{"paper_id":"ee4b1145-b023-4d1d-bcbd-44cc1b96b5db","body_text":"Endometriosis is a common gynecological disease [ 1 ,  2 ]. The main symptoms are \nchronic pelvic pain, dysmenorrhea, and sexual intercourse pain. It affects female \nfertility, leads to infertility, menstrual disorders, and other problems, and \nincreases the risk of ectopic pregnancy [ 3 ,  4 ,  5 ]. The depression in endometriosis \ngroup is believed to be underestimated. Another study [ 6 ] showed that 15.1% of \nwomen with endometriosis were diagnosed with depression. A cross-sectional study \nby Bernarda Škegro  et al . [ 7 ] showed that 44.3% of patients with \nendometriosis had depressive symptoms.\nPatients with endometriosis are often complicated by immune system diseases \n[ 8 ,  9 ], which are complicated by rheumatoid arthritis, hypothyroidism, allergic \nasthma, multiple sclerosis, systemic lupus erythematosus, Crohn’s disease, and \nulcerative colitis. The probability of immune system diseases, such as colitis, \nis significantly increased [ 10 ,  11 ]. A large-scale cohort study conducted by \nShih-Fen Chen  et al . [ 12 ] revealed that patients with endometriosis have \nan increased risk of rheumatoid arthritis (Hazard Ratio (HR): 3.71, 95% confidence interval (CI): 2.91–5.73). As \na previous study has shown, rheumatoid arthritis can increase the risk of \ndepression. A cross-sectional analysis of 156 patients with rheumatoid arthritis \nshowed that the prevalence of depression in patients with rheumatoid arthritis \n(RA) was 76.3%. The majority of patients (49.4%) suffered from \nmoderate-to-severe depression, 91% experienced sleep disorder symptoms, and \n21.8% reported negative thoughts of suicidal ideation or self-harm [ 13 ].\nSecondary depression seriously affects the life quality of patients with \nendometriosis [ 14 ]. Arthritis further reduces patients’ quality of life and \nprognosis, so identifying risk factors for depression in people with comorbid \nendometriosis and rheumatoid arthritis is necessary. However, no relevant studies \nhave been found. For this special population, the sensitivity of different \ndepression screening scales is worth exploring. Therefore, a retrospective \nresearch was conducted to explore the role of depression in endometriosis when \nusing different diagnostic criteria and scoring scales. The detection rate in \npatients with endometriosis and rheumatoid arthritis was investigated, and the \ninfluencing factors of depression were analyzed.\n\nA total of 119 patients with endometriosis complicated with rheumatoid arthritis \ndiagnosed and treated in the First Hospital of Lanzhou University from July 2021 to July 2023 were selected \nas research subjects, and complete information of 108 patients was received for \nresearch. This research has been approved by the Ethics Committee of the First Hospital of Lanzhou University \nand obtained an ethics certificate (LDYYSZLLKH2024-06). Based on the principle of \nconfidentiality, the personal and family information of patients with \nendometriosis and rheumatoid arthritis were strictly kept confidential. Informed \nconsent was obtained from all participants. This study adhered to the principles \noutlined in the Declaration of Helsinki.\nThe inclusion criteria were as follows: (1) Patients aged  ≥ 18 years old; \n(2) patients diagnosed with endometriosis; (3) patients diagnosed with rheumatoid \narthritis; (4) patients without hearing, intelligence, nor language communication \nimpairment and can communicate with others and medical staff; (5) patients who \ngave informed consent.\nThe exclusion criteria were as follows: (1) patients joining other clinical \ntrials; (2) patients who have taken psychotropic drugs 2 weeks before admission; \n(3) patients with schizophrenia, bipolar disorder, paranoid disorder, and other \nserious mental illnesses; (4) patients with adenomyosis and other diseases that \ncause pelvic pain and infertility; (5) patients with acute attacks of vaginal \nbleeding, fever, infection, etc.; (6) patients with developmental malformations \nof reproductive organs; (7) patients with tumors or serious diseases of other \norgans.\nAll 108 patients were tested for depression 10 minutes after arriving at the \ndiagnosis and treatment site, using the internationally accepted Diagnostic and \nStatistical Manual of Mental Disorders, fifth edition (DSM-5) [ 15 ], the new \ndepression assessment tool Hamilton Depression Scale (HAMD) [ 16 ], and the \nSelf-rating Depression Scale (SDS) [ 17 ] to detect the incidence of depression in \npatients with endometriosis and rheumatoid arthritis.\nThe DSM-5 diagnostic criteria for depression are as follows: persistent low \nmood; slow thinking and association; inhibition of volition and behavior; \ndecreased interests and hobbies; low self-evaluation, accompanied by insomnia and \nearly awakening, loss of appetite, and decreased sexual desire; and repeated \nthoughts of death or self-injury or self-abandonment behavior lasting for more \nthan 2 weeks (severe case). Depression triggered by organic brain diseases, \nphysical diseases, and other neuroses like anxiety disorders and \nobsessive-compulsive disorder is ruled out. In this study, the DSM-5 assessments \nwere conducted by clinicians who had received systematic training in DSM-5 \nstandards. All evaluators underwent comprehensive DSM-5 training and adhered \nstrictly to standardized procedures during the evaluation process.\nHAMD has 17 items in total. It uses a five-level scoring method, with scores \nranging from 0 to 4. A total score of more than 24 is considered severe \ndepression, more than 17 is considered mild-to-moderate depression, and a score \nless than 7 is considered to have no depressive symptoms. The HAMD’s reliability \nis 0.845, its validity is 0.926, and its Cronbach’s alpha coefficient is 0.856.\nSDS has a total of 20 items, including 10 items for forward testing and 10 items \nfor reverse testing. It adopts a four-level scoring method and is assigned 1–4 \npoints. The scores of all items are added up and multiplied by 1.25 to obtain the \ntotal score (integer is taken), and  ≥ 53 is classified as depressive state. \nThe SDS’s reliability is 0.884, its validity is 0.906, and its Cronbach’s alpha \ncoefficient is 0.931.\nOn the basis of DSM-5 detection results, patients with endometriosis and \nrheumatoid arthritis who were complicated by depression were categorized into \nobservation group, and those with endometriosis and rheumatoid arthritis without \ndepression were categorized into control group.\n(1) The internationally accepted DSM-5 depression diagnostic criteria and new \ndepression assessment tools HAMD and SDS were used to detect the occurrence of \ndepression in patients with endometriosis and rheumatoid arthritis.\n(2) The patients’ general demographic information, including age, Body Mass \nIndex (BMI), family history, comorbidities (diabetes, hypertension, \nhyperlipidemia, and coronary heart disease), educational level, working status, \nmarital status, childbirth history, whether smoking or not, and whether drinking \nor not, regular exercise habits, and average sleep duration, were collected. The \nstaging of endometriosis according to the American Society for Reproductive \nMedicine (ASRM). The ASRM classification system is divided into four stages or \ngrades according to the number of lesions and depth of infiltration: minimal \n(Stage I), mild (Stage II), moderate (Stage III) and severe (Stage IV) [ 18 ].\n(3) The clinical symptom data of patients, including dysmenorrhea, dyspareunia, \npelvic pain, painful defecation, painful urination, and infertility, were \ncollected. The Visual Analog Scale (VAS) score range is 0–10, with 0 and 10 \npoints representing painless and unbearable severe pain states, respectively. The \nobtained score is directly proportional to the patient’s pain level. The VAS \nreliability is 0.950, its validity is 0.803, and its Cronbach’s alpha coefficient \nis 0.865. Rheumatoid arthritis disease activity (DAS28), DAS28  < 2.6 points for \ndisease remission, 2.6– < 3.2 is classified as low disease activity, 3.2–5.1 is \nclassified as medium disease activity, and  > 5.1 is classified as high disease \nactivity. The higher the score, the more severe the disease activity. The \nPittsburgh Sleep Quality Index (PSQI) score ranges from 0 point to 21 points. The \nhigher the score, the worse the sleep quality. PSQI’s reliability is 0.994, its \nvalidity is 0.824, and its Cronbach’s alpha coefficient is 0.845. The Health \nAssessment Questionnaire-Disability Index (HAQ-DI) was applied to assess the \nfunctional status of patients with rheumatoid arthritis. The patients answered 20 \nquestions involving eight functional aspects (dressing, getting up, eating, \nwalking, personal hygiene, touching objects, pinching objects, and activities). \nSelect and score on 4 levels (0 to 3 points). The higher the score, the more \nsevere the physical function limitation is. The average of the eight functional \ndimension scores is the total HAQ-DI score, with 0 point indicating no functional \nlimitation, 0 points  <  a score of  ≤  1 defined as mild functional \nlimitation, 1  <  score  ≤  2 classified as moderate functional limitation, \nand 2  <  score  ≤  3 classified as severe functional limitation. The \ntest-retest reliability of HAQ-DI is 0.84, and the internal consistency is 0.86, \nindicating good reliability and validity among the Chinese population with \nrheumatoid arthritis.\nSPSS software version 21.0 (IBM Corporation, Armonk, NY, USA) was used for \nstatistical analysis. This study used the Shapiro-Wilk test to assess the \nnormality of continuous variables. Measurement indicators that conformed to \nnormal distribution, such as age and BMI, were recorded as mean  ±  standard \ndeviation. Comparisons between groups were processed by independent sample \n t  tests. Counting indicators, such as family history and comorbidities, \nwere recorded using [number of cases (percent)] records. Comparison between \ngroups was performed using  χ 2  test, when the theoretical \nfrequency T  ≥ 5 and the sample size N  ≥ 40, use the chi-square test; \nwhen 1  ≤  T  <  5 and N  ≥ 40, use the continuity correction \nchi-square test; when T  < 1 or N  < 40, use Fisher’s exact test. The influencing \nfactors of depression in patients with endometriosis and rheumatoid arthritis \nwere analyzed using logistic regression.  p -value  <  0.05 was considered \nstatistically significant.\n\nDSM-5, HAMD, and SDS were used to detect the incidence of depression in patients \nwith endometriosis and rheumatoid arthritis. DSM-5 detected 20 patients with \ndepression, with a detection rate of 18.52%; HAMD detected 21 patients with \ndepression, with a detection rate of 19.44%; and SDS detected 18 patients with \ndepression, with a detection rate of 16.67% (Fig.  1 ). No significant difference was found \nin the detection rate of depression in patients with endometriosis combined with \nrheumatoid arthritis among the three methods ( χ 2  = \n0.290,  p  = 0.865).\nDetection of depression in patients with endometriosis and \nrheumatoid arthritis . DSM-5, Diagnostic and Statistical Manual of \nMental Disorders, fifth edition; HAMD, Hamilton Depression Scale; SDS, Self-rating Depression Scale.\nIn terms of BMI, family history, diabetes, hypertension, hyperlipidemia, \ncoronary heart disease, working status, marital status, whether smoking, whether \ndrinking alcohol, and regular exercise habits between the observation group and \nthe control group ( p  \n >  0.05). The patients in the observation group \nwere younger, and they had a higher proportion of high school and below, a \nhigher proportion of childless children, and shorter average sleep time than \nthose in the control group, and the differences were statistically significant \n( p  \n <  0.001, Table  1 ).\nComparison of general demographic information of the two groups \nof patients .\nNote: The staging of endometriosis according to the American Society for \nReproductive Medicine; *, the continuity correction chi-square test was used; **, \nFisher’s exact test was used. BMI, Body Mass Index.\nNo statistically significant difference was found between the observation group \nand the control group in terms of clinical symptoms such as painful defecation, \npainful urination, and infertility ( p  \n >  0.05). The observation group \nhad a higher proportion of dysmenorrhea ( p  = 0.002), dyspareunia \n( p  = 0.002), and pelvic pain ( p  = 0.004) and higher scores of \nVAS, DAS28, PSQI, and HAQ-DI than the control group ( p  \n <  0.001, Table  2 ).\nComparison of clinical symptoms data between the two groups of \npatients .\nNote: VAS, Visual Analog Scale; DAS28, Rheumatoid arthritis disease activity; \nPSQI, Pittsburgh Sleep Quality Index; HAQ-DI, Health Assessment \nQuestionnaire-Disability Index; *, the continuity correction chi-square test was \nused.\nDysmenorrhea, dyspareunia, VAS, DAS28, PSQI, and HAQ-DI are influencing factors \nof depression in patients with endometriosis and rheumatoid arthritis, as shown \nin Tables  3 , 4 .\nVariable assignment standards .\nNote: VAS, Visual Analog Scale; DAS28, Rheumatoid arthritis disease activity; \nPSQI, Pittsburgh Sleep Quality Index; HAQ-DI, Health Assessment \nQuestionnaire-Disability Index.\nBinary logistic regression analysis of depression in patients \nwith endometriosis and rheumatoid arthritis .\nNote: VAS, Visual Analog Scale; DAS28, Rheumatoid arthritis disease activity; \nPSQI, Pittsburgh Sleep Quality Index; HAQ-DI, Health Assessment \nQuestionnaire-Disability Index. OR, odds ratio; CI, confidence interval.\n\nThis study aimed to investigate the prevalence and influencing factors of \ndepression in patients with endometriosis combined with rheumatoid arthritis. By \nusing three different depression screening tools—DSM-5, HAMD, and SDS—the \ndetection rates of depression were found to be 18.52%, 19.44%, and 16.67%, \nrespectively, with no significant differences among the three methods. This \nfinding indicates that the internationally accepted DSM-5 diagnostic criteria and \nthe HAMD and SDS assessment tools are effectively applicable in detecting \ndepression in this specific patient population. The binary logistic regression \nanalysis further confirmed the significant impact of pain symptoms (dysmenorrhea, \ndyspareunia, and pelvic pain) and the VAS, DAS28, PSQI, and HAQ-DI scores on the \noccurrence of depression in patients with endometriosis combined with rheumatoid \narthritis.\nCompared with previous studies [ 19 ,  20 ], the present research confirmed the \nassociation between dysmenorrhea and depression. A meta-analysis by Esther van \nBarneveld  et al . [ 21 ] found similar results, indicating that patients \nwith endometriosis often experience depressive and anxiety symptoms associated \nwith chronic pain. Dietrich  et al . [ 22 ] suggested that severe primary \ndysmenorrhea could trigger chronic pain-related psychological symptoms. The \nmechanism by which dysmenorrhea contributes to depression may involve multiple \nphysiological and psychological factors. Physiologically, pain transmission and \nthe release of inflammatory mediators may activate the central nervous system, \naffecting mood regulation pathways and thereby increasing the risk of depression \n[ 23 ]. Additionally, the persistent pain state may lead to decreased sleep \nquality, heightened psychological stress, and further exacerbate or induce \ndepressive symptoms [ 24 ].\nThis study also observed the impact of dyspareunia on depression, consistent \nwith the findings of Facchin F  et al . [ 23 ], both indicating a close link between sexual \ndysfunction and mental health. The relationship between dyspareunia and \ndepression may be mediated through various pathways. Psychologically, sexual \ndysfunction may lead to decreased self-esteem and increased psychological stress, \nthereby promoting the occurrence of depression [ 25 ].\nRegarding rheumatoid arthritis activity, a significant correlation was found \nbetween DAS28 scores and depression, which aligns with the results of Hughes M  et al . [ 26 ] \nand Kwiatkowska  et al . [ 27 ], who showed a close relationship between \ndisease activity levels and depression in patients with rheumatoid arthritis. The \nlink between rheumatoid arthritis activity and depression can be partially \nexplained by the complex interactions between inflammatory mediators in the \nnervous and immune systems. An exacerbated inflammatory response may affect \nneurotransmitter release and neuronal activity in the brain through multiple \npathways, leading to changes in mood and cognitive functions, including the \noccurrence of depression [ 28 ,  29 ].\nThis study emphasized the negative impact of functional impairment (measured by \nHAQ-DI scores) on depression. Uda M  et al . [ 30 ] indicated a correlation \nbetween HAQ-DI scores and depressive symptoms. A cross-sectional study by Ruhaila \nand Chong [ 31 ] showed a significant positive correlation among depressive \nsymptoms, disease activity, pain, and HAQ scores. The relationship between \nfunctional impairment and depression may reflect patients’ perceived decline in \nquality of life and adaptive capacity. Functional impairment can lead to reduced \nsocial interactions and decreased self-care ability, thereby increasing the \nprevalence of depression.\nPSQI scores, as an indicator of sleep quality, were shown to be associated with \nthe occurrence of depression. The relationship between poor sleep quality and \ndepression may be a bidirectional process. Chronic diseases, such as \nendometriosis and rheumatoid arthritis, may cause pain and discomfort, affecting \npatients’ sleep quality. Poor sleep quality or insufficient sleep may affect the \nstability of neurotransmitters in the brain, increasing the risk of depression \n[ 23 ]. Thus, a bidirectional influence can be observed between sleep disorders and \nmood disorders.\nThe mechanisms behind the observed results involve physiological and \npsychological pathways. Pain symptoms, such as dysmenorrhea, dyspareunia, and \npelvic pain, likely activate the central nervous system through pain transmission \nand the release of inflammatory mediators, which can affect mood regulation \npathways and increase the risk of depression [ 23 ]. Additionally, chronic pain may \nlead to decreased sleep quality, which further exacerbates psychological stress \nand depressive symptoms [ 23 ]. The significant correlation between DAS28 scores \nand depression in patients with rheumatoid arthritis can be explained by the \ncomplex interactions between inflammatory mediators and the nervous and immune \nsystems. Increased inflammation may affect neurotransmitter release and neuronal \nactivity in the brain, leading to mood changes and depression [ 28 ,  29 ]. Functional \nimpairment, as indicated by HAQ-DI scores, likely contributes to depression by \nreducing patients’ perceived quality of life and their ability to adapt, leading \nto increased social isolation and decreased self-care ability [ 30 ,  31 ]. Poor sleep \nquality, as indicated by PSQI scores, may contribute to depression by affecting \nneurotransmitter stability in the brain, thereby increasing the risk of mood \ndisorders [ 23 ].\nDespite providing new insights into depression in patients with endometriosis \ncombined with rheumatoid arthritis, this study has several limitations. First, \nthe cross-sectional design precluded the determination of causal relationships. \nSecond, the study sample was drawn from a single center, potentially introducing \nselection bias and limiting the generalizability of the results. Third, this \nstudy did not account for certain potential influencing factors such as patients’ \nmedication regimens and social support. Lastly, the positive sample size reported \nin this study did not meet the required sample size, which could affect the \nrobustness of the results. However, based on the odds ratio (OR) values, \nconfidence intervals, and goodness-of-fit of the binary logistic regression \nmodel, the modeling was successful, although the results should be interpreted \nwith caution. Future research should adopt multicenter, large-sample, \nlongitudinal designs combining biological markers and psychological assessment \ntools to further explore the mechanisms of depression in this specific population \nand validate additional influencing factors and intervention strategies.\nDespite the aforementioned limitations, this study revealed a high prevalence of \ndepression in patients with endometriosis combined with rheumatoid arthritis and \npreliminarily explored its influencing factors. This study also provides guidance \non the selection of depression measurement tools for this patient group. The \nfindings offer clinicians a basis for identifying and intervening in the \npsychological health issues of these patients. Early diagnosis and treatment of \ndepression can significantly improve patients’ quality of life and treatment \noutcomes.\n\nPatients with endometriosis and rheumatoid arthritis are at high risk of \ndepression. The internationally accepted diagnostic criteria for depression, \nDSM-5, can accurately detect the depression status of patients with endometriosis \nand rheumatoid arthritis. Some easier-to-operate depression assessment tools, \nsuch as HAMD and SDS, showed good results in detecting the depression status of \nthese patients. They can be used as depression assessment tools in clinical \npractice. In addition, dysmenorrhea, dyspareunia, VAS, DAS28, PSQI, and HAQ-DI \nare influencing factors for depression in patients with endometriosis and \nrheumatoid arthritis, and they can provide reference for the clinical diagnosis \nand treatment of depression.\n\nThe datasets for this study are available from the corresponding author on \nreasonable request.","source_license":"CC-BY-4.0","license_restricted":false}