Symmetric peripheral polyarthritis is the most common form of chronic inflammatory arthritis and is a characteristic of rheumatoid arthritis (RA), a chronic systemic inflammatory autoimmune disorder[1]. Hand, wrist, and knee joints are frequently affected by RA, and as the condition progresses, the joint’s lining inflames and damages the joint tissue. This tissue injury can result in deformity, unsteadiness, and chronic or long-lasting pain[2]. Treatment and management of RA can be achieved with medication and self-care techniques [3]. Biological response modifiers (biological) and disease-modifying anti-rheumatic medications (DMARDs) are two therapies that can help stop joint deformity and delay the course of RA [3]. Depression is a typical occurrence among RA patients. Compared to the general population, depression is more prevalent in RA [4]. Depression is twice as common among RA patients than in the general population [5]. Estimates of the prevalence of depression in RA patients range from 9.5% to 41.5%. [6, 7], and severe depression can also be brought on by rheumatoid arthritis [8]. The impact of receiving a diagnosis of a chronic illness for which there is no known treatment, pain-depression has been linked to higher pain side effects of medicines are some of the reasons why depression is so common in RA patients [9]. In some instances, RA-related disabilities may be the cause of depression; RA’s socioeconomic effects may also mediate depression. Current research indicates a correlation between depression and inflammation, as it has been demonstrated that elevated C-reactive protein (CRP) levels, a marker of inflammation, are linked to a higher risk of psychological distress, the pathophysiology of inflammation, and the onset of anxiety and depression [10]. Using RA as a disease model, several researchers are examining these relationships [11]. For effective treatment, it is crucial to comprehend the molecular elements of depression in RA [11]. Therefore, our research aimed to investigate the prevalence of depression among RA patients from the Majmaah province who attended the rheumatology clinic in King Khalid Majmaah Hospital (KKMH) and determine the association between the severity of rheumatoid arthritis and the level of depression.

Study Design This is a descriptive cross-sectional study. Study Area King Khalid Majmaah Hospital (KKMH) in Majmaah Province is located north of Riyadh Province in Saudi Arabia. Study Population The study participants are adult Patients diagnosed as having RA attending King Khalid Majmaah Hospital (KKMH) in Majmaah province. The total number of patients was 75, out of which 57 participated in the study. Data Collection A three-part, validated, standardised questionnaire was used to gather the data. In the first section, participants’ sociodemographic data is evaluated, and in the second, the severity of rheumatoid arthritis disease is ascertained using the HAQ-DL score (Health Assessment Questionnaire Disability Index) [12]. It is divided into eight sections; activities, reach, grasp, cleanliness, walking, eating, and dressing. For every part, there are two or three questions. Each part has a score ranging from 0 (easy to complete) to 3 (impossible to complete). The lowest score within each section is assigned to it; for example, if a question receives a score of one and another receives a score of two, the section will receive a score of two. Additionally, the minimum score for that section is 2 if an aid or device is used or if assistance from another person is needed. If the section score is already two or higher, nothing is changed [12]. The third section employed the Beck Depression Scale, a set of 21 questions, as a psychological tool to assess depression. The twenty-one questions were scored on a range of 0 to 3. Sixty-three is the maximum score that could be obtained throughout the entire exam. This indicates that on all twenty-one questions, you circled number three. The lowest possible score on the test would be zero since the lowest possible score on each question is zero. This would entail answering every question with a zero. Depression is assessed using the following criteria: [13] (1-10) These ups and downs are considered normal, (11-16) Mild mood disturbance), (17-20) Borderline clinical depression, (21-30) Moderate depression, (31-40) Severe depression, (Over 40) Extreme depression [13]. Data Analysis Numbers and percentages were used to compute and report descriptive statistics. The Fischer Exact test has been used to examine the relationship between the clinical features of the rheumatic population and the severity of depression. Additionally, the Mann-Whitney Z-test and the Kruskal Wallis H-test have been used to compare the depression scores with the patient’s baseline and clinical features. Both the Kolmogorov-Smirnov and the Shapiro-Wilk tests have been used to quantify statistical collinearity. At \(p<0.05\), statistical significance was found. Statistical Packages for Software Sciences (SPSS) version 26, Armonk, New York, IBM Corporation, was used to analyse the data. Ethical Consideration This study protected the confidentiality of participants, data was used for research only. Participants filled out informed consent before responding to the questionnaire. Ethical approval was taken from King Fahad Medical City Review Board.

This study analyzed 57 patients with rheumatoid arthritis (RA). As described in Table 1 , 42.1% was more than 50 years old, with females being dominant (82.5%). Most patients were married (96.5%) and of Saudi nationality (96.5%). Approximately 59.6% had been diagnosed with RA for less than five years. A family history of RA constitutes 26.3%. Positive RF was found in 64.9% of the patients. Positive anti-CCP was 77.2%. Most patients (93%) received conventional DMARDs, while 19.3% had targeted biologic DMARDs. Joint deformities were found in 19.3%. Regarding disease activity, approximately 42.1% were considered severe. Depression was found in 28.1% of the studied patients. Mild and moderate depression was noted in 15.8% and 12.3% of patients. In addition, HAQ results showed that 56.1% were categorized as 0 to 1. When measuring the association between the severity of depression according to the baseline and clinical characteristics of the patients (Table 2), it was found that age group, gender, occupational status, diagnosis duration, family history of RA, RF, anti-CCP, conventional DMARDs, targeted Biologic DMARDs, and joint deformities showed no significant association with the severity of depression \((p>0.05)\). No significant association was found between the Level of depression and disease activity score (Figure 1), and also no association between the Level of depression and the health assessment questionnaire was found, as shown in (Figure 2). Table 1: Demography and clinical characteristics of the rheumatoid arthritis population \((n=57)\) Study Data N (%) Age group   22 – 35 years 11 (19.3%) 36 – 50 years 22 (38.6%) \(\mathrm{>}\)50 years 24 (42.1%) Gender   Male 10 (17.5%) Female 47 (82.5%) Female: Male ratio 4.7:1 Marital status   Single 02 (03.5%) Married 55 (96.5%) Nationality   Saudi 55 (96.5%) Non-Saudi 02 (03.5%) Diagnosis duration   \(\mathrm{<}\)5 years 34 (59.6%) 5 - 10 years 13 (22.8%) \(\mathrm{>}\)10 years 10 (17.5%) Family history of rheumatoid arthritis   Yes 15 (26.3%) No 42 (73.7%) RF   Positive 37 (64.9%) Negative 20 (35.1%) Anti-CCP   Positive 44 (77.2%) Negative 13 (22.8%) Conventional DMARDs   Yes 53 (93.0%) No 04 (07.0%) Biologic DMARDs   Yes 11 (19.3%) No 46 (80.7%) Joint deformities   Yes 11 (19.3%) No 46 (80.7%) DAS 28   Mild (\(\mathrm{>}\)2.6 - \(\mathrm{\le}\)3.2) 02 (03.5%) Moderate (\(\mathrm{>}\)3.2 - \(\mathrm{\le}\)5.1) 31 (54.4%) Severe (\(\mathrm{>}\)5.1) 24 (42.1%) Severity of depression   Normal 41 (71.9%) Mild 09 (15.8%) Moderate 07 (12.3%) HAQ   0 – 1 32 (56.1%) \(\mathrm{>}\)1 – 2 23 (40.4%) \(\mathrm{>}\)2 – 3 02 (03.5%)   Table 2: Association between Level of depression and Clinical characteristics of rheumatoid arthritis Population \((n=57)\) Factor Severity of depression \(P\)-value Factor Severity of depression P-value   Normal N (%)\(^{(n=41)}\) Mild N (%)\(^{(n=9)}\) Moderate N (%)\(^{(n=7)}\)   Age group         22 – 35 years 08 (19.5%) 01 (11.1%) 02 (28.6%) 0.867 36 – 50 years 17 (41.5%) 03 (33.3%) 02 (28.6%)   >50 years 16 (39.0%) 05 (55.6%) 03 (42.9%)   Gender         Male 07 (17.1%) 0 03 (42.9%) 0.080 Female 34 (82.9%) 09 (100%) 04 (57.1%)   Diagnosis duration         <5 years 25 (61.0%) 05 (55.6%) 04 (57.1%) 0.865 5 - 10 years 10 (24.4%) 02 (22.2%) 01 (14.3%)   >10 years 06 (14.6%) 02 (22.2%) 02 (28.6%)   Family history of rheumatoid arthritis         Yes 11 (26.8%) 02 (22.2%) 02 (28.6%) 1.000 No 30 (73.2%) 07 (77.8%) 05 (71.4%)   RF         Positive 28 (68.3%) 04 (44.4%) 05 (71.4%) 0.411 Negative 13 (31.7%) 05 (55.6%) 02 (28.6%)   Anti-CCP         Positive 30 (73.2%) 07 (77.8%) 07 (100.0%) 0.406 Negative 11 (26.8%) 02 (22.2%) 0   Conventional Synthetic DMARDs         Yes 37 (90.2%) 09 (100%) 07 (100%) 1.000 No 04 (09.8%) 0 0   Targeted biologic DMARDs         Yes 07 (17.1%) 02 (22.2%) 02 (28.6%) 0.652 No 34 (82.9%) 07 (77.8%) 05 (71.4%)   Joint deformities         Yes 07 (17.1%) 03 (33.3%) 01 (14.3%) 0.560 No 34 (82.9%) 06 (66.7%) 06 (85.7%)   Figure 1: Association between the Level of depression and disease activity score \((P>0.05)\) FIgure 2: Association between the Level of depression and health assessment questionnaire \((P>0.05)\)

Most of the participants of this study were females, and this is expected as RA affects mostly women with a female/male ratio of 3:1 [14]. 42% aged more than 50 years old. This result is also expected as the most common age is adults in their sixties. as shown by the Centre for Disease Control (CDC) [15]. Approximately 59.6% had been diagnosed with RA for less than five years, and no patient suffers from severe symptoms. In this study, the prevalence of depression among rheumatoid arthritis patients was found to be 28.1%; no one of the participants had severe depression, and most of the patients had moderate and mild levels of depression. This is similar to the results of other studies conducted in KSA. For example, research conducted in Saudi Arabia to assess fatigue and mood disturbance among RA patients showed that 28.7% of RA patients had a mild mood disturbance [16], and nearly similar to research at King Abdulaziz Hospital, Jeddah, which showed that 18% of patients diagnosed with RA experienced depression [17], the prevalence of depression among RA patients in this study is also nearly similar to the results of studies conducted in the middle east and Asia as in Singapore, it was found to be 15% [18] and in Japan, 12.4% [19]. Interestingly, the results of this study show a lower prevalence of depression among patients with RA compared to European countries. Examples of those findings are in Poland, where 76% of rheumatoid arthritis patients were depressed [20]. In Turkey, a study among RA patients found that 70% suffered from depression [21]. These differences in the results may be due to long-standing disease, as in this study, most of the patients had RA for less than five years. Another explanation could be due to confounding factors that could enhance the appearance of depression symptoms, like cold weather, as the study conducted in Iran found that depression was more prevalent where the weather was cold [22]. When measuring the association between the severity of depression according to the baseline and clinical characteristics of the patients, it was found that age group, gender, occupational status, diagnosis duration, family history of RA, RF, anti-CCP, conventional synthetic DMARDs, targeted biologic DMARDs, and joint deformities had no significant association with the severity of depression (all \(p>0.05\)). This study also observed that there was no significant association between the severity of depression and DAS 28 \((p=0.510)\), and the association between the severity of depression and HAQ did not reach statistical significance (p=0.372). The most likely explanation for this insignificant association is that most participants are newly affected with rheumatoid arthritis, no complications or deformities are present, and the HAQ score is low among more than half of the patients. This finding is supported by other studies that showed a significant association between depression and severe long-standing RA. An example of those studies is a Systematic review, and Meta-Analyses performed in 72 studies, including 13,189 cases; it found that depression is mainly current in RA and associated with poorer RA issues [23]. Another study is the one conducted in Japan to assess the severity of the RA disease and depression found that depression among patients with RA was associated with worse HAQ [24]. According to the findings of this research, more research with a larger sample size is recommended. Also, analytical studies and clinical trials are recommended for searching all factors affecting depression among RA patients in KSA.  

In this study, the prevalence of depression among the RA-studied group was 28.1%. Among them, 12.3% were moderately depressed, and the rest are with mild depression, so regular assessment of the RA patients is needed, and antidepressants should be given if the depression worsens. Health-related quality of life HAQ results showed that 56.1% were categorized as 0 to 1, and no significant association was found between the severity of depression and age group, gender, occupational status, diagnosis duration, family history of RA, RF, anti-CCP, conventional synthetic DMARDs, targeted biologic DMARDs, and joint deformities. The association between the disease severity, health-related quality of life, and level of depression was found to be insignificant. Larger sample size studies. We need to confirm our findings in the future.  

The authors declare no conflict of interests. All authors read and approved final version of the paper.  

All authors contributed equally in this paper.