RA^
8.86* 4.37 0.191314 23.60
#
5.69 0.074571
Group II
OA^^
7.84* 5.38 0.19131 21.71
#
6.66 0.07457
M–mean for the group, *p < 0.005 (LSD test),
#
p < 0.001 (Student’s t-test), ^ rheumatoid arthritis, ^^ osteoarthritis.
PSYCHOLOGY, HEALTH & MEDICINE 7
having symptoms of depression. With rheumatic diseases the prevalence of depression
is significantly more frequent and results from chronic stress as well as chronic
inflammatory process. Regardless of the pathogenesis of the inflammatory rheumatic
disease, the prevalences of depression were similar at 40 to 60%. Depression is also
more common in patients with osteoarthritis compared with the general population, at
40% in patients with OA and 9% in the general population (Axford et al., 2010;
McDonough et al., 2014; Meesters et al., 2014; Moll et al., 2011; Palagini et al., 2013;
Rathbun et al., 2013; Thombs et al., 2007).
In Poland no epidemiological studies assessing the prevalence of depression in the
general population had been carried out, with only a study assessing the prevalence
among patients who had reported the symptoms to the primary care physician (and not
in the general population) –in that study the prevalence was 40.3% (BDI ≥10) (Wojnar
et al., 2002). In this present study, the prevalence of symptoms of depression in the
control group was 23.53%. These values are similar to data for the general population
(Ayuso-Mateos et al., 2001). A Beck depression inventory (BDI) below 10 was the cut-
offpoint, according to validation studies of Beck Depression Inventory carried out in
other countries (Shim, Baltrus, Ye, & Rust, 2011). Patients with RA (group I) and OA
(group II) manifested the symptoms of depression significantly statistically more often
in comparison with group III, with 75.83% of group I patients (RA) and 50% of group
II patients (OA) vs. 23.53% in group III. The obtained results confirmed that the
symptoms of depression occurred more often in patients with RA than in patients
with OA (Mella, Bértolo, & Dalgalarrondo, 2010). The studies carried out in other
countries show from 17% to 41.5% of patients with RA suffer from depression, while
the symptoms of depression as well as depression combined with fear occur in 53.2 to
70.8% of patients, depending on the diagnostic method and analysed population
(Dickens, Jackson, Tomenson, Hay, & Creed, 2003; Isik, Koca, Ozturk, & Mermi,
2007; Mella et al., 2010). The different scales for the evaluation of depression, such as
Centre for Epidemiological Studies-Depression (CES-D) scale, Hospital Anxiety and
Depression Scale (HADS-D), BDI and Hamilton Rating Scale for Depression as well as
other scales were used in the studies, which makes the comparison of the obtained
results difficult. Beck Depression Inventory was used in the present study to diagnose
the symptoms of depression, but not the depression itself. This explains why the
percentage of diagnosis of depression symptoms is so high. However, it was only by
5 percentage points higher than individual reports published in international literature
–therefore these results coincide. Based on the analysis carried out within the present
study it was proved that 50% of patients with OA manifest the symptoms of depression,
which agrees with literature data. Data from other countries show that depression
occurs in 28.3 to 40.7% of patients with OA and 50.0% of patients with OA manifest
the symptoms of fear (Dickens et al., 2003). Therefore the symptoms of depression can
be found more often in patients with RA (75.83%) than in patients with OA (50.0%);
however these differences were not statistically significant.
The impact on how the patients cope with stress related to the symptoms of
depression in groups I and II was also assessed using FIRST scale. Mean values of
FIRST scale in both these groups of patients were significantly statistically higher. This
demonstrates that patients with RA and OA more often manifest sleep deterioration as
a response to stressors. This can indicate that patients with RA and OA more often
8B. KWIATKOWSKA ET AL.
manifest the symptoms of depression due to their psychological predispositions. This
fact can also explain the obtained results indicting that the values of BDI scale in the
group of patients with RA and patients with OA were dependent on the values of FIRST
scale. The relation between the prevalence of depression and increased sensitivity to
insomnia have been confirmed in numerous studies (Axford et al., 2010; Dickens,
McGowan, Clark-Carter, & Creed, 2002).
The present study shows as well that although the increased values of FIRST scale
were related to higher values of BDI scale, they were also interdependent with the values
of AIS scale. It was demonstrated that in patients with RA (group I) and patients with
OA (group II) showing the symptoms of chronic insomnia, the values of BDI scale were
significantly statistically higher than in patients with AIS<6 (17.02 vs 12.13; 15.6 vs 8.05;
5.45 vs 1.81, respectively). Insomnia is one of the criteria of diagnosis of depression and
can precede other symptoms of depression (Soldatos, Dikeos, & Paparrigopoulos,
2003). The obtained results confirm the interrelationship between increased sensitivity
to situational insomnia and chronic insomnia as well as the occurrence of insomnia
symptoms in the analysed groups. The results show that the patients with RA and OA
not only manifested the symptoms of depression more often than the healthy indivi-
duals, but in general experienced more difficulties in coping with stress, which is
confirmed by studies carried out in other studies (Basińska, 2003; Covic, Adamson, &
Hough, 2000). Similar relationships are described in studies of the general population
(Gawlik & Nowak, 2006).
The fact that this study was carried out with the use of a questionnaire constitutes a
limitation. The obtained data are based on the declarations of respondents and not on
observations of their behaviour. In the case of BDI, FIRST and AIS, which are subject to
some controversy in terms of depression symptoms, it can be expected that the
declarations differed from actual behaviours. In the case of questions relating to
HAQ, VAS and DAS 28, there is only a slight risk that the respondents provided
false information. It can therefore be assumed that the data obtained in the study are
not fundamentally affected. The low number of participants in the study groups
constituted another limitation as a more detailed statistical analysis was not possible.
The large number of questionnaires validated for Polish conditions that were used in
the study constitute, on the other hand, its strength.
5. Conclusions
Symptoms of depression occur more often in patients with rheumatoid arthritis
(75.83%) than in patients with osteoarthritis (50.0%); however these differences are
not statistically significant. Sleep deterioration as a response to stressors occurred more
often in the group of patients with rheumatoid arthritis and osteoarthritis than in the
healthy subjects. Patients with rheumatoid arthritis find it difficult to cope with stress.
Insomnia as a reaction to stress occurs more often in this group. The symptoms of
depression very often coexist with rheumatic disorders, influencing their course and
manifestation. Simple screening tests for depression should be carried out for each
patient. When depression is diagnosed in a group of patients with rheumatic disorders,
parallel treatment for depression should be introduced as it ensures increased thera-
peutic effectiveness for both diseases.
PSYCHOLOGY, HEALTH & MEDICINE 9
6. Declarations
The procedures followed were in accordance with the ethical standards of the respon-
sible committee on human experimentation (institutional: Bioethics Committee of the
National Institute of Geriatrics, Rheumatology) and with the Helsinki Declaration of
1975, as revised in 2000.
Disclosure statement
No potential conflict of interest was reported by the authors.
Funding
This study was not funded from any sources. Our institution has not received any payment or
services from a third party (government, commercial, private foundation, etc.) for any aspect of
the submitted work (including but not limited to grants, data monitoring board, study design,
manuscript preparation, statistical analysis, etc.).
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