NEW YORK (Reuters Health)—Effective pharmacotherapy of rheumatoid arthritis (RA) is not associated with meaningful improvements in mental health, according to a systematic review and meta-analysis.
“We were surprised by the small effect sizes for mental-health outcomes across all of the treatments included in this review, but particularly for the anti-TNF versus disease-modifying antirheumatic drug (DMARD) comparison, as anti-TNF has received the most attention as having potential antidepressant effects,” Dr. Faith Matcham from King’s College London told Reuters Health by email.
About 17% of RA patients have depressive disorders and a quarter screen positive for anxiety disorders, much higher prevalences than in the general population. Increasing evidence linking inflammatory pathways in RA and depression suggests that therapies targeting inflammatory cytokines might improve mental health outcomes in patients with high levels of inflammation.
Dr. Matcham’s team investigated the effect of targeted biologic and Janus kinase inhibitor (JAK) treatments on mental and physical health in their systematic review and meta-analysis of 71 randomized trials including more than 34,000 participants. Overall, 57 studies were included in pairwise meta-analysis and 54 were included in network meta-analysis.
In pairwise meta-analysis, treatment with biologic DMARDs was associated with about a two-point improvement (versus control treatments) in the mental component summary (MCS) score of the 36-item Short Form (SF36). There was a four-point improvement in the physical component summary (PCS) score, the researchers report in Arthritis and Rheumatology, online June 6.
When compared with placebo controls, biologic DMARDs provided a substantial benefit for PCS outcomes but not for MCS outcomes (standardized mean differences (SMDs), 0.52 versus 0.27, respectively).
The network meta-analysis for biologic versus conventional synthetic DMARDs showed consistently small effect sizes for MCS and moderate effect sizes for PCS outcomes.
“We were fairly surprised to see such large differences in effect size for mental- versus physical-health related quality of life (HRQoL) outcomes,” Dr. Matcham said. “We had thought that there might be a slightly larger impact of targeted pharmacological treatments on physical HRQoL, but effect sizes of physical HRQoL outcomes were consistently approximately twice the size of those for mental HRQoL outcomes.”
For MCS outcomes, the largest effect sizes were found for anti-IL-6, and the smallest effect sizes were found for JAK inhibitors.
“Mental-health issues are unlikely to resolve themselves without dedicated psychological support,” Dr. Matcham said. “Whilst effective management of symptoms such as pain or swelling may alleviate distress for some patients, many won’t experience a meaningful improvement in mental health as a result of targeted RA treatment.”
“Ideally, multi-disciplinary rheumatology services would include dedicated psychology or liaison psychiatry time, providing psychological therapies or support patients with adjusting to the diagnosis, treatment regimens, and other behavioral or lifestyle changes needed to help improve health outcomes,” she said.
“Integrating mental-health services into routine clinical care is important to reduce stigma related to mental-health problems (as mental and physical health would be seen as equally important) and to ensure patients receive psychological support that is relevant to their physical health needs and rheumatological diagnosis,” Dr. Matcham added.
“If this is not possible, simply asking patients about their mental health as part of routine follow-up and creating standardized mental-health care pathways that make use of primary-care or community mental-health services can go a long way to improve the management of mental health needs,” she said.
Reference
- Matcham F, Galloway J, Hotopf M, et al. The impact of targeted Rheumatoid Arthritis pharmacological treatment on mental health: A systematic review and network meta-analysis. Arthritis & Rheumatology. 2018 Jun 6. [Epub ahead of print]
