Psychosocial and behavioral correlates of persistent pain post disease-modifying treatment change in rheumatoid arthritis: a 12-month cohort study

Pain is a debilitating and persistent symptom of rheumatoid arthritis (RA), associated with impaired functional capacity and reduced quality of life. Despite targeted disease-modifying treatments, many RA patients experience persistent pain, suggesting mechanisms operating independently of classic inflammatory pathways. Psychological factors, such as depression and anxiety, can impact patterns of appraisal and behavioral coping strategies. Understanding how these associations underpin pain symptoms in RA is key for developing targeted symptom management interventions. Using data from the Patient-Reported Outcomes in patients with Persistent Rheumatoid Arthritis (PROsPer-RA) cohort, pain trends were assessed over 12 months following disease-modifying adjustment, mapping these against socioeconomic, psychological, and behavioral factors to identify associations and mechanisms. This prospective study followed RA patients recruited to PROsPer-RA switching or escalating disease-modifying treatment. Clinical and patient-reported outcomes were collected at baseline, 3, and 12 months, including disease activity, joint pain (visual analog scale), widespread pain index (WPI), depression and anxiety symptoms, and cognitive and behavioral responses to symptoms. Latent growth curve models estimated associations between predictor variables and pain outcomes at baseline and over time. Mediation analyses examined whether cognitive and behavioral responses mediated the relationship between depression/anxiety symptoms and pain outcomes. Among 209 eligible patients, baseline joint pain was 49.8$$\:\pm\:$$24.9 out of 100 (worst pain) and WPI was 4.9$$\:\pm\:$$3.6 out of 17 areas, which persisted at similar levels at 3 and 12 months. Higher baseline pain was associated with male gender, financial stress, lower education, and unemployment. Higher levels in both pain outcomes associated with worse depression and anxiety symptoms at baseline and over time. Avoidance-based behavioral responses, particularly fear avoidance, were associated with worse pain and mediated the relationship between depression/anxiety symptoms and both pain outcomes. In this RA cohort, pain symptoms persisted at moderate-to-high levels over 12 months despite changing disease-modifying treatments. These symptoms were driven by psychological and behavioral factors alongside socioeconomic factors. Current RA therapies may be insufficient without considering the non-inflammatory processes driving persistent pain. Disease management should incorporate strategies that target mental health as well as cognitive and behavioral response patterns to symptoms.