Case reports001. Pure Red Cell Aplasia: A Rare and Challenging Extra-Articular Manifestation of Rheumatoid Arthritis

Abstract

Background: Co-morbid mood disorders in rheumatoid arthritis (RA) are frequent, but often underrecognised and undertreated, contributing to increased morbidity and mortality. The NICE quality standard for RA management (QS33) recommends that patients should have a holistic annual review, including an assessment of mood. A specialist nurse-led annual review clinic was piloted, during which patients, in the context of a holistic review, were asked the casefinding questions for anxiety and depression (GAD2 and PHQ2). This qualitative study aimed to explore patients' experiences of being asked the case-finding questions and their perspectives of the annual review clinic. Method(s): Ethical approval was obtained. A purposive sample of patients attending the annual review clinic, who scored >=3 on the case-finding questions, were invited to participate in a face-to-face, semi-structured interview. A topic guide was utilized to generate data. Interviews were transcribed verbatim and the transcripts formed the data which were analysed thematically using principles of constant comparison. Data saturation was reached after fourteen interviews. Result(s): Participants were all White British, reflecting local population demographics. Twelve were female and ten retired, with an average age of 63 years. Most patients reported the case-finding questions were acceptable and described anxiety or depression as either secondary to RA or completely separate. Some perceived RA flares to be triggered by worsening mood, thus affecting help-seeking. Within the annual review, participants appreciated the emphasis on understanding the wider psychosocial impact of their RA, which they often perceived to be poorly explored by their rheumatologist, whose main focus was on joint symptoms. Some participants reported their doctor to be dismissive of mood concerns, while several also perceived appointments to be anxiety provoking, recursively affecting help-seeking. In contrast, the clinic nurse was described approachable and was perceived to actively listen to mood concerns, facilitating disclosure. Recently diagnosed patients described the clinic as a learning process about potential complications of RA. Participants valued the time taken for a detailed review, and although several expressed initial concerns about seeing a nurse instead of their doctor, most felt their problems were addressed. Conclusion(s): Participants reported the nurse-led clinic as an ideal setting to discuss their mood. Use of the case finding questions in an annual review setting could assist early recognition and treatment of co-morbid anxiety and depression in patients with RA leading to improved patient outcomes.