International Journal of Rheumatic Diseases 2014

ORIGINAL ARTICLE

Health-related quality of life and depression in a sample of

Latin American adults with rheumatoid arthritis
Hugo SENRA,1 Heather ROGERS,2 Gillian LEIBACH,3 Marv
ın L. P. ALTAMAR,4

5
Silvia L. O. PLAZA,5 Paul PERRIN3 and Maria A. S. DURAN
1
Centre of Psychology of the University of Porto, Porto, Portugal, 2Department of Psychology, University of Deusto, Bilbao, Spain,
3
Department of Psychology,Virginia Commonwealth University, Richmond, Virginia, USA, 4Clınica Saludcoop, Neiva, Colombia,
and 5Grupo de Investigacion Carlos Finlay, Facultad de Salud, Universidad Surcolombiana, Neiva, Colombia

Abstract
Objective: To compare the health related quality of life (HRQoL) and depression of individuals with rheuma-
toid arthritis (RA) to healthy controls in Colombia, as well as to examine the connections between these two
variables in individuals with RA.
Method: One hundred and three individuals with RA were recruited from ambulatory centers in Colombia. Sev-
enty-three control participants were recruited from the local community. Both groups differed with respect to
age, gender and marital status (P < 0.001), while education and socio-economic levels were similar. HRQoL
was assessed using the Short Form-36 (SF-36) and depressive symptoms were assessed using the Patient Health
Questionnaire-9 (PHQ-9).
Results: A multivariate analysis of covariance found that RA patients reported substantially higher depressive
symptoms and lower HRQoL than healthy controls (P < 0.01 and P < 0.05, respectively). The effect sizes of the
differences between patients and controls in HRQoL and depressive symptoms were all large. All SF-36 HRQoL
variables were significantly correlated with depressive symptoms in patients and controls (P < 0.05). Social
functioning and vitality were uniquely associated with depressive symptoms in the RA group (P < 0.01 and
P < 0.05, respectively), whereas education and social functioning were uniquely associated with depressive
symptoms in controls (P < 0.05 and P < 0.005, respectively).
Conclusions: Research indicates that individuals with RA have deteriorated HRQoL, and this study extends
these findings to a Colombian sample and highlights the importance of the independent relationship between
depressive symptoms and vitality in this group of Colombians with RA.
Key words: Colombia, depression, health-related quality of life, rheumatoid arthritis.

INTRODUCTION are lower in less-developed rural regions.4 Conversely,

Rheumatoid arthritis (RA) is a heterogeneous chronic
inflammatory disease that affects joints and typically
follows a progressive course leading to disability.1 Prev-
alence for RA varies throughout the world2,3 and rates
Correspondence: Hugo Senra, PhD, Centre of Psychology of the
University of Porto, University of Porto, Rua Alfredo Allen
4200-135, Porto, portugal.
Email: hugo_senra@hotmail.com
rates are higher in North America and northern Europe
compared to southern Europe.5 In the United States,
approximately 1.4% of women and 0.74% of men
develop RA.6 Similar prevalence rates of 0.5–1.0% for
adults have been identified in other developed coun-
tries,7,8 where there is typically an increase with age,
although the incidence and severity of RA may be
decreasing over time.9
A number of factors have been identified that may
put individuals at risk of developing RA.7–10 Genetics

© 2014 Asia Pacific League of Associations for Rheumatology and Wiley Publishing Asia Pty Ltd
H. Senra et al.
contribute to its development in 50% of cases10 and
women are at greater risk of RA and more severe disabil-
ity once diagnosed.9 Other risk factors include smoking,
obesity, complications during pregnancy, exposure to
pathogens, hormones, diet, socioeconomic status, older
age and ethnicity.7,9
Due to the debilitating symptoms commonly associ-
ated with RA and comorbid health problems, health-
related quality of life (HRQoL) is often negatively
affected.10–14 HRQoL refers to the effect that one’s
health status or condition has on his or her ability to
function.15 Several studies have shown that individuals
with RA experience poorer HRQoL, in both the emo-
tional and physical domains, compared to the general
population, and these results have been found world-
wide.12,16–19 RA affects patients so immensely that it is
ranked as one of the chronic illnesses to have the great-
est impact on HRQoL, which has important implica-
tions for the mental and physical health of individuals
diagnosed with this disease.20
As with reduced HRQoL, mental health problems are
also common in individuals with RA.2,8,21–23 The preva-
lence of depression is approximately 20%, which is
nearly three to five times greater than the healthy popu-
lation22,24,25 and higher disability in RA is a significant
predictor of depression.2 Other factors associated with
depression among individuals with RA include being
unmarried, living in an urban setting, sleep problems
and pain.2,21 Depression is also associated with a vari-
ety of negative health outcomes in individuals with RA,
including more general pain, hardships, treatment
denial, fatigue and prognosis, as well as decreased qual-
ity of life.26,27 A generally higher rate of depression in
individuals with RA is problematic due to the increased
burden that is related to depression, as well as the bur-
den that is associated with the way patients perceive
and manage their RA.28
Although research has begun to examine HRQoL and
depression in individuals with RA, no research to date
has been conducted on these variables in Latin America,
where medical resources and health services for coping
with RA may vary substantially from those in developed
countries. As a result, the purpose of the current study
was to compare HRQoL and depression of individuals
with RA to healthy controls in Cali, Colombia, as well
as to examine the connections between these two vari-
ables in individuals with RA. Given the prevalence of
depression among individuals with RA, this study aims
to understand more about the underpinnings of depres-
sion as it relates to RA in a diverse, under-researched
population. It is hypothesized that individuals with RA
2 International Journal of Rheumatic Diseases 2014
will have lower HRQoL and higher depression than
controls, and that HRQoL will be significantly associ-
ated with depression in the RA group.
METHOD
Participants
One hundred and three individuals with RA were
recruited from ambulatory centers in Colombia from
December 2012 to June 2013. Inclusion criteria for the
RA group required the patient to be between the ages of
18 and 79, evaluated by a rheumatologist or internal
medicine specialist and meet the American College of
Rheumatology/European League Against Rheumatism
(ACR/EULAR) Collaborative Initiative 2010 Rheuma-
toid Arthritis Classification Criteria (http://www.rheu-
matology.org/practice/clinical/classification/ra/ra_2010.
asp),1 and cognitively able to complete the protocol.
Seventy-three control participants were recruited from
the local community and consisted of healthy individu-
als between ages 18 and 79 who were without any
rheumatologic or chronic disease. Individuals with a
history of alcohol or drug abuse, neurologic impair-
ment, psychiatric problems interfering with indepen-
dent decision making, comorbid terminal illness with
< 6 months to live, or current hospitalization for any
reason were excluded from the study.
Measures
The Disease Activity Scale of 28 joints (DAS-28)29
assesses RA disease activity and is a composite measure
that consists of: (i) the number of 28 joints in the
hands, wrists, elbows, shoulders and knees that are ten-
der and/or swollen; (ii) erythrocyte sedimentation rate
(ESR) or C-reactive protein (CRP) in the blood, as a
measure of inflammation; and (iii) the patient’s Visual
Analog Scale (VAS) score of how he/she is feeling on
the day of the evaluation, from 0 (very good) to 10
(very bad). A total score is calculated, which represents
the extent of disease activity. The following cut-off
points have been established: < 2.6 indicates disease
remission, 2.6–3.2 indicates low disease activity,
3.2–5.1 indicates moderate disease activity and > 5.1
indicates severe disease activity.29
The Patient Health Questionnaire-9 (PHQ-9)30 from
the Primary Care Evaluation of Mental Disorders
(PRIME-MD) was administered as a measure of self-
reported depressive symptoms. The scale consists of
nine items that evaluate the characteristics of major
depressive disorder. It asks respondents to identify how
often they have been bothered by each item during the

past 2 weeks using a Likert scale ranging from 0 (not at
all) to 3 (nearly every day). Total scores range from 0 to
27, with higher scores indicating more depressive symp-
toms. Traditional cut-off scores for depression have
been identified: total scores from 1 to 4 for minimal
depression, 5 to 9 for mild depression, 10 to 14 for
moderate depression, 15 to 19 for moderately severe
depression, and 20 to 27 for severe depression. Partici-
pants completed the Spanish version of the scale,31
which has strong psychometric properties in medical
populations32 and the general population.33
The Short Form-36 (SF-36) is a self-report health
questionnaire that is commonly used to evaluate qual-
ity of life in a variety of chronic diseases by investigators
in more than 20 countries.34 The instrument compre-
hensively evaluates health-related quality of life
(HRQoL) using eight different health dimensions:
physical functioning, role-physical (role limitations due
to physical problems), bodily pain, general health,
vitality, social functioning, mental health and role-emo-
tional (role limitations due to emotional problems).
Responses are scored on a 0–100 scale, with
higher scores representing higher HRQoL. The Spanish
version of the SF-36 has well-established reliability and
validity.34
Procedure
All patients were evaluated by a rheumatologist or inter-
nal medicine specialist. After signing an informed con-
sent, the DAS protocol was administered, followed by
socio-demographic and psychosocial data collection by
a trained research assistant. The healthy controls were
interviewed by a trained research assistant who col-
lected socio-demographic information and adminis-
tered the psychosocial scales. This study received ethics
committee approval and all participants provided
informed consent.
Statistical analyses
The data were analyzed using IBM SPSS Statistics for
Windows, Version 20.0.35 Independent t-tests and chi-
square analyses were performed to examine socio-
demographic differences between patients and controls.
A multivariate analysis of covariance (MANCOVA), con-
trolling for age, gender and education, was conducted
with group as the independent variable and the eight
SF-36 sub-scales as dependent variables. Individual
ANCOVAs for each sub-scale and PHQ-9 total were per-
formed. Pearson’s correlations were conducted to exam-
ine the bivariate relationships among all study variables
within patients and controls separately. In order to
International Journal of Rheumatic Diseases 2014
HRQoL and depression in Latino adults with RA
examine the relationship between depressive symptoms
and HRQoL, separate hierarchical regressions with
PHQ-9 total score as the dependent variable were con-
ducted for patients and controls with demographic vari-
ables (age, gender and education) and DAS-28 if
relevant entered in the first block and select SF-36 sub-
scales, entered in the second block. DAS-28 was ana-
lyzed as a continuous variable.
RESULTS
Table 1 describes the socio-demographic characteristics
of the samples. The RA patients were significantly older
than the healthy controls (53.8 vs. 37.3 years;
P < 0.001), more likely to be female (85.4% vs. 45.8%;
P < 0.001), more likely to be married (63.1% vs.
52.8%; P < 0.001) and more likely to have lower edu-
cational levels (57.4% vs. 40.3% had nine or fewer years
of education; P < 0.05). Although the socio-economic
levels were significantly different between patients and
controls (P < 0.05), both were primarily comprised of
individuals from the lowest socio-economic levels in
the country, with approximately 85% living in strata 1
and neighborhoods. The individuals with RA had been
living with the disease for an average of 13.0 years
(SD = 11.6) and had been diagnosed an average of
11.1 years (SD = 10.1) prior to being recruited for the
study. The mean DAS-28 of individuals with RA was
4.87 (SD = 1.46). According to the DAS-28 total at the
time of evaluation,32 approximately 85% of the sample
had moderate to severe disease activity (45.6% [n = 47]
with severe disease activity and 38.8% [n = 40] with
moderate disease activity). Low disease activity was
present in 8.7% (n = 9) and 6.8% (n = 7) were in dis-
ease remission. Regarding the medical treatment, 94
patients were taking non-steroidal anti-inflammatory
drugs (NSAIDs), 80 were taking disease modifying anti-
rheumatic drugs (DMARDs), 79 took corticosteroids,
46 took biologic DMARDs and 13 patients were taking
other medications (e.g., antidepressants, opioids, anti-
convulsants, muscle relaxants).
MANCOVA
The overall omnibus MANCOVA revealed a statistically sig-
nificant effect for participant status (patients vs. con-
trol), Pillai’s Trace = 0.383, F8,162 = 12.57, P < 0.001,
ƞ2 = 0.383. As a result, eight follow-up univariate analy-
sis of covariance (ANCOVAs) were run to identify the loca-
tion of the significant differences between patients and
controls on the HRQoL variables. In each of these
ANCOVAs, the independent variable was participant status
3
H. Senra et al.

Table 1 Socio-demographic characteristics of the samples

Socio-demographic characteristics RA patients (n = 103) Healthy controls (n = 72) t or v2 P-value
Age, years, mean (SD) 53.8 (12.7) 37.3 (10.2) 9.19 < 0.001
Gender (female) 85.4% 45.8% 31.15 < 0.001
Marital status
Single 12.6% (n = 13) 22.2% (n = 16) 22.09 < 0.001
Married 63.1% (n = 65) 52.8% (n = 38)
Divorced/separated 12.6% (n = 13) 11.1% (n = 8)
Widowed 11.7% (n = 12) 1.4% (n = 1)
Other 0.0% (n = 0) 12.5% (n = 9)
Education
≤ 9 years 57.3% (n = 59) 40.3% (n = 29) 4.90 0.027
> 9 years 42.7% (n = 44) 59.7% (n = 43)
Socio-economic level
1 17.5% (n = 18) 29.2% (n = 21) 9.32 0.05
2 68.0% (n = 70) 54.2% (n = 39)
3 12.6% (n = 13) 9.7% (n = 7)
4 1.0% (n = 1) 6.9% (n = 5)
5 1.0% (n = 1) 0.0% (n = 0)
6 0.0% (n = 0) 0.0% (n = 0)

Table 2 Covariate-adjusted health-related quality of life and depression scores for patients and controls
Variable Patients Controls F-statistic P-value Partial Ea-squared
Physical functioning 49.18 (2.48) 90.21 (3.11) 85.82 < 0.001 0.335
Role-physical 29.87 (4.26) 75.39 (5.29) 36.15 < 0.001 0.176
Role-emotional 33.81 (4.72) 73.86 (5.90) 22.67 < 0.001 0.118
Vitality 55.11 (2.47) 69.01 (3.08) 10.00 0.002 0.056
Mental health 60.01 (2.33) 74.92 (2.92) 12.83 < 0.001 0.070
Social functioning 66.52 (2.63) 84.70 (3.29) 15.02 < 0.001 0.081
Pain 49.05 (2.57) 80.11 (3.21) 46.10 < 0.001 0.213
General health 49.68 (2.12) 68.45 (2.65) 24.57 < 0.001 0.126
Depression 7.26 (0.53) 4.76 (0.66) 7.01 0.009 0.04

(patients vs. control) and the dependent variable was
each of the HRQoL scores in the omnibus MANCOVA.
Additionally, an ANCOVA was run in the same manner
for depression. The results of these ANCOVAs appear in
Table 2. Across every index, patients reported substan-
tially lower scores on the HRQoL variables than con-
trols, as well as depression. The effect sizes of the
differences in all HRQoL variables and depression were
large.36 As a result, this study’s hypothesis that RA
patients would have lower HRQoL and higher depres-
sion than controls found strong support.
depression severity score with the subscales of SF-36
were moderate both in the patient and control group.
In the patient group, correlation coefficients ranged
from r = 0.29 for role-emotion to r = 0.65 for men-
tal health. In the control group, correlations ranged
from r = 0.27 for physical functioning to r = 0.73
for mental health. In both groups, higher depression
was associated with lower HRQoL in all SF-36 compo-
nents. Finally, higher depression level was moderately
associated wither higher levels of disease activity in the
patient group.

Correlation matrix Regressions

A correlation matrix was generated to examine the In the first hierarchical multiple regression for depres-
bivariate relationships among all variables in the cur- sion in the patient group, the three demographic vari-
rent study (Table 3). The correlations of the PHQ-9 ables (education, gender and age) and DAS-28 were

4 International Journal of Rheumatic Diseases 2014

 Table 3 Correlation matrix
Patients

PHQ–9 SF-36 QOL SF-36 QOL SF-36 QOL SF-36 QOL SF-36 SF-36 QOL SF-36 SF-36 QOL DAS-28
Depression Physical Physical role Emotional role Vitality QOL Mental Social QOL Pain General Disease
functioning limitations limitations health functioning health activity†
Controls
PHQ–9 0.53*** 0.33*** 0.29*** 0.57*** 0.65*** 0.54*** 0.54*** 0.46*** 0.32***
Depression
SF-36 QOL 0.27* 0.57*** 0.49*** 0.43*** 0.40*** 0.62*** 0.69*** 0.37*** 0.47***

International Journal of Rheumatic Diseases 2014

Physical
functioning
SF-36 QOL 0.42*** 0.35*** 0.74*** 0.36*** 0.30*** 0.51*** 0.60*** 0.38*** 0.37***
Physical role
limitations
SF-36 QOL 0.45*** 0.30** 0.37*** 0.30*** 0.33*** 0.37*** 0.48*** 0.34*** 0.32***
Emotional
role limitations
SF-36 QOL 0.45*** 0.39*** 0.50*** 0.35*** 0.72*** 0.32*** 0.65*** 0.47*** 0.28***
Vitality
SF-36 QOL 0.73*** 0.43*** 0.49*** 0.49*** 0.68*** 0.44*** 0.55*** 0.46*** 0.29***
Mental health
SF-36 QOL 0.56*** 0.29** 0.40*** 0.65*** 0.46*** 0.59*** 0.58*** 0.32*** 0.35***
Social
functioning
SF-36 QOL 0.48*** 0.36*** 0.45*** 0.28** 0.48*** 0.45*** 0.52*** 0.40*** 0.49***
Pain
SF-36 QOL 0.44*** 0.30** 0.33*** 0.33*** 0.34*** 0.45*** 0.43*** 0.38*** 0.24**
General health
*Correlation is significant at the 0.05 level (2-tailed). **Correlation is significant at the 0.01 level (2-tailed). ***Correlation is significant at the 0.001 level (2-tailed). †DAS-28 was only
assessed for patients. DAS-28, Disease Activity Score of 28 joints; PHQ-9, Patient Health Questionnaire-9; SF-36 QOL, Short Form-36 Quality of life.

5
HRQoL and depression in Latino adults with RA
H. Senra et al.

entered into the first step. The model was statistically
significant (F4,97 = 4.37, P = 0.003) and accounted for
approximately 15% of the variance of depression
(r2 = 0.152; adjusted r2 = 0.117). In this model, disease
activity (DAS-28) was uniquely associated with depres-
sion (Δr2 = 0.152; ΔF4,97 = 14.35, P = 0.003), while
age, gender and education were not. In the second step
demographic variables (education, gender and age)
were entered into the first step, which was not signifi-
cant (F3,68 = 2.14, P = 0.103, r2 = 0.86). The second
step adding the six HRQoL variables was significant,
and accounted for approximately 50% of the variance
(F9,62 = 6.85, P < 0.001, r2 = 0.499, adjusted
r = 0.426). Education and social functioning were
2

(Table 4), the six HRQoL variables (physical function- uniquely associated with depression (Δr2 = 0.413,
ing, role-physical, vitality, social functioning, pain and ΔF6,62 = 8.50, P < 0.001), whereas physical function-
general health) were added to the model. The model ing, physical role, vitality, pain and general health
was statistically significant (F10,91 = 11.57, P < 0.001) were not.
and accounted for approximately 56% of the variance
of depression (r2 = 0.560; adjusted r2 = 0.511). In this
DISCUSSION
model, vitality and social functioning were uniquely
associated with depression (Δr2 = 0.41, ΔF6,91 = 14.04, The purpose of the current study was to compare the
P < 0.001), while demographic variables, disease activ- HRQoL and depression of individuals with RA to
ity and the remaining SF-36 components were not. healthy controls in Colombia, and to examine the con-
In the second hierarchical multiple regression for nections between these two variables in individuals
depression in the control group (Table 5), the three with RA. As expected, the RA group reported substan-
tially higher depressive symptoms and lower HRQoL
Table 4 Regression for health-related quality of life and
than healthy controls, with all differences reaching
depression in patients large-sized effects. Social functioning and vitality were
uniquely associated with depressive symptoms in the
Variable Beta P-value RA group, whereas education and social functioning
Age 0.008 0.922 were uniquely associated with depressive symptoms in
Gender 0.121 0.091 controls. All SF-36 HRQoL variables were significantly
Education 0.135 0.078 correlated with depressive symptoms in both patients
SF-36 QOL Physical functioning 0.175 0.125 and controls.
SF-36 QOL Physical Role Limitations 0.155 0.100 The current results directly support our study’s main
SF-36 Vitality 0.366 0.000
hypothesis and are consistent with literature document-
SF-36 Social functioning 0.263 0.009
ing problems in mental health and HRQoL among RA
SF-36 Pain 0.067 0.596
SF-36 General health 0.152 0.072 patients.37–46 However, to the authors’ knowledge, this
DAS-28 Disease activity 0.031 0.704 is one of the few studies addressing HRQoL and mental
health in Latin American RA patients. Previous racial
DAS-28, Disease Activity Score of 28 joints; SF-36 QOL, Short Form-
36 Quality of life. and ethnic approaches to community health suggested
the need for addressing cultural differences in under-
standing health across different cultures or ethnici-
Table 5 Regression for health-related quality of life and ties.47–49 In the literature,38,48 Latinos with RA were
depression in controls more likely to report fair or poor health and fewer days
Variable Beta P-value of activity limitations than Whites and Blacks, which
can be explained by the fact that ‘a fair response’ carries
Age 0.19 0.65
a less negative connotation in Spanish than in Eng-
Gender 0.17 0.96
lish.38,50 In addition, there is also some evidence that
Education 0.23 0.03
SF-36 QOL Physical functioning 0.37 0.72 African-American rural residents tend to show worse
SF-36 QOL Physical role limitations 0.17 0.13 SF-12 mental health in comparison with Caucasian-
SF-36 Vitality 0.89 0.47 American rural residents.51 This study’s findings from a
SF-36 Social functioning 0.38 0.003 Colombian sample help to fill this gap in the literature.
SF-36 Pain 0.73 0.552 SF-36 social functioning, which in our study was
SF-36 General health 0.12 0.27 independently associated with depressive symptoms in
DAS-28, Disease Activity Score of 28 joints; SF-36 QOL, Short Form- both patients and controls, comprises the impact of
36 Quality of life. physical or mental health on social activities.52 Previous

6 International Journal of Rheumatic Diseases 2014


cross-sectional research on RA53 associated SF-12 men-
tal health component with depression, after adjusting
for confounding factors. Another study,54 using the
Arthritis Impact Measurement Scales,55 which measure
the physical, social and emotional well-being
of patients with RA, explained depression variability by
poor physical function, comorbidities and social
inactivity.
SF-36-measured fatigue was independently associated
with depression only in the RA group, not in controls.
RA is a condition which often involves systematic pain,
loss of function and fatigue.56 Such symptoms are unli-
kely to occur in healthy people who do not have a dis-
abling and painful condition. Since the control group is
not experiencing the same levels of fatigue as the RA
group, it is less probable that fatigue would be related
to depression. Some literature suggests that fatigue
mediates the relationship between pain and depression
in RA patients, promoting therefore the synergetic effect
of both conditions.57,58 Finally, the RA group showed
more depressive symptoms than controls, and therefore
can be considered more vulnerable to the negative
effect of such symptoms, including loss of vitality and
energy.59,60
The relationship between SF-36 HRQoL components
and depressive symptoms has been reported in previous
literature.43,53,54,57,61–63 There is some evidence that RA
is directly responsible for a decrease in quality of life,
therefore predisposing patients to depressive symp-
toms.43,53,61,62 On the other hand, depression contrib-
utes to deteriorated quality of life due to its disabling
effect.43,59,60 Therefore, our study corroborates the idea
that RA patients are more likely to be exposed to a dou-
ble distressing and disabling condition caused by the
concurrent negative effect that RA and depressive symp-
toms have in general health and quality of life.
Although previous research indicates that disease
activity is a predictor of depression in RA patients,64,65
in the present study DAS-28 was not independently
associated with PHQ-9 when taking into account
HRQoL. Because bivariate results indicated that dis-
ease activity is positively correlated with HRQoL com-
ponents and negatively correlated with depression in
this sample, QOL seems to mediate this relationship.
This finding is in line with prior research that high
disease activity can have a direct and negative impact
on patients’ quality of life and functioning65 and by
this route can likely increase patients’ levels of
depression.64
There are some limitations to be acknowledged in
the current study. First, the incidence and prevalence
International Journal of Rheumatic Diseases 2014
HRQoL and depression in Latino adults with RA
of RA are two to three times greater in women than
in men (http://www.hopkinsarthritis.org/arthritis-info/
rheumatoid-arthritis/ra-symptoms/) and this difference
is reflected in our sample. However, men may have
been under-represented in this study and the findings
may not generalize to this specific patient group. Sec-
ond, this study was cross-sectional, and because
patients and controls were not assessed over time, we
are not able to understand the real inter-effect between
variables or to argue anything in terms of causality.
Longitudinal research to clarify the causal relationship
between depressive symptoms and HRQoL is war-
ranted. Third, functional status was only assessed using
the SF-36 and no other measure, such as the Health
Assessment Questionnaire for Rheumatoid Arthritis
(HAQ-DI), was used. Data from a more specialized
measure of functional assessment may provide a better
explanation for the relationship between HRQoL and
depression in RA patients. Finally, because all partici-
pants from this study were from a smaller Colombian
city, caution should be taken when generalizing the
findings to individuals in other areas in Colombia,
other Latin American countries, or Latinos in the US.
Future research should include individuals from
under-studied populations, including minority groups
in the US (e.g., Latinos and Asians), as well as those
living in different socio-cultural contexts in various
countries.
The current study highlights the importance of assess-
ing HRQoL in the medical and psychological follow-up
of RA patients, especially regarding social functioning
and vitality. Such practice might be helpful to monitor
patients’ depressive symptoms over time and to inform
interventions. However, more longitudinal research is
needed to clarify the predictive value of these factors for
depressive symptoms over time in RA patients. Evi-
dence-based psychotherapeutic interventions should
also be considered as part of these patients’ follow-up,
as there is growing evidence of persistent HRQoL and
mental health problems in RA compared to healthy
individuals, even in the initial stages of the dis-
ease.57,66–68 Psychotherapy is regarded as a good
resource to monitor and treat depressive symptoms,
promote quality of life, contribute to modifying illness
perceptions, bolster the use of social support and there-
fore promote general adjustment to RA,69–71 Finally,
the findings of the present study strengthen the notion
that individuals with RA from Latin America are at risk
of having reduced HRQoL38 and therefore depression,
which may lead to additional functional limitations
and reductions in HRQoL.
7
H. Senra et al.

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Tikly M (2012) Functional disability and health-related
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International Journal of Rheumatic Diseases 2014