Where Mental Health & Rheumatology Overlap

Dr. Gorgens

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.

References

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2. 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.
3. 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.
4. 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.
5. 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.
6. 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.
7. The 2022 ACR guideline for physical, psychosocial, mind-body, and nutritional interventions for RA: An integrative approach to treatment. Project Plan. 2021 Dec.