Coping and psychological adjustment in recent-onset inflammatory polyarthritis: the role of gender and age

J. Ramjeet, M. Koutantji3, E. M. Barrett1 and D. G. I. Scott1,2

School of Nursing and Midwifery Research Unit, 1 Norfolk Arthritis Register, Norfolk and Norwich University Hospital NHS Trust, UK School of Medicine Health Policy and Practice and 2 School of Medicine Health Policy and Practice, University of East Anglia, Norwich and 3 Department of Surgical Oncology and Technology, Imperial College London, London, UK.

Correspondence to: J. Ramjeet, School of Nursing and Midwifery Research Unit, Yorkon Building, University of East Anglia, Norwich, Norfolk NR4 7TJ, UK. E-mail: J.Ramjeet{at}uea.ac.uk


    Abstract
 Top
 Abstract
 Introduction
 Method
 Results
 Discussion
 References
 
Objectives. To examine the role of gender, age and coping in psychological adjustment of patients with early inflammatory polyarthritis (IP).

Methods. One hundred and twelve patients with IP of up to 18 months' duration from the Norfolk Arthritis Register completed questionnaires measuring coping, anxiety, disability and pain.

Results. Thirty-six per cent of the patients were at risk of depressive symptoms. Women had significantly higher levels of depression and anxiety than men. Regression analyses showed that pain and (low) illness acceptance predicted levels of depression. Younger age, wishful thinking and covering up predicted anxiety levels.

Conclusions. The study found higher levels of depression and anxiety for women than men with early IP. Psychological distress was predicted by younger age, specific coping strategies and high levels of pain.

KEY WORDS: Rheumatoid arthritis, Gender, Coping, Psychological adjustment


    Introduction
 Top
 Abstract
 Introduction
 Method
 Results
 Discussion
 References
 
Inflammatory polyarthritis (IP) encompasses a set of chronic systemic conditions that include rheumatoid arthritis (RA) and are characterized by painful swollen joints and disability. In the RA literature depression was identified as the most common psychological problem [1], and in a systematic review Dickens et al. [2] also found that RA patients were more likely to suffer from depression than healthy controls. Depressive symptoms have been associated with female sex [3–5], age [6] and the use of passive pain coping strategies [7–9] in RA.

The aim of this study was to examine the role of gender, age and coping in psychological adjustment in a community sample of patients. Specifically, there would be (i) gender differences in levels of depression and anxiety, and (ii) positive correlations between physical and psychological measures. Finally, we explored the extent to which age, gender, and coping strategies would be significant predictors of psychological distress.


    Method
 Top
 Abstract
 Introduction
 Method
 Results
 Discussion
 References
 
Participants
Participants were from the Norfolk Arthritis Register (NOAR). This is a population-based register which covers a population of 0.5 million, predominantly (99%) of European Caucasoid origin within a specified area of Norfolk, England [10]. Patients were recruited to this study between June 1998 and October 2000. The criterion for early IP was onset of symptoms up to 18 months prior to entering the study. Women over 16 yr and men 45 yr and over were included. Younger men were excluded because RA is rare in this age group [11]. Of the 112 patients, five (four females and one male) were taking antidepressant medication (information for four patients was not available).

Table 1 shows baseline characteristics of the male and female groups.


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TABLE 1. Baseline characteristics (means and standard deviations) of the male and female groups

 
Procedure
Permission to undertake the study was granted by the local research ethics committee. The patients were visited by the NOAR nurse, who collected a range of physiological data, and J.R., who administered a series of self-report psychological questionnaires.

Measures
Depression
The Centre for Epidemiological Studies Depression Scale (CES-D) [12] was designed to measure depressive symptomatology in the general population. This measure offers a cut-off point score (≥16) for risk of depression.

Anxiety
Anxiety was measured by the State-Trait Anxiety Inventory (STAI) [13]. Trait anxiety measures how a person generally feels, and was used as a general indicator of anxiety.

Disability and pain
The Stanford Health Assessment Questionnaire (HAQ) [14] was used to measure disability. A baseline HAQ of >1 is the most important predictor of future disability [10].

Pain was measured with a 101-point visual analogue scale (VAS) [15].

Disease measures
Rheumatoid factor and tender swollen joint count were collected.

Coping with illness
Coping was measured with the London Coping with Arthritis Questionnaire (LCA) [16], designed specifically for RA patients.

Design and statistical analyses
A cross-sectional design was used with an alpha level of 0.05 for all statistical tests. As the CES-D scores were not normally distributed, a square root transformation was applied and the transformed scores were used. The t-test was used to examine gender differences, and correlations with hierarchical linear regression analyses were used to explore relationships between psychological and physical variables.


    Results
 Top
 Abstract
 Introduction
 Method
 Results
 Discussion
 References
 
The results showed that, in terms of psychological adjustment, over 36% of the total sample were at risk of depression. The overall mean CES-D score for women was 15.88 (S.D. = 11.72) with men having a mean score of 11.50 (S.D. = 8.67). The t-test demonstrated that women had significantly higher scores than men (t = –2.03, P < 0.05).

The overall mean trait anxiety score (STAI) for women was 37.82 (S.D. = 10.38), while men had a mean score of 33.58 (S.D. = 8.32). The t-test demonstrated women also had significantly higher anxiety scores than men (t = –2.14, P<0.05).

There were no significant gender differences in levels of disability or pain.

There were significant positive correlations between variables of pain, disability, anxiety and depression, and between disability, pain and tender/swollen joint count.

Predictors of psychological distress in early IP
Hierarchical regression analyses were performed in order to determine the predictors of depressive symptoms. Sex and age were entered into the regression in step 1, pain and disability were entered in step 2 and then the coping strategies in step 3.

The results indicated that age and gender together accounted for 7.8% of the variance [adjusted R2 = 0.08, F(2, 106) = 5.50, P<0.01]. When pain and disability were added to the model, this accounted for 27.6% of the variance [adjusted R2 = 0.28, F(4, 104) = 11.30, P<0.01] and when coping was entered the whole model accounted for 39% of the total variance [adjusted R2 = 0.39, F(8, 100) = 9.64, P<0.01]. In the final model, pain and the coping strategy of accepting the illness (low) were significant predictors of depression.

A second hierarchical regression analysis was performed to predict levels of trait anxiety. Age and gender together accounted for 16% of the variance in levels of anxiety symptoms [adjusted R2 = 0.16, F(2, 106) = 11.19, P<0.01]. When pain and disability were added, this accounted for 27% of the variance [adjusted R2 = 0.27, F(4, 104) = 10.71, P<0.01]. When coping strategies were entered, the whole model accounted for 38% of the total variance [adjusted R2 = 0.38, F(8.100) = 9.39 P<0.01]. In the final model, (younger) age, wishful thinking and covering up were significant predictors of trait anxiety.


    Discussion
 Top
 Abstract
 Introduction
 Method
 Results
 Discussion
 References
 
In this investigation, over 36% of the total sample were at risk of depression. This included 30 women and 11 men, women having higher levels of depressive symptoms than men. A longitudinal study of women with established RA found that loss of valued activities, e.g. cooking and shopping, was a significant risk factor for the development of depressive symptoms [17]. The higher levels of anxiety in women may be a reaction to the illness onset. Future studies could examine the longitudinal relationship between mood and disease duration to determine whether anxiety reduces with adjustment to the disease. The associations between disability, depressive symptoms and pain in early IP patients were similar to previous research in RA [7].

The results of the regression analysis indicated that, together with high levels of pain and younger age, specific coping strategies predicted distress. The direction of the relationship is still unclear, however, as the data are cross-sectional.

Possible markers of the presence of anxiety and depression are high levels of disability and pain [18]. When patients present with increased levels of these symptoms, health-care professionals should be alerted to the possibility of concurrent distress.

This study's findings suggest that younger age, passive coping strategies and high levels of pain are risk factors for the presence of distress. For some early IP patients, however, psychological interventions targeting pain and mood may be necessary.


    Acknowledgments
 
We thank Diane Bunn, the participants and the Arthritis Research Campaign UK for part-funding the research and their continued support of NOAR. We also thank Professor Deborah Symmons, ARC Epidemiology Unit, University of Manchester, for her advice and permission to access the clinical and laboratory material used in this study.

D.G.I.S. completed a sponsored talk/meeting and received a grant from Wyeth, Schering Plough and Abbott (manufacturer of biological treatment for RA). No other conflict of interest has been declared by the other authors.


    References
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 Abstract
 Introduction
 Method
 Results
 Discussion
 References
 

  1. De Vellis BM. Depression in rheumatological diseases. Baillieres Clin Rheumatol 1993;17:2.
  2. Dickens C, McGowan L, Clark-Carter D, Creed F. Depression in rheumatoid arthritis: a systematic review of the literature with meta-analysis. Rheumatology 2002;64:52–60.
  3. Dowdy SW, Dwyer KA, Smith CA, Wallston KA. Gender and psychological well being of persons with rheumatoid arthritis. Arthritis Care Res 1996;9:6:449–56.[ISI][Medline]
  4. Fifield J, Reisine S, Sheehan TJ. Gender differences in the expression of depressive symptoms in patients with rheumatoid arthritis (abstract). Arthritis Rheum 1996;37(Suppl. 9):S283.
  5. Krol B, Sanderman R, Suurmeijer T, Doeglas D, Van Rijswijk M, Van Leeuwen M. Medical, physical and psychological status related to early rheumatoid arthritis. Clin Rheumatol 1995;14:143–50.[ISI][Medline]
  6. Wright GE, Parker JC, Smarr KL, Johnson JC, Hewett JE, Walker SE. Age, depressive symptoms and rheumatoid arthritis. Arthritis Rheum 1998;41:298–305.[CrossRef][ISI][Medline]
  7. Brown GK, Nicassio PM, Wallston KA. Pain, coping strategies and depression in rheumatoid arthritis. J Consult Clin Psychol 1989;57:652–7.[CrossRef][ISI][Medline]
  8. Zautra AJ, Manne SL. Coping with rheumatoid arthritis: A review of a decade of research. Ann Behav Med 1992;14:1:31–9.
  9. Covic T, Adamson B, Howe G, Spencer D. The role of passive coping and helplessness in rheumatoid arthritis depression and pain. J Appl Health Behav 2002;4:31–5.
  10. Symmons D, Harrison B. Early inflammatory polyarthritis: results from the Norfolk Arthritis Register with a review of the literature. Risk factors for the development of inflammatory polyarthritis and rheumatoid arthritis. Rheumatology 2000;39:835–43.[Free Full Text]
  11. Symmons D, Turner G, Webb R et al. The prevalence of rheumatoid arthritis in the United Kingdom: new estimates for a new century. Rheumatology 2000;41:793–800.
  12. Radloff, L. The CES-D Scale: a self report depression scale for research in the general population. Applied Psychol Meas 1977;1:385–401.
  13. Spielberger CD, Gorsuch RA, Lushere RE. Manual for the State-Trait Anxiety Inventory. Palo Alto, CA: Consulting Psychologists Press, 1973.
  14. Fries JF, Spitz PW, Young DT. The dimensions of health outcomes. The Health Assessment Questionnaire, disability and pain scales. J Rheumatol 1982;9:789–93.[ISI][Medline]
  15. Huskisson EC. Visual analogue scales. In: Melzack R, ed. Pain measurement and assessment. New York: Raven Press, 1983:33–7.
  16. Newman S, Fitzpatrick R, Lamb R, Shipley M. Patterns of coping in rheumatoid arthritis. Psychol Health 1990;4:187–200.
  17. Katz PP, Yelin EH. The development of depressive symptoms among women with rheumatoid arthritis. The role of function. Arthritis Rheum 1995;38:1:49–56.[ISI][Medline]
  18. Van Der Heide A, Jacobs JWG, Van Albada-Kuipers GA et al. Physical disability and psychological well being in recent onset rheumatoid arthritis. J Rheumatol 1994;21:28–32.[ISI][Medline]
Submitted 28 April 2005; revised version accepted 4 May 2005.



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