Влияние успешной психофармакотерапии расстройств тревожно-депрессивного спектра на выраженность хронической усталости у больных ревматоидным артритом
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Abramkin AA, Lisitsyna TA, Veltishchev DYu, Seravina OF, Kovalevskaya OB, Glukhova SI, Nasonov EL. Influence of successful psychopharmacotherapy of anxiety-depressive spectrum disorders on the severity of chronic fatigue in patients with rheumatoid arthritis. Terapevticheskii Arkhiv (Ter. Arkh.). 2021; 93 (5): 551–560.
DOI: 10.26442/00403660.2021.05.200786
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Материалы и методы. Обследованы 128 пациентов с достоверным диагнозом РА. Для оценки выраженности усталости использовали шкалу FSS (Fatigue Severity Scale), клинически выраженной усталость считалась при FSS≥4 баллов. РТДС диагностированы психиатром в ходе полуструктурированного интервью по критериям Международной классификации болезней 10-го пересмотра у 123 (96,1%) пациентов. Выраженность депрессии определяли по шкале депрессии Монтгомери–Асберг (MADRS), тревоги – по шкале тревоги Гамильтона (HAM-A). ПФТ предложена всем пациентам с РТДС, согласились на лечение – 52, отказался – 71. В зависимости от проводимой терапии выделены следующие терапевтические группы: 1-я – базисные противовоспалительные препараты – БПВП (n=39), 2-я – БПВП+ПФТ (n=43), 3-я – БПВП + генно-инженерные биологические препараты – ГИБП (n=32), 4-я: БПВП+ГИБП+ПФТ (n=9). Длительность терапии ГИБП варьировала от 1 года до 5 лет, длительность ПФТ – от 6 до 96 нед. Динамику РТДС и исходы РА через 5 лет оценивали у 83 (67,5%) больных. Предикторы хронической усталости через 5 лет наблюдения определяли с помощью многофакторной логистической регрессии.
Результаты. По результатам многофакторного логистического регрессионного анализа с клинически значимой усталостью через 5 лет после включения в исследование независимо положительно ассоциировалась только исходная клинически значимая усталость (отношение шансов 13,57; 95% доверительный интервал 3,044–60,486; p=0,01) и отрицательно – успешное лечение РТДС (отношение шансов 0,162; 95% доверительный интервал 0,032–0,809; p=0,027), R2=0,385, p<0,0001.
Заключение. Учитывая существенное влияние факторов, связанных с психическим здоровьем, на выраженность усталости, а также значимое положительное влияние ПФТ РТДС, всем больным РА с клинически значимой усталостью показана диагностика РТДС и в случае их выявления – назначение ПФТ.
Ключевые слова: ревматоидный артрит, расстройства тревожно-депрессивного спектра, хроническая усталость, предикторы, антидепрессанты
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Aim. To assess the influence of psychopharmacotherapy (PPT) of anxiety and depressive disorders on fatigue severity in patients with rheumatoid arthritis (RA).
Materials and methods. 128 RA-patients were included. Severity of fatigue was measured with fatigue severity scale (FSS), clinically important fatigue was diagnosed in patients with FSS≥4. Anxiety and depressive disorders (ADD) were diagnosed by a licensed psychiatrist in 123 (96.1%) of RA-patients in accordance with ICD-10 in semi-structured interview. Severity of depression and anxiety was evaluated with Montgomery–Asberg Depression Rating Scale (MADRS) and Hamilton Anxiety Rating Scale (HAM-A). RA-patients with ADD were divided into the following treatment groups: 1 – сDMARDs (n=39), 2 – сDMARDs+PPT (sertraline or mianserine), n=43, 3 – сDMARDs+bDMARDs (n=32), 4 – сDMARDs+bDMARDs+PPT (sertraline or mianserine), n=9. Biologics treatment duration varied from 1 to 5 years, antidepressants – from
6 to 96 weeks. 83 (67.5%) RA patients were assessed at five-years follow-up. Multinominal logistic regression analysis was conducted to determine factors associated with clinically important fatigue.
Results. Multinominal logistic regression analysis showed clinically important fatigue at baseline to be positively associated (OR 13.57; 95% CI 3.044–60.486; p=0.01) and remission of ADD – negatively associated (OR 0.162; 95% CI 0.032–0.809; p=0.027), with clinically important fatigue at 5 years follow-up (R2=0.385, p<0.0001).
Conclusion. Due to significant relationship between mental health status, antidepressants treatment and clinically important fatigue
in RA-patients, all patients reporting clinically important fatigue should be recommended mental health counselling by a licensed psychiatrist.
Keywords: rheumatoid arthritis, anxiety-depressive spectrum disorders, chronic fatigue, predictors, antidepressants
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1. Katz P. Fatigue in Rheumatoid Arthritis. Curr Rheumatol Rep. 2017;19(5):25. DOI:10.1007/s11926-017-0649-5
2. Hewlett S, Chalder T, Choy E, et al. Fatigue in rheumatoid arthritis: time for a conceptual model. Rheumatology (Oxford). 2011;50(6):1004-6.
DOI:10.1093/rheumatology/keq282
3. Overman CL, Kool MB, Da Silva JAP, Geenen R. The prevalence of severe fatigue in rheumatic diseases: an international study. Clin Rheumatol. 2016;35(2):409-15. DOI:10.1007/s10067-015-3035-6
4. Pollard LC, Choy EH, Gonzalez J, et al. Fatigue in rheumatoid arthritis reflects pain, not disease activity. Rheumatology. 2006;45(7):885-9. DOI:10.1093/rheumatology/kel021
5. Druce KL, Jones GT, Macfarlane GJ, Basu N. Patients receiving anti-TNF therapies experience clinically important improvements in RA-related fatigue: Results from the British Society for Rheumatology Biologics Register for Rheumatoid Arthritis. Rheumatol (Oxford). 2015;54(6):964-71. DOI:10.1093/rheumatology/keu390
6. Gossec L, Steinberg G, Rouanet S, Combe B. Fatigue in rheumatoid arthritis: Quantitative findings on the efficacy of tocilizumab and on factors associated with fatigue. The French multicentre prospective PEPS study. Clin Exp Rheumatol. 2015;33(5):664-70
7. Krupp LB, LaRocca NG, Muir-Nash J, Steinberg AD. The fatigue severity scale. Application to patients with multiple sclerosis and systemic lupus erythematosus. Arch Neurol. 1989;46(10):1121-3. DOI:10.1001/archneur.1989.00520460115022
8. Ream E, Richardson A. Fatigue: A concept analysis. Int J Nurs Stud. 1996;33(5):519-29. DOI:10.1016/0020-7489(96)00004-1
9. Nordin Å, Taft C, Lundgren-Nilsson Å, Dencker A. Minimal important differences for fatigue patient reported outcome measures-a systematic review. BMC Med Res Methodol. 2016;16(1):62.DOI:10.1186/s12874-016-0167-6
10. Meade T, Manolios N, Cumming SR, et al. Cognitive Impairment in Rheumatoid Arthritis: A Systematic Review. Arthritis Care Res (Hoboken). 2018;70(1):39-52. DOI:10.1002/acr.23243
11. Nikolaus S, Bode C, Taal E, van de Laar MAFJ. Fatigue and Factors Related to Fatigue in Rheumatoid Arthritis: A Systematic Review. Arthritis Care Res (Hoboken). 2013;65(7):1128-46.DOI:10.1002/acr.21949
12. Matcham F, Ali S, Hotopf M, Chalder T. Psychological correlates of fatigue in rheumatoid arthritis: A systematic review. Clin Psychol Rev. 2015;39:16-29. DOI:10.1016/j.cpr.2015.03.004
13. Van Dartel SAA, Repping-Wuts JWJ, Van Hoogmoed D, et al. Association between fatigue and pain in rheumatoid arthritis: Does pain precede fatigue or does fatigue precede pain? Arthritis Care Res. 2013;65(6):862-9. DOI:10.1002/acr.21932
14. Grøn KL, Ørnbjerg LM, Hetland ML, et al. The association of fatigue, comorbidity burden, disease activity, disability and gross domestic product in patients with rheumatoid arthritis. Results from 34 countries participating in the Quest-RA programme. Clin Exp Rheumatol. 2014;32(6):869-77
15. Novaes GS, Perez MO, Beraldo MBB, et al. Correlation of fatigue with pain and disability in rheumatoid arthritis and osteoarthritis, respectively. Rev Bras Reumatol. 2011;51(5):447-55. DOI:10.1590/S0482-50042011000500005.
16. Rongen-van Dartel SAA, Repping-Wuts H, Donders R, et al. A multidimensional “path analysis” model of factors explaining fatigue in rheumatoid arthritis. Clin Exp Rheumatol. 34(2):200-6. DOI: 27049923
17. Feldthusen C, Grimby-Ekman A, Forsblad-D’Elia H, et al.Explanatory factors and predictors of fatigue in persons with rheumatoid arthritis: A longitudinal study. J Rehabil Med. 2016;48(5):469-76. DOI:10.2340/16501977-2090
18. Żołnierczyk-Zreda D, Jędryka-Góral A, Bugajska J, et al.The relationship between work, mental health, physical health, and fatigue in patients with rheumatoid arthritis: A cross-sectional study. J Health Psychol. 2020;25(5):665-73. DOI:10.1177/1359105317727842
19. Silva CFR, Duarte C, Ferreira RJO, et al. Depression, disability and sleep disturbance are the main explanatory factors of fatigue in rheumatoid arthritis: a path analysis model. Clin Exp Rheumatol. 2020;38(2):314-21.
20. Druce KL, Basu N. Predictors of fatigue in rheumatoid arthritis. Rheumatology. 2019;58(Suppl.5):29-34. DOI:10.1093/rheumatology/kez346
21. van Hoogmoed D, Fransen J, Bleijenberg G, van Riel P. Physical and psychosocial correlates of severe fatigue in rheumatoid arthritis. Rheumatology (Oxford).2010;49(7):1294-302. DOI:10.1093/rheumatology/keq043
22. Olsen CL, Lie E, Kvien TK, Zangi HA. Predictors of Fatigue in Rheumatoid Arthritis Patients in Remission or in a Low Disease Activity State. Arthritis Care Res. 2016;68(7):1043-8. DOI:10.1002/acr.22787
23. Druce KL, Jones GT, MacFarlane GJ, Basu N. Determining pathways to improvements in fatigue in rheumatoid arthritis: Results from the British Society for Rheumatology Biologics Register for rheumatoid arthritis. Arthritis Rheumatol. 2015;67(9):2303-10. DOI:10.1002/art.39238
24. Druce KL, Bhattacharya Y, Jones GT, et al. Most patients who reach disease remission following anti-TNF therapy continue to report fatigue: Results from the British Society for Rheumatology Biologics Register for Rheumatoid Arthritis. Rheumatol (Oxford). 2016;55(10):1786-90. DOI:10.1093/rheumatology/kew241
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26. Aletaha D, Neogi T, Silman AJ, et al. 2010 Rheumatoid arthritis classification criteria: An American College of Rheumatology/European League Against Rheumatism collaborative initiative. Arthritis Rheum. 2010;62(9):2569-81. DOI:10.1002/art.27584
27. Nasonov EL. Rheumatology. Russian Clinical Guidelines. Moscow: GEOTAR-Media, 2017 (in Russian).
28. Amirdzhanova VN, Koilubaeva GN, Goriachev DV, et al. Validatsiia russko-iazychnoi versii Health Assessment Questionnaire (HAQ). Nauchno-prakticheskaia revmatologiia. 2004;(2):59-64 (in Russian)
29. Fransen J, van Riel PLCM. The Disease Activity Score and the EULAR Response Criteria. Rheum Dis Clin North Am. 2009;35(4):745-57. DOI:10.1016/j.rdc.2009.10.001
30. van Gestel AM, Prevoo ML, van ’t Hof MA, et al. Development and validation of the European League Against Rheumatism response criteria for rheumatoid arthritis. Comparison with the preliminary American College of Rheumatology and the World Health Organization/International League Against Rheumatism Criteria. Arthritis Rheum. 1996;39(1):34-40. DOI: 10.1002/art.1780390105
31. Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand. 1983;67(6):361-70. DOI: 10.1111/j.1600-0447.1983.tb09716.x
32. Hamilton M. The assessment of anxiety states by rating. Br J Med Psychol. 1959;32(1):50-5. DOI: 10.1111/j.2044-8341.1959.tb00467.x
33. Montgomery SA, Asberg M. A new depression scale designed to be sensitive to change. Br J Psychiatry. 1979;134:382-9. DOI: 10.1192/bjp.134.4.382
34. Luria AR. Higher cortical functions of a person and their disorders in local brain lesions. 2nd ed. Moscow: MGU, 1962 (in Russian)
35. Khersonskii BG. The method of pictograms in the psychodiagnostics of mental illness. Kiev: Health, 1988 (in Russian)
36. Zejgarnik BV. Pathology of Thinking. 2nd ed. Moscow: MGU, 1962 (in Russian)
37. Almanac of Psychological Tests. 3rd ed. Moscow: KSP, 1995 (in Russian)
38. Rubinstein SYa. Experimental methods of pathopsychology and experience of their application in the clinic. Ed. Butenko G. Moscow: Publishing house of the Institute of Psychotherapy, 2010 (in Russian)
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40. Gerasimov AN. Medical Statistics: a tutorial. Moscow: Med. inform. agency, 2007 (in Russian)
41. Choy EH. Effect of biologics and targeted synthetic disease-modifying anti-rheumatic drugs on fatigue in rheumatoid arthritis. Rheumatol (Oxford). 2019;58(Suppl. 5)V51-5. DOI:10.1093/rheumatology/kez389
42. Chauffier K, Salliot C, Berenbaum F, Sellam J. Effect of biotherapies on fatigue in rheumatoid arthritis: A systematic review of the literature and meta-analysis. Rheumatology. 2012;51(1):60-8. DOI:10.1093/rheumatology/ker162
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1 ФГБНУ «Научно-исследовательский институт ревматологии им. В.А. Насоновой», Москва, Россия;
2 Московский научно-исследовательский институт психиатрии – филиал ФГБУ «Национальный медицинский исследовательский центр психиатрии и наркологии им. В.П. Сербского» Минздрава России, Москва, Россия;
3 ФГАОУ ВО «Российский национальный исследовательский медицинский университет им. Н.И. Пирогова» Минздрава России, Москва, Россия;
4 ФГАОУ ВО «Первый Московский государственный медицинский университет им. И.М. Сеченова» Минздрава России (Сеченовский Университет), Москва, Россия
*79096237832@ya.ru
________________________________________________
Anton A. Abramkin*1, Tatiana A. Lisitsyna1, Dmitrii Yu. Veltishchev2,3, Olga F. Seravina2, Oksana B. Kovalevskaya2, Svetlana I. Glukhova1, Evgeny L. Nasonov1,4
1 Nasonova Research Institute of Rheumatology, Moscow, Russia;
2 Moscow Research Institute of Psychiatry – branch of the Serbsky National Medical Research Center of Psychiatry and Narcology, Moscow, Russia;
3 Pirogov Russian National Research Medical University, Moscow, Russia;
4 Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
*79096237832@ya.ru