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Journal of Psychosomatic Research, Vol. 46, No. 2, pp. 155164, 1999 Copyright 1999 Elsevier Science Inc.

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(Received 11 May 1998; accepted 4 August 1998) AbstractThis study aimed to establish the relationship between depression, illness perception, coping strategies, and adverse childhood events in rheumatoid arthritis patients. Sixty-two out-patients with rheumatoid arthritis (RA) completed the Hospital Anxiety and Depression Scale, Illness Perception Questionnaire, London Coping with Rheumatoid Arthritis Questionnaire, and Childhood Development Questionnaire, and underwent a clinical assessment of their physical state. Depressed patients were more disabled than the nondepressed, had a more negative view of their illness, and used more negative coping strategies. There was no association between depression and childhood adversity. Once disability was controlled for, there continued to be a signicant correlation between depression and: (i) viewing the consequences of the illness negatively (Spearmans correlation coefcient [r]0.37, p0.003); and (ii) the perceived ability to control the illness (r0.26, p0.04). The relationship between depression and negative coping strategies became insignicant. This study indicates the close relationship between depression and a negative view of the illness. 1999 Elsevier Science Inc. Keywords: Coping; Depression; Disability; Illness perception; Rheumatoid arthritis.


In recent years there has been a growing trend to explore the psychological features of patients who suffer from rheumatoid arthritis (RA). Anxiety and depression are the most frequently measured variables. Using semistandardized psychiatric interviews, the prevalence of depression in subjects with RA has been found to be between 12.5% and 25% [1]. Such prevalence rates of depression are consistent with rates of depression among other chronic illness populations [2, 3], and are higher than that found among the general population. The etiology of depression in RA is complex. When depression is measured by semistandardized interview, there is little evidence of a direct relationship between markers of the severity of arthritis and the extent of depression [4, 5]. Social factors such as isolation and conict have been shown to predict depression in this group of patients [2, 6, 7]. Cognitive variables are also likely to be important in determining the mood of RA patients. Subjective illness representations, based on implicit, common-sense beliefs, may inuence psychological well-being and an individuals
Departments of * Psychological Medicine and Rheumatology, Manchester Royal Inrmary, University of Manchester, Manchester, UK. Address for correspondence: Prof. Francis Creed, Department of Psychological Medicine, Rawnsley Building, Manchester Royal Inrmary, University of Manchester, Oxford Road, Manchester M13 9WL, UK. Tel: 0161 276-5331; Fax: 0161 273-2135; E-mail: francis.creed@man.ac.uk



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ability to cope [8]. Negative or maladaptive coping strategies (e.g., self-blame and avoidance) have been associated with depression in RA patients [9], whereas positive or adaptive coping styles are associated with improved well-being [10, 11]. Many of the etiological factors for depression in RA are likely to be interrelated in a complex fashion. In addition, it is likely that there are possible uninvestigated confounding variables that independently predict these etiological variables. An example of this might be childhood experiences that independently predict vulnerability to depression in adult life [12], but that also predict adult illness behaviors, thus inuencing how individuals adapt to being ill [13, 14]. With respect to arthritis this is a subject that has been little explored. This study examines the relationship between depression, illness perception, and the effects of coping in a population of out-patients with RA. In addition, the role of adverse experiences in childhood in predicting depression in this group is investigated. Specically, we hypothesize that, in patients with rheumatoid arthritis, depression is correlated with: (i) a negative perception of their illness, that is, it is more serious/has a greater inuence on their life; (ii) a reduced ability to cope; and (iii) more adverse experiences in childhood.
METHOD Study population
Consecutive patients with rheumatoid arthritis (RA), according to the American Rheumatism Association criteria [15], attending two rheumatology out-patient clinics in teaching hospitals were studied. All subjects were between 18 and 80 years of age. Subjects were excluded if they were considered to have signicant other major illness, to increase the homogeneity of the group.

Potentially suitable subjects were identied by examination of their clinic notes prior to their attendance in out-patients. Subjects were approached while they were waiting to be seen by the clinic doctors. Eligible patients giving informed consent then completed the study assessment. The study assessments consisted of a number of questionnaires and a physical examination by the researcher (H. M.). The assessments took approximately 20 minutes in total and were designed to be completed in the short period before patients were called to see their doctor. When patients were summoned away before they had completed the assessments sufcient instructions were included to enable the patients to complete the assessments at home and return them by post. Basic demographic data were collected along with details of the duration of RA, past psychiatric history, and whether subjects were taking antidepressants or not. Social support was assessed by asking the patient who lived at home with them. Subjects were asked whether they thought current treatments were helping them or not. In previous research in RA depression has sometimes been considered to be a continuous variable, measurable using a depression scale, whereas other researchers have identied depressed cases and compared them with their nondepressed counterparts. Both the continuous and categorical conceptualizations of depression have disadvantages; the former fails to identify patients with clinically signicant depressive disorders, which may respond to treatment, and the latter ignores subjects with signicant depressive symptoms but who fail to reach criteria for diagnosable depressive disorder. In this study depression and anxiety were assessed using the Hospital Anxiety and Depression (HAD) questionnaire [16]. This questionnaire has been used widely in hospital/out-patient settings and enables analysis of depression as a linear variable and also identies probable caseness. The cutoff scores for the diagnosis of probable depression (score of 10 on the depression subscale) and probable anxiety (score of 10 on the anxiety subscale). In addition, the HAD was chosen for use in this study because it is easily applied, avoids assessment of physical symptoms of depression, and has been validated in RA patients. The higher the score, the greater the degree of anxiety and depression. The ways individuals perceive and respond to a health threat, such as an illness, depend on the ways the health threat is represented in their own minds [17]. In Leventhals model, the cognitive and emotional aspects of illness representations, occurring in response to a health threat, determine the nature

Depression and illness perception in RA


of coping procedures, and the appraisal of the effectiveness of coping. Illness representations, the subsequent coping procedures, and the criteria by which their effectiveness is judged are determined by common-sense beliefs and the social context in which the threat occurs. Research in this area has identied ve components of illness representations: (1) disease identity (i.e., the symptoms and their labels); (2) timeline (i.e., time to develop and duration); (3) consequences; (4) causes; and (5) controllability [17]. Illness representations were measured in this study using the new Illness Perception Questionnaire (IPQ) [18]. This questionnaire provides a measure of the ve components of illness representation derived from Leventhals model. This questionnaire has previously been validated among chronic illness populations such as insulin-dependent diabetes, chronic fatigue syndrome, and chronic pain patients [18]. In this study, an adapted version of the questionnaire was used specically for RA patients; the term arthritis was substituted for illness in each question as recommended by other researchers using the IPQ in RA populations (John Pimm, personal communication). Upon completing the IPQ, patients were required to score statements according to what they thought about their illness. The IPQ measures the dened components: (i) Illness identitya list of 12 common symptoms are rated as being absent (score 0) or present (score 1). Some of the symptoms listed are typical of arthritis (e.g., stiff joints) and some are not (e.g., headaches). This scale provides a measure of the perceived symptoms load with high scores indicating a greater number of symptoms. (ii) Timeline patients rate three statements relating to the perceived duration of their arthritis. Each of the three items is scored 15, with low scores representing short perceived duration of arthritis. (iii) Consequence patients rate seven items relating to the expected effects and outcome of their arthritis. Each of the seven items is scored 15, with low scores representing less severe outcome. (iv) Control/curepatients rate six items relating to the extent to which they perceive their arthritis is under control of themselves or their doctors. Each item is rated 15, with low scores representing less control over their arthritis. (v) Causepatients rate a list of ten possible causes of the arthritis relating to personal ideas about etiology of the illness. Each of the ten items is rated 15, with high scores indicating a strong belief that a given etiological factor is important. Due to the varied nature of the etiological factors listed it is not appropriate to reduce this scale to a single score. For this reason, scores on the Causal Beliefs scale are not included in the analysis. The coping strategies of patients were measured using the self-administered London Coping with Rheumatoid Arthritis Questionnaire. This questionnaire has 36 items and has been designed specically for rheumatoid arthritis populations. Each item is scored from 1 (never) to 6 (always) according to how much the patient uses each coping strategy [10]. Adverse childhood events were measured by semistructured interview using the Childhood Development Questionnaire (CDQ) [19]. Patients were asked about events in their childhood, concentrating on serious life events (abuse, separation from parents, parental marital discord) as well as early experiences of illness in the family. Scores are obtainable on four items relating to early experience of illness: parental physical illness; parental mental illness; sibling physical illness; and physical illness in self. Other items are rated as having occurred or not. An overall score reecting adverse experiences in childhood was obtained by totaling the scores from the individual items (illness and nonillness-related). This questionnaire is currently being tested in work in the general community and in other out-patient settings. Subjects were asked to record current severity of pain and severity of disease activity using two 100-mm visual-analog scales (VAS) where 0 mm represented no pain/disease activity and 100 mm represented the most severe pain/disease activity imaginable. Subjective disability in functions of daily living was assessed using the HAQ. This self-administered questionnaire and is used widely in community/out-patient settings for rheumatoid arthritis patients [20, 21]. Patients are asked to score themselves on their functional ability in completing daily tasks; these include dressing and grooming, rising from chair/bed, eating, walking, hygiene, reach, grip, and general activities. Each component is scored 0 (no disability) to 3 (severe disability). Patients requiring help to perform an activity or requiring a physical aid, such as a walking stick to aid walking, scored at least 2 on the item for which help was required. An overall disability score is obtained by taking the average score from the eight activities of daily living just listed.

Physical examination
Disease severity was clinically assessed by the trained researcher (H.M.) using the 28-joint count quantitative articular index, which involves scoring joints for swelling, tenderness, and limitation of movement [22, 23]. Joints assessed were: proximal-interphalangeal (n10); metacarpophalangeal (n10); wrists (n2); elbows (n2); shoulders (n2); and knees (n2). This measure is quick and easy to apply; it yields information about disease activity that is comparable with fuller joint counts [23, 24].

Nonparametric statistical techniques were used. Subject characteristics are documented as median values with interquartile ranges to indicate the distribution of scores around the median.


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Spearmans correlation coefcients were used as a measure of linear correlation between variables. Partial correlation analysis was performed to establish the strength of association between two variables while controlling for a third. To establish differences between probable cases of depression and probable noncases, MannWhitney U tests were used for continuous variables, and chi-square tests were performed on categorical variables. Analyses were performed using SPSS for Windows. Ethical permission was granted by Central Manchester and Salford Health Authority ethics committees.


Seventy-two eligible subjects with RA (ARA criteria) were initially approached. Two subjects refused consent and eight did not complete/return their questionnaires fully despite remailing. Analysis was thus performed on 62 subjects (86% of those approached). Forty-six consecutive cases were recruited from one clinic and 16 from the other. Fifty-two patients were female and 10 were male. The median age was 59.5 years (interquartile range [IQR]50.7568). The great majority of subjects had wellestablished RA with only one subject having the disease for less than 1 year. The median duration of arthritis was 15 years (IQR625). The median HAQ score was 2 (IQR1.472.5) and the median VAS pain score was 48.5 (IQR27.164.4). The median HAD depression score was 7 (IQR 4.759.25). There were 11 cases (17%) of depression (determined by HAD depression score 10). Nineteen subjects (31%) reported a previous history of depression and 5 (8%) were currently taking antidepressant medication.

Relationship between depression scores and other variables HAD depression score correlated with three dimensions of the IPQ (see r1 column in Table I) and a number of coping strategies (r1 column in Table II). Neither the timeline dimensions of the IPQ nor childhood experiences correlated signicantly with HAD depression score (Table I). In addition, HAD depression score correlated signicantly with the HAQ score (r0.49, p0.0001), the number of joints with limited movement (r0.38, p0.002), and VAS pain (r0.25, p0.043). There were no other signicant correlations between HAD depression score and measures of disease activity (i.e., number of swollen or tender joints). Comparison of depressed and nondepressed subjects Comparison of depressed (HAD depression score 10) and the nondepressed subjects can be seen in Table III. Depressed patients were signicantly more disabled (HAQ), had a greater number of joints with limited movement, and were signicantly less satised with their current treatment. The groups were similar with regard to demographic variables (age and gender), duration of arthritis, most measures of disease activity (tender joints, no swollen joints, VAS pain) (Table III). Current treatment with antidepressant medication, or past history of depression also did not differ signicantly between the two groups. Depressed patients viewed the consequences of their illness as being more serious and believed they had less control over their illness, and that it would not be cured (Table IV). However, there were no signicant differences between depressed and nondepressed patients on IPQ variables measuring illness identity or timeline.

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Table I.Spearmans correlation between depression (HAD score) and illness perception, and childhood experience scores Score IPQ Illness identity Timeline Consequence of illness Control/cure Childhood Parental physical illness Parental mental illness Sibling physical illness Self physical illness Overall adversity r1 0.31 0.06 0.48 0.40 0.14 0.01 0.02 0.03 0.06 p-Value 0.014 0.64 0.0005 0.001 0.27 0.91 0.86 0.82 p 0.65 r2 0.23 0.06 0.37 0.26 0.17 0.07 0.03 0.002 0.09 p-Value 0.075 0.67 0.003 0.04 0.19 0.6 0.8 0.99 p 0.5

r1 Spearmans correlation coefcient between variable and HAD score; r2 partial correlation coefcient between variable and HAD score controlling for disability.

Coping Median scores on the coping questionnaire are shown in Table IV (only coping strategies that are signicantly different between depressed and nondepressed subjects are shown). Depressed subjects were signicantly more likely to use the following coping strategies: (1) My arthritis can make me self-conscious so that I avoid people; (2) I try to rest as much as possible; and (3) I try to avoid situations where my arthritis would become evident. They were less likely to use the strategy of: (4) My arthritis has helped me to develop into a better person. There were no signicant differences between groups with regard to other coping strategies used. Childhood experience The depressed group scored signicantly lower on experience of parental physical illness in childhood (MannWhitney U test, U150.0, p0.01). There was no other signicant differences in childhood adversity between the depressed and nondepressed subjects.
Table II.Spearmans correlation coefcients of depression scores and coping strategies Strategy Feel self-conscious Avoid situations Rest as much as I can Im a better person because of RA Try to stay active Activities to take mind off RA Prefer to be alone if in pain Avoid some foods b/c RA Pray to God helps r1 0.39 0.25 0.35 0.26 0.41 0.35 0.30 0.29 0.26 p-Value 0.002 0.049 0.002 0.051 0.001 0.005 0.020 0.024 0.043 r2 0.2 0.17 0.14 0.16 0.19 0.22 0.25 0.25 0.18 p-Value 0.15 0.22 0.31 0.26 0.19 0.12 0.07 0.08 0.19

Only the coping strategies that correlated with depression scores to a signicant or near signicant degree are included. r1 Spearmans correlation coefcient between variable and HAD score; r2 partial correlation coefcient between variable and HAD score controlling for disability.


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Table III.Demographic and physical variables of the depressed and nondepressed groups (medians and interquartile range are shown for continuous variables) Nondepressed (n 51) Age (years) Gender (% female) Duration of RA years Pain (VAS) No. of tender joints No. of swollen joints No. joints with limited movement Disability (HAQ) Social support Treatment satisfaction No. of previous treatments Depression history Current depression treatment 59 43/51 (84.3%) 16.25 48.0 1 9 7 1.88 29/47 (62.8%) 44/51 86% 3 14/51 (27.5%) 3/51 (5.9%) IQR 48.868 6.825.2 2663 05 515 315 1.252.25 Depressed (n 11) 61.5 9/11 (81.8%) 10 57.0 08 10 16 2.5 8/10 (80.0%) 6/11 (54.5%) 3 5/11 (45.5%) 2/11 (18.1%) IQR 56.869.8 524 34.578 0.38 415 1221 2.382.88 p-Value 0.25 0.84 0.36 0.26 0.79 0.007 0.0005 0.31 0.019 0.054 0.24 0.18

Other variables Controlling for the effects of disability. Because depression scores correlated highly with some measures of arthritis severity, particularly the HAQ score, a partial correlation analysis was performed to assess the relationship between depression and coping, illness perception, and childhood experience while controlling for disability. The results of the partial correlation analysis can be seen in Tables I and II (r2 column in each case). Despite controlling for disability, depression can still be seen to correlate signicantly with the consequence and the control/cure dimensions of the IPQ. There was no correlation of HAD depression score with coping strategies or childhood experiences once disability was controlled for.
Table IV.Illness perception and coping variables of the depressed and nondepressed groups Variable IPQ Illness identity Timeline Consequence Control/cure Coping Feel selfconscious Avoid situations Rest as much as I can Im a better person Nondepressed 9 4.33 3.57 3.17 IQR 711 45 3.144 2.673.67 Depressed 10 5 4 2.67 IQR 810 3.335 3.714.57 22.83 p-Value 0.99 0.56 0.004 0.008

2 4 4 3

14 35 34 13

4 6 5 1

45 46 45 11.25

0.002 0.032 0.028 0.02

Only coping strategies that differ signicantly between groups are shown due to the large number of different strategies compared.

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The main nding of the study is the clear association between depression and illness perception. Components of illness perception that correlate most strongly with depression are consequence, indicating patients view their illness as serious, and control/cure, indicating they feel they have little control over their illness. The relationship between these components of illness perception and depression is evident even when disability is controlled for. The association between the control/cure subscale of the IPQ and depression concurs with previous psychological studies measuring loci of control of health, suggesting that perceived internal or personal control is conducive to being mentally healthy [25]. As the data are cross-sectional, it is impossible to make causal statements about these relationships. Do patients view their illness more negatively because they are depressed, or do they become depressed because they view their illness so seriously and feel they have no control over it? The latter view gains support from longitudinal work suggesting that negative cognitive processes precede depression in RA patients [26]. On the other hand, our analysis included patients with probable depressive disorder, which is itself disabling and associated with a more negative view of perception of illness and other aspects of life [27]. Understanding the importance of illness perception in depressed RA patients may help clarify previous work concerning the relationships between depression, pain, and disability. Cross-sectional studies have shown signicant associations between depression and pain intensity [2832], but longitudinal studies have produced conicting results [3336]. Similarly, there is some evidence indicating that disability results in depression [37] and other evidence indicating that depression results in disability [36]. It is likely that most measures of pain and disability are affected by illness perceptions and this may play a part in explaining these relationships. There may also be an interaction effect in the way that coping is only associated with depression at high levels of pain [9, 29]. The more marked depression indicated by HAD scores of 11 is very likely to be associated with negative views of illness. Further longitudinal studies with objective measures are needed. The conicting ndings of recent research is likely to be due to variations in methodology used. There is evidence to suggest that the relationship between depression and physical variables, and depression and some cognitive variables (particularly coping) may depend on the severity of disease (RA) in the groups studied, which might account for the variability of ndings [29, 38]. There are a number of methodological considerations in relation to the current study. It is typical of other studies in terms of age, gender, duration of arthritis, and HAQ scores, but the sample was rather small, with only 11 patients with depression. It is possible that group sizes were inadequate to demonstrate true differences between depressed and nondepressed subjects (i.e., a type II error may have resulted). The study used a self-administered questionnaire, not a research interview, but the prevalence of depression (17%) was similar to other studies using a research interview [1]. Controlling for differences in the degree of disability is an important methodological strength of this study, not always performed in this type of investigation. This allows us to refute the suggestion that patients who are depressed view their illness as being more serious, simply because it is more serious; that is, the disease has been


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severe in the past, creating more limitations of activities, and greater perceived disability. However, the HAQ score is only one measure of functional disability. Its reliance on self-reports of the patient may mean that the score is elevated as the result of depression independent of the effect of disease severity. Such an effect may be the result of changes in perception of the severity of illness or the reporting of illness in depressed subjects. In the presence of such an effect, controlling for the effects of disability using partial correlation would weaken the apparent correlation between depression and other measures such as illness perception and coping. In the future, larger studies will need to encompass different aspects of disability using more objective measures. We have conrmed previous research that depressed patients are more likely to use passive or avoidance coping strategies, rather than positive and active ones. However, the fact that the signicant correlation between depression and coping disappeared once disability was controlled indicates that most dimensions of coping are independent of depressed mood some may be related to severity of disability. Alternatively, the lack of direct association between depression and coping may be due to the nature of the patients under study. Previous work has shown that poor coping is associated more clearly with depression in subjects with severe illness [9]. By selecting a consecutive group of out-patients we may have not included a sufcient number of subjects with severe illness. Childhood experiences were not associated with depression in this group. This nding contrasts with previous research that conrms this association in psychiatric populations [12]. Little research has examined the role of childhood events and the development of depression in individuals with denite organic disease. Although our data are comparable to those of previous research, in that depressed subjects had experienced more separations from and losses of parents than the nondepressed subjects [14], we failed to show signicant differences between the groups. It is possible that this is the result of a type II error. Alternatively, it may result from the fact that the effects of childhood experiences are insignicant compared with those of current illness-related factors, cognitive factors, and social factors in this patient group. Future studies using more stringent criteria for diagnosis of depression, with larger group sizes, need to be performed to assess any link between depression and adverse childhood experiences in this population. To clarify the relationships between depression, illness perception, coping, disability, and childhood experiences, longitudinal studies are required. Studies that reduce depression or use cognitive techniques to change illness beliefs will provide the opportunity to change one variable and consider the effect on the other associated variable(s).

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