Dutch Study Examines Factors that Contribute to Depression in AS

Men, people who are employed, have a lower income, perceive less control over their lives, and are less satisfied about their social roles, are among those with ankylosing spondylitis (AS) more prone to depression, a Dutch study has shown.

While disease activity contributes only moderately to depression, mastery —  the extent to which one perceives control over life and disease — appears to be central and may be enhanced to improve the mental well-being of AS patients, the researchers said.

The study with those findings, “Depression in ankylosing spondylitis and the role of disease-related and contextual factors: a cross-sectional study,” was published recently in the journal Arthritis Research & Therapy.

Several studies have shown that people with AS experience mental health problems more often than the general population, including a greater risk of depression and anxiety.

This is most likely due to multiple factors. Dealing with symptoms such as impaired physical functioning, pain, and fatigue may be an explanation, but disease activity itself and inflammation also may be important contributors.

So-called contextual factors, such as education, employment, and coping skills, may play a part, although they have been studied less.

To assess the main drivers of depression in AS and understand their relationships, researchers at Maastricht University Medical Center, in the Netherlands, created a model of direct and indirect (or mediated) effects of risk factors. They hypothesized that, similar to other chronic diseases, contextual factors would contribute more than disease-related factors to depressive symptoms in AS.

The team used data from 245 adult patients (mean age 51.2, 62.4% men) who participated in a survey-based study at six hospitals in the Netherlands. Depressive symptoms were assessed with the Hospital Anxiety and Depression Subscale (HADS-D), a seven-item questionnaire.

For measuring contextual risk factors, patients were asked about their educational level, whether they were employed, their work disabilities, as well as lifestyle, general health, and satisfaction with social roles. Mastery was assessed with the seven-item Pearlin scale.

Disease-related factors, including disease activity, physical function, presence of extra-articular manifestations (e.g., psoriasis, uveitis, and inflammatory bowel disease, IBD), physical function, and spinal pain were assessed by specific measures.

Results showed that 44 patients (18%) had a HADS-D score of 8 or higher, indicating possible depression.

When they looked at the link between depression and each potential risk factor, the investigators found that men, patients who were employed, and those with decreased mastery had increased depressive symptoms.

Higher disease activity, as measured by the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), lower satisfaction with social roles, and an annual income up to €40,000 ($44,432) also were associated with increased depressive symptoms, but indirectly through weaker mastery.

Notably, disease activity was the only factor related to AS that appeared to influence the risk of depression. Still, its effects were only moderate and smaller than that of mastery and male gender.

“In summary, the current study showed that both contextual and disease-related factors are associated with depressive symptoms in AS. Mastery … likely has a key role in this process,” the researchers wrote.

Importantly, mastery not only has a direct relation with depression, but also mediates other factors “as a sort of final common (psychological) pathway,” they noted.

“Timely diagnosis and management of depression in AS will improve patients’ health and likely save societal costs. Future studies should investigate how mastery can be enhanced, and whether this results in better mental well-being in AS,” the researchers added.