Depression in Rheumatoid Arthritis

A Case Study

Mrs. A is a 50-year-old high-school teacher who was diagnosed with RA at the age of 45. In addition to her pain and joint swelling, she complains of depressed mood, fatigue, insomnia, and loss of concentration. For several years prior to her diagnosis, she felt depressed and did not sleep well, but she reports that her RA has made these symptoms worse. For much of the time, she feels out of control of her pain despite being aggressively treated with various combinations of disease-modifying drugs. She knows that it’s important to maintain her functioning, but she finds herself being sedentary and avoiding activities that she fears may worsen her RA symptoms. She is concerned that she may lose friends due to the limitations in her ability to relate socially. She feels that her RA is severely disrupting the quality of her life.

Depression and Arthritis

Although the prevalence rate of depressive disorders in the United States is estimated to range between 5% and 10%, depression is especially common in rheumatoid arthritis (RA). In some studies, the prevalence of depression in RA has been found to be almost three times higher than in the general population.¹ Moreover, some of the highest rates of depression have been found in socioeconomically disadvantaged and vulnerable patient groups with RA, such as low-income Latinos, who may possess greater health-related comorbidities and functional impairments than other patient populations.^2,3 However, despite its prevalence, depression may not be identified or evaluated in rheumatology practice, creating a vast unmet clinical need that has far-reaching public health implications. Comorbid depression can increase medical utilization and healthcare costs in RA.^4,5 Thus, the management of depression in rheumatology care represents a formidable challenge for both patients and health service providers alike.

Identifying Depression in the RA Clinical Setting

It may be difficult to identify depression in the rheumatology clinic.⁴ One reason is that the inflammatory response, contributing to poor sleep and fatigue, may mask the existence of depression, causing the clinician to focus treatment on reducing disease activity and the immune response rather than the mood disturbance. Another reason is that there may be no formal evaluation of mood as part of the clinical interaction. Rheumatologists may be reluctant to address mood disturbance and other psychological issues of their patients due to time constraints, lack of resources, inadequate professional training, or the belief that other professionals should be dealing with such problems.⁶ Unfortunately, when depression is not identified or treated, patients may misattribute the source of their symptoms to RA. They may believe that their RA is not responding to conventional medical treatment if their symptoms, due to depression, persist. Unwittingly, patients may continue to seek other medical treatment for their RA to alleviate their depressive symptoms. Rheumatologists may reinforce this pattern by providing medical treatment when the underlying problem is depression.

Depressive Disorders Overview

Depressive disorders vary by type and severity. Depressive symptoms are found in almost all patients at some time over the course of RA. It is common for patients with RA to feel sad, fatigued, or demoralized while coping with the pain, fluctuations in disease activity, and limitations in physical mobility related to their medical condition. For some patients, however, depression is more serious, reaching or surpassing a clinical threshold. An adjustment disorder with depressed mood is diagnosed when depressed mood and/or anhedonia (loss of pleasure) result from the diagnosis of RA or from exacerbations in pain or disease activity.  Adjustment disorders are particularly common in chronic medical illnesses due to their deleterious impact on quality of life. Importantly, if the depression lifts after a period of six months and patients return to their premorbid mood state, the adjustment disorder is resolved. When the symptoms of depression persist beyond six months, a diagnosis of major depressive episode is made when depressed mood and/or anhedonia are accompanied by four other symptoms.⁷ If another previous depressive episode can be documented, the diagnosis of major depressive disorder, recurrent, is used. Many RA patients may have dysthymic disorder, a form of minor depression in which depressive symptoms have persisted over a period of at least two years but have not met the criteria for the diagnosis of major depression. Dysthymic patients may be at greater risk than nondepressed patients for experiencing a depressive episode when under chronic stress or while in the midst of a disease flare or disabling pain. Importantly, all types of depression can become intertwined with patients’ medical circumstances, creating difficulties in diagnosis, adherence, treatment decision-making, and management.

Factors Associated with Depression in RA

Considerable research has been conducted on the variables associated with depression in RA.⁸ Although it has long been known that arthritis is associated with psychiatric comorbidity, an important question is whether having arthritis increases the risk of developing depression, or whether depression increases the odds of developing arthritis. A large, epidemiological study conducted in the Netherlands in which patients were sampled in their homes revealed that having arthritis (of any type) significantly increased the odds of developing depression two years later, while prior depression had no effect on the development of arthritis.⁹ Although the study did not address the factors or mechanisms associated with arthritis that led to this outcome, the significance of this study is that it highlighted the potential impact of arthritis on the emotional functioning of patients residing in the community. For many years, a central issue related to impact of arthritis has concerned the relative influence of disease activity versus psychosocial factors in explaining depression.

A biopsychosocial perspective examining the conjoint influence of multiple factors has been the dominant paradigm for studying depression in RA among behavioral medicine researchers.¹⁰ Much of this research has focused on the contributions of disease activity, pain, and disability to mood disturbance. Many studies have shown that heightened disease activity, pain, and disability may lead to depression.¹¹ However, in addition to the independent effects of these variables, cyclical, synergistic relationships among these factors may partly explain their impact on depression. One scenario posits disability may be the final common pathway through which these other factors affect depression. For example, high disease activity may give rise to pain that creates impairments in functioning, including disability. Disability, in turn, may contribute to depression by interfering with mobility, performance in social roles, or by limiting the ability to engage in meaningful or valued life activities. Once mood deteriorates, patients may struggle to cope with their pain and self-manage their condition, further perpetuating this downward spiral.

Another way to view the impact of disease-related factors is to consider them as risk factors, not as actual determinants of depression in RA. The rationale for this perspective is that psychological factors also have been shown to affect depression and may either mitigate or exacerbate the effects on disease characteristics. For example, illness beliefs may affect the interpretation of symptoms and disease course and reflect the underlying meaning to patients of being sick or incapacitated by their medical circumstances. For instance, considerable research over the past 25 years has shown that the perception of helplessness in the face of pain or heightened disease activity plays a central role in depression in RA.¹² Likewise, catastrophizing—the tendency to have dire thoughts about pain or the consequences of RA—may contribute to both depression and anxiety.¹³

Dysfunctional beliefs about RA may also lead to maladaptive coping that, in turn, contributes to depression. For example, helplessness has been associated with passive or avoidant pain coping strategies that negatively impact mood.¹⁴ In contrast, internality (perception of control) is related to active pain coping that tends to be protective of mood. Illness beliefs and coping mechanisms may serve as important explanatory links between disease activity and mood, functioning as mechanisms through which factors such as pain and/or disability lead to depression and emotional distress (see Figure 1). The implication of this model is that treating disease activity is insufficient for the amelioration of depression. Emphasizing the implementation of strategies to correct dysfunctional beliefs or improve pain coping mechanisms may lead to improvement in mood.

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Figure 1: Schema illustrating the linkage between RA disease activity and depression. Effect of disease activity (A) on depression (D) dependent on (B) illness of beliefs, meaning of illness, and (C) coping, management.

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.

Depression can be easily identified in rheumatology practice. Screening mechanisms can be integrated into the evaluation process and used intermittently to assess depression over the course of managing patients’ disease activity and response to medications. Brief self-report instruments such as the Patient Health Questionnaire (also known as the PHQ9) can be completed within a few minutes and provide cutoff scores that have high specificity and sensitivity for detecting depressive disorder.²⁶ The clinician can use the data to alter the treatment plan for a patient and determine whether the depression should be treated.

After depression has been identified, the rheumatologist must decide on a management approach. If the patient’s depression is mild and does not impair role functioning, some basic education about depression and treatment provided by the rheumatologist or a rheumatology nurse may be sufficient. However, if the patient is likely to have a depressive disorder, consultation with a mental health professional is necessary to arrive at a definitive diagnosis and establish a management approach. Behavioral medicine specialists, either PhD clinical psychologists or psychiatrists who have training in understanding the relationship between psychological factors and chronic disease, are the most qualified to serve RA patients with depression and to coordinate their treatment with rheumatology professionals.

The high prevalence of depression in RA increases the importance of adopting an integrated approach to clinical management in which the medical and psychosocial needs or patients are effectively addressed and managed on a continuous basis. This approach, espousing a comprehensive view of the health of the RA patient, holds the most promise to yield optimal medical and psychological outcomes in rheumatology care.

Dr. Nicassio is clinical professor in the department of psychiatry at David Geffen School of Medicine at the University of California, Los Angeles. Myra Irani is with the California School of Professional Psychology, Los Angeles, at Alliant International University.

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