Arthritis & Depression

People with arthritis have high rates of depression and anxiety, both of which are underdiagnosed and many of those affected don’t receive mental health treatment – which could potentially help with their physical arthritis symptoms.

Doctors Should Watch for Depression in Rheumatoid Arthritis Patients

People with Rheumatoid Arthritis are twice as likely to be depressed.

People with rheumatoid arthritis are twice as likely to experience depression but are unlikely to talk to a doctor about it, according to researchers at the University of North Carolina at Chapel Hill. In the study, published in Arthritis Care & Research, researchers found that almost 11 percent of RA patients had moderately severe to severe symptoms of depression, demonstrating a worrisome link between rheumatoid arthritis and depression. 

The study also found that only one in five of the patients with arthritis and depression discussed it with their rheumatologists. Those who did were always the ones to bring up the topic – not the physician. When it was brought up, it was often not discussed at any length.

Why not? Because when patients visit their specialists, their arthritis is understandably the main focus, says Betsy Sleath, PhD, the study’s lead author. But in discussing a patient’s arthritis, depression is a topic rheumatologists should consider broaching.

"Chronic diseases can greatly affect a patient's psychosocial well-being, and depression can also affect a patient's adherence to treatment regimens," Sleath says. "Since many arthritis patients see their rheumatologist more often then their primary-care physician, we recommend that rheumatologists take steps to screen patients for signs of depression."

Depression Can Worsen Joint Pain

Treating mental as well as physical health may alleviate symptoms.
| By Jennifer Davis and Mary Ann Dunkin

When your joints are aching and painful, here’s an aggravating factor you may not have considered: your mood. Understandably, being in pain can cause you to feel depressed, but research suggests the opposite is also true: being depressed can make pain worse.

In fact, a 2011 study published in The Journal of Bone and Joint Surgery showed that for people with osteoarthritis (OA), depression can have just as strong an effect on knee pain as physical damage.  

“The finding was particularly true in patients with radiographic findings of less severe – mild to moderate – knee osteoarthritis,” says lead author Tae Kyun Kim, MD, PhD, director of the division of knee surgery and sports medicine at the Joint Reconstruction Center at Seoul National University Bundang Hospital in South Korea.

Dr. Kim’s research team studied data from 660 Korean men and women older than age of 65. They measured the severity of participant’s OA damage with X-rays, questioned patients about their pain and interviewed them to diagnose depressive disorders. As expected, those with the most joint damage reported feeling the most pain. Surprisingly, participants with mild-to-moderate knee OA who were experiencing depression also reported severe pain, even if X-rays didn’t show the significant damage that typically indicates pain.

The reason for increased pain severity with depression is not clear, researchers say. However, some hypotheses have been proposed, says Marina B. Pinheiro, a researcher at the University of Sydney, Australia, who found a significant connection between depression and nonspecific back pain in a study of 2,148 twins from a Spanish twin registry. Nonspecific means that other serious pathologies and nerve root compromise have been ruled out, she says. “It is very likely OA is a cause, although we did not assess this directly.” The study was published in 2015 in the journal Pain.

The Pain-Depression Connection

One hypothesis for the pain/depression connection is depression leads to lifestyle changes that can worsen pain, says Pinheiro. “For instance, individuals with depression usually engage less in physical activity, become less socially participative, and have worse sleep quality.These factors have been shown to influence back pain.”

Another theory proposes that high levels of depression weaken a person’s ability to deal and cope with the current pain problem, Pinheiro says. “So based on this theory, the individuals’ perception about their condition, for example back pain, might become more negative when compared with individuals that are not depressed.

“In addition, there is a plausible biological link as both conditions – pain and depression – share common biological pathways and neurotransmitters, such as serotonin and norepinephrine.”

Jon T. Giles, MD, an assistant professor of medicine at Columbia University and rheumatologist at New York Presbyterian Hospital in New York City, says “Painful sensations are relayed through the brain in a very complex way, and can be modulated up or down,” he says. With stress, poor sleep, anxiety and depression, which are known to influence pain levels, “stimuli feel more painful than they would in someone without the adverse psychosocial factors.”

Treating Depression and Pain

Because depression might amplify pain responses in OA and other musculoskeletal conditions, Dr. Giles says clinicians should use antidepressants and other treatments if necessary to alter mood, rather than just prescribing medications designed to block pain.

“Antidepressant medications have been found to have analgesic as well as antidepressant effects,” agrees Dr. Kim.

Dr. Giles says it’s also important for caregivers who treat musculoskeletal conditions to screen patients for potential psychological aggravators of pain and refer them for treatment when needed. Likewise, people with painful musculoskeletal conditions who are experiencing emotional stress, an ongoing blue mood or other signs of depression – including fatigue, irritation and loss of interest in favorite activities – should mention it to their doctor who can prescribe or refer them for treatment that could potentially improve both their depression and their pain.

Rheumatoid Arthritis and Depression

RA is a chronic condition affecting all aspects of your life, often leading to depression.

As many as 40% of people with RA experience significant symptoms of depression, which can lead to more physical function problems, higher disease activity, poorer health overall and an increased need for medical care.

Depression Can Make Your RA Worse

“People with mental health conditions definitely tend to have more functional limitations,” says Louise Murphy, PhD, director of the arthritis program at the Centers for Disease Control and Prevention (CDC) in Atlanta. Gary Kennedy, MD, director of geriatric psychiatry at Montefiore Medical Center in New York City agrees, “Not only does depression increase the odds of developing other health problems, such as heart attack, it may also worsen arthritis-related pain.”

It could also mean you are less likely to seek help for your condition. According to the National Alliance on Mental Illness, someone who has depression and a chronic illness may be less likely to adhere to treatment, and more likely to smoke, drink alcohol, eat poorly and neglect physical activity. All of these behaviors can lead to poorer outcomes.

Could the Link Between RA and Mental Health Be Inflammation?

We know that pain and disability are linked to depression in RA, but a developing theory is that inflammation also plays a role. “There is a body of literature recognizing depression as an inflammatory state. There is a well-documented event called cytokine-induced depression, where cytokines are increased and depression occurs,” explains Patricia Katz, PhD, professor of medicine at University of California San Francisco who studies the relationship between functional and psychological status among adults with chronic health conditions. Cytokines are communication molecules involved in the immune response. Specific proinflammatory cytokines, such as interleukin-1, interleukin-6, and tumor necrosis factor-α, are involved in the pain and inflammation process.

Dr. Katz and and her colleague Mary Margaretten co-authored a 2011 report in the International Journal of Clinical Rheumatology that reviewed what is currently known about the link between RA and depression and what role inflammation might play. Dr. Katz says continuing to focus on which inflammatory chemicals play a role in depression could make a difference in treatment. “If increased inflammation is leading to depression and you find out that the primary driver of that inflammation is TNF, then that might suggest treatment with a TNF inhibitor would make a difference,” she explains. But she adds, “There is more work needed.”

Don’t Hide From the Problem

Mental health issues in people with RA are under-reported and underdiagnosed. This is not surprising to Michael Clark, MD, director of the chronic pain treatment program at Johns Hopkins University in Baltimore. “We’ve known for a long time that psychological disorders of all types are increased in patients with chronic pain,” he says. However, a stigma persists about psychological issues that may keep patients from talking about it with their doctors at all. If you think you may be depressed, talk to your doctor and work together to develop an assessment and treatment plan.

Because mental health and disability are strongly linked, not diagnosing or treating one can impact the other greatly. For example, having depression may mean you don’t have the energy to exercise, and similarly, having a lot of pain and inflammation may cause you to be depressed. Eventually, this influences sleep, activity, social interactions, adherence to treatment, and self-care. Dr. Murphy recommends, “Treating mental health conditions should be regarded as a fundamental part of managing arthritis symptoms.”

Treating the Person

There are many treatment options available to you, from medications to psychotherapy to deep relaxation and acupuncture. Having a collaborative health care team is vital to success. Your rheumatologist and mental health specialist need to be on the same page to coordinate treatment and reduce potential drug interactions.

Medications used to treat anxiety and depression include selective serotonin reuptake inhibitors (SSRIs) and serotonin–norepinephrine reuptake inhibitors (SNRIs). Dr. Murphy recommends self-management classes for anxiety and depression, pointing out that a CDC study found that these classes were “associated with a considerable and sustained decrease in mental distress.” Cognitive behavioral therapy, a type of psychotherapy that focuses on changing negative thought patterns and behaviors, might be prescribed for you. Alternative therapies such as acupuncture, massage and yoga are also effective in alleviating symptoms of depression and arthritis.

Physical activity is another good option. Almost any kind of activity can help reduce pain and depression – and it’s essential for managing other arthritis symptoms, too. You can use Your Exercise Solution to help you choose and modify activities that are right for you.

Enjoying life is an achievable goal. Dr. Kennedy recommends, “That’s why you must give as much attention to your mental well-being as you do to your physical health.”

Stress and Worry Affect RA

Research suggests emotional distress may trigger or worsen RA, but many questions remain.
| By Jennifer Davis

Can trauma or stress trigger the development of rheumatoid arthritis? Can worrying make the disease worse?

Research examining the role of trauma and emotional distress in rheumatic diseases suggests the answers to both questions may be yes.

For example, a 2009 study by researchers at the Centers for Disease Control and Prevention found that people who reported two or more traumatic childhood events – including physical, emotional, or sexual abuse -- had twice the risk of rheumatic disease compared with those who reported no childhood trauma.

Psychological Stress May Affect Disease Outcomes

Further, many studies have described relationships between psychological stress and poor outcomes in RA, including disease flares, says Daniel Clauw, MD, professor of anesthesiology, rheumatology and psychiatry at the University of Michigan in Ann Arbor.

In one of those studies, researchers at the University of Nebraska analyzed the records of 1,522 U.S. veterans with RA. They found that those who also had a diagnosis of post-traumatic stress disorder (PTSD) had higher scores of self-reported pain, physical impairment and tender joint count, and worse global well-being than those with RA but no PTSD. Results of the study were published in 2013 in the journal Arthritis Care & Research.

Worry May Worsen Symptoms

In a Dutch study published the same year in Annals of the Rheumatic Diseases, researchers found a correlation between worry, RA symptoms and disease activity.

Trying to understand how daily stressors and worrying impact symptoms and disease activity in RA, researchers gathered data from 80 RA patients once a month for six months. Patients answered questions about daily stressors (for example, long appointment wait times or losing something valuable); level of worry; and symptoms of pain, fatigue and disease activity.

Researchers also took blood samples to measure levels of the stress hormone cortisol as well as inflammatory cytokines -- including TNF-alpha and interleukin-1 beta (IL-1β) -- believed to play a key role in RA severity. (Some biologics, including etanercept (Enbrel) and adalimumab (Humira) are TNF inhibitors, and anakinra (Kineret) is an IL-1 inhibitor.)

Their findings showed that “patients who have a tendency for more worrying reported slightly more disease activity, more swollen joints and more pain one month later,” explains lead author Andrea W. M. Evers, PhD, a clinical psychologist and coordinator at Radboud University Nijmegen Medical Centre in the Netherlands.

Understanding the Role of Emotions

Researchers say such findings point to the need for more studies about exactly how stress and worrying impacts the disease process. Dr. Clauw says one presumption is that stress leads to changes in the functioning of the autonomic, neuroendocrine and/or immune systems.

Authors of the Dutch study offer another possible explanation: because worrying affects emotional well-being and behavior, it could lead to less treatment adherence.

Despite the growing evidence that emotional stress can affect the immune system, quantifying or explaining the effect can be difficult due to the subjectivity of stress and people’s response to different stressors, experts say.

Terry L. Moore, MD, director of the division of rheumatology at St. Louis University School of Medicine in Missouri, questions the findings of the Dutch study in particular, because he says it had too many difficult-to-measure variables at play.

“Self-reported disease activity, pain and fatigue – some of the things they were monitoring -- are very subjective,” Dr. Moore says. “You are relying on patients to tell you what went on during the day. Fatigue varies – what one says is fatigue another might not view that way.”

While the medical community continues to search for answers, Evers says there is no question patients with the tendency to worry extensively can be helped with psychological interventions like cognitive-behavioral therapy.

When to See a Doctor About Depression

Some symptoms mean you could use a doctor's help.

If you are wondering when to see a doctor about depression, consider first that feeling down in the dumps is part of being alive. One day you're grumpy and out of sorts, spirits low; next day you're back in the groove, ready to dive into the things you love. But when, for two weeks or more, you feel like sitting out the rest of your life, you may be clinically depressed. Depression is a medical condition that requires treatment  – and can be helped – by a doctor. Experts suggest seeking help if you have any of these symptoms of depression:

• Your low spirits persist for two weeks or more.
• Your depression is interfering with your relationships and your job.
• You have thoughts of harming yourself.
• You have persistent physical symptoms such as headaches, digestive disorders and chronic pain not associated with arthritis that do not respond to routine treatment.
• Your symptoms include any five of the following: sleeplessness or oversleeping; loss of appetite or overeating; frequent tears and feelings of sadness; inability to concentrate; little appetite for things you usually enjoy; fatigue; irritability, restlessness or moving about in slow motion; a feeling of worthlessness or pervasive guilt.

The above are typical symptoms of major depression. Less than half of the 10 to 40 percent of people with depressive symptoms have major depression. Other classifications of depression include:

Dysthymia. A less severe form of depression that includes long-lasting symptoms that do not seriously disable a person but keep one in a constant state of feeling down. Symptoms may include all of the above with the additional feeling of hopelessness.

Bipolar disorder. Also called manic-depressive disorder, it is characterized by extreme highs and lows in mood. The disorder affects thinking, judgment and social behavior. Symptoms include the above as well as racing thoughts, increased talking, unusual irritability and abnormal elation.

Antidepressants: OK for RA?

What you should know if your doctor recommends antidepressants in addition to your prescribed RA treatments.
| By Susan Bernstein

If your doctor diagnoses you with either depression or anxiety, you may be prescribed one of the many drugs on the market designed to block or regulate brain chemicals that may be at the root of these mood disorders. Commonly prescribed antidepressants include:

• Selective serotonin reuptake inhibitors (SSRIs): Fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), escitalopram (Lexapro)
• Serotonin-norepinephrine reuptake inhibitors (SNRIs): Duloxetine (Cymbalta), venlafaxine (Effexor), milnacipran (Ixel), desvenlafaxine (Pristiq)
• Tricyclic antidepressants: Amitriptyline (Elavil, Endep)
• Norepinephrine-dopamine reuptake inhibitors: Bupropion (Wellbutrin, Zyban)

Antidepressants are used to treat not only depression, but anxiety, chronic pain and sleep issues. In fact, doctors may prescribe antidepressants for treating chronic pain caused by RA, or even sleep problems, rather than for depression or anxiety. The drugs’ use for these symptoms in people with RA remains controversial, as they may not be that effective in reducing RA pain. Some studies suggest that antidepressants may even treat inflammation itself, but this has not yet been determined.

Your rheumatologist may prescribe an antidepressant for you, or he may refer you to a mental-health professional like a psychiatrist who will prescribe these drugs. For people with RA who are diagnosed with depression, adding an antidepressant may help regulate their mood, make them feel better emotionally, and even help them sleep better. What should you know about adding an antidepressant to the drugs you’re already taking for RA?

SSRI antidepressants, when taken along with a nonsteroidal anti-inflammatory drug like ibuprofen or naproxen, can increase internal bleeding risk. In addition, these antidepressants, if taken over the long term, have been linked to bone loss. People with RA who have taken long-term corticosteroids like prednisone to control inflammation may also be at higher risk for bone loss, so bone density testing and monitoring may be important.

As with any new medication, it’s important to discuss the possible side effects or interactions with your rheumatologist. You’ll also want to track how effective the antidepressant is at reducing your depression or anxiety. To learn more about arthritis drugs and their possible interactions or side effects, check the Arthritis Today Drug Guide.

Antidepressant drugs aren’t the only tool you and your doctor can use to treat your depression or anxiety:

Seek counseling. A mental-health professional like a therapist, psychologist or psychiatrist can discuss how RA increases your stress or causes you frustration or grief, and recommend ways to manage feelings more effectively.

Talk it out. Join an arthritis self-management or support group to learn coping techniques and feel that you’re not alone in living with RA.

Get moving. Exercise is nature’s mood lifter. Regular physical activity, including exercises designed to improve range of motion (ROM), strength and cardiovascular fitness, has been shown to relieve depression symptoms by actually increasing levels of serotonin, dopamine, norepinephrine and other mood-related brain chemicals. Arthritis exercise classes or videos can help improve physical function and help you do your daily tasks more easily, so you may feel less frustrated by your RA.