Risk Factors Associated With Depressive Symptoms in Venezuelan Patients With Rheumatoid Arthritis Nardy N. Rivero-Carrera, MD,* Natali Serra-Bonett, MD,* Soham Al Snih,MD, PhD,Þ Julio V. Duque-Criollo, MD,* and Martı ´n A. Rodrı ´guez, MD* R heumatoid arthritis (RA) is a common chronic inflammatory disease that can lead to significant disability and increased mortality. Depression is common but probably underrecognized in patients with RA, with a prevalence ranging from 13% to 42%, 1Y3 2- to 3-fold higher than that seen in the general population. The increased prevalence of depression in RA has been supported in a meta-analysis. 4 Pain was the single most consistent variable associated with depression in RA patients. 4 As a comorbid condi- tion depression is a predictor of further disability 1 and mortality 1,5 in patients with RA. In addition, persistent depression may ham- per the response to tumor necrosis factor antagonists. 6 Depres- sion in RA patients may vary among ethnicities, as suggested by a recent study showing lower prevalence in Asians. 2 To our knowl- edge, data on the prevalence of depression in RA patients living in a Latin America country are scant. Cadena et al. 7 showed high disease activity as a risk factor for depression and low quality of life (QoL) in Colombian patients with RA. Escalante et al. 8 showed increased depression in Hispanic RA patients living in San Antonio, Tex, in a proportion inversely proportional to the level of acculturation. The main purpose of our study was to de- termine the prevalence of depressive symptoms and predisposing factors in a sample of Venezuelan patients with RA. This was a cross-sectional study in a cohort of Venezuelan patients with RA being followed at Hospital Universitario de Caracas. As most Latin American subjects, Venezuelans are a mestizo population with a variable admixture of Spanish, Native American, and African stock. Patients (N = 113) had a mean age of 51 years, were predominately female (89.4%), and were di- agnosed following the American College of Rheumatology 1987 criteria. 9 Mean disease duration was 6.79 (SD, 7.29) years. Data were acquired using the following instruments in their translated and validated-to-Spanish versions: the Center for Epidemiologic StudiesYDepression Scale (CES-D), 10 the modified Health As- sessment Questionnaire, 11 and the Short-Form 36 Health Survey for assessment of QoL. 12 The CES-D is not a diagnostic instru- ment for depression but measures the occurrence of depressive symptoms in the past week, 13 and it has been shown to be a useful psychometric instrument in patients with arthritis. 14 We estab- lished the presence of depressive symptoms when patients had a CES-D score of 16 or greater as previously reported. 13 The clin- ical activity was measured using the Disease Activity Score for 28 Joints instrument. The socioeconomic status was assessed using the Graffar classification system as adapted to Venezuela by Me ´ndez-Castellanos and Me ´ndez. 15 Statistical analysis was performed by W 2 and Fisher exact tests for categorical variables, t test for continuous variable, and multivariate analysis using logistic regression modeling to examine the factors associated with depression. The study was approved by the bioethics com- mittee of the hospital, and all patients signed an informed consent. Twenty-nine percent of patients (n = 33) fulfilled criteria for depressive symptoms. Being nonmarried or not living as a couple (P = 0.0118), the presence of extra-articular manifesta- tions (P = 0.0004), the presence of comorbidities (P = 0.0094), having at least 1 painful joint at the moment of the physical examination (P = 0.0242), and a high mean erythrocyte sedi- mentation rate (P = 0.0008) were associated with depression. Multivariate analysis modeling using a logistic regression con- firmed the impact of being unmarried, presence of extra-articular manifestations, and presence of comorbidities as independent predictor variables for depression. The multivariate analysis also identified a Disease Activity Score for 28 Joints score of greater than 2.5 and lower scores in the physical and mental components of the Short-Form 36 Health Survey instrument as independent predictor variables. The latter findings are consonant with the report by Cadena et al., 7 showing depression as a predictor of low QoL in Colombian RA patients. Comorbidity was also an independent risk factor for depression in a national study of de- pression in American RA patients. 3 Unlike previously reports, 8 but consistent with the report by Margaretten et al., 2 age was not associated to depression in our study. Unexpectedly, socio- economic level was not a predictor variable for depression in our study. Our findings suggest a high prevalence of depression among Hispanic patients with RA living in a Latin American country. However, our prevalence of 29% is relatively lower as compared with previous studies showing 45% 2 and 42% 8 among Hispanic RA patients living in the United States. Limitations of our study were the relatively small sample, its cross-sectional design that precludes the assertion of newly (RA-related) versus previously acquired depression (nonYRA related), and the 1-center, hospital-based population that limits the generalizability of the results. Patients at a higher risk for depression were single, had a high disease activity, and were sicker, as suggested by the pres- ence of extra-articular manifestations and comorbidities. Because depression seems to be frequent and may significantly add to in- creased disability and mortality in RA patients, 1,5 an early diag- nostic surveillance and opportune therapeutic intervention seem to be warranted. REFERENCES 1. Bruce TO. Comorbid depression in rheumatoid arthritis: pathophysiology and clinical implications. Curr Psychiatry Rep. 2008;10:258Y264. 2. Margaretten M, Yelin E, Imboden J, et al. Predictors of depression in a multiethnic cohort of patients with rheumatoid arthritis. Arthritis Rheum. 2009;61:1586Y1591. 3. Godha D, Shi L, Mavronicolas H. Association between tendency towards depression and severity of rheumatoid arthritis from a national CONCISE REPORT 218 www.jclinrheum.com JCR: Journal of Clinical Rheumatology & Volume 17, Number 4, June 2011 From the *Centro Nacional de Enfermedades Reuma ´ticas, Division of Rheu- matology, Hospital Universitario de Caracas, Venezuela; and †Division of Rehabilitation Sciences, University of Texas Medical Branch, Gal- veston, TX. Correspondence: Martı ´n A. Rodrı ´guez, MD, Centro Nacional de Enfermedades Reuma ´ticas, Apartado 4735, Caracas 1010, Venezuela. E-mail: martinalbertove@yahoo.com. Copyright * 2011 by Lippincott Williams & Wilkins ISSN: 1076-1608/11/1704Y0218 DOI: 10.1097/RHU.0b013e31821c7af3 Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.