Determinants of happiness and quality of life in patients with rheumatoid arthritis: a structural equation modelling approach


The current paradigm for the management of rheumatoid arthritis (RA), in both clinical and research settings, is epitomised by the treat-to-target strategy which establishes that the target of remission, or at least low disease activity, should be pursued and achieved as early and consistently as possible. This target is defined essentially by measures designed to gauge the disease process: number of tender and swollen joints and acute phase reactants supplemented by the patient’s and physician’s global impression of disease activity.3 The incorporation of patient-reported outcomes (PROs), designed to provide the patient’s perspective of the disease into clinical practice and research, is widely supported by international organisations and professional groups.

Many studies have shown that the control of inflammation through immunosuppressive therapy has a markedly positive impact on PROs: controlling the disease process is, undoubtedly, as important to prevent long-term damage as to improve patients’ quality of life (QoL).  Despite this, a sizeable proportion of patients with RA who are in remission still describe a high impact of disease and reduced QoL.

Our group has recently highlighted this view by proposing that the management of RA should pursue two different targets: disease process remission and disease impact control. Controlling the disease impact, in terms of quality and duration of life, are the final objectives of disease management, while controlling the disease process should be seen as an important means to that end, but not a guarantee.

Within this perspective, the concept of overall subjective well-being, equivalent to ‘happiness’, emerges as a decisive goal as well (‘the ultimate currency’). All healthcare professionals know patients who lead a reasonably happy and fulfilling life despite aggressive disease, while others seem to succumb to the diagnosis. Understanding the main determinants of happiness in patients with rheumatic diseases and exploring the potential avenues to maximise it is, in this light, an ethical obligation. Curing or controlling disease is, certainly, an essential contribution, but we need to understand how far disease control can go towards happiness and whether health professionals may contribute to that goal beyond disease control.

Happiness includes different aspects of life such as life satisfaction, healthy interpersonal relationships, personal growth and appreciation of nature, beauty and other people, resulting in a global predominance of positive emotions over negative ones. QoL is more focused on physical functioning and negative mental aspects, such as depressed mood and anxiety. Happiness is, therefore, a broader concept than QoL, as it goes beyond the ability to do things and incorporates the satisfaction of doing them, that is, the enjoyment of life as a whole. Personality is recognised as a key factor in predicting happiness, as it provides the context in which the roots of happiness operate.22 Although happiness levels may be negatively influenced by the experience of living with a disease, especially if it has a chronic course and causes a marked impairment in daily functioning, several studies in this area have also demonstrated that happiness may have a positive impact on physical health and longevity. This has been mostly attributed to its effect on the perception of impact disease and on the engagement in health-related behaviours.

Based on the previous literature, this study was designed to address the following hypotheses in patients with RA:

H1—Disease activity and perceived impact of disease are negatively associated to overall QoL and happiness;

H2—‘Positive’ personality traits are related with happiness, both directly and indirectly through perceived disease impact;

H3—Happiness has a mediating effect in the relation between impact of disease and QoL.

Source: Santos EJF, Duarte C, Ferreira RJO, et al Determinants of happiness and quality of life in patients with rheumatoid arthritis: a structural equation modelling approach Annals of the Rheumatic Diseases Published Online First: 06 April 2018. doi: 10.1136/annrheumdis-2017-212934