This study demonstrates high rates of depression and anxiety among Syrian AS patients and identified multiple contextual and disease-related associated predictive factors. The prevalence of depression among AS patients is varied through literature in regards to regions conducted and screening tools used. According to a previous systematic review in 2019, the prevalence ranged from 3–66% (13). In this study, nearly half of the patients had possible MMD (PHQ-9 ≥ 10), which is higher than studies that utilised the same screening tool (32, 33) and higher than studies carried out in the Netherlands (18%) (17), Northern Taiwan (25%) (34), Korea (16%) (35), Singapore (21%) (36), and other developed counties (26%) (37). Studies concerning the mental health of AS patients in the Arab world are fairly limited; our rates are lower than those of two studies from Morocco (38, 39). Compared to depression, the prevalence of anxiety in AS patients has received less attention via previous research (15), in this study 36.9% showed clinically significant anxiety, this rate is higher than in other studies (33, 36, 40), while lower than those two studies from Morocco (38, 39).
Multiple researches discussed how the disease affects the development of depression and anxiety in AS patients, but contextual factors should not be overlooked (17). The female gender is thought to be at more risk of having depression (41), but there is noted controversy in regard to AS patients. A longitudinal study found a decrease in depressive symptoms over time among female patients (37), which aligns with other studies that stated a significant association with male gender (17, 42). However, some studies reported contrary findings (33). Based on the results of this study, depressive and anxiety symptoms were more prevalent in male patients, though without a statistically significant correlation. Likewise, no significant association was found between depression or anxiety with age which is consistent with some studies (34, 37), and contrasting with others revealed a significance with age (17, 33). Low economic status was associated with high levels of depression. Income is a highly crucial issue in Syrian AS patients due to the high costs of their medical drugs, although free services are provided in governmental health facilities but biological treatments can be not available for months and this may result in deterioration of the patient’s well-being and force their health care providers to change management strategies, that and also, the generalized poor economic status affecting their other demands, this result is similar to others studies (5, 6, 17). Quitted working due to disease was the contextual factor that contributed to both depression and anxiety in this study. Physical function is one of the key domains of well-being affected by the disease, especially in advanced cases with diminished flexibility and good posture. losing a job definitely affects patients’ economic status and displaces their emotional comfort as they become dependent on others for their needs (17, 34).
Disease-related factors play a role in acquiring depressive symptoms among AS patients (41). Peripheral involvement was significantly associated with depression, while other Extra-articular manifestations (EAMs), such as uveitis, did not reveal a significant correlation in the regression model. This result is in agreement with a prior study (34). Hip pain is another unique factor that showed a significant correlation with depression and anxiety. Pain is a common and devastating symptom among AS patients in particular at the SI joints area, there is evidence of a two-way causal relationship between pain and depressive symptoms, which suggests they have a pathophysiological basis (16). Similarly, there is a proven connection between pain and anxiety (43).
A considerable body of literature has highlighted the role of disease activity and functional impairment in the development of psychological distress (41). In this study, the correlation between depression and anxiety with The ASDAS (CRP and ESR) scores was examined carefully. The regression analysis model revealed that higher ASDAS (CRP and ESR) scores were individually associated with depression, as the association with ASDAS-CRP became non-significant when adjusted against ASD-ESR. However, the explanatory power of these associations was low. Furthermore, elevated scores on BASDAI, BASFI, and BASG were significantly associated with depression. Regarding anxiety, both the ASDAS-ESR and BASDAI had a significant association, while the ASDAS-CRP score did not. Additionally, regression analysis revealed that BASFI and BASG were individually associated with anxiety, as the association between BASFI and anxiety was lost when adjusted against BASG. These findings can be clarified by the fact that the majority of the sample is at a high level of disease activity, even for subjective indices the means of those scores were far higher in comparison with other studies (33, 34). A prior study stated no connection between the two ASDAS scores and depression (44), consistent with results from one longitudinal study that showed no correlation with CRP levels (37). Nonetheless, the results of this study regarding ASDAS are in agreement with a previous meta-analysis (45). The same meta-analysis added how depression exaggerates the perception of pain, this emphasizes the possibility that this correlation with depressive or anxiety symptoms may be driven by the subjective component of ASDAS scores. Examining the correlation between CRP and ESR levels and depression or anxiety is thought to be important to determine the direct role of inflammation in psychological disorders (17), while this connection involves more complex mechanisms. Further research is needed in light of the association between disease activity markers and depression or anxiety.
The majority of patients demonstrate a high level of deteriorating QOL (ASQoL > 8), though all patients undergo some sort of biologics. This can be explained by low adherence to treatment and early discontinuation due to drug unavailability in many circumstances (46). Poorer QOL is highly correlated with the development of depression and anxiety in AS patients (16), findings of this study further support those claims by a high explanatory power (adjusted R2 = 0.59). Fatigue is one of the most common complaints of AS patients, 63 (61.2%) of patients exhibited severe fatigue. In addition, fatigue is one potential shared mechanism for the development of depression (16, 41). Given the results of this study, severe fatigue was significantly associated with depression and anxiety. Sleep disturbance is frequent in AS patients and it's related to poorer QOL and thereby depression and anxiety (16, 41). 39.8% of Syrian AS patients suffered from a high frequency of sleep disturbance, sleep disturbance was significantly correlated with depression and anxiety (16, 41, 47). Based on this study's findings and other research papers poor QOL, severe fatigue, sleep disturbance, depression and anxiety may form a vicious cycle in AS patients but this cross-sectional study cannot back up this claim (41).
4.1. Strengths and limitations:
To the best of our knowledge, this is the first research paper that assesses depression and anxiety in Syria and among a few in the Middle East. In addition, this research was done using face-to-face interviews, and all medical history of the patients was obtained from their medical records, thus recall bias is minimal. Some limitations are still present. First, this study was conducted in a single health facility which results in a small portion of observed AS patients. Secondly, all patients included in this study were under biologics and exhibited relatively high levels of disease activity, further research is recommended to include AS patients with naïve disease status. Finally, a cross-sectional study design may not be able to deduce causality and connection, thus, additional longitudinal studies are needed to obtain more precise results.