title: Burden of depressive symptoms in South African public healthcare patients with established rheumatoid arthritis: a case-control study.
abstract: OBJECTIVE
  The burden of depressive symptoms and how demographic and disease characteristics relate to depressive symptoms in patients with rheumatoid arthritis (RA) that belong to developing populations, are currently unknown and were therefore assessed in a case-control study in public healthcare patients in South Africa, a lower-middle income country. Public healthcare attendance is a surrogate of belonging to the developing population in South Africa.
  
  
  METHODS
  Demographic and RA features were recorded in 441 public and 202 private healthcare patients. The outcome characteristic was the Arthritis Impact Measure Scales (AIMS) depression score. Relationships of patient characteristics and public healthcare attendance with depressive symptoms were determined in multivariable regression models.
  
  
  RESULTS
  The mean ± SD AIMS depression score was 3.6±2.1 and 2.3±1.7 in public and private healthcare patients, respectively (p<0.0001 before and after adjustment for covariates). Physical disability was associated with depressive symptoms in both healthcare sectors. Other characteristics that were related to depressive symptoms comprised younger age, male sex and pain in public healthcare patients and fatigue and non-use of disease modifying agents in private healthcare patients. In all patients, public healthcare attendance (standardised ß [95% CI]=0.22 [0.12, 0.32], p<0.0001) and physical disability (standardised β [95% CI]=0.25 [0.16, 0.34], p<0.0001) were most strongly associated with depressive symptoms.
  
  
  CONCLUSIONS
  The burden of depressive symptoms is markedly enhanced in our developing population with RA, independent of age, sex, ethnic origin and disease characteristics. In this setting, the role of social factors should be assessed and, despite restricted resources, depressive symptoms should be routinely addressed.
authors.affiliation: Department of Rheumatology, University of the Witwatersrand and Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa.
authors.forename: A
authors.initials: A
authors.lastname: Solomon
authors.forename: B F
authors.initials: BF
authors.lastname: Christian
authors.forename: A J
authors.initials: AJ
authors.lastname: Woodiwiss
authors.forename: G R
authors.initials: GR
authors.lastname: Norton
authors.forename: P H
authors.initials: PH
authors.lastname: Dessein
mesh_terms: D000328:Adult; D000368:Aged; D001172:Arthritis, Rheumatoid / Q000150:complications* / Q000208:ethnology / Q000523:psychology*; D016022:Case-Control Studies; D017281:Cost of Illness; D003430:Cross-Sectional Studies; D003863:Depression / Q000453:epidemiology* / Q000208:ethnology; D005260:Female; D006296:Health Services; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D012044:Regression Analysis; D012307:Risk Factors; D013019:South Africa / Q000453:epidemiology