Symptoms of Anxiety and Depression Among Adults with Arthritis — United States, 2015–2017

An estimated 54.4 million (22.7%) U.S. adults have doctor-diagnosed arthritis (1). A report in 2012 found that, among adults aged ≥45 years with arthritis, approximately one third reported having anxiety or depression, with anxiety more common than depression (2). Studies examining mental health conditions in adults with arthritis have focused largely on depression, arthritis subtypes, and middle-aged and older adults, or have not been nationally representative (3). To address these knowledge gaps, CDC analyzed 2015–2017 National Health Interview Survey (NHIS) data* to estimate the national prevalence of clinically relevant symptoms of anxiety and depression among adults aged ≥18 years with arthritis. Among adults with arthritis, age-standardized prevalences of symptoms of anxiety and depression were 22.5% and 12.1%, respectively, compared with 10.7% and 4.7% among adults without arthritis. Successful treatment approaches to address anxiety and depression among adults with arthritis are multifaceted and include screenings, referrals to mental health professionals, and evidence-based strategies such as regular physical activity and participation in self-management education to improve mental health.

NHIS is an ongoing, in-person, cross-sectional survey of the civilian, noninstitutionalized U.S. population. CDC analyzed combined NHIS data from 2015, 2016, and 2017 from the Sample Adult component of the survey, in which one adult is randomly selected from each family for whom additional information is collected. Response rates for the 3 years of surveys ranged from 53.0% to 55.2% and produced a 3-year sample of 93,442 participants. A randomly selected subset of approximately half of the sample adults (46,742) completed the Adult Functioning and Disability supplement over the 3-year period. Having arthritis was defined as a “yes” response to the question “Have you ever been told by a doctor or other health care professional that you have arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?”

The Adult Functioning and Disability supplement included questions about symptoms of anxiety and depression. Respondents were classified as having symptoms of anxiety or depression if they reported the respective symptoms daily or weekly and responded that the last time they experienced symptoms, the intensity was “a lot” or “in between a little and a lot.”^† These definitions identified adults whose symptoms would likely meet Diagnostic and Statistical Manual of Mental Disorders (DSM-V) diagnostic criteria and also would be clinically managed, which are referred to in this report as “clinically relevant,” although these definitions are not clinical diagnoses.^§,¶ The final unweighted sample sizes for those with arthritis who also reported whether they had anxiety or depression symptoms were 12,094 and 12,083, respectively.

Analyses accounted for the complex survey design, including the use of supplement file sampling weights so that weighted estimates derived from the sample were nationally representative. Age-standardized prevalences (using the 2000 projected U.S. population for persons aged 18–44, 45–64, and ≥65 years)** of symptoms of anxiety and depression were calculated for adults with and without arthritis and groups of those with arthritis who had selected sociodemographic and health-related characteristics. Prevalences of speaking with a mental health professional in the past 12 months and currently taking medications for symptoms of anxiety and depression^†† also were calculated. T-tests were performed to assess statistical significance (p<0.05) when comparing differences.

During 2015–2017, age-standardized prevalences of symptoms of anxiety and depression among adults with arthritis were 22.5% (95% confidence interval [CI] = 20.8–24.3) and 12.1% (CI = 10.8–13.4), respectively. Prevalences among adults without arthritis were 10.7% (CI = 10.2–11.2) and 4.7% (CI = 4.4–5.0), respectively (Figure 1). When weighted estimates were applied, among adults with arthritis, an estimated 10.3 million reported symptoms of anxiety or depression; 4.9 million reported symptoms of anxiety only, 1.3 million reported symptoms of depression only, and 4.1 million reported symptoms of both.

Among adults with arthritis, age-specific prevalences of symptoms of anxiety and depression were higher among adults aged 18–44 years than among those aged ≥65 years; prevalence of symptoms of anxiety was also higher among adults with arthritis aged 18–44 years than adults with arthritis aged 45–64 years (Table). Age-standardized prevalences of symptoms of anxiety and depression were higher among women than among men; among those who were unemployed, unable to work, or disabled compared with employed adults; and among adults who reported their sexual identity as lesbian, gay, bisexual, or “other” than among those who reported being heterosexual. Symptom prevalences were lower among adults with higher educational and income-to-poverty ratios. Higher symptom prevalences were reported by adults with chronic pain and arthritis-attributable activity limitations, and prevalences increased with the number of co-occurring chronic conditions, increasing psychological distress, and declining self-rated health. Adults with arthritis who reported aerobic physical activity had lower anxiety and depression symptom prevalences than did inactive adults. Symptom prevalences also were higher among current cigarette smokers than among those who had never smoked.

Taking medications was less common among arthritis patients who had anxiety symptoms (44.3%; CI = 40.4–48.3) than among those with symptoms of depression (57.7%; CI = 52.4–62.9) (Figure 2). Speaking with a mental health professional in the past 12 months was reported by 34.3% (CI = 30.3–38.1) of arthritis patients with anxiety symptoms and 42.8% (CI = 37.7–48.1) of those with symptoms of depression.

Acknowledgments

Rosemarie Kobau, MPH; Susan J. Bartlett, PhD.

Corresponding author: Dana Guglielmo, obx1@cdc.gov, 404-498-5453.

¹Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, CDC; ²Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee; ³University of California, San Francisco.

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FIGURE 1. Age-standardized percentage* of adults reporting symptoms of anxiety and depression,^† by arthritis^§ status — National Health Interview Survey, 2015–2017

* Estimates age-standardized to the 2000 projected U.S. population aged ≥18 years using three groups (18–44 years, 45–64 years, and ≥65 years).

^† Respondents were classified based on a frequency question (anxiety: “How often do you feel worried, nervous or anxious?” and depression: “How often do you feel depressed?”) and an intensity question (anxiety: “Thinking about the last time you felt worried, nervous or anxious, how would you describe the level of these feelings?” and depression: “Thinking about the last time you felt depressed, how depressed did you feel?”). Respondents were classified as having symptoms if they responded “daily” or “weekly” to the frequency question and “a lot” or “in between a little and a lot” to the intensity question. Respondents were classified as not having symptoms if they responded “daily” or “weekly” to the frequency question and “a little” to the intensity question, or if they responded “monthly,” “a few times a year,” or “never” to the frequency question. For each symptom, the remaining respondents were excluded from the analysis because their symptom status could not be identified.

^§ Respondents were classified as having arthritis if they responded “yes” to “Have you ever been told by a doctor or other health care professional that you have arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?”

Abbreviations: BMI = body mass index; CI = confidence interval; K6 = Kessler-6 score.
* Estimates were age-standardized to the 2000 projected U.S. population aged ≥18 years using three groups (18–44 years, 45–64 years, and ≥65 years).
^† Respondents were classified based on a frequency question (anxiety: “How often do you feel worried, nervous or anxious?” and depression: “How often do you feel depressed?”) and an intensity question (anxiety: “Thinking about the last time you felt worried, nervous or anxious, how would you describe the level of these feelings?” and depression: “Thinking about the last time you felt depressed, how depressed did you feel?”). Respondents were classified as having symptoms if they responded “daily” or “weekly” to the frequency question and “a lot” or “in between a little and a lot” to the intensity question. Respondents were classified as not having symptoms if they responded “daily” or “weekly” to the frequency question and “a little” to the intensity question, or if they responded “monthly,” “a few times a year,” or “never” to the frequency question. For each symptom, the remaining respondents were excluded from the analysis because their symptom status could not be identified.
^§ Respondents were classified as having arthritis if they responded “yes” to the question “Have you ever been told by a doctor or other health care professional that you have arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?” Respondents with the values, “don’t know,” “missing,” or “refused,” for the arthritis case-finding question were excluded from the analytic sample.
^¶ Age group percentages are age-specific, and all other percentages are age-standardized.
** Persons who identified as Hispanic might be of any race. Persons who identified with a racial group were all non-Hispanic.
^†† Income-to-poverty ratio was calculated using income data generated using multiple imputation.
^§§ Among nine chronic conditions (asthma, cancer, chronic obstructive pulmonary disease, diabetes, heart disease, hepatitis, hypertension, kidney disease, and stroke).
^¶¶ Psychological distress was classified using the Kessler-6 scale, a 24-point scale capturing the presence and severity of nonspecific psychological distress symptoms in the past 30 days, as none/mild (Kessler-6 score [K6]≤4), moderate (5≤K6≤12), and severe (K6≥13).
*** Respondents were classified as having chronic pain if they reported having pain most days or every day in the past 3 months.
^††† Respondents were classified as having arthritis-attributable activity limitations if they responded “yes” to the question “Are you now limited in any way in any of your usual activities because of arthritis or joint symptoms?”
^§§§ Respondents were classified as active based on the 2008 Physical Activity Guidelines for Americans if they reported ≥150 minutes of moderate intensity leisure time aerobic physical activity per week, insufficiently active if they reported 1–149 minutes, and inactive if they reported zero minutes. Reported vigorous intensity physical activity minutes were counted double and added to moderate intensity physical activity minutes.
^¶¶¶ Respondents were classified as ever having smoked if they had smoked at least 100 cigarettes in their lifetime.
**** Binge drinking was defined as consuming five or more drinks (men) or four or more drinks (women) over a 2-hour period.

FIGURE 2. Age-standardized percentage* of adults with arthritis^† reporting treatment for anxiety symptoms or depression symptoms,^§ by type of treatment^¶,** — National Health Interview Survey, 2015–2017

* Estimates were age-standardized to the 2000 projected U.S. population aged ≥18 years using three groups (18–44 years, 45–64 years, and ≥65 years).

^† Respondents were classified as having arthritis if they responded “yes” to the question “Have you ever been told by a doctor or other health care professional that you have arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?”

^§ Respondents were classified based on a frequency question (anxiety: “How often do you feel worried, nervous or anxious?” and depression: “How often do you feel depressed?”) and an intensity question (anxiety: “Thinking about the last time you felt worried, nervous or anxious, how would you describe the level of these feelings?” and depression: “Thinking about the last time you felt depressed, how depressed did you feel?”). Respondents were classified as having symptoms if they responded “daily” or “weekly” to the frequency question and “a lot” or “in between a little and a lot” to the intensity question. Respondents were classified as not having symptoms if they responded “daily” or “weekly” to the frequency question and “a little” to the intensity question, or if they responded “monthly,” “a few times a year,” or “never” to the frequency question. For each symptom, the remaining respondents were excluded from the analysis because their symptom status could not be identified.

^¶ Spoke with a mental health professional in the past 12 months was defined by the question “During the past 12 months, have you seen or talked to a mental health professional such as a psychiatrist, psychologist, psychiatric nurse, or clinical social worker?”

** Taking medications was defined as responding “yes” to the question “Do you take medication for these feelings?” (anxiety) or “Do you take medication for depression?”