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. Author manuscript; available in PMC: 2021 Oct 5.
Published in final edited form as: Rheumatology (Oxford). 2020 Mar 1;59(3):692–693. doi: 10.1093/rheumatology/kez573

Comment on: Comorbidity burden in axial spondyloarthritis: Reply

Sizheng Steven Zhao 1,2,3, Daniel H Solomon 3,4, Nicola J Goodson 1,2
PMCID: PMC8491595  NIHMSID: NIHMS1741872  PMID: 31865393

We thank Dr Vandevelde and colleagues for their interest in our study [1] and their exemplary efforts to promote and improve mental health care [2]. The burden of mental health symptoms in their patient group was high – 35% with at least moderate levels of anxiety and 20% at least moderate depression – and consistent with reports from other studies in the UK and globally [3]. These findings have direct relevance for rheumatology given emerging evidence that comorbid depression impacts assessment of axSpA and other rheumatic diseases; patients with comorbid depression may struggle to meet response criteria to continue biologic therapies, even if activity of the rheumatic disease is adequately controlled.

Mental health is inextricably linked with physical health and not limited to anxiety and depression. Using data from hospitals in Boston, USA (methods and cohort characteristics are published in this journal [4]), we show that axSpA patients with depression were also much more likely to have other mental health and substance misuse disorders (table 1). 1 in 3 axSpA patients with depression also had alcohol dependence, 1 in 6 had drug related disorders and nearly 1 in 5 had history of self-inflicted injuries including suicide. Physical, mental and social care improvements are desperately needed for this vulnerable group.

Table 1.

Prevalence of mental health and substance misuse comorbidities, compared between those with and without depression.

Depression No depression P-value

N 251 1258

Anxiety 134 (53%) 96 (8%) <0.001

Suicide or self-inflicted injury 11 (4%) 1 (<1%) <0.001

Alcohol dependence 83 (33%) 118 (9%) <0.001

Drug related disorders* 42 (17%) 34 (3%) <0.001
Opioid 30 (12%) 19 (2%) <0.001
Cannabis 8 (3%) 7 (1%) 0.001
Cocaine and other stimulants 4 (2%) 3 (<1%) 0.017
Other drugs 18 (7%) 10 (1%) <0.001
*

Drug related disorders include abuse, dependence or intoxication for all drugs listed. Comorbidities were identified using ICD codes.

Care provisions for mental health disorders remain limited in many countries including the US and UK. Only a minority of people with depressive symptoms receive any treatment in the US, with fewer still able to access treatments from specialists or modalities other than anti-depressants [5]. In the UK, only 39% of rheumatology departments had access to clinical psychology in the recent BSR national audit [6]. But public attitudes and tangible investments are improving (albeit slowly). The World Health Organisation set out its comprehensive Mental Health Action Plan in 2013 [7]; this was recently echoed by Public Health England’s ‘Every Mind Matters’ campaign [8]. They acknowledge the essential role of mental health in achieving overall health for all people – a fact that rheumatology is increasingly recognising in both clinical practice and research. We hope the promising results from the Leeds clinical psychology service will inform commissioning and/or future randomised trials to improve mental health provisions.

Acknowledgements

Funding: SZ was supported by awards from the Royal College of Physicians (John Glyn bursary) and Royal Society of Medicine (Kovacs fellowship). DHS was supported by grants from the National Institute of Health (NIH-P30-AR072577 (VERITY) and NIH-K24AR055989).

Footnotes

Disclosures: The authors declare no conflicts of interest.

References

  • 1.Zhao SS, Radner H, Siebert S, Duffield SJ, Thong D, Hughes DM, et al. Comorbidity burden in axial spondyloarthritis: a cluster analysis. Rheumatology. 2019October1;58(10):1746–54. [DOI] [PMC free article] [PubMed] [Google Scholar]
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