Health Consequences of Depression
The presence of depression, due either to a previous or ongoing depressive disorder or the impact of having RA, may have far-reaching health-related consequences. Depression can lead to considerable suffering and impairment for afflicted patients.
Depression in RA has been associated with increased mortality and risk for comorbidities. For example, Ang and colleagues found that among a cohort of RA patients followed for four years, those with recurrent depression were at least twice as likely to die compared with those patients who were not depressed.15 Scherrer and colleagues examined whether depression is a risk factor for incident myocardial infarction in a sample of RA patients from a VA medical setting.16 Depressed patients were found to have a 40% increased risk of having a heart attack compared to nondepressed patients. These findings are consistent with studies from other medical populations showing increased risk for myocardial infarction among depressed patients.17 A variety of factors could serve as potential mechanisms linking depression with such health risks, including inflammation, poor adherence, or maladaptive health behaviors. However, research has not been conducted to identify these explanatory mechanisms in RA.
Depression may also aggravate RA symptoms and lead to impairment in important functional outcomes. Research has demonstrated that depression contributes to sleep disturbance and has been shown to mediate the effects of pain on poor sleep quality.18 When pain increases, depression worsens and interferes with sleep. Independent of the effects of inflammation and disease activity, depression has been correlated with greater fatigue and pain, unemployment and work disability, and impairments in quality of life and role functioning.19-21 A large, longitudinal study conducted by Morris and colleagues found that, over time, depressed RA patients had significantly poorer functional outcomes, including disability, and self-rated health than nondepressed patients.22 Depression may also lead to marital conflict, reduce the size of patients’ social network, and inhibit the receipt of social support. Negative social consequences of depression, in turn, can lead to greater depression and poorer emotional functioning.23
Moreover, there is significant evidence that depression leads to increased health-care seeking, contributing to unnecessary medical visits, procedures, and expensive treatments.5 Brief behavioral interventions that contribute to adaptive health functioning and reduce depression may lessen the deleterious impact of RA and lower medical costs.24
Clinical Management of Depression in Rheumatology
Rheumatologists face the responsibility and challenge of addressing depression in their clinical interactions with patients. Despite potential service delivery barriers, the outlook for managing depression in RA patients is positive. A major reason for optimism is that depression is a treatable disorder. Extensive research over the past 30 years has documented the efficacy of pharmacological, psychological, and behavioral treatments for depression.25 Empirically validated diagnostic procedures for identifying and managing depression can be implemented to augment the health and well-being of depressed patients with RA. A recurrent problem is that such procedures are not routinely implemented in rheumatology practice, thus perpetuating the existence of an important service delivery gap in clinical care.
