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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 13  |  Issue : 3  |  Page : 168-172

Anxiety and depression are common in fibromyalgia patients and correlate with symptom severity score


Department of Medicine, Government Medical College, Jammu, Jammu and Kashmir, India

Date of Web Publication21-Aug-2018

Correspondence Address:
Gurmeet Singh
Department of Medicine, Government Medical College, Jammu - 180 001, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/injr.injr_52_18

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  Abstract 


Background: Anxiety and depression are seen commonly in fibromyalgia patients. We conducted this study to find out the prevalence of anxiety and depression in fibromyalgia and correlate anxiety and depression with symptom severity (SS) scale.
Methods: Eighty fibromyalgia patients and 72 controls were included in this cross-sectional study. Hospital anxiety and depression scale were used to assess anxiety and depression. SS scale was used to assess SS of fibromyalgia. Quality of life (QOL) was measured using the World Health Organization QOL-BREF. The severity of pain, fatigue, and disturbed sleep were measured by 10 centimeter long visual analog scale.
Results: Fibromyalgia patients when compared to controls had higher prevalence of both anxiety (87.5% vs. 23.6%, P < 0.0001) and depression (72.5% vs. 5%, P < 0.0001). Both anxiety and depression had positive correlation with SS scale score, (r = 0.51, P < 0.0001) and (r = 0.42, P < 0.0001), respectively. Patients with anxiety and depression had poor QOL, more pain, and more disturbed sleep as compared to patients without anxiety and depression. Gender, disease duration, fatigue, and tender points had no association with anxiety and depression in fibromyalgia patients. Patients with depression had higher age as compared to patients without depression (P = 0.02).
Conclusion: Anxiety and depression are common in fibromyalgia patients and correlate with the SS scale score. Fibromyalgia patients with anxiety and depression have poor QOL, more pain, and disturbed sleep.

Keywords: Anxiety, depression, fibromyalgia, quality of life, symptom severity scale


How to cite this article:
Singh G, Kaul S. Anxiety and depression are common in fibromyalgia patients and correlate with symptom severity score. Indian J Rheumatol 2018;13:168-72

How to cite this URL:
Singh G, Kaul S. Anxiety and depression are common in fibromyalgia patients and correlate with symptom severity score. Indian J Rheumatol [serial online] 2018 [cited 2019 Oct 15];13:168-72. Available from: http://www.indianjrheumatol.com/text.asp?2018/13/3/168/236152




  Introduction Top


Fibromyalgia is a rheumatological disorder of unknown etiology. It is characterized by chronic widespread body pain, fatigue, disturbed sleep, tender points, and poor quality of life (QOL). It is not uncommonly associated with anxiety and depression which adds to disability and compromises the QOL and performance in these patients. Studies have revealed a high prevalence of depression (89%) and anxiety (41%) in a study.[1] Another review has reported the prevalence of depression to be 20%–80% and that of anxiety to be 13%–63%.[2] A prevalence of 40% of the current major depressive episode was found in another study.[3] The wide variability in the prevalence of anxiety and depression in various studies could be due to differences in the socioeconomic or psychosocial characteristics of the patients enrolled in various studies. To our knowledge, only one study from India has previously looked at anxiety, depression, and stress in fibromyalgia.[4] Symptom severity (SS) scale is a new addition in the assessment of the fibromyalgia severity and has been suggested as a tool in the management of fibromyalgia.[5] In view of paucity of data about psychological morbidity in fibromyalgia from India, we planned our study to find the prevalence of anxiety and depression in fibromyalgia patients and see for correlation of anxiety and depression with SS and QOL.


  Methods Top


Fibromyalgia patients presenting to outpatient clinic in a tertiary care teaching hospital were included in the study. Patients diagnosed according to the 1990 ACR criteria for fibromyalgia; aged 18 years and above were included in this study.[6] All the fibromyalgia patients were assessed by one investigator (GS). Seventy age- and sex-matched controls were also included in the study. Patients with comorbidities such as rheumatoid arthritis, systemic lupus erythematosus, osteoarthritis, chronic kidney disease, and diabetes mellitus were excluded from the study if found after detailed clinical examination. In addition, patients already on antidepressants and anxiolytics were excluded from the study. Age and sex matched controls were recruited from the relatives of the patients and the hospital nursing staff. SS scale was used to assess the severity of fibromyalgia symptoms in the patients over the past 1 week. Briefly, SS scale is sum of three symptoms, i.e., fatigue, waking unrefreshed, and cognitive symptoms plus extent of somatic symptoms in general. The score ranges between 0 and 12 with higher scores reflecting more severe disease.[5] Depression and anxiety were diagnosed using hospital anxiety and depression scale (HADS).[7] HADS has seven questions each for anxiety and depression with maximum possible score of three for each question. A score of 0–7 is considered normal, 8–10 as borderline abnormal, and 11–21 as abnormal. QOL was measured using the World Health Organization QOL-BREF (WHOQOL-BREF).[8] WHOQOL-BREF consists of 26 questions with a possible score of 1–5 for each question. The instrument covers mental, physical, psychological, and environmental domains. The scores for each domain are added separately and transformed to a score of 0–100. Higher scores reflect better QOL. A validated Hindi version of WHOQOL-BREF was used for Hindi speaking patients.[9] The severity of pain and fatigue in the preceding week was assessed using 10 cm visual analog scale (VAS), with 0 representing no pain or fatigue and 10 representing maximum possible pain or fatigue. Disturbance in the sleep was also assessed using 10 cm long VAS with 0 being no disturbance in the sleep and 10 being the most disturbed sleep. Hindi and English version of WHOQOL-BREF and English versions of HADS were used. For patients not conversant with Hindi and English, they were assisted by the investigators.

Statistical analysis

The data were analyzed using OpenStat software. The means of continuous variables were compared by Student's “t-”test, and the categorical variables were compared by Fisher's exact test. Pearson's correlation coefficient was calculated between anxiety and depression with SS scale score. For correlations P < 0.01 was considered statistically significant.

Ethical approval

The study protocol was approved by the Institution Ethics Committee. All the patients and controls gave written informed consent.


  Results Top


Eighty patients with fibromyalgia and 72 controls were included in the study. There was no significant difference in the age or gender distribution between patients and controls [Table 1]. Patients when compared to controls had significantly higher prevalence of both anxiety (87.5% vs. 23.6%, P < 0.0001) and depression (72.5% vs. 5%, P < 0.0001). Patients also had significantly lower scores in all the domains of WHOQOL-BREF when compared to controls with lowest scores seen in physical and psychological domains [Table 1].
Table 1: Demographic features and disease variables in patients and controls

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Comparison of fibromyalgia patients with and without anxiety

When patients of fibromyalgia with anxiety were compared with patients without anxiety, there was no significant difference in age, gender, or disease duration between the two groups [Table 2]. While patients of fibromyalgia with anxiety had significantly low QOL scores in the domains of physical, psychological, and environmental health, there was no significant difference in the social health between the two groups [Table 2]. Furthermore, patients with anxiety had significantly higher VAS scores for pain and disturbed sleep compared to patients without anxiety, while there was no significant difference in the fatigue and tender points between the two groups. Patients with anxiety also had a higher prevalence of depression (81.4% vs. 20%, P < 0.001) and higher SS score (8.4 ± 2.2 vs. 5.8 ± 1.9, P < 0.001) [Table 2].
Table 2: Comparison of fibromyalgia patients with and without anxiety

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Comparison of fibromyalgia patients with and without depression

While patients of fibromyalgia with depression had a significantly higher mean age when compared to patients without depression, there was no difference in the gender distribution or disease duration between the two groups [Table 3]. Patients of fibromyalgia with depression had significantly higher SS scores (8.6 ± 2.2 vs. 6.5 ± 2.1 P < 0.001) as compared to patients without depression. Patients with depression also had lower QOL scores in all the domains of WHOQOL-BREF. Depressed patients had significantly higher VAS for pain and disturbed sleep along with higher prevalence of anxiety. However, there was no significant difference in fatigue and tender points between the two groups [Table 3]. Anxiety had strong positive correlation with the SS scale score (r = 0.51, P < 0.0001) and depression had moderately positive correlation with SS scale score (r = 0.42, P < 0.0001) [Figure 1] and [Figure 2].
Table 3: Comparison of fibromyalgia patients with and without depression

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Figure 1: Correlation between anxiety score and symptom severity scale score

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Figure 2: Correlation between depression score and symptom severity scale score

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  Discussion Top


We found a significantly higher prevalence of anxiety (87.5%) and depression (72.5%) in our patients of fibromyalgia when compared to controls. Such high levels of anxiety and depression has been seen in many other studies with lots of variation in the prevalence of both anxiety (13%–63%) and depression (20%–89%).[1],[2],[3],[10] The reason for such a variation in the prevalence of both anxiety and depression in different studies could be use of different scales for the measurement of anxiety and depression, cultural differences or difference in the familial and social support. Fibromyalgia and depression may have a have common underlying pathophysiology. Both these conditions may have common genetic susceptibility and on exposure to adverse environmental in given patient, may lead to clinical manifestation of both these conditions. The adverse environmental could be in the form of any illness or psychological stress. Once initiated the depression and pain becomes self-perpetuating processes with each aggravating the other.[11] This might make the treatment of the fibromyalgia difficult unless this positive feedback loop is broken. The genetic studies of fibromyalgia and depression have noted alteration in the monoamine genes with polymorphism of these genes making patients predisposed to both fibromyalgia and other comorbidities.[11],[12] Both anxiety and depression had positive correlations with SS scale score. SS scale can be used for measuring the SS in patients of fibromyalgia and covers the severity of symptoms the patient had in last 1 week. A multicentric study from Europe revealed that there was an association of depressive symptoms with the SS and QOL in patients with fibromyalgia and suggested that severity of depression could be a prognostic factor to be considered for future intervention studies.[13] Another study from Spain reported that depressed patients of fibromyalgia had higher SS, poor physical fitness, and poor QOL as compared to nondepressed patients.[14] Patients in our study having anxiety had higher levels of pain as measured by VAS compared to patients without anxiety. Similarly, patients with depression also had more pain as compared to patients without depression. A study has reported that there exists a dose-response relation between pain on the one hand and anxiety and depression on the other hand. The patients having pain in one body region had less prevalence of generalized anxiety disorder (GAD) and major depressive disorder (MDD) while patients having pain in two or more regions had increase in both GAD and MDD prevalence.[15] Patients of fibromyalgia have pain as their predominant and distressing symptom. The presence of depression and anxiety in chronic painful conditions is associated with more severe pain, more disability, and poor QOL.[16] Patients of fibromyalgia with anxiety had significantly low scores of QOL in the physical, psychological, and environmental domains. Patients with depression had low scores in all the four domains QOL when compared to patients without depression. Patients of fibromyalgia have poor QOL with pain, anxiety, and depression contributing to poor QOL.[17] The QOL in fibromyalgia patient was found to be worse than general population and patients of rheumatoid arthritis.[18] Fibromyalgia patients had greater impairment of QOL when compared to systemic lupus erythematosus patients in a study from Canada.[19] The QOL in fibromyalgia appears to be reflection of underlying pain, anxiety, and depression with all these three factors, i.e., pain, anxiety, and depression having an interplay with each other forming a loop and aggravating each other. Does the treatment of depression and anxiety improve the pain and QOL in patients of fibromyalgia? A recent review suggests that none of the currently available drugs are sufficient to treat all the symptoms of fibromyalgia, i.e., pain, fatigue, sleep disturbance, anxiety, and depression. There appears to be a need for trials of drugs in combination to cover the various manifestations of the fibromyalgia.[20] A study from Turkey reported significantly higher anxiety and depression scores in fibromyalgia patients and suggested that these patients be provided psychological and social support.[21] Another recent study reported depression in 88% and anxiety in 41% of fibromyalgia patients and suggested that patients with severe fibromyalgia disease activity, high load of symptoms should be evaluated for depressive symptoms.[1] Another study reported current major depressive episode in 40.5% of the patients suggesting to actively look for and treat depression in fibromyalgia patients.[3] A study from India revealed that depression, anxiety, and stress were associated with fibromyalgia and magnitude of negative effects correlate with fibromyalgia impact questionnaire.[4]

We used the ACR 1990 criteria for the classification of fibromyalgia instead of 2010 ACR preliminary diagnostic criteria for fibromyalgia, as the 2010 ACR criteria are projected as “diagnostic criteria” as opposed to the 1990 ACR criteria which are “classification criteria.”[5],[6] The authors of the 2010 diagnostic criteria have themselves mentioned in the paper that the diagnostic criteria suggested are not meant to replace the ACR classification criteria.[5] The authors have also suggested that SS scale can be used to document SS after the diagnosis of fibromyalgia by either ACR classification or diagnostic criteria.[5]

Our study is limited by the fact that it was a cross-sectional observational study conducted in a teaching referral tertiary care hospital. We may have not succeeded in capturing the whole spectrum of the fibromyalgia patients which a physician is likely to see in community practice. We might have received fibromyalgia patients with higher disease activity or symptoms not being controlled in the primary care. In addition, there was unequal distribution of patients in anxiety and no anxiety, depression, and no depression groups which may have been responsible for some of the results not reaching significance.

We found out that our patients of fibromyalgia had high prevalence of both anxiety and depression as compared to control population and the SS had strong correlation with both anxiety and depression. Furthermore, fibromyalgia patients had poor QOL which was associated with anxiety and depression. Thus, all the patients of fibromyalgia presenting to the physicians need to be screened for underlying anxiety and depression.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Gota CE, Kaouk S, Wilke WS. The impact of depressive and bipolar symptoms on socioeconomic status, core symptoms, function and severity of fibromyalgia. Int J Rheum Dis 2017;20:326-39.  Back to cited text no. 1
    
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Santos Dde M, Lage LV, Jabur EK, Kaziyama HH, Iosifescu DV, Lucia MC, et al. The association of major depressive episode and personality traits in patients with fibromyalgia. Clinics (Sao Paulo) 2011;66:973-8.  Back to cited text no. 3
    
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Alok R, Das SK, Agarwal GG, Salwahan L, Srivastava R. Relationship of severity of depression, anxiety and stress with severity of fibromyalgia. Clin Exp Rheumatol 2011;29:S70-2.  Back to cited text no. 4
    
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Wolfe F, Clauw DJ, Fitzcharles MA, Goldenberg DL, Katz RS, Mease P, et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res (Hoboken) 2010;62:600-10.  Back to cited text no. 5
    
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Wolfe F, Smythe HA, Yunus MB, Bennett RM, Bombardier C, Goldenberg DL, et al. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Report of the multicenter criteria committee. Arthritis Rheum 1990;33:160-72.  Back to cited text no. 6
    
7.
Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983;67:361-70.  Back to cited text no. 7
    
8.
The World Health Organization quality of life assessment (WHOQOL): Position paper from the world health organization. Soc Sci Med 1995;41:1403-9.  Back to cited text no. 8
    
9.
Saxena S, Chandiramani K, Bhargava R. WHOQOL-Hindi: A questionnaire for assessing quality of life in health care settings in India. World Health Organization Quality of Life. Natl Med J India 1998;11:160-5.  Back to cited text no. 9
    
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dos Santos EB, Quintans Junior LJ, Fraga BP, Macieira JC, Bonjardim LR. An evaluation of anxiety and depression symptoms in fibromyalgia. Rev Esc Enferm USP 2012;46:590-6.  Back to cited text no. 10
    
11.
Maletic V, Raison CL. Neurobiology of depression, fibromyalgia and neuropathic pain. Front Biosci (Landmark Ed) 2009;14:5291-338.  Back to cited text no. 11
    
12.
Buskila D, Sarzi-Puttini P, Ablin JN. The genetics of fibromyalgia syndrome. Pharmacogenomics 2007;8:67-74.  Back to cited text no. 12
    
13.
Soriano-Maldonado A, Amris K, Ortega FB, Segura-Jiménez V, Estévez-López F, Álvarez-Gallardo IC, et al. Association of different levels of depressive symptoms with symptomatology, overall disease severity, and quality of life in women with fibromyalgia. Qual Life Res 2015;24:2951-7.  Back to cited text no. 13
    
14.
Del Pozo-Cruz J, Alfonso-Rosa RM, Castillo-Cuerva A, Sañudo B, Nolan P, Del Pozo-Cruz B, et al. Depression symptoms are associated with key health outcomes in women with fibromyalgia: A cross-sectional study. Int J Rheum Dis 2017;20:798-808.  Back to cited text no. 14
    
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Manchikanti L, Pampati V, Beyer C, Damron K. Do number of pain conditions influence emotional status? Pain Physician 2002;5:200-5.  Back to cited text no. 15
    
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Bair MJ, Wu J, Damush TM, Sutherland JM, Kroenke K. Association of depression and anxiety alone and in combination with chronic musculoskeletal pain in primary care patients. Psychosom Med 2008;70:890-7.  Back to cited text no. 16
    
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Campos RP, Vázquez Rodríguez MI. Health-related quality of life in women with fibromyalgia: Clinical and psychological factors associated. Clin Rheumatol 2012;31:347-55.  Back to cited text no. 17
    
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Tander B, Cengiz K, Alayli G, Ilhanli I, Canbaz S, Canturk F, et al. A comparative evaluation of health related quality of life and depression in patients with fibromyalgia syndrome and rheumatoid arthritis. Rheumatol Int 2008;28:859-65.  Back to cited text no. 18
    
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Da Costa D, Dobkin PL, Fitzcharles MA, Fortin PR, Beaulieu A, Zummer M, et al. Determinants of health status in fibromyalgia: A comparative study with systemic lupus erythematosus. J Rheumatol 2000;27:365-72.  Back to cited text no. 19
    
20.
Calandre EP, Rico-Villademoros F, Slim M. An update on pharmacotherapy for the treatment of fibromyalgia. Expert Opin Pharmacother 2015;16:1347-68.  Back to cited text no. 20
    
21.
Uçar M, Sarp Ü, Karaaslan Ö, Gül AI, Tanik N, Arik HO, et al. Health anxiety and depression in patients with fibromyalgia syndrome. J Int Med Res 2015;43:679-85.  Back to cited text no. 21
    


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3]



 

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