Type Department of Psychiatry, Hind Institute of Medical

Type of article- Original Research Article



Title – Depression in patients of Primary
knee osteoarthritis – a cross- sectional study

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Authors: Haseeb Khan 1, Pooja
Dhaon2, R.R. Singh 2,
Arvind Vaish 2.

title – Depression in OA




Department of  Psychiatry, Hind Institute of Medical
Sciences, Safedabad,

      Barabanki, Uttar Pradesh, India.

2.    Department of  Medicine ,Hind Institute of Medical Sciences,

      Barabanki, Uttar Pradesh, India.


Key words: Knee Osteoarthritis, Depression, Physical

No disclosures.

No conflicts of Interest.

Word count:


Text:  1800


Tables: 3

Figures: 1

table/figure: nil

Acknowledgement: NA

Contribution of Authors

1) Haseeb
Khan- data collection and compilation, statistical analysis, writing the review
of literature.

2) Pooja
Dhaon- compilation of data, writing and reviewing the manuscript.

3) R. R
Singh – – compilation of data, writing and reviewing the manuscript.

4) Arvind
Vaish – – compilation of data, writing and reviewing the manuscript.



Corresponding author.


Dr Pooja


of Medicine,

Institute of Medical Sciences.


Pradesh India.

[email protected]








Aim and Objective

To find prevalence of depression
and  its  relationship with functional status in
patients with primary knee osteoarthritis (OA).

Material and methods

The study included 100 patients (33
males, 67 females) of primary knee OA fulfilling ACR criteria. Demographic and
diseases variables were recorded for all patients. Functional status was
assessed using  Western
Ontario and McMaster Universities Index (WOMAC) and Depression was
assessed using Hamilton Depression Rating Scale (HAM-D).


Significant Depression (HAM-D >
13) was present in 19% patients. Depression was associated with female sex  and associated co-morbid conditions. There was
a significant positive co-relation between WOMAC score and HAM-D score in all


Treatment of OA patients should
include psychotherapy along with pharmacotherapy in order to achieve better
quality of life.

Key words: Depression ,








          Osteoarthritis (OA) is a chronic
degenerative disorder characterized by the loss of articular cartilage,
hypertrophy of bone at the margins, subchondral sclerosis, and range of
biochemical and morphological alterations of the synovial membrane and joint
capsule. It is the second most common rheumatologic problem and it
is the most frequent joint disease with a prevalence of 22% to 39% in India (1,2).


of the knee is a major cause of mobility impairment, particularly among females
with a prevalence of about 29% in India (3). OA  knee not only impairs the physical ability of
patients but also causes long term psychological impact (4). There is evidence
that disability explained by OA patients is not explained by radiographic
damage and some complains of the patient presenting with painful OA may be due
to psychological factors like anxiety and depression (5,6) . Studies from
various part of the world  which have
evaluated the concordance between OA and depression, found about 20% to 30 %
patients of OA to have major depression (7,8,9).  There is limited data from India in this regard. Pazare et.al.
studied about 40 patients of OA and  found 80% patients showing varying degree of
depression (10). Management of OA is targeted at pain management and less
attention is given to presence of concomitant depression in the patient. It has
been also found that co morbid depression is clearly linked to reduced
adherence to pain interventions (11,12). Thus this study was planned with the
following aim and objectives: 1) To find prevalence of Depression in patients
of primary knee OA in North India. 2) To find
the relationship between depression and functional status in patients of knee




Material and Methods:


It was a cross-sectional study carried out between January
and March 2017   in the Rheumatology clinic
of Department of Medicine of Hind Institute of Medical Sciences, Safedabad,
Uttar Pradesh. The study was approved by the Institutional Ethical Committee
and written informed consent was obtained from each participant. One hundred
patients with primary knee OA were included into the study. The diagnosis of primary  knee OA was made based on the American
College of Rheumatology criteria, which include knee pain with radiographic
changes of osteophyte formation and at least one of the following: patient age
>50 years, morning stiffness lasting <30 minutes, or crepitus on motion (13).    Exclusion Criteria Patients were excluded from the study if they had inflammatory joint disease, metabolic bone disease, systemic, neurological, or another muscular-skeletal problem leading to chronic pain; had a psychiatric disorder; taken an anxiolytic or antidepressant drug within 6 months; treated with physical therapy or given corticosteroid injections to knees during the last six months; or had a history of knee surgery.   Socio-demographic data and clinical history of all subjects were recorded and all patients were physically examined. The pain intensity, functional status and radiographic severity in patients were assessed with Visual Analogue Scale (VAS – 0-100 cm), the Western Ontario and Mc-Master Universities Osteoarthritis Index (WOMAC), and the Kellgren-Lawrence grading system, respectively.    Assessment of Depression   Depression was assessed in all patients using the Hamilton Depression Rating Scale (HAM-D) by a Psychiatrist. Although the HAM-D form lists 21 items, the scoring is based on the first 17. Eight items are scored on a 5-point scale, ranging from 0 = not present to 4 = severe. Nine are scored from 0-2. The severity was assessed as follows: 0-7 = Normal, 8-13 = Mild Depression, 14-18 = Moderate Depression, 19-22 = Severe Depression,   >23
= Very Severe Depression (14). For this study,  the patients with a HAM-D score of > 13
were considered to be significantly depressed.

 Western Ontario
and Mcmaster Universities Osteoarthritis(WOMAC) Index

The WOMAC Index is a self-administered questionnaire that
assesses the three dimensions of pain, disability and joint stiffness in knee
and hip OA using a battery of 24 questions, five related to pain, two related
to stiffness and 17 related to physical function. The total score of WOMAC-OA
ranges from 0 (no disability) to 96(severest disability) (15) . The WOMAC KGMC
index is modified WOMAC as per Indian conditions to evaluate patients (16).


Radiographic Evaluations

Radiographic evaluations were performed with use of weight-bearing
antero- posterior radiograph taking right knee as the index knee. Radiographs were
evaluated by one of the authors with use of the Kellgren-Lawrence grading scale
(17) for OA severity. The

radiographs of each knee were graded according to the presence
of osteophytes, joint-space narrowing, sclerosis, and cysts (Grade 0, no
features of OA; Grade 1, small osteophyte of doubtful importance; Grade 2,
definite osteophyte but an unimpaired joint space; Grade 3, definite osteophyte
with moderate diminution of joint space; and Grade 4, definite osteophyte with
substantial joint-space reduction and sclerosis of subchondral bone).



Statistical analysis

Statistical analysis of data was performed by using SPSS
20.0 (SPSS Inc., Chicago, IL, USA)
software. Continuous variables were expressed as mean  and standard deviation (SD) and categorical
variables were expressed in percentages. For the comparison of

characteristics between patients with significant
depression and without depression, independent sample t-test was used and to compare
the frequencies, chi-square test was used. Analyses of correlations between
independent variables and the HAM-D scores were conducted using Spearman’s rho
correlation test. The level of significance was 0.05 and the confidence interval
was 95%.




Characteristics of the study
sample- demographic variables


Out of the 100 patients of primary
knee osteoarthritis enrolled in the study, 33 (33%) were males and 67 (67%)
were females. Of the 67 females, 58 (86.5%) were postmenopausal. The
demographic variables of the patients are as shown in table 1. The female
patients enrolled had significantly more duration of knee pain and a higher BMI
compared to males. While male patients in the study were significantly more
engaged in smoking compared to females (table 1).  There was no difference in WOMAC score
between male and female patients.


Depression in patients:

As per the HAM- D score, 52 patients did not have
depression while 48 patients had depression. Twenty nine   patients had mild depression, 14 had
moderate depression, 3 had severe depression while 2 had very severe
depression.   A comparison was made
between demographic and disease variables in patients who had significant
depression ( HAM-D score > 13) and patients who had no depression (HAM-D score
< 13). Patients who were significantly depressed were more females, with more associated co- morbidities and higher WOMAC conventional and KGMC scores. The Mean Ham – D score was 9.25 + 7   in females and 3.42 + 4.5 in males (p 0.0001).   Co-relation between Depression and WOMAC (conventional and KGMC).   All the domains of WOMAC (conventional and KGMC) were compared to HAM-D scores in all patients using Spearman's correlation coefficient (rho). There was a significant positive co- relation between HAM- D scores and all domains of WOMAC (table 3) (Figure 1). Apart from WOMAC,  Knee pain on VAS Scales and duration of knee pain were also compared to HAM-D score and there was a significant positive co-relation between duration of pain but not between knee pain on VAS scale (Table 3).   Discussion This was a cross-sectional study to find prevalence of depression and its relationship to functional status in patients of primary knee OA. The results of the study show that OA is more common in female patients and in patients with higher BMI. Female Sex and obesity are known risk factors for knee OA (3). About 19% patients in the study screened positive for significant depression. The result is similar to other large cross-sectional studies published earlier. Roseman et al. and Sale et al. published survey on about 1000 patients of OA and reported prevalence of depression in about 20 % patients (8,9). However, an Indian study by Pazare et al on co-relation of self efficacy and depression in elderly patients of OA found varying degree of depression to be present in about 80% patients (10). The higher prevalence of depression in the study was because the study sample included patients aged 65-70 years and they did not grade depression. In the present study, the mean age of patients was 55 years and only patients with HAM-D score > 13 were considered as depressed.

Depression was
found more in females  and even the
severity was more in females. This finding has been reported in majority
studies. Biological factors like menopause apart from social factors contribute
to the higher prevalence and increased severity of depression in females
(18,19) .

About 50% of
patients who had depression, had associated co-morbidities in the study
compared 25% patients who did not have depression. A study by Amonker et al.
which reported risk factors associated with geriatric depression also had
similar result (20). Thus depression is often accompanied by 2 or 3 other
clinical diagnosis. It may be because of stress caused by disease and social
and physical restriction that increases the financial burden and makes the
patient prone to depression.


Higher levels
of depression in our patients was associated with increased duration and
severity  of knee pain,  more stiffness and decreased function than the
non- depressed patients.  Chronic pain
and depression accompany each other and worsen the quality of life of patients (21)  . Previous studies looking at the
association between pain and depression in patients with knee OA report
different findings. Some studies reported a strong correlation between the
severity of pain and depressive symptoms (22-25), while the others did not
(5,6). In our study, pain scores of WOMAC were higher in knee OA patients with
depression, compared to those without, and a strong correlation was present
between the HAM D score and the pain scores of WOMAC.

 Previous studies
have demonstrated association between depression and disability also. While
disability leads to depression, presence of depression can worsen disability in
patients of knee OA. Some studies in literature (26,27, 28) report a strong
association between disability and depression , other studies (5,24)report no association.
In our study, it was determined that the WOMAC scores, were at a higher  in knee OA patients with depression, compared
to those without depression, and a positive correlation was present between the
HAM D score, and WOMAC score.


The study has
some limitations. The sample size is small for the study. It’s a
cross-sectional study and thus cannot determine the causal relationship between
depression and knee OA. Thus, a prospective longitudinal study is
warranted to determine the nature of the bidirectional relationship between
pain and depression in knee OA. There
was no control group so a comparison could not be made.


In conclusion, depression is a co-morbidity found in
patients with knee OA and it was found to be strongly associated with more pain,
and disability in patients with OA of the knee. Our findings indicate that the
assessment for and management of depression should be integrated into care of
patients with knee OA.


































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Legend Figure
1. Linear scatter diagram showing positive co-relation between HAM-D score and
WOMAC score ( Conventional and KGMC). a) Spearman co-relation co-efficient rho
– 0.35 ( p<0.001). b) rho – 0.32 (p<0.001).                                                                         Variable Patients  (n – 100) Age in years ( mean + SD) 55.4 + 8.5 Sex (Males/females),n 33/67 BMI in kg/m2 ( mean + SD) 28 + 5.4 Socio economic class ( n, %) a)      lower b)      middle- upper     62 (62%) 38 (38%) Smokers (n, %) 30 (30%) Associated co- morbid conditions (n,%) 30 (30%) Duration of disease in months ( mean + SD) 28.7 + 44 VAS pain in mm ( 0 – 100) ( mean + SD) 60.1 + 20.2 Severity of OA by K – L grading (n,%)    Grade  2 >
Grade  3

53 (53%)
47 (47%)

WOMAC (0 – 86) (
mean + SD)



11.39 + 4.3

Stiffness WOMAC

3.5 + 2.6

Function WOMAC

33.5 + 13.6

Function KGMC

32.6 + 11.1


47.4 + 16.5

Total KGMC

48.4+ 19.1

1. Characteristics of the study sample- 
Demographic and Disease variables














































Table 2.Comparison of Demographic variables in patients with
and without depression



(HAM-D>13) (n-19)

(HAM-D <  13) (n – 81) p value Age in years (Mean + SD) 55.84 + 8.04 55.34 + 8.63 p ns Sex (n, %) Male (n-33) Female (n- 67)   2 (10.5%) 17 (89.5%)   31 (38.2%) 50 (61.8%) Chi square- 5.35 p 0.02 Body Mass Index in kg/m2 (Mean + SD) 29.8 + 6.02 27.4 + 5.19 p ns Socio economic class (n, %) Lower Middle- upper   13 (68.4%) 6 (31.6%)   49 (60.4%) 32 (31.5%) Chi square 0.4105 p ns Smoking (n,%) 5 (26.3%) 25 (30.8%) p ns Associated co- morbid conditions (n %) 10 (52.6%) 20 (24.6%) Chi square 5.2 p 0.016 VAS pain ( 0 – 100mm) (Mean + SD) 64.2 + 13.9 59.3 + 21.4 p ns Duration in months (Mean + SD) 35.8 + 52.8 26.4 + 43.2 p ns Severity of OA as per K-L grading  (n, %)    Grade 2 > Grade 3

7 (37%)

46 (57%)
 35 (43%)

Chi square 2.45
p ns



13.3+ 4

10.9 + 4.34


Stiffness WOMAC

2.7 + 2.3

3.8 + 2.63


Function WOMAC

40.6 + 14.2

31.8 + 13.03


Function KGMC

38.8 + 10.5

31.1 + 10.7



56.7 + 14.9

45.3 + 16.1


Total KGMC

58.7+ 18.6

46.03 + 18.5















 Table 3. Relationship between Depression and
selected variables.



 coefficient (rho)

 p value

pain (0-100)



(in months)


p<0.05 WOMAC Pain WOMAC 0.27 p<0.05 Stiffness WOMAC 0.36 p<0.001 Function  WOMAC 0.3 p<0.05 Function KGMC 0.35 p<0.001 Total WOMAC 0.35 p<0.001 Total KGMC 0.32 p<0.001