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10-10-2018 | Mental health | Editorial | Article

Why depression and anxiety matter in patients with inflammatory arthritis

Author:
Susan Bartlett

Learning objectives

From work-related stress to managing life with a chronic illness, depression and anxiety can affect anyone at any age, and they are the most common mental health problems affecting people with inflammatory arthritis (IA). While everyone experiences episodes of sadness and low mood, clinical depression is characterized by unrelenting sadness, loss of interest in daily activities, irritability, and feelings of helplessness and hopelessness that significantly interfere with day-to-day life, lasting at least two weeks. Significant episodes of depression often involve changes in sleep, appetite and weight, difficulty concentrating, and unexplained somatic symptoms (headache, back pain, muscle ache, gastrointestinal distress, etc.) Generalized anxiety is excessive nervousness and worry about everyday problems that often is accompanied by muscle tension, exhaustion, and difficulty falling asleep. High levels of anxiety over time may lead to panic attacks causing individuals to avoid situations and progress to trouble leaving their homes (agoraphobia).

Identifying and managing depression and anxiety are important goals, as treating emotional distress improves health and quality of life. Growing evidence shows that for IA patients with anxiety and depression, treating emotional distress may also be key to achieving good outcomes.

The impact of mood disorders on work-related outcomes and quality of life

Decades of research have shown that rheumatoid arthritis (RA) patients who are depressed experience increased pain and fatigue, greater disability, and poorer health-related quality of life compared with people with RA who are not depressed [1]. Healthcare costs, job loss, rates of comorbidities, and early mortality are also higher in depressed people with RA than people with RA who do not have depression [1,2].  Adults with RA and depression are more likely to be unemployed due to disability, and those who are employed report more days of work missed and higher lost annual wages due to missed work days [2]. Mood disorders are an important predictor of both suboptimal adherence and a blunted response to treatment, including biologic therapy. Given this, symptoms of depression and anxiety have important implications for clinical decision-making when treating patients with IA, especially those who are not achieving remission. Yet, in rheumatology settings, depression continues to be poorly recognized and undertreated [3] raising new questions about whether mental health also should be assessed and managed to optimize outcomes in IA.

Prevalence of mood disorders in patients with inflammatory arthritis

It is no surprise that life with IA is more complex, unpredictable, and stressful, leaving patients to struggle with a range of emotions. People with arthritis are nearly twice as likely to develop a mood disorder, especially those under 45 years of age than people without the condition [4]. Pooled estimates using clinical interviews (the gold standard) suggest that one in six people with IA are experiencing major depression, and up to half will have clinically relevant symptoms of depression [1,5]; in psoriatic arthritis (PsA), rates could be as high as one in three patients [6]. Furthermore, contrary to what’s seen in the general population, among 47 countries and more than 200,000 participants, the odds of depression in IA appears to be higher in men (OR=3.1; 95% CI 2.2– 4.3) than women (OR=2.5; 95% CI 2.0 –3.2) [7]. A similar pattern is seen with anxiety disorders, although some studies suggest the prevalence of anxiety may be even higher [5].

Growing evidence suggests that mood disorders not only result from living with rheumatic diseases but may also be implicated in the likelihood of developing RA [8,9] and PsA [10], though not all studies have found this association [11]. The social context in which patients live is important as well. Stress not only contributes to the experience of more pain and emotional dysregulation and higher disease activity in RA but may be a risk factor for onset. An intriguing study from Australia where over 12,000 individuals were assessed at 3-year intervals showed that perceived stress (but not stressful life events) significantly increased the odds of having osteoarthritis and RA over time [12]. Some studies have suggested a relationship between post-traumatic stress disorder and RA onset in those with a history of military service [5]. Studies like this suggest there may be common biopsychosocial pathways linking mental health disorders with the onset and severity of rheumatic diseases.

The impact of mood disorders on inflammatory arthritis symptoms

Symptoms of significant emotional distress are not uncommon around the time of diagnosis and occur in about 21% of individuals. However, it appears that living with persistent anxiety and depression over time results in poorer outcomes. In people with early RA and PsA, persistent depression and anxiety are linked with higher disease activity and a reduced odds of reaching remission [13-16]. A compelling reason why this matters to rheumatologists is that depression appears to be the most reliable predictor of non-adherence to treatment and discontinuation of medications across all chronic diseases [17]; in RA, it is one of the strongest predictors of stopping biologic treatment [18]. We and others have found that anxiety and depression significantly influence patient perceptions about how well symptoms can be controlled by medication and self-management. Rates of smoking are higher in RA patients (36%) than the general population (20%), and higher still among RA patients who report being depressed (47%) [19], perhaps due to nicotine’s mild antidepressant properties. Similar patterns are found with depression and obesity and physical inactivity – each risk factor results in worse outcomes. Patients with suboptimal responses to therapy, particularly those whose DAS28 scores are inflated by high pain, tender joint counts, and patient global scores may be experiencing emotional distress and as a result are not likely to respond to escalations in arthritis medications. Red flags for depression are younger adults, and those with higher pain, fatigue, disability, comorbidities, and more severe disease. Unemployment and greater disability are important risk factors as well.

Treatment for mood disorders

High levels of depression and anxiety can be readily identified using validated questionnaires (see Box 1). Once identified, depression and anxiety are treatable. There are many outstanding cognitive-behavioral self-help programs with proven efficacy available online that are reasonable first lines of treatment for individuals with mild-to-moderate levels of symptoms. Those with high levels of symptoms will benefit from a short course of treatment and possibly medication for brief periods. Individuals with a history or chronic symptoms, higher levels of distress, and those with other psychological comorbidities will benefit from working directly with mental health professionals.

Box 1

Brief Questionnaires to Identify Anxiety and Depression
PHQ-9, Patient Health Questionnaire (depression), 9 items [20]
GAD-7, Generalized Anxiety Disorder Scale, 7 items [21]
HADS, Hospital Anxiety and Depression Scale, a 7-item anxiety subscale and a 7-item depression subscale [22]
PROMIS Anxiety and Depression short forms, 6 or 8 item versions [23]

Conclusion

In summary, anxiety and depression affect as many as one in three people with IA, and contribute to pain, fatigue, disability, non-adherence, and poorer outcomes in these patients. Brief questionnaires are available to help rheumatologists identify those with high levels of emotional distress. Effective self-help and brief counseling interventions are available to reduce suffering, and are likely to improve disease control, medication adherence, and persistent symptoms that do not respond to treatment escalation.

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