Anxiety and Depression Among US Adults With Arthritis: Prevalence and Correlates

 
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Arthritis Care & Research
Vol. 64, No. 7, July 2012, pp 968 –976
DOI 10.1002/acr.21685
© 2012, American College of Rheumatology
 ORIGINAL ARTICLE

Anxiety and Depression Among US Adults With
Arthritis: Prevalence and Correlates
LOUISE B. MURPHY,1 JEFFREY J. SACKS,2 TERESA J. BRADY,1 JENNIFER M. HOOTMAN,1                                AND
DANIEL P. CHAPMAN1

Objective. There has been limited characterization of the burden of anxiety and depression, especially the former,
among US adults with arthritis in the general population. The study objective was to estimate the prevalence and
correlates of anxiety and depression among US adults with doctor-diagnosed arthritis.
Methods. The study sample comprised US adults ages >45 years with doctor-diagnosed arthritis (n ⴝ 1,793) from the
Arthritis Conditions Health Effects Survey (a cross-sectional, population-based, random-digit– dialed telephone interview
survey). Anxiety and depression were measured using separate and validated subscales of the Arthritis Impact Mea-
surement Scales. Prevalence was estimated for the sample overall and stratified by subgroups. Associations between
correlates and each condition were estimated with prevalence ratios and 95% confidence intervals using logistic
regression models.
Results. Anxiety was more common than depression (31% and 18%, respectively); overall, one-third of respondents
reported at least 1 of the 2 conditions. Most (84%) of those with depression also had anxiety. Multivariable logistic
regression modeling failed to identify a distinct profile of characteristics of those with anxiety and/or depression. Only
half of the respondents with anxiety and/or depression had sought help for their mental health condition in the past year.
Conclusion. Despite the clinical focus on depression among people with arthritis, anxiety was almost twice as common
as depression. Given their high prevalence, their profound impact on quality of life, and the range of effective treatments
available, we encourage health care providers to screen all people with arthritis for both anxiety and depression.

INTRODUCTION                                                     Anxiety and depression are generally more common
                                                                 among people with arthritis than in the general population
Depression, a well-documented comorbidity among peo-
                                                                 (8,9), and interplay independently and synergistically
ple with chronic diseases, including arthritis (1– 6), can
                                                                 with clinical outcomes such as pain and disability (10,11).
exacerbate functional disabilities (1), affect adherence to
                                                                    Many studies examining the occurrence of these condi-
treatment (2), and be a barrier to self-care and self-man-
                                                                 tions among people with arthritis have studied depression
agement behaviors (3,4). Despite its high prevalence in the
general population and equal or stronger incapacitating          only, have studied people with one type of arthritis (e.g.,
effects on physical function (5), anxiety is often underrec-     rheumatoid arthritis), or were clinic-based, not popula-
ognized and undertreated (6). Until recently, anxiety has        tion-based, samples (4,12–17). International population-
been regarded largely as a comorbidity of depression, but        based studies identifying major depression using the
its independent effects, including its role as a potential       World Health Organization Composite International Diag-
risk factor for depression, are increasingly recognized (7).     nostic Interview (WHO-CIDI) indicate prevalences ranging
                                                                 from 2.2% (Japan) to 19% (Ukraine; in the US, age ⱖ18
                                                                 years ⫽ 7–9% and age 54 – 65 years ⫽ 11%) (9,18,19). The
    The findings and conclusions in this report are those of      prevalence of anxiety disorders among people with arthri-
  the authors and do not necessarily represent the official
  position of the Centers for Disease Control and Prevention.
                                                                 tis also varies internationally; a survey of 18 countries in
    1
      Louise B. Murphy, PhD, Teresa J. Brady, PhD, Jennifer M.   the early 2000s found that people with arthritis were con-
  Hootman, PhD, Daniel P. Chapman, PhD: CDC, Atlanta,            sistently more likely than those without arthritis to have
  Georgia; 2Jeffrey J. Sacks, MD, MPH: Sue Binder Consulting,    anxiety disorders. Additionally, across the countries sur-
  Inc., Atlanta, Georgia.
    Address correspondence to Louise B. Murphy, PhD, Ar-
                                                                 veyed, US adults with arthritis had the first or second
  thritis Program, Division of Population Health, CDC, 4770      highest prevalence of each of the 4 specific anxiety disor-
  Buford Highway NE, Mailstop K-51, Atlanta, GA 30341.           ders examined (generalized anxiety disorder [6%], social
  E-mail: lmurphy1@cdc.gov.                                      phobia [8%], agoraphobia/panic disorder [3%], and post-
    Submitted for publication October 11, 2011; accepted in
  revised form March 20, 2012.                                   traumatic stress disorder [5%] [18]). The 2001–2003 US
                                                                 National Comorbidity Study Replication found that each

968
Anxiety and Depression in US Adults With Arthritis                                                                    969

                                                              representation and reduce sample variation, the numbers
   Significance & Innovations                                  were then sorted by census division and metropolitan
   ●   One-third of US adults with arthritis ages ⱖ45         status (i.e., urban versus rural counties) in each stratum.
       years reported having at least one of anxiety          Numbers were then selected with equal probability within
       and/or depression.                                     each of the 7 strata, with oversampling in those strata with
   ●   Although there is considerable clinical and re-        high percentages of Hispanics and non-Hispanic blacks
       search focus on depression among people with           (21).
       arthritis, anxiety was more common than depres-          To maximize response rates, letters were mailed to the
       sion (31% and 18%, respectively).                      addresses associated with potential residential phone
                                                              numbers at least 2 weeks prior to the first call. Trained
   ●   A distinct profile of those with anxiety and/or
                                                              interviewers called each number to identify 1) residential
       depression did not emerge in the multivariable
                                                              numbers and 2) household members who were ages ⱖ45
       models, indicating that all people with arthritis
                                                              years and had doctor-diagnosed arthritis or chronic joint
       should be screened for anxiety and depression.
                                                              symptoms. We restricted our analysis to respondents with
   ●   Only half of the respondents with anxiety and/or       doctor-diagnosed arthritis (n ⫽ 1,793), who were identi-
       depression had sought help for their mental health     fied with a response of “yes” to: “Have you ever been told
       condition in the past year, suggesting there is an     by a doctor or other health professional that you have some
       unmet need for treatment of mental health condi-       form of arthritis, rheumatoid arthritis, gout, lupus, or fi-
       tions among people with arthritis.                     bromyalgia?” Given this method of case ascertainment, in
                                                              this article, arthritis refers to people with arthritis and
                                                              other rheumatic conditions. Interviews were conducted in
                                                              English (or Spanish as needed) from June 2005 to April
                                                              2006. All residents in each household who met the inclu-
of the 6 anxiety disorders measured was more common           sion criteria were eligible. Participants were compensated
among people with arthritis (the prevalence among people      with a 100-minute prepaid long-distance phone card or a
with arthritis ranged from 1% for agoraphobia to 6% for       $5 donation to the Arthritis Foundation. Among eligible
social phobia; 10% reported a specific phobia) (9). All        households, Council on American Survey Research Orga-
anxiety disorders were measured using the WHO-CIDI. A         nizations response and completion rates were 51% and
study of Australians ages ⱖ18 years with arthritis indi-      86%, respectively (i.e., those with at least 1 age-eligible
cated that one-quarter had experienced an anxiety disor-      resident). Response and completion rates for eligible peo-
der in the past 12 months (19). A comparable estimate for     ple in the household were 31% and 75% for the first
the US is lacking.                                            household participant identified as eligible and 16% and
   To better characterize the burden of anxiety and depres-
                                                              80% among other eligible respondents in the same house-
sion among US adults with arthritis, we estimated the
                                                              hold, respectively (21). The ACHES protocol was ap-
prevalence of each in a national sample of adults ages ⱖ45
                                                              proved by the CDC Institutional Review Board.
years with self-reported doctor-diagnosed arthritis. As de-
                                                                Using a standardized questionnaire, interviewers col-
pression and anxiety can be highly responsive to clinical
                                                              lected information on sociodemographic characteristics
treatment (20), better recognition and detection of these
                                                              and medical and psychosocial aspects of arthritis, includ-
conditions is a necessary first step to reducing the burden
                                                              ing physical functioning and limitations, work effects,
of these mental health conditions among people with ar-
                                                              knowledge and attitudes about arthritis, self-management
thritis. Therefore, we also examined the correlates of each
                                                              and self-care behaviors, and mental health. ACHES meth-
condition to identify the sociodemographic, clinical, and
                                                              ods are described in detail elsewhere (21–23).
other characteristics that can help health care providers
(HCPs) identify those who are likely to have anxiety
and/or depression.                                              Study outcomes. Anxiety and depression were assessed
                                                              using the Arthritis Impact Measurement Scales (AIMS).
                                                              Originally developed for use in longitudinal trials of rheu-
MATERIALS AND METHODS                                         matoid arthritis to detect changes over time (24), AIMS
                                                              was subsequently validated for use in studies of other
   Study sample. We analyzed data from the Arthritis Con-     arthritis types (25).
ditions Health Effects Survey (ACHES), a cross-sectional,       The AIMS anxiety and depression module comprises 12
random-digit– dialed telephone survey. ACHES, con-            questions (6 for anxiety and 6 for depression) and mea-
ducted by the Centers for Disease Control and Prevention      sures the frequency of symptoms (rating of 0 – 6; see Sup-
(CDC), was designed to be representative of the civilian      plementary Appendix A, available in the online version of
noninstitutionalized US population of adults ages ⱖ45         this article at http://onlinelibrary.wiley.com/journal/
years with arthritis and/or chronic joint symptoms (21).      10.1002/(ISSN)1529-0131a) in the past month. Following a
   Telephone numbers were selected from a proprietary list    validation study that reported that an AIMS depression
linking phone numbers to US Census blocks. These num-         subscale score of ⱖ4 was comparable to the Center for
bers were first partitioned into 7 strata based on census-     Epidemiologic Studies Depression Scale (CES-D) score
estimated percentages of Hispanics and non-Hispanic           cutoff for probable depression (16), multiple subsequent
blacks associated with each block. To ensure geographic       studies using AIMS to quantify the occurrence of anxiety
970                                                                                                                  Murphy et al

and depression among people with arthritis have used ⱖ4            the participants rated their confidence on 3 aspects of
as the threshold for both conditions (4,14,16). Consistent         self-management: belief that self-management education
with this, for each condition, we calculated the average           (SME) courses would help to manage arthritis or joint
subscale value and defined the presence of the condition            symptoms, ability to manage arthritis or joint symptoms,
as a mean value of ⱖ4.                                             and ability to engage in moderate physical activity at least
  Following the series of AIMS questions, respondents              3 times/week.
reported help-seeking behaviors (“During the past 12
months, have you sought help for stress, depression, or               Statistical analysis. We examined the prevalence of
problems with emotions?”) and from whom this help was              anxiety and depression (to estimate the public health bur-
sought (i.e., “Did you seek help from any of the following:        den) and then stratified by independent variables to iden-
Family or friends? A self-help group or support group? A           tify potential correlates for logistic regression models. For
priest, minister, rabbi, or other religious counselor? A ther-     each outcome, we estimated the associations with inde-
apist or counselor? A physician?”).                                pendent variables with unadjusted and multivariable ad-
                                                                   justed prevalence ratios (PRs) and 95% confidence inter-
   Independent variables. We examined variables repre-             vals (95% CIs) (30). Last, we determined the proportion of
senting 3 domains of interest: 1) sociodemographic char-           respondents with anxiety and/or depression who had
acteristics (i.e., age, sex, race/ethnicity, highest educa-        sought help for mental health conditions in the past 12
tional attainment, and current employment status) to               months and estimated the likelihood, with PRs and 95%
develop a profile of affected individuals, 2) arthritis symp-       CIs, of help seeking for anxiety, depression, and both con-
toms and physical function that can increase the likeli-           ditions.
hood of arthritis and depression, and 3) potentially mod-             Sampling weights, based on the distribution of US
ifiable health and self-management behaviors that are               adults ages ⱖ45 years with arthritis in the 2003–2005
associated with arthritis symptoms and mental and phys-            National Health Interview Survey (NHIS) (21), were ap-
ical function.                                                     plied in all analyses to infer estimates to the national
   Respondents reported the severity of each of 3 symp-            population of civilian noninstitutionalized adults ages
toms (i.e., joint pain or aching, stiffness, and fatigue) in the   ⱖ45 years with doctor-diagnosed arthritis. Statistical sig-
past 7 days using a 0 –10 scale (where 0 ⫽ no symptoms             nificance was defined using 2 criteria: nonoverlapping
                                                                   95% CIs and a Wald’s test (test of statistical significance of
and 10 ⫽ most severe) and the number of days that they
                                                                   variable overall in the model) P value of less than or equal
had experienced joint pain or aching in the past 7 days.
                                                                   to 0.05. Analyses conducted in SAS, version 9.1 and
   The survey included the Short Form 36 (SF-36) physical
                                                                   SUDAAN, version 10 (Research Triangle Institute) ac-
functioning subscales and a series of questions about the
                                                                   counted for the complex survey design.
degree to which arthritis interfered with routine activities
(e.g., spending time with family and friends, errands/shop-
ping, and household chores) (21,26). The SF-36 and inter-
ference variables were measured using Likert-style re-             RESULTS
sponse scales (a lot, a little, or not at all), which we
dichotomized (a lot versus a little/not at all). We analyzed       Among adults with arthritis, 30.5% (11.5 million) reported
individual items rather than the SF-36 score, since these          anxiety, 17.5% (6.6 million) reported depression, and
individual items correspond to questions clinicians might          14.7% (5.5 million) reported both. Most respondents with
use when asking about patients’ physical function. Initial         depression also had anxiety (84%), whereas half of those
analysis showed moderate to strong correlations among              with anxiety also had depression (49.5%) (Figure 1).
the function (r ⫽ 0.4 – 0.8) and interference variables (r ⫽
0.5– 0.8). Therefore, we restricted analyses to 3 function
variables (difficulty in walking several hundred feet, wash-
ing or bathing, and bending, kneeling, or stooping) and 1
interference variable (difficulty with errands and shop-
ping). These physical function and interference variables
have been associated with loss of independence among
                                                                                                                     Depression Only
people with arthritis (27) and loss of independence has                Anxiety Only     Anxiety & Depression            1.0 million
been correlated with depression in at least one previous
                                                                         6.0 million         5.5 million
study (4).
   Physical activity was measured with 6 validated ques-
tions on frequency and duration of participation in leisure-
time activities of moderate or vigorous intensity (28). Cat-
egories were based on the total number of minutes of
physical activity each week, where 1 minute of vigorous
exercise was equivalent to 2 minutes of moderate activity:
recommended (ⱖ150 minutes), insufficient (10 –149 min-              Figure 1. Number of US adults ages ⱖ45 years with arthritis who
utes), or inactive (⬍10 minutes) (29). Using a 0 –10 scale         have anxiety and/or depression, 2005–2006, Arthritis Conditions
(where 0 ⫽ no confidence and 10 ⫽ highest confidence),               Health Effects Survey.
Anxiety and Depression in US Adults With Arthritis                                                                         971

  Prevalence and correlates of anxiety. At least half of            Among those with anxiety, depression, or both, more
the people in the following 6 subgroups reported anxi-           than half (55%) of all respondents had not sought help in
ety: unemployed, unable to work, or disabled (62%);              the past year. This was only slightly improved when lim-
respondents who reported “a lot” of difficulty with bath-         ited to those who were currently seeing a doctor or HCP for
ing or dressing (63%), “a lot” of interference with er-          their arthritis or joint symptoms (46%) (Table 3). Across
rands or household chores in the past 7 days (51%), or           all sociodemographic groups, 36 – 66% of respondents had
that their arthritis or joint symptoms affected whether          not sought help (Table 3), and among those who were
they worked for pay (52%); severe fatigue in the past 7          currently seeing a doctor or HCP for their arthritis or joint
days (50.2%); and no confidence in their ability to engage        symptoms, the range was 21– 61%. Similar patterns were
in moderate physical activity at least 3 times/week (56%)        observed among those with each of anxiety, depression,
(Table 1).                                                       and both conditions (data not shown).
  Almost all of the independent variables were signifi-
cantly associated with anxiety in unadjusted models (Ta-         DISCUSSION
ble 1). In the multivariable model, anxiety was signifi-
cantly higher among respondents who were ages 45– 64             One-third of respondents with arthritis had anxiety, de-
years (PR 1.7; referent: age ⱖ65 years), reported severe         pression, or both. Anxiety was almost twice as common as
joint pain in the past week (PR 1.9; referent: no pain), and     depression (31% and 18%, respectively), and virtually all
reported good (PR 1.4) or poor/fair self-rated health (PR        respondents with depression also had anxiety. Approxi-
1.6; referent for self-rated health: excellent/very good) (Ta-   mately half of the respondents with anxiety and/or depres-
ble 2). Anxiety was also higher among respondents who            sion had sought help for their mental health condition in
had no or moderate confidence in their ability to engage in       the past year. Most of the statistically significant associa-
moderate physical activity at least 3 times/week (PRs 1.5        tions observed in the multivariable analysis were moder-
and 1.3, respectively; referent: high confidence) (Table 2).      ately strong; nevertheless, a distinct profile of characteris-
After multivariable adjustment, respondents who were             tics of those with anxiety and depression did not emerge.
overweight or obese were 20% less probable to report                We found that anxiety was more common than depres-
anxiety (PR 0.8) (Table 2).                                      sion in this population-based sample of people with ar-
                                                                 thritis, a pattern that has been observed in clinic-based
  Prevalence and correlates of depression. Depression            samples (4,12–14,16). Anxiety can elicit independent and
prevalence was highest among those who reported “a lot”          at least equally debilitating effects as depression (5,31,32).
of difficulties bathing or dressing themselves (48%) (Table       Despite this and the high prevalence of anxiety in previous
1). At least one-third of people in the following subgroups      studies, few influential rheumatology texts (33) mention anx-
reported depression: unemployed, unable to work, or dis-         iety, suggesting that the magnitude and impact of this prob-
abled (45%); Hispanics (37%); severe fatigue in the past 7       lem among people with arthritis are underrecognized (31).
days (36.3%); and respondents whose arthritis or joint              The US Preventive Services Task Force recommends
symptoms affected whether they worked for pay (33%),             screening of all adults for depression when systems are in
who had “a lot” of interference with errands or household        place to ensure accurate diagnosis, effective treatment, and
chores in the past 7 days (36%), who had no or a low level       appropriate followup; there is insufficient evidence sup-
of confidence in their ability to manage their arthritis or       porting universal screening when effective treatment and
joint symptoms (34% and 45%, respectively), or who had           followup are unavailable (34). HCPs do not appear to rou-
no confidence in their ability to engage in moderate phys-        tinely and systematically screen for anxiety or depression
ical activity at least 3 times/week (42%).                       (35). We believe that screening of all people with arthritis
  Several correlates of depression were observed in unad-        for anxiety and depression is indicated when the same
justed models (Table 1). In multivariable models, depres-        conditions (e.g., effective treatment) are met. Although
sion was significantly more common among those who                there are differences in the treatment for depression and
were ages 45– 64 years (PR 1.6; referent: age ⱖ65 years),        anxiety, pharmacotherapy and cognitive– behavioral ther-
reported low confidence in their ability to manage their          apy are considered effective methods of treating depres-
arthritis or joint symptoms (PR 2.3), and had only moder-        sion and many forms of anxiety (20). Furthermore, the
ate confidence in their ability to engage in moderate phys-       appropriate treatment of depression among people with
ical activity at least 3 times/week (PR 1.5) (Table 2).          arthritis can lead to clinically significant reductions in
                                                                 pain, improved functional outcomes, and continued com-
   Prevalence of help seeking for anxiety and depression         pliance with antidepressant use for at least 1 year follow-
in the past year. Help seeking was highest among people          ing treatment (36). For this reason, treating existent mental
with both conditions (57.1%) and lowest among those              health conditions should be regarded as a fundamental
with anxiety only (45.1%; people with depression ⫽               part of managing arthritis symptoms. Both anxiety and
51.3%) (data not shown). Respondents were most likely to         depression were common among respondents who were
have sought help from their doctor (82– 83%), followed by        currently being seen by an HCP for their arthritis and joint
family and friends (45– 46%); therapist/counselor (43–           symptoms, but approximately half of those reporting anx-
46%); priest, minister, rabbi, or other religious counselor      iety or depression had not sought help for their mental
(15–16%); and self-help or support groups (11–13%; sum           health conditions in the past year. HCP visits for manage-
exceeds 100% because respondents sought help from mul-           ment of arthritis symptoms may be an opportunity to
tiple sources).                                                  screen for and treat anxiety and depression.
972                                                                                                                      Murphy et al

      Table 1. Associations of sociodemographic, disease, and physical function and health behaviors, self-management, and self-
                            efficacy with each of anxiety and depression: prevalence and unadjusted PRs*

                                                                         Anxiety                            Depression

                                                               Prevalence       Unadjusted         Prevalence       Unadjusted
                                                                (95% CI)        PR (95% CI)         (95% CI)        PR (95% CI)

  Sociodemographic
    Age, years
      45–64                                                  39.3 (35.7–42.9)    1.9 (1.6–2.3)   21.8 (18.9–24.8)   1.7 (1.4–2.2)
      ⱖ65                                                    20.6 (17.5–23.6)         1.0        12.6 (10.0–15.2)         1.0
    Sex
      Men                                                    26.2 (22.1–30.4)         1.0        15.0 (11.7–18.2)         1.0
      Women                                                  33.5 (30.6–36.3)    1.3 (1.1–1.5)   19.1 (16.7–21.4)   1.3 (1.0–1.6)
    Race/ethnicity
      Non-Hispanic white                                     28.8 (26.1–31.5)         1.0        22.5 (16.2–28.8)         1.0
      Hispanic                                               45.6 (33.9–57.3)    1.6 (1.2–2.1)   37.3 (25.9–48.8)   2.4 (1.7–3.4)
      Non-Hispanic black                                     32.7 (25.7–39.8)    1.1 (0.9–1.4)   16.8 (7.4–26.1)    1.5 (1.1–2.0)
      Non-Hispanic other†                                    40.1 (27.1–53.1)    1.4 (1.0–2.0)   15.4 (13.3–17.5)   1.1 (0.6–1.9)
    Education
      Less than high school                                  44.1 (37.6–50.5)    2.3 (1.8–2.9)   31.5 (25.4–37.6)   3.8 (2.6–5.6)
      High school or some college                            32.2 (29.0–35.4)    1.7 (1.3–2.1)   17.9 (15.3–20.5)   2.2 (1.5–3.1)
      Completed college or greater                           19.3 (15.4–23.1)         1.0         8.1 (5.4–10.8)          1.0
    Employment status
      Employed                                               28.4 (24.1–32.7)         1.0        12.5 (9.4–15.5)          1.0
      Unemployed, unable to work, or disabled‡               62.4 (56.6–68.1)    2.2 (1.8–2.6)   44.8 (38.6–51.0)   3.5 (2.7–4.6)
      Retired                                                31.1 (23.7–38.5)    0.7 (0.6–0.9)   11.1 (8.7–13.6)    0.9 (0.6–1.2)
      Other§                                                 19.6 (16.5–22.6)    1.1 (0.8–1.5)   14.1 (8.7–19.6)    1.1 (0.7–1.7)
  Disease and physical function
    No. of days in the past week with pain, aching, or
         stiffness
      None                                                   11.5 (7.2–17.8)          1.0         4.5 (2.4–8.3)           1.0
      1 or 2                                                 19.8 (14.7–26.2)    1.7 (1.0–3.0)    9.2 (5.9–14.0)    2.1 (1.0–4.4)
      3 or 4                                                 30.7 (24.3–37.9)    2.7 (1.6–4.4)   12.9 (8.7–18.9)    2.9 (1.4–6.0)
      ⱖ5                                                     35.8 (32.7–38.9)    3.1 (2.0–4.9)   21.8 (19.3–24.5)   4.9 (2.6–9.2)
    Severity of joint pain in the past 7 days
      None (0)                                                9.0 (5.2–15.1)          1.0         5.4 (2.6–11.0)          1.0
      Low (1–3)                                              19.7 (15.6–24.7)    2.2 (1.2–4.0)    7.6 (5.1–11.1)    1.4 (0.6–3.2)
      Moderate (4–6)                                         28.8 (25.3–32.5)    3.2 (1.9–5.6)   15.6 (13.0–18.7)   2.9 (1.4–6.1)
      Severe (7–10)                                          46.9 (42.2–51.7)    5.2 (3.0–9.0)   31.1 (26.9–35.7)   5.7 (2.7–12.0)
    Severity of joint stiffness in the past 7 days
      None (0)                                               14.3 (9.5–19.0)          1.0         6.9 (3.6–10.1)          1.0
      Low (1–3)                                              20.1 (15.3–24.8)    1.4 (0.9–2.1)    9.2 (5.6–12.8)    1.3 (0.7–2.5)
      Moderate (4–6)                                         29.7 (25.8–33.7)    2.1 (1.5–3.0)   16.6 (13.4–19.7)   2.4 (1.4–4.1)
      Severe (7–10)                                          48.2 (43.4–52.9)    3.4 (2.4–4.8)   30.4 (26.1–34.7)   4.4 (2.7–7.3)
    Severity of fatigue in the past 7 days
      None (0)                                               12.4 (8.7–16.0)          1.0         6.0 (3.3–8.7)           1.0
      Low (1–3)                                              18.9 (14.1–23.7)    1.5 (1.0–2.3)    7.9 (4.6–11.2)    1.3 (0.7–2.4)
      Moderate (4–6)                                         34.0 (29.5–38.6)    2.8 (2.0–3.8)   14.9 (11.6–18.2)   2.5 (1.5–4.1)
      Severe (7–10)                                          50.2 (45.5–55.0)    4.1 (3.0–5.6)   36.3 (31.8–40.9)   6.0 (3.8–9.6)
    Self-reported general health status in the past 7 days
      Very good/excellent                                    16.5 (13.1–19.9)         1.0         7.1 (4.8–9.4)           1.0
      Good                                                   27.0 (22.9–31.0)    1.6 (1.3–2.1)   13.8 (10.7–16.9)   2.0 (1.3–2.9)
      Poor/fair                                              48.3 (44.0–52.7)    2.9 (2.3–3.6)   31.0 (27.0–35.1)   4.4 (3.1–6.2)
    Limited in any way because of arthritis or joint
         symptoms
      No                                                     20.5 (17.5–23.6)         1.0        10.4 (8.2–12.6)          1.0
      Yes                                                    39.8 (36.3–43.3)    1.9 (1.6–2.3)   23.8 (20.7–26.8)   2.2 (1.8–2.9)
    Difficulty bathing or dressing yourself?
      A little/none                                          27.9 (25.4–30.3)         1.0        14.9 (12.9–16.8)         1.0
      A lot                                                  62.8 (54.3–71.2)    2.2 (1.9–2.6)   47.7 (38.7–56.7)   3.2 (2.5–4.0)
    Difficulty walking several hundred feet
      A little/none                                          25.2 (22.5–27.9)         1.0        12.1 (10.2–14.1)         1.0
      A lot                                                  46.0 (41.0–50.9)    1.8 (1.6–2.1)   32.4 (27.8–37.1)   2.7 (2.1–3.3)
                                                                                                                      (continued)
Anxiety and Depression in US Adults With Arthritis                                                                                                  973

                                                                 Table 1. (Cont’d)

                                                                                  Anxiety                                Depression

                                                                       Prevalence          Unadjusted           Prevalence          Unadjusted
                                                                        (95% CI)           PR (95% CI)           (95% CI)           PR (95% CI)

    Difficulty bending, kneeling, or stooping
       A little/none                                                21.6 (18.6–24.5)            1.0          10.4 (8.2–12.6)             1.0
       A lot                                                        41.0 (37.3–44.6)       1.9 (1.6–2.2)     25.4 (22.3–28.6)       2.4 (1.9–3.1)
    Do arthritis or joint symptoms now affect whether
         you work for pay or not?
       No                                                           21.5 (18.9–24.1)            1.0          10.3 (8.4–12.2)             1.0
       Yes                                                          51.8 (47.2–56.4)       2.4 (2.1–2.8)     33.0 (28.6–37.3)       3.2 (2.5–4.0)
    Did arthritis or joint symptoms interfere with
         errands or shopping in the past 7 days?
       A little/none                                                24.8 (22.2–27.3)            1.0          12.2 (10.4–14.1)            1.0
       A lot                                                        51.1 (45.8–56.4)       2.0 (1.8–2.4)     36.4 (31.2–41.5)       3.0 (2.4–3.6)
    Satisfaction with current ability to do usual
         activities
       Somewhat satisfied/very satisfied                              20.0 (17.3–22.6)            1.0           9.4 (7.5–11.3)             1.0
       Neutral                                                      39.0 (28.3–49.7)       2.0 (1.4–2.7)     20.2 (11.5–28.9)       2.1 (1.3–3.4)
       Somewhat dissatisfied/very dissatisfied                        48.1 (43.6–52.5)       2.4 (2.0–2.8)     31.4 (27.3–35.5)       3.3 (2.6–4.2)
   Health and self-management behaviors
    Body mass index, kg/m2
       Under- and normal weight (⬍25)                               31.1 (26.8–35.5)            1.0          14.7 (11.4–18.0)            1.0
       Overweight (25 to ⬍30)                                       25.5 (21.6–29.4)       0.8 (0.7–1.0)     13.5 (10.5–16.5)       0.9 (0.7–1.3)
       Obese (ⱖ30)                                                  36.0 (31.7–40.3)       1.2 (1.0–1.4)     23.6 (19.8–27.4)       1.6 (1.2–2.1)
    Physical activity level¶
       Meets recommendations                                        26.4 (23.4–29.6)            1.0          12.8 (10.7–15.3)            1.0
       Insufficient                                                  29.8 (25.3–34.8)       1.1 (0.9–1.4)     17.2 (13.7–21.3)       1.3 (1.0–1.8)
       Inactive                                                     42.8 (37.4–48.4)       1.6 (1.4–1.9)     30.6 (25.7–36.1)       2.4 (1.9–3.1)
    Have you ever taken a self-management education
         course?
       No                                                           30.2 (27.7–32.8)            1.0          17.0 (15.0–19.0)            1.0
       Yes                                                          34.7 (26.8–42.5)       1.1 (0.9–1.5)     21.9 (15.2–28.6)       1.3 (0.9–1.8)
    Confidence that a self-management education course
         would help manage symptoms
       No confidence                                                 25.4 (19.8–31.1)       0.9 (0.7–1.1)     17.0 (12.2–21.9)       1.1 (0.7–1.5)
       Low (1–3)                                                    30.8 (24.8–36.8)       1.1 (0.8–1.3)     16.9 (12.1–21.7)       1.1 (0.8–1.5)
       Moderate (4–6)                                               34.4 (29.9–38.9)       1.2 (1.0–1.4)     18.6 (15.1–22.1)       1.2 (0.9–1.6)
       High (7–10)                                                  29.2 (25.0–33.3)            1.0          16.1 (12.8–19.4)            1.0
    Confidence in ability to manage arthritis or joint
         symptoms
       No confidence                                                 45.7 (32.5–59.0)       2.0 (1.4–2.7)     34.3 (21.5–47.2)       3.0 (2.0–4.5)
       Low (1–3)                                                    49.3 (38.4–60.2)       2.1 (1.6–2.7)     44.7 (33.9–55.6)       3.9 (2.9–5.3)
       Moderate (4–6)                                               40.6 (35.6–45.6)       1.7 (1.5–2.1)     22.3 (18.2–26.4)       1.9 (1.5–2.5)
       High (7–10)                                                  23.4 (20.5–26.2)            1.0          11.5 (9.4–13.5)             1.0
    Confidence in ability to engage in moderate physical
         activity at least 3 times/week
       No confidence                                                 55.8 (45.5–66.2)       2.5 (2.0–3.1)     42.4 (31.8–53.0)       4.1 (3.0–5.6)
       Low (1–3)                                                    48.0 (38.7–57.3)       2.1 (1.7–2.6)     30.5 (22.2–38.9)       3.1 (2.2–4.2)
       Moderate (4–6)                                               40.2 (34.9–45.5)       1.8 (1.5–2.1)     25.6 (20.9–30.3)       2.5 (1.9–3.2)
       High (7–10)                                                  22.7 (20.0–25.4)            1.0          10.3 (8.4–12.2)             1.0
    Currently being treated by doctor or HCP for
         arthritis or chronic joint symptoms?
       No                                                           26.0 (22.9–29.2)            1.0          13.5 (11.0–15.9)            1.0
       Yes                                                          35.5 (31.9–39.2)       1.4 (1.2–1.6)     21.8 (18.7–24.8)       1.6 (1.3–2.0)

   * PR ⫽ prevalence ratio; 95% CI ⫽ 95% confidence interval; HCP ⫽ health care provider.
   † Alaska Native/American Indian, Asian, and Native Hawaiian or other Pacific Islander.
   ‡ Disabled and unable to work were combined because of small sample sizes.
   § Homemakers and students were combined because of small sample sizes.
   ¶ Categories were: recommended (ⱖ150 minutes), insufficient (10 –149 minutes), or inactive (⬍10 minutes), where 1 minute of vigorous exercise was
   equivalent to 2 minutes of moderate activity.

  The relationship across anxiety, depression, and pain is                    dently and synergistically as a risk factor and outcome for
complex, with evidence that each condition acts indepen-                      each other (10,11,37). Furthermore, each is an indepen-
974                                                                                                                            Murphy et al

                                                                          treated because it can be an appropriate response to stress-
      Table 2. Sociodemographic, physical, and psychosocial
      characteristics associated with anxiety and depression:             ful life events and circumstances, and therefore treatment
        statistically significant multivariable adjusted PRs*              may not seem indicated (7). In fact, psychosocial distress
                                                                          among people with arthritis may signal the presence of
                                          Anxiety,       Depression,      other threats to their well-being, such as economic insecu-
                                         PR (95% CI)     PR (95% CI)      rity (the prevalence of each of anxiety and depression in
Sociodemographics
                                                                          our study was higher among those who were unemployed,
  Age, years                                                              disabled, or unable to work) (38). In at least one study,
    45–64                                1.7 (1.3–2.1)    1.6 (1.1–2.2)   anxiety was an even stronger predictor of functional lim-
    ⱖ65                                       1.0              1.0        itations than depression among people with arthritis (5),
Arthritis symptoms and physical                                           and it can be an obstacle to the behavioral changes asso-
    health and function                                                   ciated with reducing pain and depression, such as physi-
  Severity of joint pain in the                                           cal activity. Minor and Brown examined the efficacy of an
       past 7 days†                                                       exercise program for people with arthritis, and both high
    No pain (0)                               1.0              1.0        baseline anxiety and depression scores were indepen-
    Low (1–3)                            1.6 (1.0–2.5)    1.3 (0.6–2.7)
                                                                          dently associated with an increased risk of not exercising
    Moderate (4–6)                       1.6 (1.0–2.5)    1.6 (0.8–3.2)
    Severe (7–10)                        1.9 (1.2–3.0)    1.8 (0.9–3.6)
                                                                          at 3, 9, and 18 months postintervention (32).
  Self-reported general health                                               Ideally, treatment and management of anxiety and de-
       status                                                             pression include simultaneous clinical and self-manage-
    Very good/excellent                       1.0              1.0        ment interventions. There are multiple inexpensive,
    Good                                 1.4 (1.1–1.7)    1.4 (1.0–2.0)   convenient, and evidence-based self-management inter-
    Poor/fair                            1.6 (1.2–2.1)    1.5 (1.0–2.3)   ventions for anxiety and depression that complement clin-
Health and self-management                                                ical care. Aerobic exercise is an effective treatment for
    behaviors                                                             mild to moderate depression and is associated with reduc-
  Body mass index, kg/m2                      1.0                         tions in anxiety (39); some strength training activities may
    Under- and normal weight             0.8 (0.7–1.0)
       (⬍25)
    Overweight (25 to ⬍30)               0.8 (0.7–0.9)                       Table 3. Percentage with anxiety, depression, or both in
    Obese (ⱖ30)                               1.0                            the past month who have not sought help in the past 12
  Confidence in ability to                                                          months for “stress, depression, or problems
       manage arthritis or joint                                                                 with emotions”
       symptoms
                                                                                                                           Currently
    No confidence                                          1.1 (0.6–1.9)
                                                                                                                         being treated
    Low (1–3)                                             2.3 (1.6–3.3)
                                                                                                                        for arthritis or
    Moderate (4–6)                                        1.2 (0.9–1.6)
                                                                                                               Overall joint symptoms
    High (7–10)                                                1.0
  Confidence in ability to engage
                                                                            Overall                               55            46
       in moderate physical
                                                                            Age, years
       activity at least 3 times/
                                                                              45–64                               50            43
       week
                                                                              ⱖ65                                 65            56
    No confidence                         1.5 (1.1–2.1)    1.5 (1.0–2.3)
                                                                            Sex
    Low (1–3)                            1.2 (1.0–1.6)    1.1 (0.8–1.7)
                                                                              Men                                 60            53
    Moderate (4–6)                       1.3 (1.1–1.6)    1.5 (1.2–2.1)
                                                                              Women                               53            43
    High (7–10)                               1.0              1.0
                                                                            Race/ethnicity
  * The multivariable adjusted model comprised all but 1 variable             Hispanic                            40            40
  examined in unadjusted models. This table shows statistically sig-          Non-Hispanic black                  63            21
  nificant associations only; PRs for all variables examined in this           Non-Hispanic other*                 53            53
  multivariable model are shown in Supplementary Table 1 (available           Non-Hispanic white                  56            48
  in the online version of this article at http://onlinelibrary.wiley.
  com/journal/10.1002/(ISSN)2151-4658). PR ⫽ prevalence ratio;              Highest level of education
  95% CI ⫽ 95% confidence interval.                                            Less than high school               60            57
  † Severity of each of fatigue, joint stiffness, and joint pain was          High school or some college         53            46
  highly correlated (r ⫽ 0.7). To reduce collinearity, only the latter        Completed college or greater        55            51
  was included in the multivariable models; joint pain was selected
  because it is generally the most modifiable symptom among people           Employment status
  with arthritis, and was also strongly associated with both anxiety          Employed                            66            61
  and depression (see Table 1). Because severity of pain was highly           Unemployed, unable to work,         37            32
  correlated with number of days in the past week with pain, aching,            or disabled†
  or stiffness (r ⫽ 0.6), only severity of pain was included in the
  multivariable models.                                                       Retired                             66            57
                                                                              Other‡                              55            39

dent determinant of disability, further complicating this                   * Alaska Native/American Indian, Asian, and Native Hawaiian or
                                                                            other Pacific Islander.
interrelationship. Similar to depression, anxiety can per-                  † Disabled and unable to work were combined because of insuffi-
sist and worsen if untreated (7); the importance of ad-                     cient sample sizes.
                                                                            ‡ Homemakers and students were combined because of insufficient
dressing anxiety is emerging only now (18). Kessler et al                   sample sizes.
propose that anxiety may be underrecognized and under-
Anxiety and Depression in US Adults With Arthritis                                                                            975

also elicit the same effects for depression (29). For those    tion had a high positive predictive value (44). Second,
wanting guidance on safely exercising, community-based         ACHES is a cross-sectional study and it is not known
physical activity programs (e.g., Walk With Ease, Enhance-     whether the correlates studied are predictors or sequelae
Fitness) teach people with arthritis strategies to reach       of anxiety and depression. Third, several 95% CIs in both
recommended levels of physical activity without exac-          unadjusted and multivariable analyses bordered on statis-
erbating symptoms or worsening disease (40). SME inter-        tical significance, especially for depression, for which
ventions (e.g., Chronic Disease Self-Management Program,       there were fewer people affected. This suggests that there
Arthritis Self-Management Program) have been proven to         was insufficient power to detect modest statistically sig-
lead to reductions in anxiety and depression (40). There-      nificant associations. Last, despite multiple strategies to
fore, another strategy for HCPs is recommending par-           maximize survey participation, response rates were low,
ticipation in physical activity and evidence-based SME         particularly among blacks and Hispanics. A previous ana-
interventions (http://www.cdc.gov/arthritis/interventions.     lysis indicated that the sociodemographic characteristics
htm). Recommendation from an HCP is key; ACHES re-             of ACHES respondents are similar to adults with arthritis
spondents who had received a recommendation from their         ages ⱖ45 years in the nationally representative NHIS (22),
HCP to attend an SME class were 18.5 times more likely to      suggesting that ACHES results are generalizable to the US
report attending one than those without a recommenda-          population.
tion (41).                                                        ACHES is the most comprehensive population-based
   AIMS anxiety and depression subscales were used to          national survey of US adults with arthritis to date. We
define these conditions. AIMS is one of the most com-           found that both anxiety and depression are common
monly used and reported instruments for the study of           among people with arthritis and the prevalence of anxiety
anxiety and depression among people with rheumatic con-        was higher than the prevalence of depression. A distinct
ditions (4,13–16). As mentioned previously, although           profile of people with these conditions was not evident
AIMS subscales have not been validated directly in pop-        because the prevalence of these conditions was relatively
ulation-based studies, the AIMS depression subscale is         high across all of the subgroups. Approximately half of the
strongly correlated (r ⫽ 0.81) with the CES-D (42), a pop-     affected respondents whose arthritis was being treated by
ulation measure of depression symptoms. Increasing lev-        an HCP had not sought treatment in the past year for their
els of AIMS depression and anxiety scores are also asso-       mental health condition, indicating a missed opportunity
ciated with lower levels of physical function (measured        for HCP intervention. This is important because HCPs can
with the Health Assessment Questionnaire [HAQ]) (4,13),        have a significant impact on reducing the burden of anxi-
suggesting construct validity. To our knowledge, the AIMS      ety and depression among people with arthritis through
anxiety subscale has not been validated against any other      systematic screening for both conditions, treatment based
population-based measure of anxiety. We believe there is       on current standards of care, and their strong influence in
construct validity to the anxiety subscale because of the      recommending physical activity and SME programs to
association between anxiety and HAQ physical function          their patients.
scores (4,13). Also, we found that having sought help in
the past 12 months for mental health conditions was            ACKNOWLEDGMENTS
strongly associated with both anxiety (PR 3.5, 95% CI          The authors would like to thank the Battelle staff for co-
2.9 – 4.2) and depression (PR 3.4, 95% CI 2.9 – 4.0) (data     ordinating all aspects of ACHES, the ACHES steering
not shown), suggesting that the subscales detect mental        group’s expertise and time in development of the survey,
distress.                                                      and the ACHES respondents for their participation in this
   The types of anxiety disorders (e.g., generalized anxiety   study.
disorder, panic disorder) detected by the AIMS anxiety                       AUTHOR CONTRIBUTIONS
subscale have not been characterized. Also, because symp-         All authors were involved in drafting the article or revising it
toms of anxiety can be a manifestation of depression (43),     critically for important intellectual content, and all authors ap-
                                                               proved the final version to be published. Dr. Murphy had full
the proportion of anxiety among respondents attributable
                                                               access to all of the data in the study and takes responsibility for
to depression is unknown.                                      the integrity of the data and the accuracy of the data analysis.
   Our estimates indicate that the population burden of        Study conception and design. Murphy, Sacks, Brady, Hootman,
anxiety and depression among adults with arthritis is sub-     Chapman.
stantial, but may be underestimated for several reasons.       Acquisition of data. Sacks.
                                                               Analysis and interpretation of data. Murphy, Hootman, Chapman.
We used a conservative definition of depression (i.e., the
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