|Ahead of print publication
Depression in patients of primary knee osteoarthritis: A cross-sectional study
Pooja Dhaon1, Haseeb Khan2, Rana Ravneesh Singh1, Mukesh Shukla3
1 Department of Medicine, Hind Institute of Medical Sciences, Barabanki, Uttar Pradesh, India
2 Department of Psychiatry, Hind Institute of Medical Sciences, Barabanki, Uttar Pradesh, India
3 Department of Community Medicine, Veer Chandra Singh Garhwali Government Institute of Medical Science and Research, Srinagar (Garhwal), Uttarakhand, India
Department of Medicine, Hind Institute of Medical Sciences, Safedabad, Barabanki, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Aim and Objective: The aim and objective are to find the prevalence of depression and its relationship with functional status in patients with primary knee osteoarthritis (OA).
Materials and Methods: The present study included 100 patients (33 males and 67 females) of primary knee OA fulfilling the American College of Rheumatology criteria. Demographic and diseases variables were recorded for all patients. Functional status was assessed using the Western Ontario and McMaster Universities Index (WOMAC), and depression was assessed using the Hamilton Depression Rating Scale (HAM-D).
Results: Significant depression (HAM-D >13) was present in 19% of patients. Depression was associated with female sex and associated comorbid conditions. There was a significant positive correlation between WOMAC score and HAM-D score in all patients.
Conclusion: Female patients with knee OA have associated depression, which is associated with poor functional status.
Keywords: Hamilton Depression Rating Scale, Knee Osteoarthritis, Western Ontario and McMaster Universities Index
| Introduction|| |
Osteoarthritis (OA) is a chronic degenerative disorder which not only affects the articular cartilage but also results in hypertrophy of bone at the margins, subchondral sclerosis, and changes of the synovial membrane and joint capsule. It is a common rheumatological problem with a prevalence of 22%–39% in India.,
OA knee is the foremost cause of mobility impairment, particularly among females with a prevalence of about 29% in India. OA knee not only impairs the physical ability of patients but also causes long-term psychological impact. There is substantive evidence of the fact that disability experienced by OA patients is not explained by radiographic damage alone. Some complaints of the patient presenting with painful OA may be due to psychological factors such as anxiety and depression., Several cross-sectional studies from various parts of the world which have evaluated the concordance between OA and depression, found about 20%–30% patients of OA to have major depression.,, A longitudinal prospective study from Italy demonstrated that people with knee OA have greater odds of developing depression compared to people without OA. There are limited data from India in this regard. Pazare et al. studied about 40 patients of OA and found 80% of patients showing varying degree of depression. The management of OA is targeted at pain management, and less attention is given to the presence of concomitant depression in the patient. It has been also found that comorbid depression is clearly linked to reduced adherence to pain interventions., Thus, this study was planned with the following aim and objectives: (1) to find the prevalence of depression in patients of primary knee OA in North India and (2) to find the relationship between depression and functional status in the patients of knee OA.
| Materials and Methods|| |
This was a cross-sectional study carried out between January and March 2017 in the Rheumatology Clinic of Department of Medicine of Hind Institute of Medical Sciences, Safedabad, Uttar Pradesh, India. The study was approved by the Institutional Ethical Committee, and written informed consent was obtained from each patient. One hundred patients with primary knee OA were consecutively included in the study. The diagnosis of primary knee OA was made based on the American College of Rheumatology criteria of 1987 for knee OA. It includes knee pain with radiographic changes of osteophyte formation and at least one of the following: patient age >50 years, morning stiffness lasting <30 min, or crepitus on motion.
Patients were excluded from the study if they had known inflammatory joint disease or metabolic bone disease, systemic, neurological, or another musculoskeletal problem leading to chronic pain; had a psychiatric disorder; taken an anxiolytic or antidepressant drug within 6 months; treated with physical therapy or given corticosteroid injections to knees during the past 6 months; or had a history of knee surgery.
Sociodemographic data and clinical history of all participants were recorded, and all patients were physically examined. The pain intensity was assessed using the visual analog scale (VAS - 0–100 cm). The functional status was assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and radiographic severity in patients was assessed by the Kellgren–Lawrence grading system.
Assessment of depression
The assessment of depression was done in all patients by a psychiatrist using the Hamilton Depression Rating Scale (HAM-D). The original HAM-D form lists 21 items, but the scoring is based on the first 17. There are eight items which are scored on a 5-point scale ranging from 0 = not present to 4 = severe. The rest nine items are scored from 0 to 2. The severity was assessed as follows: 0–7 = normal, 8–13 = mild depression, 14–18 = moderate depression, and 19–22 = severe depression, >23 = very severe depression. For this study, the patients with a HAM-D score of >13 were considered to be significantly depressed.
Western Ontario and McMaster Universities Osteoarthritis Index
The WOMAC index is a self-administered questionnaire which assesses the three dimensions, namely pain, disability, and joint stiffness in knee and hip OA using 24 questions. Out of the 24 questions, 5 are related to pain, 2 are related to stiffness, and 17 are related to physical function. The total score of WOMAC–OA ranges from 0 (no disability) to 96 (severest disability). The WOMAC-KGMC index is modified WOMAC as per Indian conditions to evaluate patients.
Radiographic evaluations were done with the use of weight-bearing anteroposterior radiograph of the right knee. Radiographs were evaluated by one of the authors with the use of the Kellgren–Lawrence grading scale. The radiographs were graded as Grade 0 - no features of OA; Grade 1 - small osteophyte of doubtful importance; Grade 2 - definite osteophyte but an unimpaired joint space; Grade 3 - definite osteophyte with moderate diminution of joint space; and Grade 4 - definite osteophyte with substantial joint space reduction and sclerosis of subchondral bone. In the present study as ACR criteria were used to include patients of knee OA, only patients having Kellgren–Lawrence Grade 2 or more on radiographs were included.
Statistical analysis of data was performed using the SPSS 20.0 (SPSS Inc., Chicago, IL, USA) software. Continuous variables were expressed as mean and standard deviation, and categorical variables were expressed in percentages. For the comparison of characteristics between patients with significant depression and without depression, an independent sample t-test was used and to compare the frequencies, the Chi-square test was used. Analyses of correlations between independent variables and the HAM-D scores were conducted using the Spearman's correlation test. The level of statistical significance was 0.05, and the confidence interval was 95%.
| Results|| |
Characteristics of the study sample demographic variables
Of the 100 patients of primary knee OA enrolled in the study, 33 (33%) were male, and 67 (67%) were female. Of 67 females, 58 (86.5%) were postmenopausal. The demographic variables of the patients are shown in [Table 1]. The female patients enrolled had a significantly longer duration of knee pain and a higher body mass index (BMI) compared to males, whereas male patients in the study were significantly more engaged in smoking compared to females [Table 1]. There was no difference in the WOMAC score between male and female patients.
|Table 1: Characteristics of the study sample demographic and disease variables|
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Depression in patients
As per the HAM-D score, 52 patients did not have depression, whereas 48 patients had depression. Twenty-nine patients had mild depression, 14 had moderate depression, 3 had severe depression, and 2 had very severe depression. A comparison was made between demographic and disease variables in patients who had significant depression (HAM-D score >13) and patients who had no depression (HAM-D score ≤13) [Table 2]. In 19 patients with HAM-D score >13, 10 (89.5%) patients were female and 10 (52.6%) patients had associated comorbid conditions. Nineteen patients also had significantly higher total WOMAC and total KGMC scores [Table 2]. The mean HAM-D score was 9.25 ± 7 in females and 3.42 ± 4.5 in males (P = 0.0001).
|Table 2: Comparison of demographic variables in patients with and without depression|
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Correlation between Depression and Western Ontario and McMaster Universities Index (conventional and KGMC)
All the domains of WOMAC (conventional and KGMC) were compared to HAM-D scores in all patients using the Spearman's correlation coefficient (rho). There was a significant positive correlation between HAM-D scores and all domains of WOMAC [Table 3] and [Figure 1]. Apart from WOMAC, knee pain on VAS scales and duration of knee pain were also compared to HAM-D score, and there was a significant positive correlation between duration of pain but not between knee pain on VAS scale [Table 3].
|Figure 1: Linear scatter diagram showing positive correlation between the Hamilton Depression Rating Scale score and Western Ontario and McMaster Universities Index score (conventional and KGMC). (a) Spearman correlation coefficient ρ – 0.35 (P < 0.001). (b) ρ – 0.32 (P < 0.001)|
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| Discussion|| |
This was a cross-sectional study to find the prevalence of depression and its relationship to functional status in the patients of primary knee OA. The results of the study show that OA is more common in female patients and in patients with higher BMI. Female sex and obesity are known risk factors for knee OA. About 19% of patients in the study screened positive for significant depression. The result is similar to other large cross-sectional studies published earlier. Rosemann et al. and Sale et al. published a survey on about 1000 patients of OA and reported the prevalence of depression in about 20% patients., However, an Indian study by Pazare et al. on correlation of self-efficacy and depression in elderly patients of OA found varying degree of depression to be present in about 80% patients. The higher occurrence of depression in the study was because the study sample included patients aged 65–70 years, and they did not grade depression. In the present study, the mean age of patients was 55 years, and only patients with HAM-D score >13 were considered as depressed.
The occurrence and severity of depression were seen more in females. This finding has been reported in the majority of the studies. Biological factors such as menopause apart from the social factors are responsible for the prevalence and increased gravity of depression in females.,
About 50% of patients who had depression had associated comorbidities in the study as compared to 25% of patients who did not have depression. A study by Amonker and Manker who reported risk factors associated with geriatric depression also had similar results. Thus, depression is often accompanied by 2–3 other comorbidities. It may be because of stress caused by the disease along with the social and physical restrictions that increase the financial burden and makes the patient prone to depression.
Higher levels of depression in our patients were associated with increased duration and severity of knee pain, more stiffness, and decreased function than the nondepressed patients. Chronic pain and depression accompany each other and worsen the quality of life of patients. Previous studies looking at the association between pain and depression in patients with knee OA report different findings. Some studies reported a strong correlation between the severity of pain and depressive symptoms,,,, whereas the others did not., In our study, pain scores of WOMAC were higher in knee OA patients with depression, compared to those without, and there was a positive correlation between the two.
Previous studies have demonstrated a strong alliance between depression and disability also. While disability leads to depression, the presence of depression, in turn, can worsen disability in patients of knee OA. Some studies,, have reported a strong correlation between disability and depression, whereas others, have ruled out any such association. In our study, it was determined that the WOMAC scores were higher in knee OA patients with depression compared to those without depression, and a positive correlation was present between the HAM-D score and WOMAC score.
This study has some limitations. The sample size is small for the study. It is a cross-sectional study and thus cannot determine the exact relationship between depression and knee OA. Thus, a prospective longitudinal study is required to determine the nature of the bidirectional relationship between pain and depression in knee OA, although it is not very practically feasible thing to do. There was no control group, and hence, a comparison could not be made. Since the prevalence of OA is very high, this study can be considered as a pilot study.
| Conclusion|| |
Depression is associated with patients of knee OA, and it was found to be strongly associated with more pain and disability in the patients. Thus, the findings of the study imply that all patients with knee OA must be assessed for the presence of depression.
Disclaimer: This is an original study and no part of the study has been copied from elsewhere.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]