In patients with rheumatoid arthritis (RA), the diagnostic performance of screening instruments for depression was good, while screening instruments for anxiety were more variable, according to study results published in Arthritis Care & Research.

Previous studies reported higher rates of depression and anxiety in patients with RA, compared with the general population. As there are limited data on the diagnostic performances of available tools for assessing depression and anxiety in RA, the goal of the current study was to investigate the validity, reliability and optimal cut point of multiple screening instruments for mental disorders for patients with RA.

The study cohort included adults with RA, recruited through the Arthritis Centre clinic in Winnipeg, Manitoba, and through community clinics between November 2014 and July 2016.

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Each participant completed the Patient Health Questionnaire (PHQ-2 or PHQ-9), the Patient Reported Outcomes Measurement Information System depression short form 8a and anxiety short form 8a, the Hospital Anxiety and Depression Scale anxiety score (HADS-A) and depression score (HADS-D), the Overall Anxiety Severity and Impairment Scale, the Generalized Anxiety Disorder 2-and 7-item scales, and the Kessler-6 scale.

Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Axis I Disorders (SCID-1) research version was used as the criterion standard to confirm clinical depression and anxiety disorders in the study participants.

The study included 150 participants (127 women, mean age 59.8 years) who completed the SCID-1 shortly after enrollment. Using the criterion standard of the SCID-1 to confirm clinical diagnosis, the prevalence of current depression was 11.3%, prevalence of generalized anxiety disorder was 7.3%, and prevalence of any anxiety disorder was 19.3%.

For depression, Kessler-6 scale and the HADS-D (cut point ≥ 11) had the lowest sensitivity (35% for both) and the highest specificity (96% and 94%, respectively). Sensitivity was highest for the PHQ-2 (88%) and PHQ-9 (87%), with specificity of 84% and 77%, respectively.

For anxiety, sensitivity was highest for the HADS-A with a cut point ≥ 11 points (91%), and lowest for HADS-A with a cut point ≥ 8 points. While the specificity was lowest for the former (45%), it was the highest for the latter (91%).

All depression and anxiety instruments had acceptable internal consistency and reliability. For depression instruments, internal consistency ranged between 84% to 97% and the test-retest reliability interclass correlation coefficient ranged between 84% and 88%. For anxiety instruments, internal consistency ranged between 69% to 93% and the test-retest reliability interclass correlation coefficient ranged between 69% and 83%.

Based on the area under the curve, the diagnostic performances of all the depression and anxiety instruments were remarkably similar. While the diagnostic performance for depression was generally good, it was not excellent (area under the curve <0.90). The diagnostic instruments for anxiety were less accurate than those for depression; performance was better for identifying generalized anxiety disorder than for any anxiety disorder.

The study had several limitations, among them are the inclusion of patients from the same region indicating that the findings may not apply to other settings, limited access to biologic therapies and mental health support, potential participant bias, and potential limitations due to administration of multiple instruments at the same time.

“[T]he optimal choice of screening instrument, and optimal cut point, may vary depending on the situation and purpose of administration. Regardless, incorporation of screening tools for depression and anxiety into clinical practice may improve outcomes for patients with RA,” wrote the researchers.


Hitchon CA, Zhang L, Peschken CA, et al. Validity and reliability of screening measures for depression and anxiety disorders in rheumatoid arthritis. Arthritis Care Res (Hoboken). 2020;72(8):1130-1139.