When a patient first learns they have a rheumatic disease, they may have difficulty coping with the diagnosis, which can require help beyond the rheumatology clinic. A licensed psychologist can help such patients manage their anxiety and depression by teaching them life and coping skills.
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“Patients worry their ability to live a full and meaningful life is threatened [after diagnosis],” says Susan J. Bartlett, PhD, clinical psychologist and professor of medicine, McGill University, Montreal, and adjunct professor of medicine, Johns Hopkins University, Baltimore. “Although many patients have an initial crisis period, they often end up doing quite well emotionally with their rheumatology care team’s support. But some patients experience disabling or persistent levels of emotional distress. These individuals can benefit from additional evaluation and counseling from a psychologist.”
In some cases, a rheumatologist may refer a patient to a clinical psychologist for evaluation if they suspect the patient may be depressed and would benefit from counseling. At her first meeting with a newly diagnosed patient, Dr. Bartlett aims to ascertain if they are experiencing depression or anxiety. If so, she tries to understand the level of depression or anxiety, the type of support they have available and how well they are coping with their disease.
To assess patients, Dr. Bartlett uses the Patient Health Questionnaire-9 (PHQ-9), which uses diagnostic criteria to assess a patient’s level of depression. The test evaluates key areas, such as loss of interest or pleasure doing things, difficulties with concentrating and sleep, poor appetite or overeating, and feelings of hopeless and failure.
“When patients report feeling down and depressed most of the time and no longer find pleasure in activities they previously enjoyed for at least two weeks, it may be a sign of a major depressive episode that requires intervention,” she says.
For depressed patients, Dr. Bartlett counsels them to exercise, which is now viewed as a first-line treatment for mild to moderate depression. She also considers if a brief trial of cognitive behavioral therapy and medication may be helpful for these patients.1
For anxiety, Dr. Bartlett uses a scale, such as the Patient-Reported Outcomes Measurement Information System (PROMIS) anxiety scale, to assess the severity of symptoms. She asks patients if they have a personal or family history of anxiety and panic attacks. If so, panic attacks may return during periods of stress, such as receiving a new diagnosis.
“Patients experience anxiety differently—such as changes in bowel habits, muscle tension, headaches, feeling on edge or pervasive worry that they can’t control,” she says. “I get a sense of how they experience anxiety and then talk with them about how they can relieve or avoid it, such as doing relaxation exercises or meditation, along with exercising regularly.”
Dr. Bartlett meets weekly with individuals experiencing high levels of depression or anxiety for a few months. “I will work closely with their rheumatologist to help patients feel more comfortable and confident in managing their disease and talking about their feelings,” she says. “Depression in patients with rheumatic diseases is important to identify and address, not only because of the impact on quality of life, but because depressed patients are less likely to take prescribed medications.”
It’s important for patients to learn to live with their rheumatic disease. Dr. Bartlett teaches patients skills to more effectively self-manage their condition. She’ll help them identify reliable information sources, such as the ACR, where they can read about their condition(s) online. She will also point patients to such resources as online self-management programs, stress management classes and local exercise classes tailored to meet the needs of people with rheumatic conditions.
Dr. Bartlett also helps patients learn to communicate confidently and effectively with their medical team, employers, family members and friends. She will discuss how patients can partner with their rheumatologist to share in decision making and ensure they get the treatment that best fits their needs, preferences and values.
Further, Dr. Bartlett teaches patients how to set boundaries with family members, friends and other health professionals who may offer alternate suggestions on how to manage medications or lifestyle.
“The key is for the patient to let others know that, at this time, they are committed to following their rheumatology team’s recommendations,” Dr. Bartlett says. “Some patients may also need to learn how to educate others about their disease—although they may look fine, they may not feel well. Family members need to learn to be flexible, because the disease is unpredictable.”
Karen Appold is a medical writer in Pennsylvania.
- Herring MP, Puetz TW, O’Connor PJ, Dishman RK. Effect of exercise training on depressive symptoms among patients with a chronic illness: A systematic review and meta-analysis of randomized controlled trials. Arch Intern Med. 2012 Jan 23;172(2):101–111.