Exploring health care encounters and treatments for mental disorders in individuals with inflammatory arthritis : epidemiologic and health services research studies

The full abstract for this thesis is available in the body of the thesis, and will be available when the embargo expires.Pharmaceutical Sciences, Faculty ofGraduat

Management of gout from the patient perspective

Introduction: Suboptimal medication adherence and poor health outcomes in patients with gout, the most common inflammatory arthritis, has prompted efforts to optimize care delivery. The Virtual Gout Clinic, an electronic health technology supported collaborative care model for gout involving rheumatology, pharmacy, and dietetics, offers a promising solution. The purpose of this thesis is to gain an in-depth understanding of how individuals engage in managing their gout and also explore the complexity of the Virtual Gout Clinic using mixed methods to optimize the context and delivery of this care model. Objectives: 1) To explore individual experiences with gout in a Canadian population and to understand the phenomenon of becoming actively engaged in the management of gout with an emphasis on factors which facilitate management; and 2) to explore how participants with gout experience the Virtual Gout Clinic and to understand and explain quantitative outcomes from the evaluation of this care model. Methods: For the first objective, I used a constructivist grounded theory design and conducted semi-structured telephone interviews with participants diagnosed with gout completing the Virtual Gout Clinic. I applied an explanatory sequential mixed methods design for objective 2, as this design enables interview questions used in the qualitative component to be informed by quantitative outcomes of the Virtual Gout Clinic (adherence, serum uric acid) for a comprehensive final interpretation. Results: 1) Analysis of 12 interviews constructed four themes: describing the severity of gout; processing the diagnosis and management of gout; interfering with management of gout; and facilitating management of gout. 2) The experience of the Virtual Gout Clinic was described by three conceptual categories: learning through the Virtual Gout Clinic; receiving personalized support; and knowing someone cares. Suboptimal health outcomes were explained by practical and perceptual barriers to gout management, such as lacking knowledge and fearing side-effects of medications. Conclusion: This thesis provided novel insight into the process of patients becoming actively engaged in the management of gout with an emphasis on facilitating factors. An interdisciplinary model of care is a promising approach to optimize care delivery by providing both emotional and practical support as well as ongoing individualized education.Pharmaceutical Sciences, Faculty ofGraduat

Insights on mental health when living with rheumatoid arthritis: a descriptive qualitative study of threads on the Reddit website

Background: Reddit is a highly visited social news and discussion website where individuals anonymously ask questions, post opinions and share experiences, which provide a valuable pool of publicly available data. Our objective was to systematically search and analyze threads on the social news website, Reddit, to understand experiences of individuals with rheumatoid arthritis (RA) regarding their mental health. Methods: We conducted a patient-oriented descriptive qualitative study. We identified threads from two subreddits, “r/Thritis” and “r/Rheumatoid”, using keywords such as “mood”, “mental health”, “stressed”, “depressed”, “anxious” over a 1-year period between June 2018 and June 2019. For included threads, we extracted the title, original post, and corresponding comments and responses. We applied thematic analysis using an inductive approach. Results: Of 81 threads identified, we included 27. We identified four themes: 1) Navigating the management of RA explores how the physical impacts of the disease, lack of health resources/support and the complexity of medications affect mental health; 2) Experiencing impact on relationships and social isolation includes experiencing misconceptions of RA, feeling misunderstood and feeling guilt; 3) Experiencing loss, touches on the helplessness brought by challenges with performing self-defining activities such as self-care, work, and childbearing/parenting; and finally, 4) Experiencing emotional struggles captures how tension between fighting through and despair has led some to suicide ideation and thoughts of death. Conclusions: Online forums and communities such as Reddit have created opportunities for individuals with RA to share experiences on mental health matters, which they may not necessarily be able to share with others.Pharmaceutical Sciences, Faculty ofOther UBCReviewedFacult

Impact of arthritis on the perceived need and use of mental healthcare among Canadians with mental disorders: nationally representative cross-sectional study

Objective To evaluate the association between having arthritis and the perceived need for mental healthcare and use of mental health support among individuals with mental disorders.Design A cross-sectional analysis using data from Canadian Community Health Survey—Mental Health (2012).Setting The survey was administered across Canada’s 10 provinces using multistage cluster sampling.Participants The study sample consisted of individuals reporting depression, anxiety or bipolar disorder.Study variables and analysis The explanatory variable was self-reported doctor-diagnosed arthritis, and outcomes were perceived need for mental healthcare and use of mental health support. We computed overall and gender-stratified multivariable binomial logistic regression models adjusted for age, gender, race/ethnicity, income and geographical region.Results Among 1774 individuals with a mental disorder in the study sample, 436 (20.4%) reported having arthritis. Arthritis was associated with increased odds of having a perceived need for mental healthcare (adjusted OR (aOR) 1.71, 95% CI 1.06 to 2.77). In the gender-stratified models, this association was increased among men (aOR 2.69, 95% CI 1.32 to 5.49) but not women (aOR 1.48, 95% CI 0.78 to 2.82). Evaluation of the association between arthritis and use of mental health support resulted in an aOR of 1.50 (95% CI 0.89 to 2.51). Individuals with arthritis tended to use medications and professional services as opposed to non-professional support.Conclusion Comorbid arthritis among individuals with a mental disorder was associated with an increased perceived need for mental healthcare, especially in men, underscoring the importance of understanding the role of masculinity in health seeking. Assessing the mental health of patients with arthritis continues to be essential for clinical care

The incidence of depression and anxiety in patients with ankylosing spondylitis: a systematic review and meta-analysis

Background: As awareness for the importance of mental health continues to expand in rheumatology, it is important to understand the epidemiology of psychiatric complications in ankylosing spondylitis (AS) with the ultimate goal of future prevention and improved quality of care. This study aims to review evidence on the incidence and determinants of depression and/or anxiety among patients with AS. Methods: We searched Medline, Embase, Cochrane Database of Systematic Reviews, CINAHL Complete, and PsycINFO for full-length observational studies that involved a sample or population of patients with AS and assessed depression and/or anxiety. Primary outcomes extracted were: 1) risk estimates for depression and/or anxiety (e.g., relative risk [RR]); and 2) determinants or factors identified as independent predictors of depression and/or anxiety using multivariable regression approaches and corresponding estimates (e.g., odds ratios [OR]). Where relevant, we pooled estimates using random effects models. Results: Out of 783 titles from our search strategy, we reviewed 39 manuscripts. Four studies assessed the incidence of depression and meta-analyzing reported estimates from three of these studies yielded a pooled RR of 1.51 (95% CI 1.28 to 1.79). Differences in risk of depression among men and women with AS were inconclusive, suggesting need for further study. The incidence of anxiety was comparatively less studied with only one included study reporting a hazard ratio of 1.85 (95% CI 1.37 to 2.49). Education level was a key determinant, with lower levels associated with higher odds of depression (OR 6.65; 9% CI 1.36 to 32.51) and anxiety (OR 9.31; 9% CI 1.39 to 62.19) among AS patients. Conclusions: Our systematic review and meta-analysis shows an increased risk of depression and anxiety among patients with AS. These findings suggest the importance of monitoring and care for psychiatric conditions in AS.Pharmaceutical Sciences, Faculty ofOther UBCReviewedFacult

EMRs and Gout Quality Indicators

Objectives: With comprehensive capture of information on patient encounters, electronic medical records (EMRs) may have utility for assessing adherence to quality indicators (QI) in gout. Our objectives were to translate 10 previously established gout QIs into relevant EMR data and evaluate and describe the feasibility of using EMRs to assess gout QIs. Methods: Using EMRs from three community rheumatology practices in Vancouver, British Columbia, Canada, we identified gout patients seen between January 01, 2012 and December 31, 2013. We translated each gout QI into potential EMR variables that would allow identification of patients the QI pertains to and whether the QI could be assessed. We extracted deidentified EMR data on gout diagnosis, medications, laboratory tests, radiologic tests, and clinical notes and calculated the percent availability of data for each QI. Results: We included 125 patients with gout, with mean age 64 ± 17 years and with males comprising 78%. Overall, there were sufficient EMR data to allow translation of seven QIs and assessment of six QIs including therapy-related gout QIs (69% to 83% data availability) and one counselling-related QI (8% data availability). The highest percent data availability was observed in the single QI translated into EMR data and assessed based on diagnostic codes and prescription medications and not laboratory tests. Conclusions: EMRs are promising tools for assessing QIs for gout. With increased use of EMRs by physicians, our study has implications for informing processes for their enhanced use to improve patient care and outcomes in gout.Medicine, Faculty ofPharmaceutical Sciences, Faculty ofOther UBCNon UBCMedicine, Department ofRheumatology, Division ofReviewedFacultyGraduateOthe

How patients with gout become engaged in disease management: a constructivist grounded theory study

Background: Prior qualitative research on gout has focused primarily on barriers to disease management. Our objective was to use patients’ perspectives to construct an explanatory framework to understand how patients become engaged in the management of their gout. Methods: We recruited a sample of individuals with gout who were participating in a proof-of-concept study of an eHealth-supported collaborative care model for gout involving rheumatology, pharmacy, and dietetics. Semistructured interviews were used. We analyzed transcripts using principles of constructivist grounded theory involving initial coding, focused coding and categorizing, and theoretical coding. Results: Twelve participants with gout (ten males, two females; mean age, 66.5 ± 13.3 years) were interviewed. The analysis resulted in the construction of three themes as well as a framework describing the dynamically linked themes on (1) processing the diagnosis and management of gout, (2) supporting management of gout, and (3) interfering with management of gout. In this framework, patients with gout transition between each theme in the process of becoming engaged in the management of their gout and may represent potential opportunities for healthcare intervention. Conclusions: Findings derived from this study show that becoming engaged in gout management is a dynamic process whereby patients with gout experience factors that interfere with gout management, process their disease and its management, and develop the practical and perceptual skills necessary to manage their gout. By understanding this process, healthcare providers can identify points to adapt care delivery and thereby improve health outcomes.Medicine, Faculty ofPharmaceutical Sciences, Faculty ofNon UBCMedicine, Department ofPopulation and Public Health (SPPH), School ofRheumatology, Division ofReviewedFacult

Management of Inflammatory Arthritis in pregnancy: a National Cross-Sectional Survey of Canadian rheumatologists

Background: With improved therapies and management, more women with inflammatory arthritides (IA) are considering pregnancy. Our objective was to survey rheumatologists across Canada about their IA management in pregnancy to identify practice patterns and knowledge gaps. Methods: We administered an online survey with questions regarding medications for IA treatment including conventional synthetic disease modifying antirheumatic drugs (csDMARDs) and biologics/small molecules in planned and unplanned pregnancies. Email invitations were sent to members of the Canadian Rheumatology Association. We calculated responses frequencies and a priori set a cut-off of ≥75% to define consensus. Results: Ninety rheumatologists participated in the survey (20% participation rate); 57% have been practicing for > 10 years, 32% for ≤10 years, and 11% in training. There was consensus on discontinuation of 4 csDMARDs – cyclophosphamide (100%), leflunomide (98%), methotrexate (96%), and mycophenolate mofetil (89%) – in planned pregnancies but varied responses on when to discontinue them or what to do in unplanned pregnancies. Respondents agreed that 3 csDMARDs – azathioprine (84%), hydroxychloroquine (95%), and sulfasalazine (77%) – were safe to continue in planned and unplanned pregnancies. There was consensus with use of 4 biologics – adalimumab (81%), certolizumab (80%), etanercept (83%), and infliximab (76%) – in planned pregnancies but uncertainty on when they should be discontinued and their use in unplanned pregnancies. Conclusions: This national survey shows consensus among rheumatologists on the use of some csDMARDs and biologics/small molecules in IA patients planning pregnancy but varied knowledge on when to discontinue and what to do in unplanned pregnancies.Medicine, Faculty ofPharmaceutical Sciences, Faculty ofOther UBCNon UBCRheumatology, Division ofReviewedFacult

Risk of Anxiety and Depression after Diagnosis of Young-Onset Colorectal Cancer: A Population-Based Cohort Study

Given the increasing incidence of young-onset colorectal cancer (yCRC; <50 years), we aimed to evaluate the risk of depression and anxiety in individuals with yCRC in comparison to average-age-onset CRC (aCRC; 50 years) and to cancer-free controls, with stratification by sex. Our cohort study identified individuals ( 18 years) with CRC and cancer-free controls (10:1) matched on age and sex using population-based linked administrative health databases in British Columbia, Canada. We assessed depression and anxiety using validated algorithms. We evaluated the risk of depression and anxiety using multivariable Cox proportional hazard models. The cohort included 54,634 individuals with CRC (46.5% female, mean age 67.9 years) and 546,340 controls (46.5% female, mean age 67.9 years). Those with yCRC as compared to aCRC had an increased risk for depression (adjusted hazard ratio [aHR] 1.41; 95% confidence interval [CI] 1.25 to 1.60), and when stratified by sex, the risk was only significant among males (aHR 1.76; 95% CI 1.48 to 2.10). When comparing individuals with yCRC to cancer-free controls, the overall risk of depression (aHR 1.00; 95% CI 0.92 to 1.10) and anxiety (aHR 1.10; 95% CI 0.95 to 1.27) was non-significant; however, males had a significantly higher risk for mental health disorders, specifically depression (aHR 1.17; 95% CI 1.03 to 1.33). Altogether, our findings that individuals with yCRC experience higher risk of depression compared to those with aCRC as well as cancer-free controls, particularly among males, suggest effects of age and sex on mental health outcomes.Pharmaceutical Sciences, Faculty ofNon UBCReviewedFacultyResearche

eHealth supported multi-disciplinary care for gout

Objective: To conduct quantitative and qualitative evaluation of an electronic health (eHealth)-supported decentralized multi-disciplinary care model for gout involving rheumatologists, pharmacist, and dietitian. Methods: We conducted a 12-month proof-of-concept study. Gout patients with ≥1 flare in the past year and serum urate (SUA) ≥360 μmol/L within the previous 2 months were followed by participating community rheumatologists on an as needed-basis, received monthly telephone consults with a pharmacist, and one telephone consult with a dietitian. Health care professionals were not co-located but had shared access to the rheumatologists’ electronic medical records (EMR) for remote communication and collaboration. In quantitative evaluation, the primary outcome was the proportion of patients with SUA <360 μmol/L at 12 months. In qualitative evaluation, we conducted semi-structured interviews with a sub-set of patients and applied constructivist grounded theory to gather patients’ perspectives. Results: Overall, 35 gout patients (86% males, mean age 60.9 ± 14.9 years) participated. At 12 months, 72% of patients achieved target SUA <360 μmol/L. Qualitative analysis of interviews with a subset of 12 patients resulted in two themes: 1) experiences with receiving care, including categories of improved knowledge about gout, receiving personalized support, and knowing someone cares; and 2) practical considerations, including categories of optimizing timing of care and coordination and accessibility. Conclusion: Our multi-method study shows that a decentralized, multi-disciplinary care for gout involving rheumatology, pharmacy, and dietetics with shared EMR access led to gout patients achieving target SUA. It was well-received by patients who perceived better education about gout and personalized care.Medicine, Faculty ofPharmaceutical Sciences, Faculty ofNon UBCMedicine, Department ofRheumatology, Division ofReviewedFacultyGraduat