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.
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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.
“Rheumatologic diseases come with emotional fallout. They can change the course of a person’s life and adversely affect their sense of self. We can add to that neurobiological factors, with new evidence suggesting depression itself may be a type of inflammatory disease,” she says.
Not all rheumatology patients have depression, notes Andrea Evers, PhD, professor of health psychology and chair of the Health, Medical and Neuropsychology Unit at Leiden University in The Netherlands. “A majority of our patients can handle a condition like rheumatoid arthritis in their lives with their existing coping resources. But rheumatologists struggle with a subgroup of patients who are prone to depression,” she says. “Sometimes, the mental health issue is independent of the disease. But we know people with high levels of rheumatic disease are already experiencing stress, which in turn has a close relationship with rheumatologic disease.”
What Does the Research Tell Us?
Research has demonstrated prevalence of depression and anxiety in such conditions as rheumatoid arthritis at double the rates in the general population, and milder levels of psychological distress are even more common.1 Studies report ranges of depression from 5–20% in patients with RA.2
Symptoms of depression and anxiety are also associated with poorer health outcomes, increased disability and reduced treatment response, and with worse health-related quality of life.3,4 But only a fraction of those with depression and anxiety receive treatment for those symptoms.5
Fatigue in RA is also associated with psychological correlates, especially poor mood.6 There is a relationship between stress and exacerbation of RA, and between resilience factors and RA management.7 Researchers have also documented the impact of psychological factors on patients’ responses to RA treatment.8
Loneliness has been shown to have an impact on patients’ daily pain in fibromyalgia, and loneliness and lack of social support are possible risk factors for worse physical and psychological functioning in a variety of somatic conditions, including RA and fibromyalgia.9,10 Rheumatology research has even identified connections with premature mortality. One recent study suggests treatment with antidepressants can lead to RA remission, and others have asked if it is possible to accurately identify a fibromyalgia or RA personality.11-13
A lot of people are trying to figure out cause and effect, says Faith Matcham, PhD, CPsychol, a post-doctoral research associate at the Institute of Psychiatry, Psychology and Neuroscience at Kings College, London, England. “I don’t think that’s the most important question, but rather how do these two things relate to each other? If you have one, how does it interact with the other?” she explains.
“In many cases, we’re not talking about a diagnosable clinical depression. There are a lot of people who are below the threshold of clinical depression, but still suffering. My research looked specifically at RA and the relationships between joint tenderness and depression and anxiety—and how symptoms of depression and anxiety affect RA symptoms,” she says. Depression is also prevalent in fibromyalgia.
Start the Conversation
Rheumatologists can create space in the clinical encounter to start a conversation about how psychiatric issues may exacerbate rheumatologic conditions. Ask how the patient is feeling, rather than focusing just on their blood counts, Dr. Matcham says. “It’s important to talk about things that aren’t just physical. But then what do you do? For some rheumatologists, it could open a can of worms if they don’t know what to do about the problems that are uncovered.
“We have a project here,” says Dr. Matcham, “to integrate mental health into physical health without adding too much cost, knowing that clinicians are busy and health services chronically underfunded. We’re not talking about turning rheumatologists into psychologists, but about making them aware of these other, mental health aspects of the patient’s life. We set up a system [so that] when [a patient] comes in for a routine rheumatologic appointment, [they’re] given a questionnaire to complete in the waiting room on an iPad.” The results, identifying symptoms of anxiety or probable depression, go straight to the rheumatologist.
Dr. Matcham says a brief, one-item assessment has been shown to predict outcomes, demonstrating that a mental health assessment doesn’t have to be long and complex to identify people at risk of poor health outcomes.14 The SF-36 Short Form Health Survey is another easy way to screen for mental health issues and is widely used in other healthcare settings, Dr. Evers adds.
“What we say to rheumatologists is this: Screen your patients in routine practice, using a questionnaire. Ask about the consequences in their daily lives. If they are at risk, refer them for specialized help,” Dr. Evers says. “We use a stepwise approach.” All patients are given information about adjustment to chronic illness and offered access to disease-specific self-help websites. Some patients may be referred to a nurse in the rheumatology practice or back to the general practitioner, who has more time to devote to these issues. A small group may need additional treatment from a psychologist.
Dr. Evers says she sometimes gets asked to consult with patients online via e-coaching. “We did a randomized controlled trial in patients with RA that showed it is as effective as a face-to-face encounter.” There are a lot of Web-based resources for self-help, she adds, although unguided sites are not as helpful as those with guides, particularly for their impact on daily life adjustment.
Dr. Matcham says, “A lot of what we use is self-help, which can be effective with lower levels of distress. But I also think it’s important to train rheumatology staff in basic mental health skills, such as how to manage conversations about mental health concerns.” She says rheumatologists also must “know what local resources are available to support their patients.” Sometimes in the UK health system, medical services will apply for money for a part-time psychologist as part of the clinical team. “That’s a really good model; it breaks down stigma and reinforces the perception that mental health and physical health are intertwined.”
Every rheumatologic group ideally would have a behavioral specialist embedded, freeing the rheumatologists to focus on treating their patients’ rheumatologic diseases, Dr. Hassett says. “Most doctors can at least get a mental health evaluation ordered. Some rheumatologists [may] feel comfortable treating a mild depression or anxiety and writing related prescriptions, although typically it is easier to send the patient back to the primary care physician, who may be more comfortable with handling psychiatric conditions. The important thing is to recognize the patient who is depressed and anxious and likely to do more poorly,” she says. “You don’t need a psychologist per se; other professionals have training in behavioral interventions, for example social workers, and those practitioners can bill for their services.”
The Importance of Attitude
Dr. Evers’ research on psychoneurobiology in chronic inflammatory conditions has pointed her toward studying the placebo effect—not merely that some patients can be tricked with a sugar pill, but that expectations of the patient and physician have an effect on response to treatment, both positive and negative. “Our research tells us the placebo effect has a major role. If there are negative expectations from treatment, there will be more side effects. But if patients are satisfied with their treatment, they will have a more positive experience and greater adherence to their treatment.”
How can doctors optimally utilize the placebo effect? “We are preparing a publication on guidelines with two major recommendations. First is the importance of transparently informing patients about the implications of the placebo effect—and that their expectations for treatment could play a huge role in the treatment’s efficacy,” Dr. Evers says. Patients must be informed about the placebo effect, but how they are told also has a role.
It’s important to address the patient’s concerns about side effects and long-term benefits, while building a trusting relationship with the clinician. “The patient is a partner in their own care and has to understand why you are asking them these questions.” For example, the clinician might tell their patient, “All drugs have side effects, but if we spend too much time dwelling on the side effects, you may worry more.”
Second, Dr. Evers recommends developing more training about the placebo effect for clinicians. “It’s a hot topic right now. Along with European and federal funding support, we have been given a grant from the Dutch Arthritis Foundation to do more work in this area.”
Re-Think Your Role
Jose Pereira da Silva, MD, PhD, associate professor of medicine and rheumatology at the University of Coimbra and University of Hospital of Coimbra in Portugal, sees psychological and mental aspects of treatment as complex, multi-faceted issues that serve to underscore the mind-body connection while challenging practitioners to look beyond conventional physical disease models if they want to serve their patients’ real needs. But the psychological domains are not well defined. “Most of us are not properly trained in how to respond,” he says.
“Do you believe your role as clinician is to take care of the disease—as defined by its clinical markers—or the patient’s illness, with all of its impacts on the person’s life? I believe my concern lies with the person. I try to engage my patients in a conversation about what’s happening in their lives.” Clinicians who don’t look at these issues miss an important opportunity to make their patients feel better, he says.
Fibromyalgia, in particular, is seen by some clinicians as largely psychological, in part because good clinical markers for it don’t exist. “But we know tumor necrosis factor [TNF] travels to the brain and affects the patient in many ways, [and] anti-TNF drugs can have an antidepressive effect. Some treatments are better at improving the patient’s sense of well-being than actually improving their disease. Biology brings all of these issues together.”
Dr. da Silva illustrates the concept with the story of a young female patient who had been treated with three biologics for RA. “One day, she came to my office with her disease finally in remission. ‘Doctor,’ she said, ‘may this be because I’m in love?’”
Larry Beresford is a freelance medical journalist in Oakland, Calif.
- Geenen R, Newman S, Bussema ER, et al. Psychological interventions for patients with rheumatic diseases and anxiety or depression. Best Pract Res Clin Rheumatol. 2012 June;26(3):305–319.
- Matcham F, Rayner L, Steer S, et al. The prevalence of depression in rheumatoid arthritis: A systematic review and meta analysis. Rheumatology (Oxford). 2013 Dec;52(12):2136–2148.
- Matcham F, Norton S, Scott DL, et al. Symptoms of depression and anxiety predict treatment response and long-term physical health outcomes in rheumatoid arthritis: Secondary analysis of a randomized controlled trip. Rheumatology (Oxford). 2016 Feb;55(2):268–278.
- Matcham F, Scott IC, Rayner L, et al. The impact of rheumatoid arthritis on quality-of-life assessed using the SF-36: A systematic review and meta-analysis. Semin Arthritis Rheum. 2014 Oct;44(2):123–130.
- Anyfanti P, Gavriilaki E, Pyrpasopoulou A, et al. Depression, anxiety and quality of life in a large cohort of patients with rheumatic diseases: Common, yet undertreated. Clin Rheumatol. 2016 Mar;35(3):733–739.
- Matcham F, Ali S, Hotopf M, Chalder T. Psychological correlates of fatigue in rheumatoid arthritis: A systematic review. Clin Psychol Rev. 2015 Jul;39:16–29.
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- Matcham F, Norton S, Scott DL, et al. Symptoms of depression and anxiety predict treatment response and long-term physical health outcomes in rheumatoid arthritis: Secondary analysis of a randomized controlled trial. Rheumatology (Oxford). 2016 Feb;55(2):268–278.