Blackwell Publishing IncMalden, USAPMEPain Medicine1526-2375American Academy of Pain Medicine?

200785449461
Original ArticlesActivities, Pain, and Depression in Knee OAParmelee et al.

PA I N M E D I C I N E
Volume 8 • Number 5 • 2007

PAIN & AGING SECTION

Original Research
Necessary and Discretionary Activities in Knee Osteoarthritis:
Do They Mediate the Pain–Depression Relationship?

Patricia A. Parmelee, PhD,* Tina L. Harralson, PhD,† Lori A. Smith, BA,‡ and
H. Ralph Schumacher, MD§
*Division of Geriatric Psychiatry, Department of Psychiatry and Behavioral Sciences, Emory University School of
Medicine, Atlanta, GA; †Center for Urban Health Policy and Research, Albert Einstein Medical Center, Philadelphia, PA;
‡
Blue Bell, PA; §Division of Rheumatology, University of Pennsylvania School of Medicine, and Philadelphia Veterans
Affairs Medical Center, Philadelphia, PA, USA

ABSTRACT

ABSTRACT Objective. This study examined direct vs indirect associations of pain and physical function with
depression in 369 older adults with osteoarthritis (OA) of the knee. A key focus was the distinction
of functional disability in necessary tasks (basic and instrumental activities of daily living) from
discretionary, leisure activities.
Design. A naturalistic longitudinal study examined effects of demographic variables, indicators of
arthritis status, general health, pain, and several measures of functional disability upon depressive
symptoms at baseline and 1 year later.
Setting and Patients. Participants with diagnosed knee OA were recruited from rheumatological and
general geriatric outpatient clinics, as well as public service announcements.
Outcome Measure. Depressive symptoms, measured with the Center for Epidemiologic Studies
Depression scale.
Results. At baseline, the relationships of depression with functional disability and activity limitation
were wholly mediated by pain. In contrast, activity participation was independently linked with
depression, even controlling health and demographic variables. A 1-year follow-up revealed that
depressive symptoms increased with increasing health problems, and with reduction in activity
participation over time. Having and retaining favorite pastimes were also associated with reduced
depressive symptomatology at baseline and follow-up, respectively.
Conclusions. These data highlight the disease-specific nature of paths among depression, pain, and
disability, and the importance of considering discretionary as well as necessary activities in evalu-
ating effects of pain upon quality of life.

Key Words. Pain; Depression; Osteoarthritis; Functional Status; Leisure

Reprint requests to: Patricia A. Parmelee, PhD, Division of he single most common source of pain and
Geriatric Psychiatry, Department of Psychiatry and
Behavioral Sciences, Emory University School of Medicine
T disability in late life is osteoarthritis (OA).
More than half of persons over the age of 65 years
1841 Clifton Road NE, Atlanta, GA 30329, USA. Tel: 404-
728-6615; Fax: 404-728-4963; E-mail: pparmel@ report some pain and stiffness due to OA [1], and
emory.edu. as many as 90% show radiographic evidence of the

© American Academy of Pain Medicine 1526-2375/07/$15.00/449 449–461 doi:10.1111/j.1526-4637.2007.00310.x

450
disease [2,3]. A total of 20–80% of OA sufferers
report some degree of activity limitation due to
the disorder [1,2,4]. Arthritis has also been shown
to be an independent risk factor for functional
decline [5].
In addition to physical limitations, OA can sig-
nificantly affect psychological well-being. Pain
and functional disability are known to be closely
correlated with emotional distress, particularly
depression, across the lifespan [6–9]. An emerging
literature confirms the links among pain, disabil-
ity, and depression1 in OA [10–14].
This article addresses two questions that remain
unanswered by existing research on emotional
consequences of OA pain and disability. The first
regards the dynamic underlying associations
among pain, depression, and disability in this sin-
gle, very disabling illness. The second is the spe-
cific form that activity impairment takes, in terms
of limitation of necessary vs discretionary activi-
ties. Each of these questions has some basis in
previous literature, and will be addressed in turn.
Depression, Pain, and Disability: Mediating or
Independent Associations?
The nature of interrelationships among pain, dis-
ability, and depression in older persons has been
the subject of a number of investigations, with
varying results. Parmelee et al. [15] found that
pain and functional disability were independently
correlated with depression among elderly institu-
tion residents. In contrast, Williamson and Schulz
[16] discovered that activity restriction wholly
mediated the relationship of pain to depressive
symptomatology in a sample of geriatric outpa-
tients. They reported similar, although less clear-
cut, findings among cancer patients of all ages [17]
and in a sample of women with breast cancer [18].
The same mediating role has been reported by
1
These and other studies cited throughout this article, like
more general research on depression, are characterized by
varying measurement approaches. We acknowledge and
appreciate conceptual differentiations among diagnosable
mood disorders, and of those disorders from “lower level”
depressive syndromes and symptoms. However, we share
the emergent view [45,46] that, at their core, depressive
disorders reflect a continuum of symptomatology that
ranges from relatively mild symptoms through diagnosable
major depressive disorders. Thus, in this article we shall
use the terms depression and depressive symptom(atology)
interchangeably to reference depressive symptoms and
syndromes that, although they may vary in degree, all have
the potential to affect quality of life of persons experiencing
them.
Parmelee et al.
Dickens and colleagues [19] for a non-age-specific
sample of low back pain sufferers. In contrast, a
recent longitudinal study comparing depressed
and nondepressed elderly community residents
found that disability did not mediate the path from
pain to depression [20].
We were unable to find any studies directly
addressing the dynamics of interrelationships
among depression, disability, and pain in OA. The
current study fills that void by examining contri-
butions of pain and disability to depression, both
cross-sectionally and longitudinally, in individuals
with OA of the knee. We reasoned that where pain
and disability are closely interwoven causally (e.g.,
in an individual with a single, very painful medical
condition), their strong intercorrelation should
translate in statistical analysis to a mediating effect
of the one more strongly correlated with depres-
sion. However, the nature of that mediating effect
may depend upon specific disease dynamics.
Williamson and colleagues [16–18] have consis-
tently demonstrated that activity restriction medi-
ates pain’s effects on depressive symptoms among
cancer patients (Figure 1a). This is logical, in that
pain is only one of a complex of symptoms (e.g.,
fatigue, treatment side effects) that act to restrict
activities and, hence, to cause depression. In con-
trast, pain is at the root of functional problems
in OA: functional limitations are usually wholly
caused by pain and covary directly with it. We
therefore hypothesized that pain, rather than
functional disability, would be the dominant inde-
pendent predictor of emotional distress in this
sample. This is directly opposite to Williamson
(a)
Pain Depression
Disability
(b)
Pain Depression
Disability
Figure 1 (a) Mediational model of associations among
pain, disability and depression: disability as mediator. (b)
Common cause model of associations among pain, disabil-
ity and depression: pain as common cause.
Activities, Pain, and Depression in Knee OA
et al.’s mediational model. However, our concep-
tual model for OA is not simply a mirror image of
theirs. Specifically, rather than a mediational effect
in which the mediated variable is presumed to be
causally precedent to the mediator, we propose a
common cause model (Figure 1b) whereby pain is
the source of both disability and depression among
OA sufferers. In cross-sectional analysis, this dif-
ferentiation is subtle, in that both models predict
a reduction in the disability–depression path when
pain is added to the model. Conceptually, how-
ever, the distinction is an important one that can
guide future, causal analyses.
Measuring Function: Activity vs Disability, and
Restriction vs Participation
A second major focus is differentiation of necessary
from discretionary activities in defining functional
limitation. This research examined effects of OA
on two distinct forms of behavior. First, we exam-
ined functional (dis)ability in terms of necessary
activities of daily life—the behaviors one must be
able to perform in order to continue functioning
independently. This article operationalizes func-
tional disability in terms of necessary activities of
daily life, operationalized as basic and instrumen-
tal activities of daily living (ADLs and IADLs). In
contrast, we use the terms activities and/or discre-
tionary activities to reference social and leisure
behaviors—the elective activities of everyday life.
Most research on functional status, depression,
and general quality of life has focused on ADL/
IADL impairment. Recently, however, investiga-
tors have begun explicitly to consider effects of
general health and specific disease states on discre-
tionary activities, distinct from more traditional
assessments of ADL/IADL disability. Zimmer
et al. [21] demonstrated, in a sample of elderly OA
sufferers, that participation in discretionary activ-
ities—particularly social activities—is associated
with emotional well-being. In a second analysis,
the same authors [22] found that persons with
greater pain and ADL/IADL disability were more
likely to have given up one or more discretionary
activities over the past year. More recent research
suggests that loss of valued activities due to illness
effects is associated with depressive symptomatol-
ogy among older persons with vision loss [23] and
a mixed-aged group of women with rheumatoid
arthritis [24], and with declines in positive affect
in a general sample of elderly community residents
[25]. In fact, Neugebauer et al. [26] found that
valued activity loss explained more variance in
451
depressive symptomatology than did standard
ADL/IADL disability.
In short, there is solid evidence that both func-
tional disability and activity participation/limita-
tion are correlated with emotional well-being.
However, these literatures have developed quite
separately and generally address quality of life
from very different perspectives. Recent evidence
indicates that the functional hierarchy underlying
the ADL–IADL distinction extends to discretion-
ary activities as well. That is, just as functional
disability appears to follow a rough progression
such that instrumental activities are impaired
before more basic ADLs [27–29], that sequence
may have begun with relinquishment of discre-
tionary activities [30]. Furthermore, previous work
on activity participation has variously examined
participation in as well as limitation of activities due
to illness effects. Given the documented tendency
of some older persons to find alternatives to
replace activities they have had to relinquish [22],
one might expect the two indices to bear some-
what different associations with well-being.
It is to these distinctions—of necessary from
discretionary activities, and of participation in vs
limitation of valued pastimes—that current ana-
lyses are addressed. Specifically, we looked at
associations of functional disability, activity partic-
ipation, and activity limitation with depressive
symptoms among persons with OA of the knee.
For functional disability, because of the central role
of pain in arthritis, we hypothesized that this sam-
ple would exhibit a mediating effect of pain on the
functional status–depression relationship. That is,
based on our common cause model (Figure 1b),
we expected that pain would wholly explain the
association between functional disability and
depressive symptoms. Because the literature is
sparser, we had less clear-cut expectations for medi-
ated vs direct effects of activity participation. How-
ever, we anticipated that, because activity limitation
parallels functional disability conceptually (i.e.,
both measure loss of function net of any adapta-
tions to illness), its relationship with depressive
symptomatology would similarly be mediated by
pain, again reflecting a common cause model.
Method
Sample
Study participants were 369 older individuals with
OA of the knee. The sample was drawn from rheu-
matology clinics at two major universities and a
Veterans Affairs Medical Center, general outpa-
452 Parmelee et al.

tient clinics operated by a large nonprofit geriatric
services provider, and respondents to public ser-
vice announcements (PSAs) run in local radio and
print media. For all participants, the knee OA
diagnosis was confirmed by medical record review
or direct physician communication. In most of the
latter instances, physicians also provided, with
subjects’ consent, copies of relevant portions of
medical records.
Recruitment methods varied somewhat across
sites, according to the medium and provider pref-
erences. All procedures were approved by institu-
tional review boards at participating sites. At
clinics operated by institutions with which project
investigators were affiliated at the time of data
collection, all knee OA patients received a letter
from their physician describing the project and
indicating that they would be contacted by project
staff. Follow-up telephone calls were made within
2 weeks to ascertain willingness to participate and
schedule data collection. At other sites, fliers
describing the study were made available in the
clinic waiting room or by attending physicians.
These persons, as well as those responding to
PSAs, telephoned the project office if they wished
to participate. This variety of recruitment sites and
methods yielded a broader and more representa-
tive sample of OA sufferers than we might other-
wise have achieved.
The sample was 64% female (N = 234) and
ranged in age from 48 to 91 years (mean = 67.9,
SD = 9.75). The majority (72.9%) were white; all
but 6 of the 100 minority respondents were black.
About half of the sample (53.4%; N = 197) were
currently married or cohabiting, and half (50.7%;
N = 187) had at least some college. Seventy per-
cent (N = 258) had OA in both knees, and most
(81.6%) reported involvement of other joints as
well (e.g., hands, hip; mean other joints = 2.68,
SD = 2.08). Only 31 people (8.4%) had experi-
enced knee symptoms for 1 year or less; 53% had
been coping with knee OA for 5 years or more. A
total of 206 respondents (55.8% of the total sam-
ple) were taking one or more over-the-counter
medications for their OA at the time of the T1
interview. Of these participants, slightly less than
half (43.7%; N = 90) used the medication on a
regularly scheduled basis (vs as needed). Another
178 (48.2%) were using prescription medication
for their OA, the majority (72.6%, N = 130) on a
regularly scheduled regimen. Other commonly
used treatments were exercise (248 participants;
67.2%) and use of heating pad or hot baths (156
participants; 42.3% of total).
A 1-year follow-up yielded a Time 2 (T2) sam-
ple of 293, representing 79.4% of the 369 baseline
respondents. Table 1 presents characteristics of
sample participants who completed both T1 and
T2 assessments vs those who dropped out before
T2. (Variables are described in the next section.)
As compared with continuing participants, those
unavailable for follow-up were somewhat younger,

Table 1 Baseline characteristics of Time 2 sample participants and dropouts

Participants Dropouts
Mean (SD) or % Mean (SD) or % F or χ2 P
Age in years 68.5 (9.6) 65.9 (10.1) 4.13 0.05
% Female 65.9 56.6 2.26
% Married/cohabiting 52.2 57.9 <1
% Nonwhite 23.5 40.8 9.08 0.003
% Some college 54.6 35.5 8.79 0.003
Income (7-point scale) 2.83 (1.51) 2.61 (1.35) 1.34
Duration of OA (months) 116.5 (122.0) 119.1 (100.7) <1
% OA in both knees 67.9 77.6 2.71
Joints other than knee 2.64 (2.07) 2.84 (2.20) <1
Self-rated health (1–4) 2.12 (0.49) 2.33 (0.60) 10.21 0.002
Number of health problems (0–34) 4.73 (2.46) 5.24 (3.20) 2.25
Depressive symptoms (0–60) 10.5 (9.44) 11.9 (10.8) 1.28*
Pain (0.83–5.33) 2.71 (1.02) 2.98 (1.07) 3.96 0.05
Functional disability (5–30) 9.70 (3.06) 10.8 (3.40) 7.82 0.005
Activity participation (0–21) 10.1 (3.00) 8.8 (3.03) 10.95† 0.001
Activity limitation (0–5) 1.53 (1.44) 1.57 (1.48) <1
Favorite pastime(s) (0–5) 4.18 (1.80) 3.53 (2.24) 7.02† 0.01

Please see text of article for description of measures. Numbers in parentheses following variable names indicate possible range of scores on that scale/variable.
For all F-values, df = 1, 367 unless otherwise indicated.
For all χ2 values, df = 1.
* df = 1, 366.
†
df = 1, 365.
OA = osteoarthritis.
Activities, Pain, and Depression in Knee OA
more likely to be ethnic minorities, and less
well-educated. At baseline, sample dropouts had
reported greater pain and disability, somewhat
poorer perceived health, and lower rates of discre-
tionary activity participation.
Measures and Procedure
Data reported here were drawn from a larger study
examining basic associations among pain, disabil-
ity, and depression, as well as factors relevant to
those associations. Data were collected in two
phases to minimize respondent burden. After
obtaining assent in the initial telephone contact,
we arranged to mail a packet of questionnaires for
completion at the respondent’s convenience. At
the same time, an in-person interview was sched-
uled, usually to occur within 2 weeks, at the
respondent’s home or another location convenient
for him/her. During these interviews, which aver-
aged about 60 minutes, the self-report question-
naires were reviewed and clarified as needed,
additional data were collected interactively, and
signed consent was obtained to contact the respon-
dent’s physician for diagnostic confirmation.
Six classes of variables were examined for this
report. Demographic characteristics included age,
sex, marital status (categorically coded to repre-
sent married/cohabiting vs single, widowed, and
divorced/separated), and race (white vs nonwhite).
Education was coded on a 7-point scale, ranging
from “less than 8th grade” through “graduate/pro-
fessional degree”; annual household income was
reported on an 8-point scale representing $10,000
increments (“less than $10,000” through “more
than $70,000”). For the 82 individuals (22.2% of
total sample) who declined to report income, we
substituted the scale mean (2.68).
Three arthritis status variables roughly repre-
sented severity of the disease. These included
duration of knee symptoms in months, involve-
ment of one or both knees, and a count of other
joints affected by OA.
General health status was represented by two
self-reported variables. First, we counted the num-
ber of unique health problems endorsed from a
34-item inventory drawn from the Multilevel
Assessment Inventory (MAI; [31]) and nonredun-
dant items from the National Center for Health
Statistics Long-Term Care Survey [32]. The MAI
also yielded a summary measure of self-rated
health, representing the average of overall health
rating (4-point scale, “excellent” to “poor”), health
now as compared with 5 years ago, and health as
compared with others of the same age (both rated
453
as “better,” “the same,” or “worse”). This scale was
coded negatively, such that higher scores indicate
poorer perceived health.
Depressive symptoms were measured with the
Center for Epidemiologic Studies Depression
scale (CESD; [33]). This widely used 20-item scale
has been shown to be valid and reliable with older
populations [34,35] and has been used in previous
investigations with OA sufferers [36,37]. Cron-
bach’s alpha for this sample was 0.89. Of the 369
baseline respondents, 93 (25.2%) met criteria for
probable depression using the standard cutoff of
16 or higher [33].
Pain was assessed generally and with specific
reference to OA pain. General (non-OA) pain was
tapped by the six-item Philadelphia Geriatric
Center (PGC) Pain Scale [15]. Alpha for this sam-
ple was 0.84. OA pain was assessed by modifying
the PGC Pain Scale to refer specifically to OA
pain and combining it with the pain subscale of
the Arthritis Impact Measurement Scales, second
edition (AIMS2; [38]). The resulting 11-item OA
pain scale (α = 0.89) taps severity, frequency, and
impact of arthritis pain.
Functional disability was also assessed generally
and with reference to limitations caused specifi-
cally by arthritis, using 28 items from the AIMS2.
Subscales tapping difficulties with mobility, walk-
ing and bending, hand and finger function, arm
function, self-care tasks, and household tasks were
averaged to produce a composite functional dis-
ability scale (α = 0.77). Subscale scores were also
averaged to yield a summary measure of OA-
specific functional disability (α = 0.80).
We measured discretionary activity participation
by combining the MAI Activities scale [31] with
items drawn from the AIMS2 Social Activity sub-
scale. Respondents indicated how often each of 21
solitary and social leisure activities (e.g., worked
on hobbies or handwork, did volunteer work, or
visited friends or relatives at their home) had
occurred within the past month (6-point scale,
“never” to “daily”). A simple count of activities
endorsed (any frequency other than “never”)
yielded a summary measure of activity participa-
tion. A second measure, activity limitation, tapped
the extent to which persons had relinquished dis-
cretionary activities because of OA or other health
problems. It was created by averaging two items:
a 6-point rating of frequency of activity limitations
during the past month, and a count of the number
of valued activities that the respondent had given
up completely due to OA (summary score range
0–5).
454
A final set of items developed for this research
was used to characterize stability and change in
discretionary activities. At baseline and again at
follow-up, all participants were asked whether
they had developed any new leisure activities since
developing OA; up to 5 were enumerated. At base-
line, participants also noted whether they had a
“favorite” discretionary activity that they particularly
enjoyed and, if so, how often they engaged in that
activity (6-point scale, “never” to “daily”). At fol-
low-up, respondents again identified newly devel-
oped pastimes. In addition, each reviewed the list
of new and favorite activities generated before,
and indicated whether she/he still took part in
each activity. This yielded counts of the number
of favored pastimes retained and number relin-
quished over the 1-year interval.
Analytic Plan
Preliminary analyses identified demographic,
general health, and OA status variables to be con-
trolled in subsequent analyses. For primary cross-
sectional analyses, stepwise ordinary least squares
(OLS) regression equations were used to construct
path models that examined direct and mediating
associations of pain and functional status with
depression while controlling the covariates identi-
fied in preliminary analyses. Three sets of path
models were generated, looking separately at the
three functional status indicators of interest (func-
tional disability, activity participation, and activity
limitation). Finally, we attempted to replicate
Neugebauer et al.’s [26] findings regarding the
relative importance of discretionary vs necessary
activities, by regressing depression simultaneously
onto the three functional measures.
OLS regression techniques were also used to
identify predictors of change in depressive symp-
tomatology over the 1-year study period. T2
depression was first residualized by regressing it
onto its parallel baseline measure, such that the
only variance remaining to be explained repre-
sented change from T1 to T2. Baseline and T2
predictors were then entered in blocks (T1, then
T2) to determine their contribution to predicting
change in depressive symptoms over the 1-year
interval.
To address measurement issues, we replicated
the basic path analyses in four ways.2 First, analy-
ses of general pain and disability were rerun using
2
Details of these analyses are available on request from the
first author.
Parmelee et al.
parallel arthritis-specific measures. Results were
virtually identical; only the general, nonarthritis-
specific analyses are reported here. Additionally, to
address potential problems of confounding, we
replicated all analyses using a modified version of
the CESD, excluding the four items tapping
somatic symptoms. This produced no meaningful
change in results, and is not reported here. Third,
we were concerned that the simple count of dis-
cretionary activities was too gross a measure to
yield meaningful data. We therefore constructed
an alternative measure that averaged frequency of
activity participation across the 21 items. Again,
results were no different from those reported here.
Finally, we examined the role of OA treatments in
relationships among pain, functional status, and
depression. Of the four treatments assessed (pre-
scription and over-the-counter medications, exer-
cise, and heat), only use of heat was associated with
depressive symptoms. On further examination,
that relationship proved to be totally mediated by
pain, and results of primary analyses were no dif-
ferent from reported here.
Results
Covariates of Depression
A preliminary analysis identified background
variables that were significantly associated with
depressive symptoms, to permit their control in
primary analyses. Demographic characteristics
(age, sex, ethnicity, marital status, education, and
income), arthritis status (duration of symptoms,
one/both knees, and joint count), and general
health status (self-rated health and number of
health problems reported) were entered simulta-
neously into an OLS regression equation predict-
ing CESD. Nonsignificant predictors were backed
out one by one until further deletions would
significantly reduce explained variance. The
final model (R = 0.400, adjusted R2 = 0.148),
F5,357 = 13.40, P < 0.001) included three demo-
graphic variables and two health status indicators.
Depressive symptomatology was significantly
lower among more educated individuals (β =
−0.118, P < 0.02). Nonsignificant trends indicated
that men (β = 0.094, P < 0.06) and minority
respondents (β = −0.091, P < 0.08) also reported
lower levels of depression. Both self-rated health
(β = 0.118, P < 0.04) and number of health prob-
lems (β = 0.291, P < 0.001) were also significantly
associated with depressive symptoms. These five
variables were therefore controlled in all cross-
sectional analyses.
Activities, Pain, and Depression in Knee OA 455

Table 2 Correlations among depression, pain, and three participate in a wider variety of discretionary
measures of functional status activities.
Functional Activity Activity
Pain Disability Participation Limitation Depression, Pain, and Functional Disability
We looked first at interrelationships among
Depression
Raw 0.349 0.304 −0.238 0.221 depressive symptoms, pain, and functional disabil-
Adjusted 0.248 0.113* −0.154** 0.134*** ity (ADL/IADL impairment). Path models were
Activity limitation constructed to examine competing hypotheses
Raw 0.484 0.467 −0.014†
Adjusted 0.440 0.391 0.066† about mediating effects of functional disability
Activity participation (the Williamson and Schulz model) vs pain as a
Raw −0.159** −0.315 common cause of both disability and depression
Adjusted −0.056† −0.200
Functional disability (our hypothesized model). Using Baron and
Raw 0.548 Kenny’s [39] criteria for mediation, we first dem-
Adjusted 0.426 onstrated that the predictor (in this case, disability)
* P < 0.05; ** P < 0.005; *** P < 0.01. bears a direct association with the mediator (pain).
†
n.s.
All raw coefficients are Pearson product–moment correlation. Adjusted
This is shown by partial coefficients displayed in
coefficients are partial correlations controlling for sex, education, minority Table 2 and was confirmed by simple linear regres-
status, self-rated health, and number of health conditions.
Unless otherwise noted, coefficients are significant at the 0.001 level. sion. Independent effects of disability and pain on
depressive symptomatology were next established
in separate regression analyses. Then, for each
Primary Analyses equation, we stepped in the alternate predictor
Primary analyses examined associations of depres- (pain added to the equation previously containing
sive symptoms with pain and three separate func- only disability; disability stepped into the equation
tional measures (functional disability, activity containing only pain) to identify reductions in
participation, and activity limitation). Intercorre- strength of association.
lations among these variables are shown in The upper rows of Table 3 present results for
Table 2. Both raw and adjusted coefficients are the functional disability measure. The table’s first
shown; the later control effects of covariates just two pairs of columns document that pain and
identified. Note that the negative coefficient for functional disability were each independently
activity participation is expected, representing associated with depressive symptoms after con-
lower levels of depression among persons who trolling relevant covariates (pain F6,361 = 16.58 and

Table 3 Direct and indirect associations of pain and three different functional status measures with depressive symptoms
Pain Only Functional Status Only Both Pain and
(Direct Effect) (Direct Effect) Functional Status
R β R β R β
Functional disability 0.465*** 0.419*** 0.465***
Race −0.101* −0.096* −0.102*
Education −0.101* −0.110* −0.100*
# Health problems 0.253*** 0.246*** 0.251***
Pain 0.246*** 0.243***
Functional disability 0.124* (0.008)
Activity participation 0.467*** 0.432*** 0.485***
Sex (0.049) 0.101* (0.059)
Race −0.107* −0.096† −0.130*
Education −0.104* −0.097† (−0.076)
# Health problems 0.254*** 0.277*** 0.246***
Pain 0.249*** 0.241***
Activity participation −0.150**** −0.137**
Activity limitation 0.467*** 0.424*** 0.465***
Race −0.107* −0.089† −0.101*
Education −0.104* −0.138**** −0.104*
# Health problems 0.254*** 0.266*** 0.251***
Pain 0.249*** 0.234***
Activity limitation 0.127* (0.027)

* P < 0.05; ** P < 0.01; *** P < 0.001; **** P < 0.005.
†
0.05 < P < 0.075.
Coefficients in parentheses are nonsignificant (P > 0.10).
456
disability F6,361 = 12.82, both Ps < 0.001). When
both predictors were in the equation (rightmost
pair of columns), pain remained significant with
practically no diminution of effect. In contrast,
effects of functional disability were completely
attenuated when pain was included in the equa-
tion. Indeed, there was absolutely no gain in pre-
dictive strength when disability was added to the
effects of pain (both multiple Rs = 0.465; ∆F < 1,
final equation F7,360 = 14.71, P < 0.001). This pre-
dicted mediating effect of pain on the disability–
depression relationship was confirmed by Aroian’s
variant of the Sobel test [39,40] (z = 4.06,
P < 0.001).
Depression, Pain, and Activity Participation
A similar set of analyses, substituting discretionary
activity participation for ADL/IADL disability,
yielded a very different result (middle portion of
Table 3). Pain and activity participation were again
significant independent predictors of depressive
symptoms (pain F6,360 = 16.58, activity participa-
tion F6,360 = 12.82, both Ps < 0.001). However, in
contrast to functional disability, activity participa-
tion retained predictive strength when combined
with pain. Stepping in activity participation as
the final predictor significantly increased variance
explained by pain and covariates alone (adjusted R2
change = 0.016, ∆F1,359 = 7.66, P < 0.006; final
F6,360 = 15.74, P < 0.001).
Depression, Pain, and Activity Limitation
A third functional variable addressed limitation of
discretionary activities attributed to OA or other
health problems (bottom rows of Table 3). Paral-
lels with functional disability are immediately
obvious. Considered singly, both pain and dis-
cretionary activity limitation significantly predict
depressive symptomatology (pain F6,361 = 16.56
and activity limitation F3,361 = 13.18, both
Ps < 0.001). However, as with functional disability,
stepping in activity limitation after pain has been
entered adds nothing to predictive strength
(∆F < 1, final F7,360 = 14.21, P < 0.001). This medi-
ating effect of pain in the association of activity
limitations with depression was confirmed by a
Sobel test (z = 3.82, P < 0.001).
Integrative Analysis
A final cross-sectional analysis examined differen-
tial strength of functional disability, activity limi-
tation, and activity participation as predictors of
depression. After control for relevant covariates,
the three measures of functional status were
simultaneously entered into a single regression
Parmelee et al.
equation with depressive symptoms as the out-
come variable. This yielded a significant increase
in explained variance (∆F3,358 = 5.74, overall
F8,358 = 11.56, both Ps < 0.001). Beta coefficients
were significant for both activity participation
(β = −0.153, P < 0.003) and activity limitations
(β = 0.125, P < 0.03), but not for functional
disability (β = 0.039, n.s). Adding pain to the
equation significantly improved prediction of
depressive symptoms (∆F1,357 = 13.79, overall
F9,357 = 12.18, both Ps < 0.001). As expected based
on separate analyses of the three functional vari-
ables, the effect for activity participation remained
significant (β = −0.137, P < 0.007), but that for
activity limitation washed out (β = 0.054, n.s).
Longitudinal Analyses
We used T2 data to identify predictors of change
in depressive symptoms over the 1-year follow-up
interval. As noted earlier, stepwise regression anal-
ysis was used first to residualize T2 CESD on its
baseline equivalent. T1 variables proven signifi-
cant in cross-sectional analyses (health problems,
pain, and function status) were then entered, fol-
lowed by parallel T2 measures. For analytic sim-
plicity, we excluded race and education because
they did not add explanatory power to the model.
Replication of analyses including those variables
did not change the pattern of findings. Separate
analyses were conducted for each of the three
functional indices. Results are shown in Table 4.
In all three analyses, number of health problems
at baseline predicted increased depression at fol-
low-up (functional disability ∆F = 3.91, P < 0.009;
activity participation ∆F = 3.38, P < 0.02; activity
limitation ∆F = 3.64, P < 0.02, all df = 3, 283).
However, neither T1 pain nor any of the T1 func-
tion variables was associated with change in depres-
sive symptoms over the 1-year period. Entering
T2 pain, functional status, and health problems did
not significantly increase explained variance in
equations using functional disability or activity
limitation (∆F3,280 = 1.07 and 1.51, respectively).
For activity participation, however, a significant
overall effect (∆F3,280 = 2.65, P < 0.05) reflects a
negative association of T2 activity participation
with T1–T2 change in depression. In other words,
persons who experienced an increase in depression
over the 1-year interval were also like to have
reduced participation in discretionary activities
over that period. Thus, paralleling cross-sectional
analyses, only activity participation was indepen-
dently associated with depression over the course
of 1 year.
Activities, Pain, and Depression in Knee OA 457

Table 4 Change in symptoms of depression over a 1-year period

Time 1 Indicators Time 2 Indicators
T1 Depression
R/β R β R β
Functional disability 0.701*** 0.715*** 0.719***
Baseline depression 0.651*** 0.642***
T1 pain (0.062) (0.008)
T1 functional disability (−0.078) (−075)
T1 health problems 0.160*** 0.124*
T2 pain (0.103)
T2 functional disability (−0.024)
T2 health problems (0.037)
Activity participation 0.701*** 0.714*** 0.723***
Baseline depression 0.646*** 0.643***
T1 pain (0.028) (−0.021)
T1 activity participation (−0.017) (0.073)
T1 health problems 0.131** (0.085)
T2 pain (0.073)
T2 activity participation −0.132*
T2 health problems (0.034)
Activity limitation 0.702*** 0.715*** 0.719***
Baseline depression 0.649*** 0.637***
T1 pain (0.050) (0.002)
T1 activity limitation (−0.047) (−0.075)
T1 health problems 0.139** (0.096)
T2 pain (0.074)
T2 activity limitation (0.058)
T2 health problems (0.040)

* P < 0.05; ** P < 0.005; *** P < 0.001.

Coefficients in parentheses are nonsignificant (P > 0.07).

Stability and Change in Discretionary Activities
Given the ascendance of discretionary activities as
(negative) predictors of depression, we conducted
a final set of analyses to delineate the role of dis-
cretionary activities in maintaining emotional
well-being. We began by replicating the cross-
sectional analysis using activity participation as the
functional indicator, and then stepping into the
equation two additional measures of discretionary
participation: number of new activities developed,
and frequency of participation in a favorite pas-
time. Addition of these two variables marginally
increased variance explained in T1 depressive
symptoms (R2 change = 0.012, ∆F2,359 = 2.78,
P < 0.065, final F7,359 = 16.46, P < 0.001). Inspec-
tion of beta coefficients indicated that participa-
tion in a favorite pastime was a significant
predictor of depression (β = −0.110, P < 0.02).
This contribution was independent of the effect of
general activity participation, for which the coef-
ficient changed only nominally, from −0.137 to
−0.134 (final P < 0.007). Number of new activities
was not significantly associated with depression
(β = 0.013, n.s).
We next examined whether stability or change
in preferred (“favorite”) activities predicted
depression. Again using T2 depression as the out-
come, we first controlled for baseline depressive
symptoms, and then entered two groups of predic-
tors in stepwise fashion. First, T1 health problems
and activity participation were supplemented with
the baseline favorite activity variable. (Because it
had proven nonsignificant in all previous analyses,
pain was not included in the equation.) We then
added the T2 health and activity participation
variables, along with three indicators of change in
activities over the interassessment interval: the
number of specific new/preferred activities named
at baseline in which respondents were still partic-
ipating (“retained” activities), those in which the
participant no longer participated, and a count of
new discretionary activities developed over the
past year. Addition of these three variables signif-
icantly improved prediction of increased depres-
sion (∆F5,257 = 2.41, P < 0.04, final F9,257 = 31.77,
P < 0.001). Of the three additional T2 variables,
only number of retained activities was significant
(β = −0.098, P < 0.04).
Discussion
This study addressed two separate but interrelated
questions regarding emotional consequences of
pain and disability in OA. First, we sought to
elucidate the mechanisms by which pain and
functional disability may affect depression, by
458
examining mediating effects in a population that
has not previously been studied from this perspec-
tive. A second objective was to determine whether
patterns of associations observed for necessary
activities of daily living apply similarly to discre-
tionary activities and pastimes.
Before discussing findings, it is important to
note some limitations of the study. Although we
recruited our respondents from varied sources,
they were volunteers and hence may not repre-
sent the general population of older adults with
OA. Additionally, the 21% attrition rate from
baseline to follow-up recommends caution in
generalizing results of this study overall, espe-
cially given that the remaining T2 sample dif-
fered in important ways from those who were
unavailable to follow-up. In particular, sample
dropouts were disproportionately ethnic minori-
ties, and had reported greater pain and poorer
physical health and functioning, as compared
with those who completed the T2 interview.
Hence, those most “at risk” at T1 were also more
likely to be lost to follow-up.
As predicted, the associations of both ADL/
IADL disability and discretionary activity limita-
tion with depression were wholly mediated by pain
in this sample of individuals with knee OA. This
is directly opposite to the pattern seen previously
in cancer patients [17,18] and persons with low
back pain [19], for whom activity restriction medi-
ated the pain–depression path. Further, both these
patterns diverge from previous work demonstrat-
ing independent paths from pain and disability to
depression among elderly long-term care residents
[15]. Geerlings and colleagues [20] similarly failed
to find a mediating role of functional disability in
a random sample of Dutch community residents;
unfortunately, these authors did not address the
alternate mediational path.
These disparate results begin to cohere if mod-
erating factors are posited. At least two separate
processes may be influencing observed patterns.
First, as Geerlings et al. [20] suggest, age itself
may shape associations among depression, pain,
and disability. In Williamson and Schulz’s cancer
patients [17], the mediation effect was much stron-
ger for younger than for older individuals; the
latter showed more independence of effects of
pain and activity restriction. Dickens and col-
leagues’ [19] pain clinic sample were also primarily
younger adults. In contrast, studies restricted to
older persons have generally found that pain and
disability contribute independently to depression
([15,20]; see, however, [17]).
Parmelee et al.
Associations among pain, disability, and depres-
sion may also vary as a function of the nature of
the illness and overall health status. Where pain
and disability are closely interwoven causally (e.g.,
in an individual with a single, very painful condi-
tion, such as knee OA), their strong intercorrela-
tion might easily translate in statistical analysis to
a mediating effect of the one more strongly corre-
lated with depression. In contrast, individuals with
multiple disabling health problems may more
readily distinguish discomfort from disability and,
hence, exhibit independent associations of each
with emotional state. Hence, because the hallmark
of arthritis is joint pain, any observed disability is
likely to stem from, and be explained by, that pain.
In contrast, cancer patients may experience a vari-
ety of symptoms, particularly if they are in active
treatment. For these individuals, pain is often just
one of an assemblage of problems that all limit
function. Function, as the primary complaint,
bears the more robust association with depression.
This line of reasoning is obviously speculative.
Generalization is limited by the nature of our sam-
ple, which was purposely selected nonrandomly to
include only persons who shared the same pain-
producing health problem—OA of the knee.
Although this is a common disorder, our sample is
obviously not comparable to the larger community
of older persons from which it was drawn. Nor can
one generalize to other chronic pain populations
without further study. The specific constellation
of health problems that any given individual
experiences is also likely to color associations
among pain, physical functioning, and emotional
well-being.
There is currently insufficient evidence to
address the roles of either age or disease specific-
ity in moderating the pain–disability–depression
dynamic. As the literature develops, it would be
useful to study these associations simultaneously
in different samples within a single study, to con-
trol potential confounding effects of methodolo-
gies and analytic strategies. Meanwhile, although
the basic interrelationship of depression, pain, and
functional disability is almost indisputable, mech-
anisms underlying it remain in question.
Turning to the distinction of necessary from
discretionary activities, our findings replicate pre-
vious work [21,25] demonstrating how valued
activities may buffer effects of illness upon emo-
tional well-being. Specifically, we found that
persons who participated in a wider range of dis-
cretionary activities reported fewer depressive
symptoms independent of pain. Additionally, hav-
Activities, Pain, and Depression in Knee OA
ing and retaining a preferred (“favorite”) pastime
appears to buffer against depression. Furthermore,
paralleling Rovner and Casten [23], depression
was greater among persons whose OA had caused
them to limit discretionary activities. Here, as for
ADL/IADL disability, the relationship appears to
be wholly mediated by pain. This suggests once
again that, where pain interferes with function, it
predisposes individuals to depression, regardless
of the nature of the activity.
Thus, whereas health-related loss of (necessary
or discretionary) function was associated with
depressive symptomatology only through pain,
activity participation per se predicted lower levels
of depression net of its correlation with pain.
Active pursuit of a highly valued activity appears
to be particularly helpful. This finding is especially
important from a clinical standpoint, because it
highlights the importance of taking a broad view
of OA pain and its effects. Historically, limitation
of discretionary activities has received little atten-
tion in either research or clinical contexts, despite
the fact that they are far more likely than necessary
activities (basic or instrumental ADLs) to be com-
promised by chronic pain [30]. The current study
confirms previous findings that the ability to
remain engaged in valued discretionary activities
may be important in protecting against emotional
distress. This recommends a broader focus in eval-
uating functional effects of OA and other pain-
producing illnesses, to ensure that effects on
quality of life are adequately captured. Although
our data do not speak directly to the issue, it may
also be prudent to encourage patients to develop
leisure interests that they can maintain in the face
of disease progression.
Recent elaboration of the concept of acceptance
of pain [41,42] is particularly relevant to this last
point, and suggests two very different tacks that
persons may take in coping with the effects of pain
upon their daily lives. First, the ability to accom-
modate chronic pain without undue emotional
distress may enable individuals to maintain valued
activities for at least some period of time. That is,
given a rational, nonjudgmental orientation to
pain, some individuals may approach the situation
as a trade-off, viewing some degree of pain as an
acceptable price for maintaining valued discre-
tionary pursuits. But acceptance may be equally
important when pain becomes so intrusive that it
precludes continued involvement in preferred
activities. Here, the ability to modify one’s goals
and lifestyle—to find and embrace alternatives to
activities relinquished on account of arthritis
459
pain—may be a key to maintaining engagement
and good emotional health [43].
Our findings also highlight the central role of
measurement strategies in evaluating effects of
functional status on depression. Had we relied
on a single measure of activity participation/
restriction, our conclusions would have been
much different, and more limited. This argues
strongly for reevaluation of typical measurement
strategies that yield unitary indices of functional
limitation or participation. Rather, future
research should focus on the complexities of
daily activity patterns, as they reflect associations
among depression, pain, and disability (see, e.g.,
[44]).
We were surprised to find that neither pain
nor functional disability (including activity limi-
tation) predicted change in depressive symptom-
atology from baseline to follow-up. This is partly
attributable to the emotional stability of our
follow-up sample (T1–T2 CESD r = 0.703).
Because we lost the most disabled T1 respon-
dents to attrition, there was perhaps some
shrinkage of variance in depressive symptoms at
T2. Nonetheless, both number of distinct health
problems identified at baseline and increase in
that number over the 1-year interval were signif-
icantly associated with increased depression.
This ascendance of general health over disease-
specific processes may reflect the diversity of our
sample, which included both very old persons
with multiple comorbidities and a handful of
younger adults whose only major health problem
was arthritis. It may also be that, given the rela-
tively slow progression of OA, 1 year is too short
a time for symptoms to manifest effects on well-
being. We have continued to track this sample
and will report additional findings as they are
available.
In closing, perhaps the primary contribution of
this study is to underscore the complexity of asso-
ciations among depression, pain, and disability in
chronic illness. Our findings confirm basic rela-
tionships, but diverge in important ways from
other recent research with different populations
and measures. We have offered, we believe, logi-
cal explanations for this disparity, but additional
study is needed to test notions about age- and
disease-specific dynamics. What is clear from this
study is the importance of the “icing” as well as
the “cake” of functional status. Clearly, emotional
well-being depends as much upon discretionary
(leisure) activities as on basic and instrumental
tasks of living. Both research and clinical
460
approaches need to incorporate this recognition
in order fully to understand and ameliorate
effects of chronic disease on quality of life of the
aged.
Acknowledgments
This research was supported by NIMH grant 1-R01-51800
to the first author for research conducted at the Philadel-
phia Geriatric Center and the University of Pennsylvania.
The authors are deeply indebted to M. Powell Lawton for
conceptual guidance. The authors thank James Hollender
and Meredith Olderman for collecting the data, as well as
Elaine Benoff, Susan Gallagher, Hui Wu, Yunqi Zhang,
and others who assisted with the project.
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