Depression symptoms are associated with key health outcomes in women with fibromyalgia: a cross-sectional study

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ORIGINAL ARTICLE Depression symptoms are associated with key health outcomes in women with fibromyalgia: a cross-sectional study 6Jes! us del POZO-CRUZ, 1 Rosa M. ALFONSO-ROSA, 1 Alejandro CASTILLO-CUERVA, 1 Borja SA~ NUDO, 1 Paul NOLAN 2 and Borja del POZO-CRUZ 2 1 Department of Physical Education and Sports, University of Seville, Seville, Spain, and 2 Department of Sport and Exercise Science, University of Auckland, Auckland, New Zealand Abstract Aim: To analyze the association between depression severity and other fibromyalgia- (FM) related symptoms such as pain, fatigue, sleep problems, severity of the disease, activity pattern, functional capacity and quality of life. Method: The sample included 105 Spanish women with FM. Quality of life was assessed by means of the EQ- 5D and symptom severity by the Fibromyalgia Impact Questionnaire. Pain, fatigue and unrestful sleep problems were assessed using 0–10 Visual Analog Scales. Activity patterns were determined by using the International Physical Activity Questionnaire while a battery of standardized field-based functional capacity tests was used to assess cardiorespiratory fitness, muscular strength, flexibility, agility and static and dynamic balance. Depression level was assessed and categorized according to the Beck Depression Inventory. Results: Sixty-two percent of the participants were depressed. Depressed patients exhibited higher pain, fatigue level, sleep problems and severity of the symptoms, reduced levels of lower limb strength and physical activity time and worse quality of life when compared with non-depressed patients (P<0.05). A negative relationship was found between total minutes of physical activity (P=0.001) and caloric expenditure (P=0.026), lower flexibility (P=0.005), hand grip strength (P=0.026) and lower limb strength (P<0.001). A positive relationship was detected between depression and total sitting time (P=0.018). These results were maintained when correlations were adjusted for body mass index. Conclusions: Depressed women with FM exhibited higher symptom severity and reported worse physical fitness and quality of life than their non-depressed peers. Key words: depression, fibromyalgia, pain, physical activity, physical fitness, quality of life. INTRODUCTION People with fibromyalgia (FM) are characterized by diffuse and widespread musculoskeletal pain 1 which may influence their daily activities. FM significantly reduces health-related quality of life (HRQoL) compared to healthy people 2,3 and people with other rheumatic diseases. 4 FM also contributes to large medical, social and labor costs, resulting in a large impact on society. 5,6 A P L 12564 Dispatch: 14.12.14 CE: Indumathi S. Journal Code Manuscript No. No. of pages: 11 PE: Krishnaveni A Correspondence: Borja del Pozo-Cruz, PhD, Department of Sport and Exercise Science, University of Auckland, Building 731 room 340, Tamaki Innovation Campus, 261 Morrin Rd, St Johns, Auckland, Private Bag 92019, Auckland, New Zealand. Email: [email protected]c.nz 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 ©2014 Asia Pacific League of Associations for Rheumatology and Wiley Publishing Asia Pty Ltd International Journal of Rheumatic Diseases 2014 The specific symptoms of FM (i.e., pain, fatigue or sleep problems) contribute to people with FM being less physically active than their peers without FM. As a result, people with FM tend to have decreased physical fitness for their age 7 and are closer to that of healthy older adults. 8 Additionally, symptoms of depression are common in people with FM. Research shows that the prevalence of mood disorders, including depression, is more than three times higher in FM subjects than in the general population. Depression symptoms appear to increase sensitivity to pain. 9 Although the underlying mechanism mediating depression and pain is not fully understood, different studies support the idea that different brain regions (including the limbic and paralimbic areas) mediate in both conditions and that a bidirectional relationship between pain and depression exists, with the symptoms of one worsening the other or making the other more likely to develop. 10 Multidisciplinary interventions, including psychological treatment, have been shown to be effective in improving FM-related outcomes and fitness. 11 Depression symptoms appear to increase the sensitivity to pain, 9 leading to reduced physical activity levels and physical function. However, the relationship between depression symptoms and the total amount of physical activity, physical function and FM-related problems is not fully understood. Therefore, the aim of this study was to examine the association of depression symptoms with activity patterns, functional capacity, symptom severity, pain, fatigue, sleep disturbance and quality of life among a sample of women with FM. PATIENTS AND METHODS Participants and study design A cross-sectional study was conducted. Participants in the study were recruited from two local FM associations (Seville, Spain). Researchers contacted the chairperson in each association and informed this person about the study. The chair of each association informed the associated members about the study and the individual members contacted the researchers if they were interested in participating in the study. Potential participants were included in the study if they were diagnosed as having FM by a rheumatologist according to the American College of Rheumatology criteria (1990 criteria) 12 and gave informed consent after receiving detailed information about the aims and study procedures. Exclusion criteria were: having any other rheumatic disease, history of cognitive impairment, severe heart, liver or kidney disease. In addition, those who answered ‘yes’ to any question on the Physical Activities Readiness Questionnaire (indicating a possible contraindication for physical fitness testing) 13 were also excluded from the study. The study was approved by the Ethics Committee of the University of Seville and was conducted following the ethical guidelines of the Declaration of Helsinki. Out of 125 initial volunteers, 105 participants were finally included in the study. Fifteen participants were excluded because they had other rheumatic diseases and five of them were excluded because they were not diagnosed with FM. Material and procedures A general standardized questionnaire was used to collect socio-demographic (i.e., age, educational level, occupational status and income) and clinical data (i.e., number of drugs taken for FM and years since clinical diagnosis) of the participants in the study. Weight, height, and waist and hip circumference were measured so that body mass index (BMI, kg/m 2 ) and waist-to-hip ratio could be calculated. Body-fat percentage was estimated using a handheld impedance analyzer (Omron BF-306, Omron Healthcare Europe BV, Hoofddorp, the Netherlands) according to the manufacturer0s instructions. 14 During the measurement the instrument records impedance from hand to hand to calculate body fat percentage from the impedance value and the pre-entered personal values, including weight, height, age and sex. To obtain information on activity patterns, the International Physical Activity Questionnaire (IPAQ) was used. 15 The short (self-administered, seven items), last-week version of the IPAQ was administered, asking about the time spent being physically active in the last 7 days. Minutes of sitting, walking, moderate-intensity (walking not included) and vigorous-intensity activities were computed so the total metabolic equivalents of task (MET) were calculated as follows: (daily minutes of walking 9days per week with walking 93.3) +(daily minutes of moderate-intensity activity 9days per week with moderate-intensity activity 94.0) +(daily minutes of vigorous activity 9days per week with vigorous activity 98.0). To assess functional capacity, a battery of fitness tests previously validated in females with FM was used. 16 This battery included the assessment of the cardiorespiratory function, upper and lower body muscular strength, upper and lower body flexibility and static and agility/dynamic balance. The physical fitness tests studied were as follows. 2International Journal of Rheumatic Diseases 2014 J. del Pozo-Cruz et al. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 To assess cardiorespiratory function, the 6-min walking test was used. 17 Participants were instructed to walk as far as they could at a fast, comfortable pace in 6 min. The maximum distance (m) walked was recorded as the score of the test. Participants were discouraged from talking during the test and were notified of each passing minute. A hand grip strength test was used to assess upper body muscular strength. 18 This test was conducted with a digital dynamometer (TKK 5401 Grip-D, Takei Scientific Instruments, Tokyo, Japan). The participants maintained the standard bipedal position during the entire test with the arm in complete extension. Each participant performed the test twice with each hand allowing a 1-min rest period between measures. The peak value was recorded for each trial. The best value of two trials was chosen as score of the test for each arm (dominant and nondominant arm) and an average score of both hands was computed as final hand grip score. The 30-sec sit to stand (30s-STS) test was used to assess lower body strength. 17 Participants were instructed to perform the task starting and finishing in the seated position. Participants were allowed a practice trial before the beginning of the test. The number of times within 30 sec that the participant could raise to a full stand from a seated position with back straight and feet flat on the floor without pushing off the arms was counted. Upper-body flexibility was assessed by the ‘back scratch’ test. 17 This test was assessed twice, alternately with both hands, and the best value was recorded. The average of both hands was used in the analysis. The modified chair sit and reach test (CST) was used to assess lower body flexibility. 17 A ruler was used to measure the distance between the end of the third digit of the hand and the toes. This value is negative if the fingertip does not reach the toes and positive if fingertip passes the toes. Both sides were measured twice and the maximal score from each leg was recorded. The final score was the average score of both sides. Motor agility/mobility was assessed by the timed up and go (TUG) test. 17 The participant had to stand up from a chair, walk 2.44 m to and around a cone, and return to the chair in the shortest possible time. The best time of two trials (1-min rest period between each trial) was recorded. The Fibromyalgia Impact Questionnaire (FIQ) assessed participants’ severity of symptoms. This is a reliable and valid questionnaire for the measurement of health status and physical function in Spanish-speaking FM patients, and it has been shown to be responsive to change. 19 The FIQ total score ranges from 0 to 100 with a higher value indicating a greater impact of the disorder. 20 The Visual Analog Scale (VAS) was used for pain assessment (VAS pain ). The VAS pain is a widely used pain evaluation instrument based on a straight line (10 cm long), scaled from 0 to 10, on which the patient marks the intensity of his or her pain. This scale has been also used and validated in FM patients, showing a good reliability and discriminatory power. 21 Another two validated VAS were used for fatigue (VAS fatigue ) 22 and unrestful sleep (VAS unrestful sleep ). 23 The Euroqol-5D (EQ-5D) 24 was used to assess participants’ HRQoL. The EQ-5D-3L includes five dimensions (mobility, personal care, usual activities, pain/discomfort and anxiety/depression), each of which has three levels (no problems, some problems or extreme problems/unable to), answers ranging from 1 to 3. The juxtaposition of the levels for these five dimensions correlates to a five-digit number, which reflects 243 possible health status values. These health status values can be converted to a health functional index or a ‘utility’, using time-trade off values (EuroQol utility ;1=full functional quality of life, 0 =death). The EQ-5D-3L also includes a vertical 20-cm VAS which is used by participants to rate their own health between 0 (worst imaginable health state) and 100 (best imaginable health state), thereby providing an overall numerical estimate of their HRQoL. 25 The Spanish 21-item Beck Depression Inventory (BDI) version was used for depression assessment. 26,27 The BDI is a 21-question multiple-choice self-report inventory, each of which has four brief statements corresponding to normal responses and to mild, moderate and severe depressive symptoms. Respondents choose the statement, scored from 0 to 3, which best describes their feelings over the previous week. Total score is obtained from the sum of the different values across all questions and patients are graded with different depression symptoms. When patients score 17 to 20 points in the BDI, they are considered clinically depressed. The BDI, previously used in FM patients, 28 has shown to be a sensitive measure for depressive symptoms and is simple to administer and code, thus showing good psychometric properties. 26 Statistical analysis The SPSS package version 17.0 for Windows (SPSS Inc., Chicago, IL, USA) was used for data analysis. The level of significance was set at P≤0.05 for all statistical analyses performed. Kolmogorov–Smirnov test was International Journal of Rheumatic Diseases 2014 3 Depression and health in fibromyalgia 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 used to determine the distribution characteristics of the variables. Data are presented as mean (!SD), unless otherwise stated. Student’s t-test for independent measures (parametric variables) or Mann–Whitney U- test (non-parametric variables) were performed to analyze differences between depression-based groups for continuous variables and Chi-square test was used to test these differences for categorical variables. Accordingly, with the distribution of data, the association between depression and functional capacity was assessed using Pearson0s correlation coefficients, while the association between depression and activity patterns was analyzed using Spearman’s correlation coefficients. As BMI was expected to influence FM-related outcomes, partial correlations adjusted for BMI were also performed. 29 The level of relationship was determined based on the recommendations of Cohen: 30 a coefficient of between 0.1 and 0.29 was considered low; a coefficient between 0.3 and 0.49 was considered moderate; and more than 0.5 was considered high. Additionally, we performed linear regression analyses to get a better understanding of the associations between depression and the main study variables. RESULTS Out of 105 women with FM assessed in this study, 62% reported to be clinically depressed according to the BDI. The mean age of participants was 55 (!9) years, hence, similar to the age of the general Spanish FM population. 31 The majority of the participants were married (63%), working (31%) and reported to have reached primary school studies (41%). The mean BMI was 29.1 (!8.1) kg/m 2 and had an average body fat percentage of 40% (Table 1). Table 2 describes the level of functional capacity, the activity patterns and the quality of life across the two groups of depression symptoms. Participants reporting clinical depression symptoms exhibited lower-limb body strength (P=0.012) than non-clinically depressed participants. Depressed participants also exhibited lower upper-limb body strength scores than their peers without clinical depression symptoms; however, this was not statistically significant (P=0.089). As shown by Pearson0s correlation coefficient, there were inverse relationships between depression symptoms and upper- (r="0.243/P=0.026) and lower- (r="0.425/P<0.001) limb strength and with lower-limb flexibility (r="0.304/P=0.005) (Fig. 1). With the exception of lower-limb body flexibility, these relationships were maintained when correlation analyses were controlled by BMI (upper [r="0.268/P=0.025] and lower [r="0.382/P=0.001] limb strength). Similarly, depressed FM participants displayed lower levels of physical activity (P=0.049) and caloric expenditure (P=0.027) when compared with nondepressed participants (Table 2). In addition, an inverse relationship between depression and the amount of physical activity level and a direct relationship between depression symptoms and sitting time (q=0.335/ P=0.001) (Fig. 1) was found. After correction for BMI, depression symptoms were related to total caloric expenditure (r="0.306/P=0.010) along with the total amount of physical activity (r="0.248/ P=0.037). However, the relationship between depression and sitting time was not present after corrections for BMI (P>0.05). Table 1 Characteristics in women with fibromyalgia (n=105) Variable Total sample (n=105) Age (years) 55.26 (9.34) Years since clinical diagnosis 9.23 (6.20) Number of drugs for fibromyalgia (median IQR)† 1 (2) Body composition BMI (kg/m 2 ) 29.07 (8.11) Body fat (%) 39.60 (6.75) WHR 0.88 (0.07) Marital status, n(%) Unmarried 16 (17.80) Married 57 (63.30) Widowed 8 (8.90) Divorced 6 (6.70) Separated 3 (3.30) Occupational status, n(%) Housewife 22 (24.40) Working 28 (31.10) Unemployed 14 (15.60) Retired 26 (28.90) Educational status, n(%) Unfinished studies 27 (30.00) Primary school 37 (41.10) Secondary school 11 (12.20) University degree 15 (16.70) Income per month, n(%) <1200 € 1 75 (83.30) 1201–1800 €10 (11.10) >1800 €5 (5.60) Values are means (standard deviation), unless otherwise indicated. FM, fibromyalgia; BMI, body mass index; WHR, waist-to-hip ratio; VAS: visual analog scale from 0 to 10; IQR, interquartile range; †painkillers, antidepressants and sleeping pills. 4International Journal of Rheumatic Diseases 2014 J. del Pozo-Cruz et al. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 Clinically depressed FM participants showed lower self-reported quality of life as measured with VAS (0.047) (Table 2) and higher self-reported severity of the symptoms (P<0.001), pain (P<0.001), fatigue (P=0.027) and sleep problems (P=0.002) than those without clinical depression symptoms (Fig. 2). According to the linear regression analysis, 30% of the total variance in depression symptoms is associated with: strength (upper and lower) and agility/dynamic balance; 7% with total caloric expenditure; 33% with self-care and anxiety/depression EQ-5D dimensions; 39% with severity of the symptoms; 12% with pain or restful sleep problems; and 11% with fatigue. The final regression model depicts that self-care and anxiety/ depression dimensions and severity of the symptoms account for 51% of the total depression symptoms variance (Table 3). DISCUSSION The current study shows that Spanish women with FM who have clinical depression according to the BDI report lower levels of quality of life, physical fitness (especially muscle strength), greater amounts of sitting time and are less physically active than their non-clinically depressed peers. Moreover, symptom severity is increased with higher levels of depression. Although small, the study sample was equally distributed among depressed symptoms groups, thus allowing for making proper comparisons between groups. The fact that 62% of our sample reported to be clinically depressed and 41% of our participants had completed primary school level study may reflect what other studies have shown in this regard, 10,32 Table 2 Physical function, activity patterns and quality of life by depression status groups (n=105) Variables Clinical depression FM group (n=60) Non-clinical depression FM group (n=45) P Physical function Cardiorespiratory function (6-min waking test, m) 416.63 (83.60) 427.37 (57.65) 0.549† Muscular function Upper body (handgrip strength, kg) 17.28 (4.99) 19.40 (5.62) 0.089† Lower body (30-s chair-to-stand test, number of stands) 7.72 (2.44) 9.30 (2.75) 0.012† Flexibility Upper body (back-scratch test, cm) "5.66 (10.76) "5.03 (7.80) 0.782† Lower body (chair sit-and-reach test, cm) "5.70 (14.68) "2.67 (14.06) 0.369† Balance Static (30-s blind flamingo test, failures) 9.78 (5.74) 7.74 (7.19) 0.187† Dynamic/agility (time up-and-go test, s) 6.80 (1.86) 6.99 (1.84) 0.650† Activity patterns (IPAQ) Total minutes of physical activity (min) 46.83 (43.21) 71.84 (57.84) 0.049† Total caloric expenditure (MET/min) 699.68 (479.81) 1213.05 (1076.61) 0.027† Total sitting time (min) 365.00 (215.28) 302.00 (180.50) 0.213† Quality of Life (EQ-5D) VAS (0–100 mm) 43.86 (20.16) 52.27 (14.93) 0.047† EQ-5D UTILITY 0.50 (0.25) 0.51 (0.23) 0.850† Values are means (standard deviation). FM, fibromyalgia; IPAQ, International Physical Activity Questionnaire; PA, physical activity; MET, Metabolic equivalent of task; EQ-5D, European quality of life questionnaire; VAS (0–100 mm), Visual Analog Scale from the EQ-5D where lower results represent a worse quality of life; P,P-value from Student’s t-test for independent measurements†or Mann–Whitney U-test‡. International Journal of Rheumatic Diseases 2014 5 Depression and health in fibromyalgia 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 It has been suggested that depression may be responsible for an increase in sensory amplification in FM, that may contribute to physical and pain comorbidities in people exhibiting higher depression symptoms. 9 Our results demonstrate that depressed participants selfreported more pain than those without depression. This is an important finding as physical activity and sedentary behaviors seem to be related to central nervous system regulation of pain in FM. 33 In this study, the depressed FM participants exhibited lower levels of physical activity, thus had a lower caloric expenditure than their non-depressed FM peers. This is consistent with previous research where correlations have been established between the amount of physical activity and BDI scores. 34 Therefore, it is important to identify people with FM who exhibit depression symptoms as they are more likely to be less physically active. This is especially important as people with FM are often Figure 1 4 Correlation between functional capacity (chair sit-to-stand test, 6-min walking test, time up-and-go test, hand grip, back-scratch test, chair sit-and-reach test and flamingo test), physical activity (min/week and total METs), sitting time (min/week) and depression (BDI). BDI, Beck Depression Inventory; MET, metabolic equivalent of task; r, Person correlation coefficient; rho, Spearman correlation coefficient. LOW RESOLUTION FIG 6International Journal of Rheumatic Diseases 2014 J. del Pozo-Cruz et al. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51