Anxiety, depression and quality of life in a group of rheumatic patients after joining a web-based self-help community
anxiety, community, depression, internet, rheumatoid arthritis
F Ursini. Anxiety, depression and quality of life in a group of rheumatic patients after joining a web-based self-help community. The Internet Journal of Rheumatology. 2008 Volume 6 Number 1.
Rheumatic diseases are chronic conditions that can have a profound influence on the psychological status of the patient. Depression is at least two times more common in rheumatic patients than in general population 1 and it’s estimated that major depressive disorder affects between 13% and 17% of patients with rheumatoid arthritis 23. In common with other painful conditions, depression associated with rheumatoid arthritis is often considered to result from the experience of chronic pain 4, and pain have a predictive value in the risk of developing depression 5. On the opposite, depression can affect pain perception 6 and the general clinical course of the disease 7. Other factors leading to depression are degree of physical disability 8, disease activity 9, and duration of disease 10. Also anxiety have been studied in rheumatic patients. Levels of anxiety are elevated in rheumatic patients and often coexist with depression 11, infact those with rheumatoid arthritis have a 4-fold probability to suffer from anxiety disorders than control 12.
Patients And Methods
For the present study 34 rheumatic patients with different diseases (RA, spondyloarthritis, SLE, other connectivitis, vasculitis) were recruited thanks to the collaboration with the italian patient association ReumAmici. This association owns a website that patients can join and therefore participate in the community activities, especially in communicating through a patient web forum.
Four different questionnaires exploring physical and mental health were administered to all patients at time 0 (before joining the website) and after 3 months of active and continuous participation to the community activities: SF-36, HAQ, Zung self-rated anxiety scale and Zung self-rated depression scale. All the questionnaires were submitted by email and self-reported by the patients.
SF-36 questionnaire 13 was used to evaluate the Quality of Life (QoL) of the patients. This survey contains 36 questions that evaluate eight health domains in both physical health and mental health. These eight domains are physical functioning (PF, ten items), social functioning (SF, two items), role limitations caused by physical problems (RP, four items), role limitation caused by emotional problems (RE, three items), mental health (MH, five items), energy and vitality (VT, four items), pain (BP, two items), and general perception of health (GH, five items). For each item score are collected and transformed to a scale from 0 (worst possible health state) to 100 (best possible health state). The italian form of SF-36 questionnaire was used 14.
HAQ questionnaire 15 was used to assess physical function of the patients. This questionnaire was developed as a comprehensive measure of outcome in patients with a wide variety of rheumatic diseases including RA, osteoarthritis, SLE, ankylosing spondylitis, fibromyalgia and psoriatic arthritis. The HAQ contains 20 items distributed across 8 components. The scores for each item range from 0 (without any difficulty) to 3 (unable to do). The highest score on any item within one component represent the dimension score. The patient also indicates wether he or she uses aids or devices or help from other individuals. The scores for each dimension are corrected for the use of aids or devices, summated, and transformed to give an overall disability index (DI) score between 0 (no disability) and 3 (very severe disability). The italian form of HAQ questionnaire was used 16.
The Zung self-rating anxiety scale 17 was used to assess level of anxiety of the patients. It is a 20-item scale, with some of the items keyed positively and some negatively. The items are answered on a four-point scale ranging from 1 (none or a little of the time) to 4 (most or all of the time). The final score range from 20 to 80. A score between 20 and 44 is considered in the normality range, while a higher score indicate at least mild-moderate symptoms of anxiety. Italian translation of the original scale was used.
The Zung self-rating depression scale 18 was used to assess level of depressive symptoms of the patients. It is a self-reported 20-item scale, where items responses are ranked from 1 (none or little of the time) to 4 (most or all of the time). Some of the items are worded positively and other are worded negatively. The final score range from 25 to 100. A score between 25 and 49 is considered in the normality range, while a higher score indicate the presence of at least mild-moderate depressive symptoms.
Data in table are presented as mean ± standard deviation. Paired t-test was used to compare the scores before and 3 months after joining the web-community. A P-value of <0.05 was considered significant.
General characteristic of the patients are summarized in Table 1. We recruited 34 patients of which 8 were male and 26 female. Mean participation time to the community was 6 days a week, 2 hours a day.
In figure 1 and table 2 are showed scores for SF-36 questionnaire, before and 3 months after joining the ReumAmici community. Mean score in vitality and mental health domains were significantly higher after 3 months, while there were no significant differences in other domains of the scale.
In figure 2 and table 3 are showed scores for HAQ questionnaire, before and 3 months after the intervention. HAQ global health scale was significantly improved after 3 months, while there were no significant differences in HAQ Disability Index and in visual Pain scale.
In figure 3 and table 4 are showed scores for Zung self-rated anxiety scale, before and 3 months after joining the website. Levels of anxiety detected 3 months after the intervention were significantly lower than before. In figure 4 and table 5 are showed scores for Zung self-rated depression scale. Also depressive symptoms were significantly improved 3 months after joining the website.
Here we have shown that participating in a web-based self-help community can greatly help rheumatic patients ad improve quality of life and symptoms of anxiety and depression. Anxiety and depression are common problems among rheumatic patients and by themselves negatively affect the quality of life. Self-help communities are powerful tools for improving quality of life and disease control in many chronic diseases, such as type II diabetes or cancer. However physical limitations in rheumatic patients can negatively affect their ability to join face-to-face standard self-help group, and, in this case, internet can greatly improve the communication ability of the high-disability rheumatic patients.
Participating in a web-based self-help community can positively affect the general health of the rheumatic patients and reduce levels of anxiety and depression. Further studies, with larger number of patients and appropriate control group, should be performed to validate this finding and to compare the effectiveness of web-based groups with that of standard face-to-face self-help groups.