WITHDRAWN - Patient Perspectives on case-finding for Anxiety and Depression in patients with Rheumatoid Arthritis: a qualitative study

Problem

Rheumatoid arthritis (RA) is a common inflammatory arthritis with systemic features. Co-morbid anxiety and depression are frequent, but often under-recognised and under-treated, and can contribute to poor treatment response, and worse physical outcomes.

The NICE quality standard for the management of RA (QS33) recommends that patients with RA should be offered an annual review. A nurse-led review clinic for patients with established RA, was piloted in a community hospital; the review included case-finding questions for anxiety and depression.

Approach

A qualitative study to explore patients' perspectives of the clinic and experiences of being asked the case-finding questions for anxiety and depression (GAD2 and PHQ2). Ethical approval was obtained.

A purposive sample of patients attending the clinic who scored positively on the case-finding questions, were invited to participate in a face-to-face interview. The topic guide explored the impact of RA, links between RA and mood, acceptability of the case-finding questions and preferences for discussion about mood. Interviews were digitally recorded with consent, and anonymised. Transcripts formed the data which were analysed thematically using principles of constant comparison, followed by use of the candidacy framework of Dixon-Woods.

Findings

Most patients recognised the negative impact of RA on their mood and found the case-finding questions acceptable. Anxiety or depression were perceived variably to be either secondary to RA or completely separate. Some perceived RA flares to be triggered by worsening mood, thus affecting help-seeking.

Several patients reported having sufficient rapport with their doctor (GP or Rheumatologist) to access care and disclose psychological problems, whilst others reported prior negative experiences of attempting to discuss mood problems with their doctor, who was described as being ‘too busy’ dealing with physical complaints, or not responsible for psychological problems. Along with reported poor continuity of care, these perceptions recursively affected help-seeking.

Patients reported trusting the clinic nurse, who was perceived to have more time to listen to psychosocial concerns and more able to give advice on potential treatments for mood problems, including having a knowledge of local services.

Consequences

Patients with RA and co-morbid anxiety and depression recognise the impact of joint pain and loss of function on their mood, but prior experiences lead them to feel they do not have candidacy for care from their GP or Rheumatologist. A case-finding approach within a nurse-led annual review, where the patient has a good relationship with the nurse, who is perceived to be responsive to discussion of psychological symptoms, could improve recognition of anxiety and depression in people with RA. Signposting to appropriate services for treatment could improve physical and mental health outcomes in people with RA.