Anxiety and depression in patients with osteoarthritis: impact and management challenges

Figures & data

Figure 1 Flow diagram summarizing the literature search, screening, and review.

Table 1 Final studies with authors, year of publication, design, and key findings

Authors	Year	Design	Key findings
Axford et al^Citation55	2008	n=170 patients completed trial of PEP to determine what may hinder its efficacy in knee OA.	Greater pain was associated with reduced coping, increased depression, and reduced physical ability.
Ayral et al^Citation54	2002	Prospective randomized study of n=112 (56/group) to access impact of video information on pre-operative anxiety of patients scheduled to undergo joint lavage for knee OA.	Pre-operative anxiety was lowered by half for patients who had viewed the video. Tolerability of knee lavage was also significantly better in the video group.
Blagestad et al^Citation53	2016	Cross-sectional study of n=39,688 participants undergoing THA from 2005 to 2011 to investigate redeemed medications.	Surgery reduced prescriptions of analgesics, hypnotics, and anxiolytics, but not anti-depressants.
Buszewicz et al^Citation52	2006	Randomized controlled trial, n=812 patients aged >50 hip and/or knee OA and pain and/or disability randomized to six sessions of self-management and education booklet (intervention group) or education booklet alone (control group).	The two groups showed significant differences at 12 months on the anxiety sub-score of HADS. No significant difference was seen in number of visits to the GP at 12 months.
Collantes-Esteve and Fernandez-Perez ^Citation51	2003	Open-label multi-center study with n=2,228 investigated the effect of a switch from celecoxib to rofecoxib among patients with OA.	The switch to rofecoxib from celecoxib favorably influenced proportions of patients with self-reported depression.
Croft et al^Citation50	2005	Mailed patient survey of n=8,995 individuals aged >50 years. Patients completed the SF-36, HADS, and WOMAC.	Severity of knee pain and related disability are worse in the presence of pain elsewhere.
Dailiana et al^Citation49	2015	Investigate and compare the impact of primary THA (n=174) and TKA (n=204) on QoL, patients’ satisfaction and detect the effect of patients’ demographic and clinical characteristics on outcome. WOMAC and CES-D10 pre- and post-operative.	WOMAC and CES-D10 improved significantly 1 year post-operatively.
Dieppe et al^Citation48	2000	Prospective study, n=500 patients, study of natural history of peripheral joint OA and its impact over 8 years. Patients reviewed at 3 and 8 years. HAQ and HADS.	The mean HAQ and HADS scores at 8 years were high, especially in those with knee disease, indicating significant disability as a result of the disease.
Ellis et al^Citation47	2012	Effect of psychopathology on the rate of improvement following TKA (n=154).	Subjects in the psychopathology group showed significantly lower SF-36 mental component summary scores both at baseline and 1 year post-operatively.
Gerrits et al^Citation46	2014	Prospective analysis of impact of chronic diseases and pain characteristics in n=1,122 individuals with remitted depressive or anxiety disorder.	Pain, not chronic disease, increases the likelihood of depression recurrence, largely through its association with aggravated sub-threshold depressive symptoms.
Gignac et al^Citation45	2013	Middle- and older-age adults with OA, n=177 or no chronic disabling conditions, n=193, aged >40 years completed a telephone interview and self-administered questionnaire assessing demographics, SRPQ, and psychological variables.	Middle-aged adults with OA reported significantly greater role limitations and more health care utilization than all other groups. Middle-aged adults and those with OA also reported greater depression, stress, role conflict, and behavioral coping efforts than older adults or healthy controls.
Hanusch et al^Citation44	2014	n=100, influence of psychological factors, including perception of illness, anxiety, and depression, on recovery and functional outcome after TKA. Function was assessed pre-operative, 6 weeks, and 1 year after using OKS and ROM.	Pre-operative function had the biggest impact on post-operative outcome for ROM and OKS. Depression and anxiety associated with a higher (worse) knee score at 1 year.
Hawker et al^Citation43	2011	Community cohort, n=529 participants with hip/knee OA. Telephone interviews assessed OA pain and disability using three time points over 2 years.	Current OA pain strongly predicted future fatigue and disability; fatigue and disability in turn predicted future depressed mood; depressed mood and fatigue were interrelated such that depressed mood exacerbated fatigue and vice versa, and that fatigue and disability, but not depressed mood, led to worsening of OA pain.
Kingsbury and Conaghan^Citation42	2012	Random online survey on assessment and treatment of OA, n=1,006 GPs randomly selected and invited to participate in, on factors influencing their management, burden on their practice, and on the need for improving care.	Achieving adequate pain control and lack of time were the most frequently cited challenges, whereas more time with patients, collaboration with specialist colleagues, and improved communication tools were the most common needs identified to improve OA management.
Kirkness et al^Citation41	2012	Pre- and post-operative measures of pain, physical function using LEFS, and QoL of n=168 patients were evaluated.	Most common comorbidities in these patients were osteoarthritis, hypertension, and major depressive disorders.
Lin et al^Citation40	2003	Randomized controlled trial, n=1,801, depressed older adults with coexisting arthritis, performed at 18 primary care clinics to evaluate whether care for depression changes pain and outcome.	Benefits of improved depression care extended beyond reduced depressive symptoms and included decreased pain as well as improved functional status and QoL.
Lin et al^Citation39	2006	Multi-site randomized-controlled trial n=1,001 participants with depression and arthritis. Baseline and 12-month interviews assessed arthritis pain severity and activity interference, depression, analgesic use, and overall functional impairment.	Systematic depression management was more effective than usual care in decreasing pain severity among arthritis patients with lower initial pain severity.
Liu et al^Citation38	2016	Patients with primary hand OA, n=247, consulting secondary care, underwent physical examination for the number of joints with bony joint enlargements, soft tissue swelling and deformities, and radiographs.	Hand OA patients report esthetic dissatisfaction with their hands regularly. This dissatisfaction has a negative impact in a small group of patients who also reported more depression and negative illness perceptions.
Lopez-Olivo et al^Citation37	2011	Evaluation of n=241 patients undergoing TKA, before and 6 months after surgery. Multiple regression models evaluated associations of baseline demographic and psychosocial variables.	Perioperative psychosocial evaluation and intervention are crucial in enhancing TKA outcomes.
Marks^Citation36	2007	Cross-sectional analyses, n=100, unilateral and bilateral radiographic and symptomatic knee OA patients underwent standard assessment using several validated questionnaires and a series of walking tests on level ground.	Efforts to heighten self-efficacy for pain and other symptoms management may influence the affective status, function, and effort-related perceptions of people with knee OA quite significantly.
Marks^Citation35	2009	n=1,000 hip OA surgical candidates examined for any historical/concurrent evidence of depression/anxiety.	Those with depression and anxiety histories were more impaired before surgery and tended to recover more slowly than those with no such history.
Montin et al^Citation34	2007	Longitudinal follow-up study, n=100 participants, State Trait Anxiety Inventory was used to measure patients’ level of anxiety before surgery and at 1 month, 3 months, and 6 months post-operatively.	Patients’ pre-operative trait anxiety impaired HRQoL both before and after surgery.
Nour et al^Citation33	2006	Older adult women (n=102) and men (n=11) with OA or RA were randomly assigned to experimental (n=68) or wait list control (n=45) groups. CES-D at baseline, pre-intervention, and post-intervention.	Self-management intervention can successfully improve involvement in exercise and relaxation among housebound older adults with arthritis.
Ozcakir et al^Citation32	2011	n=100 knee OA patients; investigate relationship between radiological severity and clinical/psychological factors. KL, WOMAC, 15 m walk, 10-step climb.	Depression was significantly higher in late-stage knee OA group. Radiological severity is an important indicative factor for pain, disability, depression, and social isolation.
Perruccio et al^Citation31	2012	Prospective study of n=494 participants who completed patient-reported outcome pre- and 12 months post-TKA. WOMAC, POMS, and HADS scoring methods used.	As symptomatic joint count increase, so does anxiety and depression both pre- and post-operatively. A comprehensive approach to OA management/care is warranted.
Pinto et al^Citation30	2013	n=124 patients assessed 24 hours before (T1) and 48 hours after (T2) surgery. Demographic, clinical, and psychological factors were assessed at T1 and several post-surgical pain issues, anxiety, and analgesic consumption were evaluated at T2.	Positive correlation between post-surgical anxiety and acute pain was reported.
Rosemann et al^Citation29	2007	Survey of n=1,021 participants to assess the prevalence, severity, and predictors of depression in a large sample of patients with OA.	There is high prevalence of depression among patients with OA and perceived pain and few social contacts were strongest predictors.
Rosemann et al^Citation28	2007	Patient questionnaires, n=1,021 to assess the impact of concomitant depression on QoL and health service utilization of patients with OA.	Appropriate treatment of depression would appear not only to increase QoL but also to lower costs by decreasing health service utilization.
Rosemann et al^Citation27	2007	Cross-sectional survey, n=1,250 OA patients to assess factors associated with visits to GPs, orthopedists, and non-physician practitioners.	Psychological factors contribute to the increased use of health care providers.
Rosemann et al^Citation26	2007	Determined factors associated with functional disability in n=1,021 patients with OA via questionnaires.	Main factors associated with functional disability were depression, pain, and few social contacts.
Rosemann et al^Citation25	2008	Cross-sectional survey of n=1,021 OA patients to determine factors associated with pain intensity in primary care.	Severity of depression showed the strongest association with pain intensity.
Sale et al^Citation24	2008	Prospective cohort study, n=1,227 individuals ≥62 years with hip/knee OA completed CES-D, WOMAC, and other questionnaire.	Prevalence of depressive symptoms was high in adults with OA. Higher depressed mood was independently and significantly associated with female gender, greater pain and fatigue, stressful life events, more coping behaviors, and receiving treatment for depression/mental illness.
Stamm et al^Citation23	2014	Health interview survey including n=3,097 subjects aged >65 years with OA, back pain, or osteoporosis to explore health care utilization compared to controls.	Patients with OA, back pain, or osteoporosis visited GPs and were hospitalized more often than controls. Problems in the ADLs, pain intensity, and anxiety/depression influenced GP consultations.
Steigerwald et al^Citation22	2012	Open-label, Phase 3b study of n=195 patients to evaluate the effectiveness and tolerability of tapentadol for severe, chronic OA knee pain.	Tapentadol significantly improved pain intensity, HRQoL, and function in patients with inadequately managed, severe, chronic OA knee pain.
Theiler et al^Citation21	2002	3-week prospective open-label multi-center study with rofecoxib 25 mg daily in n=134 (mean 69 years, SD=8) outpatients with painful OA flares of the knee or the hip.	Rofecoxib significantly SF-12 and WOMAC scores, in OA patients.
Wylde et al^Citation20	2012	Patients listed for a primary TKA were recruited from pre-operative assessment clinics. Pre-surgical evaluation included WOMAC, PSES, HAD, and SACQ questionnaires and questions about other painful joints. Patients then completed the WOMAC Pain and Function Scales at one year post-operatively.	Significant predictors of post-operative pain were greater anxiety and higher pain severity. Other significant predictors of post-operative disability were greater anxiety, worse functional disability, and a greater number of painful joints elsewhere.
Yilmaz et al^Citation19	2015	Patients with RA (n=142), FMS (n=136), knee OA (n=139) and healthy women controls (n=152) were analyzed using VAS, BDI, FIQ, TPC, DAS-28, HAQ, and WOMAC.	Positive correlation was determined between BDI, VAS, and WOMAC scores in the knee OA group. However, level of depression was only related to disease severity in women with FMS.
Zullig et al^Citation18	2015	Data were from patients (n=300) enrolled in a randomized control trial examined the association of comorbidities with baseline-OA PROs: pain, physical function, depressive symptoms, fatigue, and insomnia.	Depression was associated with worse pain, fatigue, and insomnia. Evidence that comorbidity burden is associated with worse OA-related PROs.

Abbreviations: AIMS, Arthritis Impact Measurement Scale; ASMP, Arthritis Self-Management Program; BDI, Beck Depression Inventory; CES-D, Centre for Epidemiological Studies Depression Scale; DAS-28, Disease Activity Score-28; FIQ, Fibromyalgia Impact Questionnaire; FMS, fibromyalgia syndrome; GPs, general practitioners; HADS, Hospital Anxiety and Depression Scale; HAQ, Health assessment questionnaire; HSCL-20, Hopkins Symptom Checklist Depression Scale; IPQ-R, Illness Perceptions Questionnaire-Revised; KL, Kellgren–Lawrence grading; KSS, Knee Society Scale; LEFS, Lower Extremity Function; OA, osteoarthritis; OKS, Oxford Knee Score; PEP, Patient Education Program; PHQ-9, Patient Health Questionnaire; POMS, Profile of Mood States; PSES, Pain Self-Efficacy Scale; RA, rheumatoid arthritis; ROM, Goniometer-measured range of movement; SACQ, Self-Administered Co-morbidity Questionnaire; SF-36, SF-12, Short Form Health Survey; SRPQ, Social Role Participation Questionnaire; THA, total hip arthroplasty; TKA, total knee arthroplasty; TPC, tender point counts; WOMAC, Western Ontario & McMaster Universities Osteoarthritis Index; VAS, Visual Analog Scale; PROs, Patient-reported Outcomes; ADLs, Activities of Daily Living.

Table 2 Summary of results

Impact	Summary
Epidemiology	Psychological factors such as anxiety and depression are commonly prevalent in patients with OA.
OA symptoms	Anxiety and depression contribute to index joint pain and its intensity. This pain can predict future fatigue, disability, and depressed mood.
OA outcomes	Anxiety and depression increase GP visits, health care and drug utilization, post-surgical pain, and adverse outcomes.
Sex differences	Anxiety and depression differentially impact lives of male and female patients with OA, with females showing higher levels of depressed mood.
Management challenges	Summary	Suggestions
Challenges in diagnosis	Physicians found it difficult to diagnose anxiety and/or depression in patients with OA.	Adopt NICE guidelines toward holistic assessment of patients with OA.
Challenges in self-care, collaborative care, social/phone support	Anxiety and depression pose as a challenge to physicians in structuring a management plan. Studies have reported use of various management programs with variable success.	Use “à la carte” approach. Thorough timely patient assessment required following initiation of program to access for improvement.
Challenges in pharmacotherapy	Rofecoxib and tapentadol were reported to have favorable results.	Cocktail pharmacotherapy. Other drugs like duloxetine have been approved by FDA for use in this patient cohort.
New management approaches	Music, video, and yoga have been tried with favorable results.	Can be employed as adjuvants.

Abbreviations: FDA, US Food and Drug Administration; GP, general practitioner; NICE, National Institute for Health and Care Excellence; OA, osteoarthritis.

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