Analyses from a state-based telephone survey of noninstitutionalized US adults found that 13.4 % of individuals aged 45 and over with self-reported arthritis experienced more than 14 mentally unhealthy days in the past month (Strine et al., 2004). Other studies have demonstrated that individuals with arthritis have around a 2–3-fold increase in the odds of reporting depressive and anxiety symptoms when compared with the general population (Murphy et al., 2012; Shih et al., 2006). Dunlop, Lyons, Manheim, Song, and Chang (2004), using data from a population-based cohort of men and women aged 54–65 (n = 7825), have suggested that as much as 18 % of experienced major depression may be attributed to having arthritis. However, these figures are dependent upon the populations studied and the measures utilized.

Specifically, in RA, prevalence of depression ranges from 13 to 20 % when focused on psychiatric assessment or clinical diagnosis (Dickens, McGowan, Clark-Carter, & Creed, 2002; Hyrich et al., 2006) and exceeds 50 % when based on self-report screening tools (El-Miedany & El-Rasheed, 2002). Particularly, a study of 238 Norwegian patients with clinically diagnosed early RA (≤4 years duration) found that 20 % had scores on the Arthritis Impact Measurement Scale (AIMS), indicating possible psychiatric disturbance (Smedstad, Moum, Vaglum, & Kvien, 1996). While less examined than that of RA, depression in OA has also been reported at elevated levels when compared to the general population. A 10-year study of 6153 consecutive RA outpatients found that 20 % fulfilled criteria for ‘probable’ depression, while 16.8 % of individuals with OA of the knee or hip, and 14.3 % with OA of the hand, were found to experience ‘probable’ mental distress (Hawley & Wolfe, 1993). However, slightly higher depression figures for men and women with OA (according to American College of Rheumatology criteria) were reported in a German primary care sample (19.4 %) (Rosemann, Laux, & Szecsenyi, 2007). Likewise, in a recent small clinical study (n = 86), Marks found in men and women (≥60 years) with radiographic and clinical evidence of mild to moderate knee OA that approximately 28 % of the sample were classified as having ‘possible depression’ based on The Center for Epidemiological Studies-Depression (CES-D), while 21 % had nonclinically validated moderate to severe depression.

While anxiety has been less frequently studied in isolation from depression, current research suggests that between 21 and 70 % of individuals with arthritis experience heightened levels of anxiety (El-Miedany & El-Rasheed, 2002; Murphy, Creed, & Jayson, 1988). In particular, Lok, Mok, Cheng, and Cheung (2010), in their examination of rheumatology outpatients with median disease duration of 4 years, found the point prevalence of anxiety disorders (based on the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition criteria) to be 13.0 %, with generalized anxiety disorder the most common.

Although considerable overlap between depression and anxiety has been noted in arthritis populations (Murphy et al., 2012), conjecture exists regarding the relative burden of depression compared to anxiety. While Isik, Koca, Ozturk, and Mermi (2007) reported a significantly higher prevalence of depression compared to anxiety in their small study (n = 82) of consecutive RA patients (41.5 % with depression alone vs. 13.4 % with anxiety alone), Harris, Loxton, Sibbritt, and Byles (2012) argued that anxiety may be a primary and somewhat overlooked concern. In a representative sample of older Australian women, the diagnosis of an anxiety/nervous disorder was the only significant psychosocial factor associated with arthritis following the adjustment for demographic characteristics and health-related quality of life. This finding is supported by previous case–control and clinic-based research (El-Miedany & El-Rasheed, 2002; Hawley & Wolfe, 1988; Odegard, Finset, Mowinckel, Kvien, & Uhlig, 2007; Soderlin et al., 2000), in conjunction with the recent population-based study conducted by Murphy et al. (2012). While one-third of respondents with arthritis reported experiencing either anxiety or depression, the authors noted that anxiety was twice as common as depression (31 % vs. 18 %) and depression was contingent upon the presence of anxiety (84 %). Moreover, El-Miedany and El Rasheed (2002) noted in their Egyptian outpatient study (n = 80) that 63.4 % of women with arthritis experienced depression, while an even greater proportion reported anxiety (66.2 %).

Taken together, these findings suggest that affective disturbance may have important implications over the disease course. It is important to note, however, that findings from a prospective study involving individuals with RA suggest that the prevalence or severity of depression is not dissimilar to individuals with other chronic diseases (Hawley & Wolfe, 1993) and, as such, may be related to reduced quality of life and not a function of the disease per se (Courvoisier et al., 2012; Hawley & Wolfe, 1993).

Despite its slow development, arthritis is progressive in nature and eventually leads to joint destruction, significant loss of function, and reduced health-related quality of life in many patients (Hill et al., 2007; Peters, Sanders, Dieppe, & Donovan, 2005; van Dijk, Dekker, Veenhof, & van den Ende, 2006; Zochling, Stucki, Grill, & Braun, 2007). Findings from the Centers for Disease Control and Prevention (2005) in the USA have indicated that one in three individuals with arthritis report activity limitations as a result of their condition. Findings confined to OA populations have revealed that 80 % of people experience limitations in movement, with 25 % unable to perform major daily activities (WHO Scientific Group, 2003). Further, approximately 10 % of people aged over 60 are disabled as a result of the disease (Buckwalter et al., 2004), with increased levels associated with concomitant disease (Marks & Allegrante, 2002). Similar findings have been reported with respect to RA. Severe functional decline has been noted in 10 % of individuals within 2 years, and up to half of persons with RA are work- disabled within 10 years of diagnosis (Sokka, Kautiainen, Mottonen, & Hannonen, 1999; Wolfe & Hawley, 1998).

In a cross-sectional clinical study of 111 adults with RA, Covic, Adamson, and Hough (2000) found that physical disability was predictive of depression (as measured by the AIMS) and was mediated by psychosocial factors including passive coping and helplessness. Likewise, Margaretten et al. (2009) identified a significant relationship between physical disability and increased depressive symptomatology in their socioeconomic and ethnically diverse RA cohort (n = 174). Specifically, univariate analyses revealed no significant demographic differences between patients reporting depression (measured by the Patient Health Questionnaire 9) and those that did not. Of the clinical features, only physical functioning (measured by the Health Assessment Questionnaire; p < 0.001), disease activity (measured by RA-specific Disease Activity Score in 28 [DAS28] joints; p = 0.04), along with lower use of disease-modifying antirheumatic drugs (p = 0.03) were significant predictors. When these variables were entered into the multivariate model, however, only physical functioning remained significant (p < 0.001). In this multivariate model, a reduction in depressive symptoms was noted for individuals of Asian or Pacific Islander origin (p = 0.02). This finding is supported by another rheumatological outpatient study (El-Miedany & El-Rasheed, 2002). While it was found that functional disability was the only clinical predictor of depression, the authors were able to demonstrate disparate clinical profiles for depression and anxiety. Anxiety was associated with joint tenderness and stiffness, short disease duration, as well as rheumatoid factor and nodules. This finding however, contrasts with that of Ho, Fu, Chua, Cheak, and Mak (2011) who found that among consecutive patients at a University-based hospital (n = 100), while rheumatoid factor and biological indicators of disease activity were significant in univariate analyses, the effect disappeared in the multivariate model. In this study, rheumatoid factor was associated with depressive symptoms only.

On the other hand, a two-year longitudinal study of individuals (n = 227) with early stage RA (i.e., ≤4 years duration) examined predictors of change in depression and anxiety symptoms at both 1 and 2 years (Smedstad et al., 1997). With depression (measured using the AIMS) as the outcome, it was found in multivariate analyses that 1- and 2-year change in depression scores was predicted by level of disability. Serologic indicators of disease activity such as erythrocyte sedimentation rate (ESR) , along with joint tenderness and pain levels, failed to predict the relationship. Importantly, previous depression scores also predicted depression. When cross-lagged analyses were conducted in an attempt to determine causality between the variables of interest, the only significant finding was related to depression at 1 year. High levels of disability at baseline predicted depression at time one. This effect, however, was not sustained at 2-year follow-up. In contrast, no disease-related factors were found to predict 1- and 2-year change in anxiety scores. Previous anxiety levels were the only predictor of future anxiety.

Moreover, in a nationally representative sample of US noninstitutionalized civilians, Godha, Shi, and Mavronicolas (2010) found a strong relationship between RA functional limitation severity and depression. In particular, after controlling for the confounding effects of age, physical activity, and comorbidities, patients belonging to Class II (i.e., able to perform usual self-care and vocational activities, but limited in avocational activities such as recreational activities and/or leisure; and activities related to work, school, and homemaking) were almost four times more likely to have a high tendency toward depression compared to Class I (i.e., completely able to perform usual activities of daily living such as self-care, vocational, and avocational). Meanwhile the odds of depression increased substantially (OR = 5.92) for those in Class III (i.e., able to perform self-care, but limited in vocational and avocational activities) compared to Class I. It is important to note that older age and level of physical activity were associated with a reduction in depression.

While clinical expression and progression of arthritis are highly variable, particularly for RA, with the disease course marked by periods of exacerbations and remissions (Australian Institute of Health and Welfare, 2005), pain and joint stiffness have been identified as key indicators of arthritis. Pain, in particular, is often a common reason individuals seek medical attention (Gureje, Von Korff, Simon, & Gater, 1998).

In a longitudinal examination of clinically important predictors of self-reported depressive symptoms (evaluated using the mental health component score of the Medical Outcomes Study Short Form-36 [SF-36]) in 29,524 adults aged 18 and over with rheumatic disease, Wolfe and Michaud (2009) found that 9-year incidence of depression was in the vicinity of 40 %. When RA was specifically examined, those with depression were found to be characteristically different from those without depression on a range of sociodemographic, psychological, and disease-related indicators. Using Random Forest analyses, however, the authors identified factors associated with disease severity, that is, symptom intensity (measured as a combination of the fatigue component of the Visual Analog Scale [VAS] and Regional Pain Scale [i.e., painful nonarticular joint count]), pain and global severity (measured by the VAS), and fatigue, as well as disease comorbidity to classify patients with depressive symptoms. Despite this, when recursive partitioning was applied to the data, only symptom intensity was necessary to identify participants with depressive symptoms. In addition, the cumulative impact of this indicator of disease severity was found to contribute to mortality over the study period.

Further, in a longitudinal study of 15,282 patients with RA, pain was found to account for 44 % of the variance associated with psychological functioning (as measured by the mental health component of the SF-36) (Courvoisier et al., 2012). More specifically, multivariate analyses found that pain explained 60 % of the variance associated with the stable part of psychological functioning over the study period. In this analysis, disease activity and functional disability also contributed to psychological functioning. When the variable part of psychological functioning was assessed, only pain remained as the significant explanatory variable, explaining 5 % of the variance. Moreover, in the Norton study (described in the section above) (Norton et al., 2011), the four psychological trajectories over the 3-year study period were found to be related to self-reported disease severity. Those that had high levels of depression, either high stable or high decreasing, were found to have higher levels of disease severity at baseline compared to those with low-stable or low-increasing depression. Importantly, key serological markers of inflammation, ESR and C-reactive protein (CRP) failed to predict psychological functioning over time. Interestingly, disease severity indicators were also the difference between those with high levels of depression that remained stable over the course of the study compared to those that saw improvements in mental health.

The experience of fatigue is also common to both RA and OA. Although the prevalence has varied according to the measurement used and level of active disease present, it has been suggested that up to 93 % of individuals with OA or RA experience fatigue (Belza, 1995; Wolfe, Hawley, & Wilson, 1996). When clinically significant levels of fatigue have been investigated however, this figure approaches 50 % (Wolfe et al., 1996). Moreover, haematological manifestations have been found to be prominent in arthritis, particularly in RA subpopulations. The prevalence of mild anemia in RA has ranged from 33 to 60 % (Wilson, Yu, Goodnough, & Nissenson, 2004). Wolfe and Michaud (2006) found that mild anemia (as defined by the World Health Organization) was present in 31.5 % of participants with RA, with lifetime prevalence being in the vicinity of 50 %. Using discriminant analysis, Covic et al. (2006) identified 12 specific predictors that were able to correctly classify the majority of participants (80 %) in their rheumatological sample (n = 134) based on depression status. Fatigue was found to be the strongest clinical predictor of depression (loading = 0.57), followed by pain (loading = 0.55) and physical disability (loading = 0.44). Despite this, psychological factors, particularly tension and self-esteem, were the strongest overall predictors of the relationship (loadings = 0.73). Likewise, in a large convenience community sample (n = 200) of older adults with RA (mean age 66.7 years), Franklin and Harrell (2013) examined the unique effect of pain and fatigue on depression. In this study, functional impairment accounted for a significant amount of the variance associated with depressive symptoms (β = 0.47; ). Importantly, pain did not contribute to the relationship between RA and depression following control for demographics and functional impairment. After controlling for demographics, functional impairment, and pain, fatigue was found to contribute 10 % unique variance to the RA–depression relationship.

Depending upon the variables included in the analyses, sociodemographic variables have been inconsistently linked to poor psychological adjustment to arthritis. In particular, various studies have suggested that age (particularly at diagnosis) (Patten, Williams, & Wang, 2006; Ramjeet, Koutantji, Barrett, & Scott, 2005), gender (Marks, 2013; Ramjeet et al., 2005; Theis, Helmick, & Hootman, 2007), education (Mella, Bertolo, & Dalgalarrondo, 2010), and marital status (Katz & Yelin, 1993; Strine et al., 2004) are important indicators. For instance, Strine et al. (2004), in their examination of Behavioral Risk Factor Surveillance System data, found that frequent mental distress in arthritis was associated with female gender, lower education (noncompletion of high school), marital status (previously married), younger age, ethnicity (Hispanic), and employment status. It is important to note, however, that disease-related and psychological factors were not controlled for in this study. Mella et al. (2010), on the other hand, found education to be the only demographic predictor of depressive symptoms, alongside levels of disease activity and functional impairment. In their longitudinal analysis of Swedish primary care patients (n = 158) however, Persson et al. (2005) noted that higher risk of distress was associated with younger age, female gender, and a number of psychosocial factors, including lower social support and higher distress at baseline.

Psychological vulnerability has been found to impact future levels of psychological distress. Importantly, previous levels of depression or anxiety have been found to be key predictors of short-term psychological functioning in arthritis (Smedstad et al., 1997). In a small study (n = 22) of individuals with early RA, Sharpe and colleague found that initial levels of depression consistently predicted between 37 and 58 % of the variance attributed to psychological functioning over time. In this study, coping strategies were found to predict psychological functioning in the early stages of the disease, accounting for 9 % and 5 % of the variance at times two and three, respectively. Interestingly, while disability predicted psychological functioning at all follow-up time points (i.e., 2–6), joint function improved despite decreases in mood.

Additionally, in a 2-year longitudinal study of RA, Sinclair and Wallston (2010) identified that the construct psychological vulnerability (measured by Psychological Vulnerability Scale) added 9.3 % unique variance to concurrent depressive symptoms, beyond that of personal control factors such as helplessness and functional impairment. Meanwhile, lower psychological vulnerability contributed 5.6 % unique variance to depressive symptoms 1 year later. In this analysis, age and disease comorbidity failed to predict changes in depressive symptoms (measured by the CES-D). The authors argued that this suggests that these factors do not confound the relationship between psychological vulnerability and psychological distress in arthritis.

Further, while stress and its role in arthritis will be discussed in detail in Chap. 5, it is an important predictor of long-term psychological functioning in arthritis populations. In a study of Irish women (n = 59) with established RA (mean age = 60 years) attending an outpatient clinic, it was found that perceived stress was associated with affective disturbance at 1-year follow-up (Curtis, Groarke, Coughlan, & Gsel, 2004). Correlational and hierarchical regression analyses revealed that psychological stress was the best predictor of depression and was a better predictor than disease severity on measures of positive and negative emotionality. Treharne, Lyons, Booth, and Kitas (2007) provided additional support for the significant impact of perceived stress on mental health outcomes in arthritis. In their longitudinal study involving 134 U.K. outpatients with RA, the authors found that perceived stress had the strongest relationship with psychological well-being at baseline and perceived stress had an impact on anxiety levels at 6 month follow-up.

Coping efforts have been suggested as key factors in developing a sense of control and mastery over chronic illness (Dager, Kjeken, Fjerstad, & Hauge, 2012; Shaul, 1995). Studies focused on RA subpopulations have consistently demonstrated that coping strategies employed by an individual in response to arthritis-related symptoms such as pain have a significant impact on psychological and physical health outcomes (Brown, Nicassio, & Wallston, 1989; Covic, Adamson, Spencer, & Howe, 2003; Covic et al., 2006). The majority of this research has generally concentrated on assessing the way individuals manage chronic pain according to the dichotomous problem-focused and emotion-focused approaches (or variants thereof, e.g., active vs. passive coping) proposed by Lazarus and Folkman (1987). Particularly, Curtis, Groarke, Coughlan, and Gsel (2005) found that although perceived stress was associated with affective disturbance and was the best predictor of depression in 59 Irish RA outpatients, the use of avoidant coping efforts (i.e., efforts to distract from, or avoid the stressor) contributed to the prediction of negative affect. These findings were supported in a 12-month follow-up study of this cohort of women (Curtis et al., 2004). Similarly, passive coping with pain has also been found to increase depression at 6-month follow-up. This finding, however, was specific to those with RA experiencing greater pain (Brown et al., 1989).

Previously, emotion or passive-based approaches to coping have generally been regarded as maladaptive. Snow-Turek, Norris, and Tan (1996) indicated that passive, maladaptive coping approaches have qualities that outweigh the benefits of active coping. These approaches have been previously associated with increased arthritis pain, disability, and depression in comparison to individuals who employ problem-based (or active) coping strategies (Brown, Wallston, & Nicassio, 1989; Covic et al., 2000, 2003; Evers, Kraaimaat, Geenen, Jacobs, & Bijlsma, 2003; van Lankveld, Naring, van’t Pad Bosch, & van de Putte, 2000). However, a Canadian longitudinal qualitative study involving three time points (Melanson & Downe-Wamboldt, 2003) found that older men and women with RA (n = 39) used a variety of strategies (i.e., confrontive, palliative, supportant, fatalistic, self-reliant, evasive, optimistic, and emotive) in order to adjust. Meanwhile, Gignac, Cott, and Badley (2000), using content analysis, noted that Canadian community-dwelling older adults with OA (n = 286) employed 13 distinct behavioral efforts in order to adapt to their condition. These coping efforts concerning ‘selection’ (i.e., performing activities less often), ‘optimization’ (i.e., augmenting or enriching reserves to enable continued functioning), ‘compensation’ (i.e., substituting activities), and ‘receiving help’ were integral to perceptions of dependence (or independence) and facilitated psychological adjustment. Another study utilizing a narrative biographic approach, found that Austrian RA outpatients (n = 10) described their experience as positive, with the disease seen as a challenge and facilitator of personal growth (Stamm et al., 2008).

Importantly, a recent systematic review examining the longitudinal association between coping and psychological adjustment in RA found limited evidence that passive or disengaging coping strategies such as helplessness, avoidance, and wishful thinking were prospectively associated with increased psychological distress (Vriezekolk, van Lankveld, Geenen, & van den Ende, 2011). It was also noted that there was no evidence for active or engagement-style coping (e.g., problem-solving, emotional regulation, distraction, and cognitive restructuring) playing a role in the improvement of psychological distress long-term. Therefore, coping strategies may play more of a role in understanding psychological functioning in the early stages of disease only.

Others (e.g., Gronning, Lomundal, Koksvik, & Steinsbekk, 2011) have suggested that adjusting to a chronic illness is a dynamic process, influenced not only by the disease but by the individual’s life circumstances and personal resources. This finding is supported by a recent qualitative study of older Australian women with OA (Harris, Byles, Sibbritt, & Loxton, 2015). In this study it was found that psychological adjustment over time was similar to that of RA and was attributed primarily to cognitive and attitudinal factors such as stoicism, making downward comparisons, and cognitive reappraisal. This was a dynamic “day-to-day” process involving a constant struggle between grieving physical losses and increasing dependence amidst symptom management. Therefore, adopting a balanced or flexible coping approach may be the key to long-term psychological adjustment to chronic diseases such as arthritis (Masuda et al., 2011).

Social support has been found to have direct and moderating effects (through the stress response) on the relationship between arthritis and psychological functioning (Brown et al., 1989; Dekkers et al., 2001; Evers, Kraaimaat, Geenen, & Bijlsma, 1997). Social support can be defined as the existence or perceived availability of people who care about an individual and whom they can rely on when needed (Ethgen et al., 2004). In a Dutch study of 229 randomly selected RA outpatients, the support of a spouse was found to be a significant predictor of lower depression and anxiety of individuals with RA (Kraaimaat, Van Dam-Baggen, & Bijlsma, 1995). Evers et al. (1997) found that recently diagnosed Dutch RA outpatients (n = 91) who had smaller networks (i.e., quantity of social support) experienced greater psychological maladjustment in their first year after diagnosis compared to those with a larger network. An analysis of data from an international longitudinal cohort study (Demange et al., 2004) found that RA patients (n = 542) who received more social support (i.e., perceived satisfaction with support given) or had a larger social network had better functional and psychological adjustment over time. However, it has been argued that the perceived availability and quality of the support received may be more important than the size of an individual’s network (Leskela et al., 2006). Perceived social support, in particular, has been found to be beneficial for both physical and psychological outcomes in arthritis (Demange et al., 2004; Ethgen et al., 2004; Ferreira & Sherman, 2007; Sherman, 2003). Ferreira and Sherman (2007) and Sherman (2003) found that perceived social support was associated with reduced depressive symptoms in older adults with OA.

Personality-based characteristics have been found to influence the way in which individuals appraise a given situation and the selection of coping strategies (either adaptive or maladaptive) (Folkman & Greer, 2000). A longitudinal study of Dutch outpatients with early RA (n = 78) found that neuroticism (i.e., the tendency to be relatively more tense and emotionally unstable) at diagnosis was the most consistent and effective predictor of increased psychological distress (depression and anxiety) at both 3- and 5-year follow-up (Evers et al., 2002). Further, Scheier and Carver (1987) and Scheier, Weintraub, and Carver (1986) have posited that an optimistic life approach may play a protective role in chronic disease, facilitating the choice of disease-related coping strategies and engagement in health behaviors. Optimism has been positively associated with psychological well-being (both cross-sectionally and prospectively) (Brenner, Melamed, & Panush, 1994; Fournier, de Ridder, & Bensing, 2002; Long & Sangster, 1993) and health-related quality of life (Allison, Guichard, & Gilain, 2000; Carver et al., 1994; Scheier et al., 1989) and inversely with symptom expression (Achat, Kawachi, Spiro, DeMolles, & Sparrow, 2000; Ferreira & Sherman, 2007; Scheier & Carver, 1985). Additionally, it is suggested that individuals with an optimistic outlook employ problem-based coping in response to situations appraised as controllable, and emotion-based strategies aimed at harm minimization in response to situations appraised as uncontrollable (Scheier et al., 1986). Similarly, a U.K. longitudinal study of 134 RA outpatients (predominantly women) identified pessimism as a predictor of increased anxiety at baseline and increased depression, anxiety, and decreased life satisfaction at 6-month follow-up (Treharne et al., 2007). Individuals who reported greater levels of optimism reported better adjustment in terms of anxiety at baseline and depression at 1-year follow-up.