Because rheumatologists and mental health experts both treat patients with depression, anxiety, pain, disability and sleep disorders, provider cross-training may benefit patients and providers themselves.
Explore This IssueJune 2022
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“When a patient has active psychosocial distress, this has a negative effect on their physical function. Similarly, if a patient has active physical symptoms, like a rheumatoid arthritis flare, this has a negative effect on their mental health,” explains Hanna Zembrzuska, MD, MME, clinical assistant professor in the Departments of Internal Medicine and Psychiatry at University of Iowa Health Care, Iowa City.
Like rheumatologists, psychiatrists treat disorders that are associated with systemic inflammation. “This is an exciting area of research,” Dr. Zembrzuska says.
In 2021, results from a study by Kelly et al. supported a causal association between interleukin (IL) 6 signaling and depression. The study analyzed data from more than 89,000 participants in the UK Biobank, with the authors noting the findings add to prior evidence implicating IL-6 signaling in depression.1
A separate study by Ye et al. reported that CRP concentration was associated with depressive and anxiety symptoms, and with diagnoses of depression and generalized anxiety disorder. However, further analysis of the data from nearly 145,000 UK Biobank participants found that higher IL-6 activity was associated with increased risk for depressive symptoms, although higher CRP concentration was associated with decreased risks of depressive and anxiety symptoms.2
Earlier this year, Graham-Engeland et al. found higher CRP levels in participants with both higher negative affect and either higher pain intensity or pain interference. The findings from the 212-patient study were consistent after accounting for demographic factors and body mass index. The authors noted that the findings add to the literature suggesting that negative affect, pain and inflammation are related.3
Along with the association of pro-inflammatory markers with the presence and severity of both rheumatic diseases and mood disorders, rheumatology and psychiatry overlap in other ways, says Alfred Kim, MD, PhD, assistant professor of medicine in the Division of Rheumatology at Washington University in St. Louis.
“Many rheumatologic conditions, such as systemic lupus erythematosus and psoriatic arthritis, exhibit both high frequency and severity of mood disorders,” Dr. Kim says. “Both disciplines are more ‘old school’ in their clinical approach: the signs and symptoms drive clinical decision making rather than labs and imaging.” Systemic lupus erythematosus (SLE) is a clinical diagnosis with laboratory results providing supportive evidence, and mood disorders, such as depression, are purely a clinical diagnosis, he explains.
Dr. Kim’s group reported that symptoms of depression persisted over time in his 2021 study of patients with SLE. Of the 144 patients, 61.2% had symptoms of depression for up to four years.4 Subsequently, Dr. Kim’s group reported study results showing that anxiety symptoms persisted over time in 139 patients with SLE and symptoms were independent of SLE disease activity. 5
“While we typically categorize mood disorders within the neuropsychiatric realm of SLE, our data support that mood disorders are much more complex in root cause than just SLE,” Dr. Kim says.
“Further, the severity of mood disorder was durable throughout time: If you had severe anxiety at visit one, you most likely will have equally severe anxiety at visit 10. This is a wake-up call for us at Washington University Lupus Clinic, as we had presumed that treating a patient’s SLE will also help with their anxiety,” Dr Kim adds. “This is clearly not true, and this has motivated us to find effective solutions to better manage mood disorders in our patients with SLE. These solutions will have to address health disparities, as those with more severe anxiety and depression were overwhelmingly Black, who certainly experience a high level of disparities in St. Louis.”
Cross-Provider Training Needed
Learning how different conditions, such as anxiety disorder or major depression, are classified is very important, says R. Swamy Venuturupalli, MD, FACR, founder of Attune Health in Los Angeles. He explains that psychiatry rotations are completed during medical school and while undergoing internal medicine training in residency.
Dr. Venuturupalli suggests that psychology, rather than psychiatry, provides the tools to communicate with patients with a chronic autoimmune disease who are dealing with daily stressors and anxiety.
With chronic disease, the condition can be unrelenting, with daily pain, fear and concern.
“To get past a chronic disease—to get better—one must have a very strong, positive mindset and a belief in the future. Psychological tools can really help in that aspect. But on a more day-to-day basis, the anxiety of having to deal with a chronic illness can also be alleviated by psychological tools,” Dr. Venuturupalli says.
“In that sense, psychology is a key factor in helping our patients do better and have better outcomes overall,” he adds.
A review by Taylor et al. suggests clinicians should consider wellness practices, such as mindfulness, exercise and optimized sleep and nutrition, in addition to treat-to-target pharmacological agents for a more complete and patient-centered approach to the management of patients with rheumatoid arthritis (RA). The researchers note that wellness practices can help people with RA to improve their health status by reducing inflammation and symptoms, along with improving well-being.6
Rheumatologists are often the primary doctors for their patients with chronic autoimmune illnesses. “So it is critical that rheumatologists are trained, and have a basic understanding and knowledge to help our patients, through simple measures, like sleeping and exercising well and breathing techniques, which we can learn from psychology,” Dr. Venuturupalli explains.
Being able to implement these simple measures in the practice and having a referral network for patients are essential, but it is almost impossible for patients to gain access to mental health experts, says Dr. Venuturupalli. “Referral for psychological care is exceedingly difficult, as there are very few psychologists who are available through insurance programs, and it is often very expensive for our patients, so we as rheumatologists do need to get educated.”
Dr. Venuturupalli notes that “there are a few online resources, some of which are free, such as mindfulness-meditation programs, which some of my patients with lupus use. Such resources are exceedingly helpful for our patients.”
Kim A. Gorgens, PhD, professor at the Graduate School of Professional Psychology at the University of Denver, teaches that mental illness and distress are inflammatory conditions. She suggests that psychology and rheumatology don’t overlap in ways that contribute meaningfully to patient care. “The fact that we think of mental illness as entirely separate from the physiologic basis of rheumatic illness makes this case,” she says. Interdisciplinary training occurs, but “the disciplines exist to see [treat and research] only their part of the elephant (so to speak), so we have a long way to go,” Dr. Gorgens says.
Meanwhile, Dr. Kim notes the type of interdisciplinary training that can help his patients with SLE was not available to him. “We do get some training through our primary care experiences during medicine residency, but perhaps what we are seeing in our SLE cohort requires a greater level of sophistication in managing mood disorders that is challenging for me to provide,” he adds.
At the residency level, physicians can train in a combined internal medicine and psychiatry residency or complete sequential training, Dr. Zembrzuska explains. “Both of these options allow the resident to become board certified in multiple specialties, but the combined training pathway allows for less time spent in training,” she says.
According to Dr. Zembrzuska, the benefits of provider cross-training include integrated care with a patient’s mental and physical care needs managed by one provider, higher patient satisfaction because both physical and mental needs are addressed, better overall quality of care, improved access to services, reduced delays in care and lower healthcare costs.
Improved patient outcomes are an obvious benefit to provider cross-training, says Dr. Kim. “Quality of life will absolutely improve, which is associated with survival in several SLE studies,” he says. “Provider training will also help us detect the presence of mood disorders at a much earlier stage.”
Another benefit of provider cross-training, Dr. Gorgens suggests, “would be to destigmatize the experience of mental distress for patients with other inflammatory conditions—understanding their experience as the presentation of inflammatory disease would not be a personal failing but would be managed like any other symptomatic presentation. I would love to see that happen.”
New Clinical Practice Guideline
The ACR is developing a new clinical practice guideline for physical, psychosocial, mind-body and nutritional interventions for the treatment of RA, with publication expected in spring 2023.7
The aim is to develop recommendations for evidence-based use of interventions for the effective treatment of RA, including mind-body activities; psychosocial and vocational treatments; dietary supplement and nutritional options; physical activity modalities and rehabilitative approaches; bracing, splinting and orthotics; and adjunctive therapies, such as acupuncture and massage therapy.
Like rheumatologists, psychiatrists treat disorders that are associated with systemic inflammation.
Regarding mind-body activities, the ACR team will look at several approaches, such as cognitive behavioral therapy, biofeedback, goal setting, meditation, mindfulness and breathing exercises. For psychosocial and vocational treatments, the team will assess several factors, including self-management programs, such as the Arthritis Self-Management Program; the Chronic Disease Self-Management Program, Better Choices, Better Health; and OPERAS, an on-demand program to empower active self-management; and peer mentoring/support groups.
Commenting on the in-progress ACR guideline, Dr. Kim says, “The concept of this is spot-on [because] both providers and patients are seeking non-pharmacologic approaches to improve mindfulness and optimizing physical function. My main concern, though, is whether patients from more vulnerable neighborhoods—where social determinants of health drive wide wedges in health disparities—are able to take advantage of an approach such as this.”
Katie Robinson is a medical writer based in New York.
- Kelly KM, Smith JA, Mezuk B. Depression and interleukin-6 signaling: A Mendelian Randomization study. Brain Behav Immun. 2021 Jul;95:106–114.
- Ye Z, Kappelmann N, Moser S, et al. Role of inflammation in depression and anxiety: Tests for disorder specificity, linearity and potential causality of association in the UK Biobank. EClinicalMedicine. 2021 Jun 26;38:100992.
- Graham-Engeland J, DeMeo NN, Jones DR, et al. Individuals with both higher recent negative affect and physical pain have higher levels of C-reactive protein. Brain Behav Immun Health. 2022 Feb 15;21:100431.
- Kellahan SR, Huang X, Lew D, et al. Depressed symptomatology persists over time in systemic lupus erythematosus patients. Arthritis Care Res (Hoboken). 2021 Dec 10. Online ahead of print.
- Lew D, Huang X, Kellahan SR, et al. Anxiety symptoms among patients with systemic lupus erythematosus persist over time and are independent of SLE disease activity. ACR Open Rheumatol. 2022 Feb 22. Online ahead of print.
- Taylor PC, Van de Laar M, Laster A, et al. Call for action: Incorporating wellness practices into a holistic management plan for rheumatoid arthritis—going beyond treat to target. RMD Open. 2021 Dec;7(3):e001959.
- The 2022 ACR guideline for physical, psychosocial, mind-body, and nutritional interventions for RA: An integrative approach to treatment. Project Plan. 2021 Dec.