Inflammation & Psych Issues: A Look at Potential Co-Morbidity

ATLANTA—In a session titled Mechanisms & Mediators of Psychiatric Co-Morbidity in Rheumatology at the 2019 ARP/ARC Annual Meeting, speakers said rheumatic disease affects not just the body, but can also compound psychiatric disturbances, including depression, anxiety, insomnia, fatigue and cognitive impairment, possibly making the underlying disease even worse.

Daniel Albert, MD, professor of medicine and pediatrics at The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth University, Hanover, N.H., emphasized that psychosocial stressors and inflammation, if untreated, can feed off each other. This means stress or depression due to rheumatic disease can adversely affect therapy effectiveness, which in turn can make the psychosocial stressors worse, thus becoming a self-feeding and circular conundrum.

“It is the 800 lb. gorilla in the room, because therapies do not work as well when co-morbid psychiatric disorders are left unaddressed,” said Dr. Arnold. “Actually, it’s probably more like an 8,000 lb. elephant.”

Depression and anxiety symptoms should serve as markers to manage, monitor and prevent exacerbation of these conditions. “Unfortunately, recognition and initial management of psychiatric issues is not taught in most rheumatology fellowships,” Dr. Albert said. “There should be a groundswell of interest in this topic, and the training program guidelines [should] introduce this topic to our trainees, because they certainly need it.”

Psychiatric Disease Is Undertreated
Psychiatric disorders are common and elevated in patients with rheumatoid arthritis (RA). Dr. Albert said the overall prevalence of anxiety disorders among RA patients is 16.8%, about three times greater than reported among the general population.^1,2

Compared with the general population, incidence rate ratios for depression (1.46), anxiety disorder (1.24) and bipolar disorder (1.20) are elevated in patients with RA.³ “Interestingly,” Dr. Albert said, “The incidence rate ratio for schizophrenia in RA patients is reduced (0.96).”⁴

Studies also suggest stress in the form of anxiety disorders was associated with an increased incidence of autoimmune disease.⁵ “At a minimum, one out of five rheumatology patients—possibly closer to one in three—has a significant psychiatric issue, and most have limited access to professional psychiatric care,” Dr. Albert said.

A recent study also implicated depression as a risk factor for systemic lupus erythematosus (SLE). According to the ACR, cognitive dysfunction is present in 20–80% of patients with SLE as a consequence of disease, depression or medications, especially corticosteroids. Also, anxiety disorders are present in 24% of patients with SLE, and depression is present in 39% of patients with SLE.⁶

Andrew H. Miller, MD, the William P. Timmie Professor and vice chair for research in the Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, said, “[Although] there are impressive data that show a relationship between inflammation and depression, only a subgroup of depressed patients exhibits increased inflammation—about 30%, depending on the population.”⁷