Study Examines How Depression Subtypes May Stem from Osteoarthritis

Simple Screening Tools

The study highlights the need for simple depression screening tools in routine rheuma­tology clinical practice, says Dr. Rathbun. The Patient Health Questionnaire-2 (PHQ-2) is one widely used tool. It poses two questions scored on a scale of 0 (not at all) to 3 (nearly every day):

Questions: Over the past two weeks, how often have you been bothered by the follow­ing problems?

1. Little interest or pleasure in doing things.
2. Feeling down, depressed or hopeless.

A score of three or higher is a cutoff point for depression. A more in-depth version includes nine questions.

Ms. Batterman

The Hospital for Special Surgery, New York, screens all rheumatology patients at intake and, when appropriate, triggers referrals to mental health services, says Adena Batterman, MSW, LCSW, a senior manager in the Inflammatory Arthritis Support and Education Programs.

“As part of a comprehensive psychosocial assessment, social workers screen patients for all issues that may impact your ability to cope with a rheumatic disease,” says Ms. Batterman. “There are many barriers to effective screening, especially in inflammatory arthritis, because many depression symptoms are the same as rheumatoid arthritis: sleep problems, pain and fatigue. It’s difficult to tease out what’s due to RA [rheumatoid arthritis] and what to depression.”

As in OA, depression is highly prevalent in patients with RA and associated with worse disease outcomes.⁶ Other conditions treated by rheumatologists also have high rates of depressive symptoms and depression. For example, more than 80% of patients with fibromyalgia had clinically significant depressive symptoms in a 2011 study, and their depressive symptoms were associated with higher pain perception and worse quality of life.⁷ Patients with systemic lupus erythematosus (SLE) were six times more likely to have depression than healthy controls in a 2018 study.⁸

“There is a surprisingly low incidence of rheumatologists asking about these issues in medical encounters,” says Ms. Batterman. In a 2008 study, only 19% of RA patients whose screening indicated they had moderately severe to severe depression symptoms discussed depression during their medical visits, and the patients brought it up, not the provider.⁹ “It’s important to make this screening part of a normal exam routine because of the profound impact of depression on RA disease outcomes. It’s all a part of treating the person as a whole.”

Dr. Chan

Barriers to effective depression screening and referral in rheumatology include short appointments and a lack of clear clinical directives about mental health, says Karmela Kim Chan, MD, a rheumatologist at the Hospital for Special Surgery. She says PHQ-2, while brief, is a useful first step.

“There are no treatment guidelines on mental health along the lines of treat to target, for example. But it is very important,” she says. Psychological symptoms “may alter a patient’s subjective scores for pain or fatigue, so it definitely plays a role in clinical decision making. I won’t shy away from bringing up mental health issues with my patients. Instinctively, we know that when we’re treating someone with a rheumatic disease, there may be a mental health component. It’s important not to forget about this.”