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.