Impact of Psychosocial Factors Highlighted Regarding Psoriatic Arthritis Joint Pain

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Individuals with a history of depression and psoriatic arthritis (PsA) more frequently report persistent pain in their joints following initiation of treatment compared to individuals without such a mental health history, according to recent findings.¹

These findings aligned with prior research studies on comorbid depression and remission of PsA. This new research was conducted to assess the drivers of persistent joint pain among individuals that have seemingly-controlled inflammation following treatment.

This research letter was led by Rebecca H. Haberman, MD, MSCi, of the division of rheumatology at NYU Grossman School of Medicine in New York. Haberman and colleagues acknowledged prior studies had indicated that up to 50% of PsA patients continued to experience residual pain even if their inflammation is controlled.²

“We hypothesize that it is driven primarily by noninflammatory causes, such as psychologic distress, fatigue, and sleep disturbance,” Haberman and colleagues wrote. “Here we aimed to define the prevalence and clinical characteristics of noninflammatory persistent joint pain in patients with PsA.”

Background and Methods

The investigators included a set of 121 consecutive participants in their research from the New York University (NYU) Psoriatic Arthritis Center (PAC) in the observational cohort. Their cohort was titled the NYU Psoriatic Arthritis Center (PAC) Cohort and was made up of subjects who were shown to meet the CASPAR criteria for PsA.

The Center itself was noted by the research team to have been collecting data since January 2015. The team gathered various data from the available electronic medical records (EPIC1), some of which included psoriatic disease characteristics, comorbidities, demographics, and patient-reported outcomes (PROs).

The team had implemented a specialized PsA-specific template for their search and the data points had been entered into a REDCap database. The investigators ended up using distinct cross-sectional and longitudinal populations in their research.

In the research team’s cross-sectional analysis, they looked at the results of 121 adult subjects that met the CASPAR criteria for PsA and were enrolled between March - July 2023. Some of the PROs that the team looked into included Psoriatic Arthritis Impact of Disease (PsAID)-12, RAPID, and PROMIS-10 scores, with this search evaluating elements such as subjects’ reports of fatigue, pain, functional capacity, and general mental health conditions.

In the investigators’ longitudinal analysis, there were 143 PsA patients with new diagnoses, and these subjects had had at least a single follow-up meeting ≥3 months following their first assessment. The team used ICD codes and patient reports to determine levels of depression and anxiety.

Findings

Overall, the investigators reported that 21.5% had been shown to have active disease and 78.5% reported no signs of swollen joints or signs of active synovitis during their physical assessments. Among the subjects without swollen joints, 73.7% were in full remission and 26.3% reported persistent pain in their joints.

Similar demographic data, characteristics of disease, and prevalence of fibromyalgia were observed by the research team in those with persistent pain versus subjects shown to be in full remission. Despite these facts, the former group of individuals were shown to have worse physician global assessment scores versus those in remission (2.5 compared to 1.4, P < .001) and rises in depression, fatigue, anxiety, struggles with coping, effects on their professional and social lives, and disturbances in sleep.

The investigators also identified lower global mental health scores among participants that were shown to have persistent pain (49.9 versus 45.2, P = .02), and this suggested mental health struggles. They were also able to find a moderate correlation between the number of reported tender joints and function, fatigue, difficulties with coping, disturbance in sleep, and general anxiety, and a weak link with depression.

In the research team’s secondary cohort of 143 individuals with new diagnoses of PsA, there were 28 who ended up having persistent pain in their joints following the initiation of their treatment. The team found that elements such as self-reported depression (odds ratio [OR] 2.45, 95% CI 0.92-6.50) and tender and swollen joint count increase differences at the point of baseline (OR 1.09, 95% CI 0.99-1.20) were shown to be predictive of persistent pain later on.

In the study’s conclusion, the investigators found that among those with an absence of objective inflammation, there were up to a quarter with persistent pain that had continued on, and this was found to be linked to substantial effects on several different elements of life and mental health. Comorbid depression was also found by the team to be a substantial factor contributing to persistent joint pain in PsA following their treatment.

“Understanding the modulators of residual joint pain is of critical importance to improve outcomes in PsA,” they wrote. “In patients initiating their second or later biologic, only a minority will remain on the drug and achieve remission. Although this may reflect treatment-resistant PsA, alternatively, it may also represent failure to differentiate between true inflammatory pain and pain perpetuated by other, noninflammatory factors.”

References

1. ^{Haberman RH, Zhou YY, Catron S, et al. Psychosocial Factors Significantly Contribute to Joint Pain Persistence in Psoriatic Arthritis. J Rheumatol. 2024;51(3):318-320. Published 2024 Mar 1. doi:10.3899/jrheum.2023-0909.}
2. ^{Kilic G, Kilic E, Nas K, Kamanlı A, Tekeoglu İ. Residual symptoms and disease burden among patients with psoriatic arthritis: is a new disease activity index required? Rheumatol Int 2019;39:73-81.}