Quantifying the burden of emotional ill-health amongst patients referred to a specialist rheumatology service

N. L. Maiden, N. P. Hurst, A. Lochhead, A. J. Carson1 and M. Sharpe1

Rheumatic Diseases Unit, Western General Hospital, Crewe Road, Edinburgh EH4 2XU and
1 University of Edinburgh Department of Psychiatry, Kennedy Tower, Royal Edinburgh Hospital, Morningside Park, Edinburgh EH10 5HF, UK


    Abstract
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
Objectives. (1) To determine the prevalence of emotional disorders (DSM IV depression, anxiety and panic disorders) amongst patients referred to a rheumatology out-patient service and the proportion of these detected by the rheumatologist. (2) To test the hypotheses that emotional disorders are associated with (i) broad categories of rheumatological diagnosis (systemic, inflammatory vs non-systemic, non-inflammatory), (ii) female gender, (iii) greater symptom burden and disability and (iv) markers of socio-economic deprivation.

Methods. A cross-sectional study was made of consecutive newly referred attenders at a hospital-based, regional rheumatology service. Emotional disorders, pain, health status and socio-economic factors were assessed by questionnaire. The letter to the referrer was scrutinized for the rheumatological diagnosis and mention of emotional disorder.

Results. A total of 256 patients were eligible and 203 (79%) participated. The sample was 69% female, had a mean age of 50 yr and 68 patients (33.5%) had one or more emotional disorders. Only a minority were detected. There was no association with type of rheumatological diagnosis. Patients with an emotional disorder were more likely to be female (81 vs 62%; P<0.007), to report more pain (mean Visual Analogue Score 70 vs 50 mm, P<0.001), a greater number of somatic symptoms (median 3 vs 1, P<0.001) and greater disability (median Health Assessment Questionnaire 1.1 vs 0.5, P<0.001). Emotional disorders were also associated with some, but not all, measures of lower social and economic status and life dissatisfaction.

Conclusions. Emotional disorder is present in one-third of new rheumatology referrals. The course, causation and management of this important component of rheumatological illness merit further attention.

KEY WORDS: Emotional disorders, Anxiety, Depression, Panic disorder, Rheumatology out-patients.


    Introduction
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
There is considerable evidence that psychological and social factors are important determinants of disability and pain in patients with musculoskeletal symptoms and disorders [13]. The presence of emotional disorder not only magnifies the degree of disability [4, 5] but also has been shown in some studies to pre-date and increase the risk of future musculoskeletal complaints [68]. A recent North American study found that 40% of patients referred to a rheumatology clinic had a DSM IV psychiatric diagnosis compared with 29% of similar referrals to a general medical clinic [9]. In addition, patients diagnosed with a non-systemic, non-inflammatory rheumatological disorder were more likely to have a psychiatric disorder than those with a systemic, inflammatory diagnosis.

Socio-economic deprivation and social stressors have been reported to be associated with a higher prevalence of health problems including chronic disease, increased risk of emotional ill-health, disability [10, 11] and an increased prevalence of musculoskeletal disorders and symptoms [12, 13]. Thus, deprivation may be an important marker both for poor emotional health and musculoskeletal problems.

Most of the published research to date has focused on specific rheumatic diagnostic groups such as rheumatoid arthritis [14], osteoarthritis [15], systemic connective tissue diseases, or fibromyalgia [16]. Only recently has research turned to the broader question of the burden of psychological and social problems in subjects presenting with rheumatic symptoms, and who may or may not have an identifiable rheumatic disease [9, 17]. We are not aware of any published data on the prevalence and associations of emotional disorders in unselected new rheumatology out-patients in a British National Health Service (NHS) setting. In a companion paper, we report the prevalence of medically unexplained symptoms and their relationship with emotional disorders in this patient group [18].

The primary aim of this study was to determine the prevalence of emotional disorders (DSM IV diagnoses of anxiety, depressive disorder and panic disorder) amongst patients with musculoskeletal symptoms newly referred to a regional rheumatology out-patient service and the proportion detected by the assessing rheumatologist. The secondary aims were to examine the relationship between emotional disorders and (i) the broad category of musculoskeletal diagnosis, (ii) gender, (iii) symptom burden and disability, and (iv) ecological and individual markers of socio-economic deprivation.

The main hypothesis was that there would be a higher prevalence of psychiatric disorders in the group of patients with a non-systemic, non-inflammatory disorder compared with the group with a systemic, inflammatory disorder as found by O'Malley et al. [9]. Subsidiary hypotheses were that emotional disorder would be associated with female gender, greater symptom burden and disability and greater social deprivation and dissatisfaction.


    Patients and methods
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
Design
This study was cross-sectional in design. Six consultants and five specialist registrars at five hospitals provide the Lothian rheumatology out-patient service. A similar range of clinical problems is seen at each general clinic as referrals are distributed by clerical staff according to the availability of appointments. Few patients are referred to named consultants. The study was conducted between September 2000 and April 2001 in seven out of a total of 21 general rheumatology clinics at two—one central and one peripheral—out of the five possible sites (Western General Hospital and Roodlands Hospital). Four consultants and five specialist registrars participated. The Western General Hospital, situated within Edinburgh, is the base of the Lothian rheumatology service and is the site of the majority of rheumatology clinics. Roodlands Hospital is located in a rural area and serves communities of different socio-economic status. The number of clinics studied was limited to seven to ensure that the researcher was able to contact every new patient booked to attend one or two consultant clinics on each weekday. All patients newly referred to the Lothian rheumatology service and allocated to selected clinics during the period of the study were included. Ethical approval was obtained from the Lothian Research Ethics Committee.

Referred patients were sent written information about the study by post 1 to 2 weeks prior to their clinic appointment and advised that they could contact the principal researcher or an independent doctor for further information. On the day of their clinic visit, they were seen by the researcher and written consent for participation sought. Participating subjects were then asked to complete self-report questionnaires about symptoms of emotional disorder, health status and disability and socio-economic circumstances, before their consultation.

Measures
Demographic information. The patient's age, gender and postcode (for coding Carstairs deprivation category; see below) was recorded from the medical notes.

Rheumatologists' diagnoses. The rheumatological diagnoses recorded in the clinic letter to the general practitioner following the consultation were noted. The primary rheumatological diagnosis was categorized as either systemic (i.e. inflammatory disease) or non-systemic (non-inflammatory articular, periarticular or non-articular disorders). This categorization was performed by one researcher, who was not aware of the questionnaire results, using explicit definitions of diagnostic categories as shown in Table 1Go. The letter was also scrutinized for mention of emotional disorder.


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TABLE 1. Primary diagnoses given to patients (to illustrate case mix; n=203)a

 
Emotional disorder. A self-rated patient questionnaire was used to make probable diagnoses of emotional disorder (depression and anxiety). The Patient Health Questionnaire (PHQ) [19] is a self-administered version of the Primary Care Evaluation of Mental Disorders (PRIME-MD) [20]. This questionnaire provides diagnoses of major depressive disorder, other depressive disorder, panic disorder and anxiety based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition: Primary Care Version (DSM IV) [21]. The PHQ has been shown to have comparable validity to the original PRIME-MD, which uses brief, structured interviews and is of proven reliability and validity. The diagnosis of somatoform disorder was not used, as this requires a clinical judgement to be made regarding the adequacy of a biological explanation for all physical symptoms that the patient has reported. However, the PHQ symptom checklist was used to assess the number of somatic symptoms being experienced by patients. The alcohol and eating disorder sections of the PHQ were omitted.

Heath status (symptoms and disability). Health status was assessed using both the modified Health Assessment Questionnaire (HAQ) for disability [22] and the MOS Short Form-12 (SF-12) for physical and mental health status [23]. The SF-12 is a shorter version of the SF-36 with comparable performance [24]. It was scored using published regression weights and scoring rules to produce T-scores for physical and mental health status. In T-score notation the normal population mean is 50 with a standard deviation of 10. Lower scores indicate worse physical and emotional health status. Pain was measured using a 100-mm visual analogue pain scale (0=no pain, 100=maximum pain).

Social and economic status and dissatisfaction. A number of measures of social and economic status were made. The Carstairs deprivation category based on the postcode of residence and ranging from 1 (most affluent) to 7 (most deprived) was determined [25]. It is derived from the level of male unemployment, overcrowding, car ownership and the distribution of social class within the population of the postcode area. In addition to this ecological factor, socio-economic status was assessed using personal factors. These included housing tenure (owner occupied/rented), household access to a car/van [26] and educational level (further education after finishing school). Subjective financial strain was also assessed by asking: ‘How well would you say you are managing financially at the moment?’ with responses coded as living comfortably or doing all right/just about getting by/finding it difficult [27]. Social circumstances were ascertained by asking whether patients lived alone or with dependent relatives and smoking status. Patients were also asked about their level of satisfaction with their work status and home life: ‘How satisfied are you with your current job or work status (retired, student, seeking work, working at home)?’ and ‘How satisfied are you with your current home life?’ with the responses coded as very satisfied/satisfied/not particularly satisfied/dissatisfied/severely dissatisfied.

Statistical analysis
Power calculation. The power calculation was based on the hypothesis that there would be a higher prevalence of psychiatric disorders in the group of patients with a non-systemic, non-inflammatory disorder compared with the group with a systemic, inflammatory disorder as found by O'Malley et al. [9]. A study size of approximately 200 subjects was required to detect a difference in frequency of psychiatric disorders of 50% in those with a non-systemic, non-inflammatory disorder vs 30% in those with a systemic, inflammatory disorder, with 80% power ({alpha}=0.05, two-tailed test). This difference in prevalence between the two groups was based on the data from O'Malley et al. [9] and was considered the minimum difference that would be of clinical interest and importance.

Analysis. The PHQ was used to generate individual DSM IV diagnoses of depressive, panic and anxiety disorders, which were then combined to produce a single category of ‘emotional disorder’ which was used in further analysis. Although emotional health was also measured using the SF-12, this continuous measure was not used to categorize patients with regard to emotional disorders. Associations between the presence or absence of a psychiatric disorder and categorical variables were examined using the {chi}2-test and relative risks with 95% confidence intervals (CI) calculated. Differences between means for continuous variables in those with a psychiatric diagnosis vs those without were examined using the t-test and for non-normally distributed data, the Mann–Whitney U-test. The relationship between socio-economic variables, pain and disability with emotional disorder was explored using stepwise logistic regression.


    Results
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
Of the 279 patients booked to attend the designated clinics during the study period, 23 did not attend their appointments leaving 256 eligible to participate. Of these, 44 did not give consent and the researcher missed a further nine on the day of their clinic visit. This left 203 patients who agreed to participate and who completed a questionnaire, which gives a participation rate of 79% of attenders and 73% of all those referred. The mean age of the study patients was 50 yr (S.D. 15.0) with a range of 19–87 yr; 139 patients (68.5%) were female. Non-participants had a mean age of 48 yr and 68.4% were female. Of those participating, 158 patients (78%) attended the Western General Hospital and 45 (22%) attended Roodlands Hospital; 113 (56%) were seen by a consultant and 90 (44%) were seen by a specialist registrar.

Rheumatological diagnosis
The diagnosis of a systemic rheumatological disorder was made in 66 patients (32.5%) and 137 (67.5%) were given a non-systemic diagnosis (Table 1Go). A psychiatric diagnosis was made by the rheumatologists in only 15 patients (7.4%) (12 of depression, three of anxiety).

Emotional disorder
Sixty-eight patients (33.5%) were identified from the questionnaire as having an emotional disorder (DSM IV diagnosis of anxiety, depressive disorder or panic disorder). Twenty-six patients (13%) had more than one emotional disorder, most commonly both major depression and anxiety disorder which were simultaneously present in 15 patients. A total of 96 diagnoses of emotional disorder were made: major depression in 34 (17%), other depressive disorder in 23 (11%), anxiety in 26 (13%) and panic disorder in 13 (6%).

Detection of emotional disorder by the rheumatologists
Of the 15 patients diagnosed with a psychiatric disorder by the rheumatologists, only three had no DSM IV diagnosis identified by the questionnaire (10 had depression±another disorder and two had anxiety alone). Conversely, of the 34 patients with major depression on the PHQ, only six (18%) were diagnosed with depression by the rheumatologists. There was no significant difference in the detection rate of emotional disorders between consultants (6/32, 19%) and specialist registrars (6/36, 17%). Any previous experience or training in psychiatry amongst the rheumatologists was not assessed. Twelve of the 15 patients diagnosed with an emotional disorder by the rheumatologists were also given a rheumatological diagnosis (seven of arthralgia/back pain, four of osteoarthritis and one of ankylosing spondylitis). That only one out of these 12 patients had an inflammatory arthritis suggests that the rheumatologists were less likely to diagnose an emotional disorder in the presence of an inflammatory disease.

Association between rheumatological diagnosis and emotional disorder
There was no association between the two categories of rheumatological diagnosis (systemic, inflammatory or non-systemic, non-inflammatory) and the presence or absence of emotional disorder. The prevalence of emotional disorders was 36% in those diagnosed with an inflammatory arthritis, 27% in those with a connective tissue disease, 30% in those with osteoarthritis and 33% in those with arthralgia, back pain or fibromyalgia. Thus, the prevalence of emotional disorders was similar in each rheumatological diagnostic group.

Associations between gender, symptoms, health status and emotional disorder
Patients with an emotional disorder were significantly more likely to be female [Relative risk (RR) 1.95, 95% CI 1.15–3.30]. They were also more disabled (P<0.001) and had worse physical function (P<0.001), reported more pain (P<0.001) and reported a higher median number of somatic symptoms in general (P<0.001) (see Table 2Go).


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TABLE 2. Relationship between emotional disorder, demographics, broad rheumatological diagnosis, pain, disability, health status and reported number of somatic symptoms

 

Associations between socio-economic status and emotional disorder
The relationship between emotional disorders and social and economic factors was explored (Table 3Go). There was no association with Carstairs deprivation category, car access, living alone or living with dependent relatives. However, there was an association with living in rented housing (RR 1.5, 95% CI 1.0–2.2), perceived financial strain (RR 1.8, 95% 1.21–2.6) and not undertaking further education after finishing school (RR 1.5, 95% CI 1.0–2.3). In addition, there was a strong association with dissatisfaction with work status (RR 1.6, 95% CI 1.1–2.4) and home life (RR 2.2, 95% CI 1.5–3.1).


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TABLE 3. Relationship between emotional disorders and socio-economic factors

 

Independent predictors of emotional disorder
Exploratory stepwise logistic regression was performed as shown in Table 4Go to determine the significant independent predictors of emotional disorders. The socio-economic variables that were significantly associated with emotional disorders on univariate analysis (i.e. living in rented housing, financial strain, lack of further education, dissatisfaction with work status and home life) were analysed adjusting for age and gender. Financial strain [odds ratio (OR) 2.8, 95% CI 1.4–5.6 (P=0.003)] and home dissatisfaction [OR 2.7, 95% CI 1.3–6.0 (P=0.012)] were the significant independent predictors of emotional disorders among the variables examined. When pain (Visual Analogue Score, VAS) and disability (HAQ) were entered into the model in addition to the socio-economic variables, then home dissatisfaction remained significant [OR 3.7, 95% CI 1.6–8.6 (P=0.003)] in this model even after adjusting for pain and disability (Table 4Go).


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TABLE 4. Predictors of emotional disorders as analysed by an exploratory stepwise logistic regression model

 


    Discussion
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 
Main findings
One-third of new attenders at Lothian rheumatology clinics had an emotional disorder (anxiety or depressive disorder diagnosis). The most common diagnostic category was major depression (17%), which was either missed or not commented upon by the rheumatologists in 82% of cases. More than one emotional disorder was present in 13%. Those with a systemic, inflammatory rheumatological diagnosis were just as likely to have a psychiatric diagnosis as those with a non-systemic, non-inflammatory disorder.

Emotional disorders were strongly associated with female gender, more pain, increased disability and more somatic symptoms. In addition, those with an emotional disorder were significantly more likely to report financial strain and dissatisfaction with their work and home situations and they were less likely to have undergone further education after finishing school. An exploratory logistic regression suggests that home dissatisfaction is the most important independent predictor of emotional disorders among these socio-economic factors.

Limitations
When interpreting the results the representativeness of the sample must be considered. For the clinics studied, referrals are randomly distributed between the general rheumatology clinics by clerical staff according to clinic templates. The clinics included in the study were chosen to maximize the number of different consultants' clinics and to provide a spread throughout the week while allowing a feasible number of patients for the researcher to contact in the allocated time. We believe that the participating clinics were representative of the service as a whole. Our participation rate of 79% of attenders was adequate and although there may have been some potential for non-response bias, it is reassuring that non-participating patients had similar demographic characteristics to the study patients. Therefore, non-response bias is unlikely to have led to an overestimate of the prevalence of emotional disorders or to have affected the associations found.

Another potential limitation of the study is that there was no assessment of the inter-observer agreement among the participating rheumatologists as regards the making of rheumatological diagnoses. However, the diagnoses were coded by a single researcher who was unaware of the questionnaire results.

The detection of emotional disorder by the rheumatologists was assessed only by it being mentioned in the clinic letter. While it is possible that the clinician was aware of emotional symptoms but did not record them, this means that this information was not passed to the referring doctor.

We also need to consider the ability of the self-administered PHQ to detect psychiatric morbidity accurately. The PHQ was chosen over other self-report instruments as it has the advantage of producing categorical psychiatric diagnoses rather than indices of severity. In primary care settings, good agreement has been found between the PHQ diagnoses and those made at interview by mental health professionals (sensitivity 75%, specificity 90%, overall accuracy 85%) [19]. If anything, the use of the PHQ may have led to an underestimate of the prevalence of psychiatric morbidity. Furthermore, in our study the low SF-12 mental score in the group with an emotional disorder was consistent with the results of the PHQ.

The association of emotional disorder and social and economic factors and dissatisfaction was tested using multiple variables. Consequently, the significant associations found must be interpreted with caution.

Interpretation
In interpreting these findings, the cross-sectional design of this study makes it impossible to know whether the emotional disorders detected were transient or persistent. Neither was it possible to determine whether the association between attendance at a rheumatology clinic and emotional disorders reflects chance association, common cause or a causal association between these illnesses. A causal relationship could operate in either direction. Emotional disorder may have exacerbated the pain and disability and led to referral or emotional disorder may be a consequence of having a rheumatological disease.

Other studies
There is a body of work relating to emotional disorders in patients with specific rheumatic conditions such as rheumatoid arthritis [14, 28], osteoarthritis [15], connective tissue diseases and fibromyalgia [16]. To our knowledge, however, this is the first study which has investigated the prevalence of emotional disorders in newly referred, unselected patients to general rheumatology clinics in a British NHS setting. Allowing for differences in study design, the prevalence of emotional disorders in these new, unselected rheumatology referrals is of the same order as in patients with specific rheumatic diseases. Thus, the burden of emotional disorders affects a significant proportion of patients with musculoskeletal symptoms referred to hospital rheumatology clinics irrespective of diagnosis. In addition, these data call into question the specificity of the associations previously reported between emotional disorder and type of rheumatic disease.

This study also found that rheumatologists' detection of emotional disorders is poor. Similar findings have been made in the United States [9]. O'Malley et al. reported the prevalence of emotional disorders to be 40%, although the prevalence of major depression was lower at 7%. They also found an increase in the number of somatic symptoms reported by patients with current emotional disorder, but no relation with gender or disability. In addition, they found that patients with a psychiatric disorder were much less likely to receive a diagnosis of a systemic, inflammatory condition. This difference may be explained by the use of different disease categories or referral selection bias. There are several possible reasons for the low detection of emotional disorders, which include misattribution of emotional distress to ‘physical disease’, and the difficulty of identifying this in the context of arthritis [14, 29]. Rheumatologists may over-read signs as an explanation for symptoms, for example attributing symptoms to ‘early osteoarthritis' rather than emotional distress.

The results of our study should also be compared with a study by Carson et al. [4], which found that the prevalence of emotional disorders among new attenders at general neurological out-patient clinics in Edinburgh was 47% (the prevalence of major depression was 26%). As in our study, emotional disorders were strongly associated with increased disability, more pain and more somatic symptoms.

This study suggests associations between social and economic deprivation and emotional disorders. A link between socio-economic deprivation and poor physical and emotional health has been repeatedly noted. Although Carstairs deprivation category, which is an ecological rather than an individual variable, and car access may not have been sufficiently discriminatory measures of deprivation for our small study, the association between housing tenure and educational level and emotional disorders shown in our study is in agreement with others [26, 30]. The association and interaction between financial strain and emotional disorders is interesting. Although the presence of a psychiatric disorder may heighten financial worries or actually lead to a reduction in the standard of living, it has also been shown that sustained economic hardship can lead to clinical depression [31] and financial strain is strongly associated with the onset of emotional disorders [27]. Perceived financial strain, however, may not only relate to actual levels of poverty/affluence but to personality factors such as a tendency to worry or be pessimistic. Equally, the level of satisfaction expressed by a patient about their work and home lives may be a cause or a consequence of an emotional disorder. Whatever the nature of these interactions, financial strain and work and home dissatisfaction may act as markers for the presence of an emotional disorder. Furthermore, the relationships between emotional disorders, rheumatic symptoms, disability, coping skills and socio-economic deprivation are likely to be complex and multidirectional.

Implications
The results of this study suggest that emotional disorders are common in patients referred to rheumatology services, that they are associated with disability and that they are often unrecognized. At present, there is scant provision to treat this aspect of patients' illness positively in traditional rheumatology out-patient services. There is arguably a need to improve both the detection and management of emotional disorder to provide a more comprehensive treatment service.

The first problem to be addressed is how to detect those with psychiatric morbidity. The reporting of multiple somatic symptoms should act as a trigger for the consideration of an emotional disorder and our results would suggest that tactful enquiry into a patient's satisfaction with their home and work lives and financial situation may also help identify patients at risk. At present, rheumatologists may feel reluctant to explore these non-biological areas or to diagnose emotional disorders because of a lack of training or a belief that they would be unable to help. A screening questionnaire for psychiatric disorders scored prior to the consultation may be useful, but research has shown that merely providing clinicians with information about psychiatric diagnoses has only a moderate impact on their behaviour [19, 32].

The second aspect of improving service provision for these patients involves the implementation of effective evidence-based treatments. These include antidepressant drugs [33] and cognitive behavioural therapy [34] as well as health education for self-management [35]. The extent to which these treatments can be provided by rheumatologists themselves and the role of specific liaison psychiatry and psychology services requires further investigation.

Conclusion
In conclusion, one-third of new referrals to rheumatology clinics have an emotional disorder (DSM IV diagnosis of anxiety, depressive or panic disorder). In this study rheumatologists significantly under-diagnosed emotional disorders. These patients had more pain and greater disability. Emotional disorder was not associated with broad categories of rheumatological diagnosis. Patients with emotional disorder were less likely to have undergone further education and more likely to be experiencing financial strain and dissatisfaction with their home and work lives. More research is needed into the persistence of emotional disorders and the extent to which they directly contribute to symptoms and disability. However, on the available evidence it seems likely that improved detection and management of emotional disorder in rheumatology services is likely to improve the outcome for patients using these services.


    Acknowledgments
 
We are grateful to the Women of Scotland Luncheon 2000 who funded this study and all of the patients who participated. We thank the medical staff of the Rheumatic Diseases Unit who allowed their patients to be studied and the rheumatology clinic nursing, secretarial and appointment staff who helped with this study. We would like to thank A. Lee for statistical advice and P. Boreham for data entry.


    Notes
 
Correspondence to: N. Maiden. E-mail: nicolamaiden{at}hotmail.com Back


    References
 Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 

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Submitted 25 March 2002; Accepted 28 November 2002





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