憂鬱症是膝關節炎疼痛的獨立危險因子


  【24drs.com】南韓的研究人員發現,並存憂鬱症是經放射診斷證實罹患輕中度膝關節炎患者之疼痛的獨立預測因子。
  
  資深作者Tae Kyun Kim醫師表示,並存憂鬱症對膝關節炎(KOASs)的影響幾乎等於放射診斷看到的嚴重度;這樣的發現對輕中度膝關節炎來說特別重要,罹患輕中度膝關節炎卻有不合理或持續症狀的患者,應考量憂鬱症的可能性。
  
  Kim醫師與首爾國立大學盆唐醫院的同事們,在觀察膝關節炎高齡患者的放射診斷與疼痛程度差異後進行這項研究,他們在3月16日線上發表的文章以及3月份的骨與關節外科期刊上解釋,這代表關節炎患者的疼痛感覺會受到骨關節損傷以外的因子影響;因為憂鬱症在高齡患者身上並不罕見,研究人員懷疑這可能解釋部分差異。
  
  這些患者來自韓國健康與老化縱向研究,這是一項以群眾為基礎、前瞻性世代研究,針對高齡韓國人的健康、老化與常見的高齡疾病進行研究。在1,000位研究自願者中,660位(368位女性、292位男性)完成膝部放射診斷,以西安大略與曼徹斯特大學骨關節炎指標、以及憂鬱症的診斷訪談。這些患者都是65歲以上、平均年齡為71.5歲,平均身體質量指數為24.3 kg/m2。
  
  西安大略與曼徹斯特大學骨關節炎指標系統是個包括24項問題的問卷,評估疼痛、僵硬程度與功能。最高的分數是96分;有症狀的膝關節炎定義為至少39分以上。病患也完成一項短版的36分評估健康相關生活品質的問卷。
  
  在660位患者中,556位是KOAS陽性、104位是KOAS陰性。KOAS陽性的患者,相較於KOAS陰性對照組,年紀較大(P<0.001),比較可能是女性(P<0.001),且身體質量指數比較高(P<0.05)。他們的憂鬱症盛行率是26.9%,KOAS陽性患者則是5.8%(P<0.001)。KOAS陽性患者在短版36的生活品質也比較差,且有較多的憂鬱症狀(兩者的P<0.001)。
  
  作者們指出,在邏輯氏迴歸分析中,有憂鬱症狀與KOAS陽性之間的勝算比為5.87(95%信賴區間[CI]為3.01-11.44)。然而,憂鬱症的影響限制在放射診斷嚴重度輕到中度患者;克葛蘭-勞倫斯等級(一種放射線檢驗嚴重度)0到1分的患者,有憂鬱症的勝算比為2.97(95% CI為1.04-8.47),2或3分患者則是72.08(95% CI為8.88-584.77)。憂鬱症並未與克葛蘭-勞倫斯等級4以上的KOAS陽性風險增加有關。
  
  Kim醫師表示,他們的發現支持並存憂鬱症解釋了放射診斷嚴重度及症狀嚴重度之間差異的假設。
  
  舊金山加州大學風濕免疫學助理教授Mary Margaretten醫師指出,關節炎患者經常有憂鬱的問題,且比一般大眾更為常見;令人驚訝的是,KOA越嚴重,並未與憂鬱症有關,但也許是相較於輕中度患者,放射診斷(KOA)更嚴重的患者隨著時間過去有一套應付機轉,而這是輕中度患者還沒有學到的。
  
  未參與這項研究的Margaretten醫師表示,關節炎與憂鬱之間的關係可以是並行的。與關節炎有關的疼痛及失能可以造成憂鬱症狀,但憂鬱症也可能造成患者的疼痛感覺。她提醒,由於這是項斷面性研究,憂鬱與關節炎造成膝疼痛之間的因果關係無法確認。
  
  Kim醫師的結論是,當KOA患者有不明原因的持續疼痛,臨床醫師應考量患者是否有並存憂鬱症,特別是罹患輕中度關節炎的患者;應針對這些患者篩選是否並存憂鬱症,或諮詢精神科專家決定應考慮的最佳治療選擇。
  
  資料來源:http://www.24drs.com/professional/list/content.asp?x_idno=6485&x_classno=0&x_chkdelpoint=Y
  

Depression Independent Risk Factor for Pain With Knee Arthritis

By Norra MacReady
Medscape Medical News

March 22, 2011 — Coexisting depression is an independent predictor of pain among people with radiographic evidence of mild to moderate osteoarthritis of the knee, researchers in South Korea have found.

"The contribution of comorbid depression to knee osteoarthritis symptoms [KOASs] is almost equal to that of radiographic severity," senior author Tae Kyun Kim, MD, told Medscape Medical News. "As this finding is particularly important for mild to moderate knee osteoarthritis, due consideration for the presence of depression should be given to patients who suffer irrationally severe or persistent symptoms from mild to moderate knee osteoarthritis."

Dr. Kim and his colleagues at Seoul National University Bundang Hospital in Seongnam, South Korea, decided to conduct their study after observing that elderly people with knee arthritis show a substantial disparity between radiographic findings and reported pain levels. This suggests that "the perception of pain in arthritis is influenced by factors other than the degree of osteoarthritic joint damage," they explain in an article published online March 16 and in the March issue of the Journal of Bone and Joint Surgery. Because depression is common in elderly people, the researchers suspected it might account for some of that discordance.

The patients were participants in the Korean Longitudinal Study on Health and Aging, a population-based, prospective cohort study on health, aging, and common geriatric illnesses seen in elderly Koreans. Of the 1000 study volunteers, 660 (368 women and 292 men) had completed a radiographic examination of the knee, symptom evaluation using the Western Ontario and McMaster Universities Osteoarthritis Index, and diagnostic interviews for depression. The patients all were aged 65 years or older, with a mean age of 71.5 years and a mean body mass index of 24.3 kg/m2.

The Western Ontario and McMaster Universities Osteoarthritis Index system consists of a 24-item questionnaire that evaluates pain, stiffness, and function. The highest possible score is 96; symptomatic knee osteoarthritis is defined as a score of at least 39. Patients also completed a short-form 36 scale that assessed health-related quality of life.

Of the 660 patients, 556 were KOAS-positive, and 104 were KOAS-negative. KOAS-positive patients were older (P < .001), more likely to be female (P < .001), and had a higher body mass index (P < .05) than their KOAS-negative counterparts. Their prevalence of depressive disorders was 26.9% compared with 5.8% in the KOAS-negative patients (P < .001). KOAS-positive patients also had a poorer health-related quality of life on the short-form 36, and more depressive symptoms (P < .001 for both).

On logistic regression analysis, the presence of depressive symptoms was associated with an odds ratio of 5.87 (95% confidence interval [CI], 3.01 - 11.44) of being KOAS-positive, the authors report. "However, the influence of a depressive disorder was limited to subjects with a radiographic severity of minimal to moderate; the odds ratio for the presence of a depressive disorder was 2.97 (95% CI, 1.04 to 8.47) in patients with a Kellgren-Lawrence grade [a measure of radiographic severity] of 0 or 1, and 72.08 (95% CI, 8.88 to 584.77) in those with a Kellgren-Lawrence grade of 2 or 3." Depressive disorders were not associated with an increased risk of being KOAS-positive in participants with a Kellgren-Lawrence grade of 4.

"Our findings support the hypothesis that comorbid depression explains the discordance between radiographic severity and symptomatic severity," Dr. Kim said.

"Depression is common in patients with arthritis, and much more prevalent than in the general population," said Mary Margaretten, MD, assistant professor of medicine in the Division of Rheumatology at the University of California–San Francisco. "It is surprising that more severe [KOA] is not associated with depression, but perhaps patients with severe radiographic [KOA] have developed coping mechanisms over time that the patients with more mild and recent arthritis have not yet learned.

'The relationship between arthritis and depression can certainly go both ways," said Dr. Margaretten, who was not involved in this study. "The pain and disability associated with arthritis can contribute to depressive symptoms, and just as possible, depression can contribute to a patient's perception of pain." She warned that "since this is a cross-sectional study, causality between depression and knee pain from arthritis cannot be determined."

Clinicians should suspect comorbid depression in patients with KOA whenever the symptoms seem unaccountably severe or persistent, especially when the arthritis is mild to moderate, Dr. Kim concluded. "For those patients, screening for the presence of comorbid depression or consultation with a psychiatrist to determine optimal treatment should be considered."

This study was supported by grants from Pfizer Global Pharmaceuticals and Seongnam City Government in Korea. One or more authors received funding support from Pfizer Global Pharmaceuticals and from the Seongnam City Government in Korea. Dr. Margaretten has disclosed no relevant financial relationships.

J Bone Joint Surg. 2011;93:556-563.

    
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