Predictors of Comorbid Depression in Iranian Patients With Knee Osteoarthritis

Moghtadaei, Mehdi; Moayedfar, Mehdi; Dehghani, Mohammad; Rahmati, Fatemeh; Mazaheri, Sahleh

doi:10.17795/soj-7586

Volume 3, Issue 4 (11-2016) JROS 2016, 3(4): 0-0 | Back to browse issues page

‎ 10.17795/soj-7586

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Moghtadaei M, Moayedfar M, Dehghani M, Rahmati F, Mazaheri S. Predictors of Comorbid Depression in Iranian Patients With Knee Osteoarthritis. JROS 2016; 3 (4)
URL: http://jros.iums.ac.ir/article-1-193-en.html

Predictors of Comorbid Depression in Iranian Patients With Knee Osteoarthritis

Mehdi Moghtadaei

¹, Mehdi Moayedfar¹

, Mohammad Dehghani²

, Fatemeh Rahmati³

, Sahleh Mazaheri³

1- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, IR Iran
2- Alzahra Hospital, Isfahan University of Medical Sciences, Isfahan, IR Iran
3- Payame Noor University of Baharestan, Esfahan, IR Iran

Keywords: Osteoarthritis, Pain, Comorbid Depression

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Abstract

Copyright © 2016, Iran University of Medical Sciences. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.

1. Background

Osteoarthritis (OA) is considered as the most common disorder of musculoskeletal system in both developed and developing countries (1). Since OA mostly affects the elderly, a population with high prevalence of depression, the coexistence of OA and depression is frequent (2, 3). According to the great body of evidence, depression significantly affects the quality of life of the patients with OA (2, 4). Individuals with depression report more severe pain and unfortunately more than half of the patients with chronic pain end up with depression (2, 5, 6). In other words, the pain causes more depression and the depression causes more pain and this interaction finally leads to the sooner end stage of the disease (7). Theoretically, patients with depression exhibit decreased brain serotonin function and elevated cortisol secretion (8). Serotonin is a pain modulator and its decline is associated with increased pain perception (9). In addition, the higher amount of cortisol weakens the immune system, leading to the lower anti-inflammatory and higher pro-inflammatory cytokine release which finally results in higher pain perception (10, 11).

The link between depression and pain was previously evaluated in several chronic diseases (5, 12, 13). Nearly all of the former studies reported a positive correlation between depression and pain. Such positive correlation between pain and depression is also found in OA (2, 14), leading to the inconsistency between radiographic symptoms and the amount of declared pain. This inconsistency adversely affects the assessment of OA and results in inappropriate management of the disease (15, 16). However, considering this association in the OA assessment and management would diminish its adverse effect. In addition, since the higher depression level could be associated to the higher pain perception, the depression management could lead to less pain level which results in an improved quality of life of such patients (17).

2. Objectives

3. Methods

In a cross-sectional study, a total of 100 patients with knee OA referred to the medial center from 2012 to 2014 were selected and enrolled to the study after confirming the OA according to the Kallgren and Lawrence osteoarthritis grading system (18, 19). Patients with any other comorbid diseases, which could affect the pain and depression levels, including diabetes, cardiovascular and psychiatric disease were excluded from the study. Each patient signed the written informed consent. In addition, Iran University of Medical Sciences institutional review board reviewed and approved the waiver of authorization to use protected health information (PHI) for research purposes for this study.

Totally, 80 (80%) females and 20 (20%) males were evaluated. The mean age of the patients was 58 years, ranging from 42 to 75 years. Table 1 contains the detailed demographic characteristics of the patients.

To analyze the depression level, Persian version of Beck depression inventory-II (BDI-II) (20) was applied. Briefly, the BDI-II contains 21 questions and each answer is scored on a scale of 0 to 3; while higher total scores indicate more severe depression symptoms. In this regard, it is divided into four levels including 0 - 13, 14 - 19, 20 - 28 and 29 - 63 which correspond to minimal, mild, moderate and severe depression, respectively (20).

Visual analogue scale (VAS) was used to assess pain severity. VAS is a self-reported criterion, in which the respondent is asked to place a perpendicular line on the VAS line according to the pain he/she is experiencing. VAS is the most common scale in pain evaluation and represents the intensity of pain on a scale of 0 - 10, where 0 indicates no pain and 10 indicates the worst pain ever felt (21).

Previously reported prevalence of OA was considered to determine the required sample size (22). Regarding the prevalence of 15.4% in the urban area of Tehran, reported by Davatchi et al. and at type I error of 10%, the minimum sample size of this study was 50.

Statistical analysis was performed using IBM SPSS for windows, version 21. Central tendency and variability of numeric variables were evaluated using the mean and standard deviation, respectively. Independent sample T-test, one-way ANOVA, Chi-square test, Pearson and Spearman correlation coefficient tests were used to analyze the significant associations and correlations between the variables. P values ≤ 0.05 were regarded as statistically significant.

4. Results

The results were provided in two separate sections including the analysis of associations showed by P-value and analysis of correlations indicated by r-value. The mean and standard deviation (SD) of pain and depression scores were calculated according to the aforementioned criteria. In this regard, the mean ± SD of depression and pain scores were 10.06 ± 4.36 and 4.12 ± 1.6, respectively. The detailed mean ± SD of pain and depression scores according to the corresponding variables are demonstrated in Table 2.

Totally, 60 negative or minimal depressions, 30 mild depressions and 10 moderate depressions were observed in the population with OA. Bivariate analysis of variables showed a significant association between depression score and factors including age (P = 0.04), marital status (P = 0.01) and regular sport activity (P = 0.03). In this regard, patients who were married, employed and physically active had significantly lower depression scores. The mean depression score was also significantly high in higher grades (P = 0.02). Correlation analysis showed a significant positive correlation between depression and pain (r = 0.381, P = 0.008, 95% CI) and OA grade (r = 0.332, P = 0.009, 95% CI). In addition, a significant negative correlation was observed between depression score and age (r = -0.259, P = 0.024, 95% CI). No other significant correlation was observed between depression score and variables including gender, marital status, etc.

As expected, the mean pain score was significantly higher in higher grades of OA (P = 0.015). The pain score was also significantly higher in patients with higher BMI (P = 0.03). Moreover, a significant association was observed between pain score and age group. In this regard, patients aged less than 50 years old reported higher pain, which was significantly different from those of older age groups (P = 0.04). No other significant association was observed between pain and other variables including gender, education, etc. The correlation of pain and OA grade was also significantly positive (r = 0.512, P = 0.001, 95% CI), as expected.

The detailed results of association and correlation analyses are also demonstrated in Table 2.

Table 1. The Socio-Clinico-Demographic Characteristics of Patients

Variable Group	N, %
Age
<; 50	18
≥ 50	82
Gender
Male	20
Female	80
OA grade
I	15
II	24
III	38
IV	23
Body mass index (BMI), Kg/m²
<; 25	12
25 - 29.9	36
29.9	52
Education
Undergraduate	62
Graduate	20
Postgraduate	18
Occupation status
Working	54
Retired	46
Regular sport activity
Yes	18
No	82
Marital status
Married	58
Single/divorced/widow	42
Financial satisfaction
Totally satisfied	17
Relatively satisfied	71
Dissatisfied	12
Smoking
Yes	19
No	81

Abbreiation: OA, osteoarthritis.

Table 2. The Statistical Analysis of Correlation and Association Between Socio-Clinico-Demographic Characteristics of Patients With Pain and Depression Score^a,b

Variable Group	Pain, Mean (SD)	Association (P-Value)	Correlation (r, P-Value)	Depression (Mean ± SD)	Association (P-Value)	Correlation (r, P-Value)
Age		0.04*	0.115, 0.09		0.04*	-0.259, 0.024*
<; 50	4.41 (1.5)			10.41 (5.4)
≥ 50	3.98 (1.6)			9.9 (5.1)
Gender		0.06	0.076, 0.31		0.06
Male	3.88 (1.6)			9.82 (5.6)		0.164, 0.08
Female	4.36 (1.4)			10.3 (5.3)
OA grade		0.01*	0.512, 0.001*		0.02*	0.332, 0.009*
I	2.62 (1.2)			8.89 (5)
II	3.36 (1.3)			9.25 (4.8)
III	4.4 (1.5)			10.3 (5.6)
IV	6.1 (1.5)			11.2 (4.1)
Body mass index(BMI) (kg/m²)		0.03*	0.175, 0.09		0.1	0.011, 0.4
<; 25	3.8 (1.4)			9.51 (4.2)
25 - 29.9	4.06 (1.3)			10.7 (5.3)
>; 29.9	4.5 (1.6)			9.97 (5.5)
Education		0.22	-0.022, 0.42		0.11	-0.066, 0.23
Undergraduate	4.1 (1.3)			9.43 (4.8)
Graduate	4.08 (1.4)			10.43 (5.8)
Postgraduate	4.18 (1.7)			10.32 (5.2)
Occupation status		0.08	0.112, 0.12		0.18	0.085, 0.2
Working	4.01 (1.3)			10.1 (4.6)
Retired	4.23 (1.5)			10.02 (5.7)
Regular sport activity		0.11	0.155, 0.1		0.03*	0.122, 0.09
Yes	4.16 (1.6)			9.08 (5.5)
No	4.08 (1.6)			11.04 (5.7)
Marital status		0.09	0.101, 0.15		0.01*	0.141, 0.07
Married	4.02 (1.5)			7.86 (4.8)
single/divorced/widow	4.22 (1.4)			12.26 (6.1)
Financial satisfaction		0.9	0.055, 0.35		0.06	-0.051, 0.34
Totally satisfied	4.12			10.21
Relatively satisfied	4.18			10.08
Dissatisfied	4.06			9.89
Smoking		0.2	-0.036, 0.46		0.31	0.013, 0.5
Yes	4.16			10.08
No	4.08			10.04

^a*, Significant value.

^bP value <; 0.05 was considered significant.

5. Discussion

Pain is the most primary reason of seeking health care in patients with OA. The pain level is usually correlated with radiographic changes, where higher OA grade is accompanied by higher pain experience (23). However, in a considerable number of patients with OA, pain and radiographic symptoms do not accord with each other and radiographic signs without pain or pain without radiographic signs are frequently reported (15, 16, 24). This strong variability in the patients with OA makes it difficult to properly identify the affected individuals and subsequently evaluate the disease progression. Several psycho-socio determinants may explain the different pain perception in the patients with OA (25) and predispose patients to report more or less pain. Among them, depression is a common condition in the elderly, which affects a considerable number of patients with OA (26, 27). A significantly higher association of knee pain and radiographic signs was observed in patient without depression symptoms (28). As a result, a comprehensive understanding of interactive pain/depression correlation in the patients with OA could optimize the assessment and management of OA.

According to the study analysis, a significant correlation was observed between pain and depression level. Such correlation was also reported in many former studies. Kim et al. reported that the presence of depression was associated with an increased risk of knee arthritis and suggested that the assessment of comorbid depression should be integrated to the assessment and management of OA (29). Leite et al. showed a high frequency of depression in patients with OA, which can impact the pain and physical function of such patients, and proposed the depression control along with OA management to reach superior outcomes (2). Creamer and Hochberg reviewed the relationship between OA pain and psychological variables and proposed that better understanding of this complex interaction improves the effectiveness of many pharmacologic interventions (14). In this regard, the current study also evaluated the effect of clinical, social and demographic variables on comorbid depression in patients with OA. According to the study analysis, depression score was significantly higher in younger patients and higher OA grades. Moreover, depression score was significantly lower in married and physically active patients with OA. In addition, depression was significantly correlated with the pain, OA grade and age of patients with OA. Interestingly, OA grade was simultaneously correlated with both depression and pain, which could confirm the study hypothesis. As higher OA grade generally causes more pain and pain triggers depression, correlation of OA grade and depression could be expected.

The determinants of comorbid depression were also evaluated in other investigations (30-32). Miller and Cano investigated the risk factors of comorbid pain and depression in chronic disorders including OA. They suggested that certain demographic groups including younger and female patients were more likely to have comorbid depression and chronic pain and proposed that such groups may benefit from depression screening (33). However, correlation of comorbid depression with age is debating and even contradictory in some studies. While some studies showed the positive correlation of depression and age, others mentioned an inverse correlation (33-35). The study data also showed an inverse correlation between comorbid depression and age in Iranian patients with OA. This age effect could be interpreted by higher activity limiting impact of OA on this age group. Since the patients aged less than 50 years old need more mobility to take part in their routine activities, the OA imposed restriction could affect their mood more considerably. Surprisingly, both pain and depression scores were higher in younger patients with OA of the study. This also could confirm the interactive effect of pain and depression on each other. In this regard, higher depression score of younger patients with OA could lead to more pain perception, vice versa.

The cross-sectional nature of the study was considered as the biggest limitation of the study. Since the data were collected in a cross-sectional study, it was impossible to explore whether the depression symptoms were the consequence of OA pain or not. The study could not even evaluate which one was earlier, pain or depression. As previously mentioned, the correlation of pain and depression was two-sided, where pain could lead to more depression and depression could cause more pain. Since higher depression is correlated with more pain perception or report, future therapeutic approach of OA needs to be re-evaluated to consider the depression role; especially in patients which the radiographic score and pain level do not accord. In addition, socio-demographic determinants of depression in patients with OA, including age, marital status, physical activity and etc. should be considered to evaluate affected patients.

Footnotes

Authors’ Contribution: Study design, Mehdi Moghtadaei and Mehdi Moayedfar; data acquisition, Mehdi Moayedfar, Mohammad Dehghani, Fatemeh Rahmati and Sahleh Mazaheri; manuscript preparation and revision, Mehdi Moghtadaei, Mehdi Moayedfar, Mohammad Dehghani, Fatemeh Rahmati and Sahleh Mazaheri; study supervision, Mehdi Moghtadaei.

Conflict of interest: There was no conflict of interests regarding the current study.

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Subject: Knee surgery
Received: 2019/09/9 | Accepted: 2016/11/15 | Published: 2016/11/15

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