All rheumatologists have observed the impact of their patients’ mental health status on the long-term treatment of rheumatologic conditions. Depression, anxiety and even loneliness can lead to poor clinical outcomes and nonadherence to treatment, whether the patient is following medication regimens or participating in regular exercise. On the other hand, a patient’s resilience and positive attitude will aid in chronic disease management.
Research has confirmed these links between rheumatologic conditions and psychological comorbidities. But what can practicing rheumatologists do with this information? They are not likely to become experts in psychology or start providing cognitive-behavioral therapy for patients struggling to cope. But there are things rheumatologists can do, depending on the structure of their practice and its relationship with other providers. Some of the better models come from Europe, where much of the research has been done and where medical psychologists often are better integrated into hospitals and medical practices.
“What we’re talking about is a clear association between psycho-social conditions and rheumatic disease, even though there’s not an obvious chicken-and-egg causality,” says Yvonne C. Lee, MD, rheumatologist at Brigham and Women’s Hospital, Boston. Sometimes, one might trigger the other, but it can go either way. “Rheumatologists should be aware [that] depression is common among rheumatology patients and [be] alert for it in their own patients. If they note symptoms of depression, it is imperative to make sure it gets appropriately evaluated and managed,” Dr. Lee says.
“Although it’s not necessarily [the] rheumatologist’s job to treat depression, they should acknowledge the problem, discuss the issues with their patients and make a plan for further evaluation and management through the patient’s primary care physician—or refer [the patient] to a specialist.” It would help to have access to a medical psychologist if the health system can facilitate such a referral, she says, but a broad range of other healthcare workers also deal with psycho-social issues, from social workers to psychologists to psychiatrists.
Health professionals use the term psychiatric comorbidities to describe the simultaneous presence of anxiety or depression with rheumatologic conditions, notes clinical psychologist Afton Hassett, PsyD, associate research scientist in anesthesiology at the University of Michigan, and immediate past president of the ARHP. Dr. Hassett studies the impact of cognitive and affective factors in clinical pain conditions, such as RA, fibromyalgia and lupus. “These comorbidities are extremely common, and they further interact with chronic pain, all of which impact how a person lives,” she says.