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Medicine Matters rheumatology

Hello, and welcome to the fourth Medicine Matters podcast in a series on quality of life. Today, we will be talking to Dr Dana DiRenzo, from Johns Hopkins University in Baltimore in the USA, about physical activity in patients with rheumatic diseases.

Firstly, Dana, why is exercise important for patients with rheumatic diseases?

Having a rheumatic disease is life-altering. It can affect mood, and it can affect your physical function, your ability to participate in the activities that you love, your overall quality of life. When you have a disease that leads to increased levels of pain, fatigue, and stiffness, this of course can be upsetting and can be wearing.  It may impact the relationships that you have with friends and family, or your co-workers. Mood disturbance is not only prevalent among patients with inflammatory arthritis, but also lupus, scleroderma, vasculitis, Sjogren’s Syndrome, myositis, essentially all the autoimmune diseases. Studies vary about anxiety and depression, but typically occurs in about 20-25% of individuals.

And how do these mood disorders affect patients with rheumatic diseases?

So if you have a new patient who is depressed or anxious at baseline, they are going to be more difficult to manage and have worse outcomes than a new patient who doesn’t have anxiety or depression at baseline. In cohort studies of rheumatoid arthritis, patients with anxiety and depression at baseline and at 2 year follow-up, they have more disability and they have more disease activity compared to those who do not have anxiety and depression. And this is similar in lupus, depressive symptoms are a strong predictor of poor medication adherence, healthcare utilization, and clinical outcomes. And this is also similar in scleroderma, where depression symptoms, it mediates the effect of pain and physical function. So overall, anxiety and depression are major determinants of health-related quality of life, that is found across the board in autoimmune diseases.

So is there a correlation between disease activity and a patient’s mental health and quality of life?

So this is a great question. We’re only beginning to understand this. Historically this question was not investigated because it was felt that the answer was simple. A patient’s mood and their quality of life, they’re completely dependent on disease activity. And what we’re finding now, there’s many studies coming out that this is not the case. You can improve disease activity with medications, some of which are very powerful, potent immunosuppressants, and this does not necessarily improve the quality of life. This is a critical point to understand and this is why it is very important for the physician to talk about these issues and screen for them. It is not entirely clear why disease activity and mood aren’t 100% correlated. It’s very likely that this reflects the uncertain nature of autoimmune disease - there are flares, you can be in remission for years and then suddenly your disease might be active again - this is stressful. On a similar note, anxiety and the perception of stress are highly correlated.  Exposure to stressful situations coupled with poor coping strategies has been associated with increased pain and disease activity in RA, and cytokine production in lupus. Mechanistically, perceived stress and anxiety are associated with increased activation of the sympathetic nervous system, and then this will release inflammatory cytokines. This leads to downregulation of the parasympathetic nervous system. Collectively, this is known as the inflammatory reflex.

How can rheumatology healthcare professionals address mental health during a consultation?

You can screen before the appointment starts, this may be something like having the patient check-in and fill out a form in a waiting room before the appointment begins. For example, you can screen for depression with a 2 question Patient Health Questionnaire, known as the PHQ-2 form. If that’s positive, which it likely will be in about 25% of your patients, you can follow this up with a 9 question form. Or, for example in anxiety, you can use the Generalized Anxiety Disorder questionnaire, or the PROMIS, the Patient-Reported Outcomes Information System collection of questionnaires. Other options would be the SF-36 or the HADS, or the Beck Inventory. There are many, many different questionnaires that are available to you. And, I would encourage use of questionnaires and forms because in my experience, patients aren’t gonna bring this up on their own, and as we just discussed, one of the largest predictors of clinical and functional outcomes at one year, is mental health. If you do not feel that questionnaires will fit into your work flow, then you can always just ask: “How are you feeling emotionally about your disease?” Ask the patient: “Are you depressed? Are you anxious?” You will be surprised about the answers you get, and importantly, your patients will like you for it.

What treatments are available to improve patients’ mental health?

There are several strategies that you can recommend to your patients to improve mental health and quality of life. I’ll focus on 3 broad categories. Of course there’s also medications that one can take but a lot of patients shy away, in my experience, from the medications because they’re already taking several as prescribed by the rheumatologist. So, in terms of non-prescription, non-pharmacological treatment, there’s a couple. So one of these is self-management, another broad category would be mindfulness-based interventions, and a third type of category would be cognitive behavioral therapy. So to discuss these in more detail, in terms of self-management strategies, these are group or online based programs that encourage understanding of disease, they centralize the role of the individual in managing symptoms, emotions, and medications, and they promote healthy lifestyle behaviors, and they really hone in on diet and exercise.

In terms of mindfulness-based interventions, these are group-based therapies that are usually 8 weeks or longer sometimes in length designed to train individuals to cultivate mindfulness, which is present-moment awareness and non-judgement. Programs typically include traditional seated meditations; they can include whole-body scans, gentle yoga, and various exercises to cope with pain, bodily sensations, and emotions. And then a third different strategy of non-pharmacologic treatment includes cognitive behavioral therapy. This is individualized psychotherapy that may be online or in-person. CBT focuses on the relationship between thoughts, physical signs and symptoms, and behaviors. Traditional cognitive behavioral therapy, this is typically a one-on-one session with a trained psychologist, and this could branch off into different group-based therapies or pain coping skills training. And these types of programs are offered online even, or in app-based format.

So these are just three different types of strategies, many more are available and it’s all going to boil down to the individual; what are they going to feel comfortable with and what are they going to find value in? And based on personal experience, they’re going to need some coaxing, especially if they are unfamiliar. So I encourage the rheumatologist to even try these things out on your own. Go to a mindfulness class, try a gentle yoga class, test out some of these apps. Then you can tell your patients about them first hand. So you have “vetted” the program, if you will, and the patients will thank you for it.

Finally, what other resources and tools are available to support patients in managing their mental health?

So there are many different settings to get help, there’s smartphone apps, there’s web-based applications, there’s community programs and there are traditional office-based programs that are typically guided by a psychologist or other mental health provider. The mindfulness apps include programs like Calm, Headspace, MINDBODY, Buddhify, Insight Timer. These are just to name a few. There are multiple different mindfulness apps available. Typically these apps are free, and you can upgrade for a small fee to use a premium version of it, which include typically extended meditation. There are also general mental health apps that use CBT and other methods to help you cope with depression, anxiety and stress, and these apps would include the What’s Up app, MoodKit app. There’s also Self-Help for Anxiety Management, or SAM for short and a dozen or more apps that are diary-based, that help you keep track of your anxious and depressed thoughts. So for those who are looking for programs that are in person, they may investigate community programming as well as their local medical facility. Once you start looking, you may be surprised at the amount of group practices available. So, mindfulness groups, tai chi groups, support groups. There’s many offered in the community, it’s just a matter of locating them. And of course, meeting with a psychologist is always a good way to start, to be honest. So if you have a one-on-one session they can discuss different methods with you and then help you find these different programs.

So the bottom line is: Mental health is important and closely linked to clinical outcomes. Incorporating talking points into every patient visit will make conversation easier, especially if someone is having problems. And this will also help to facilitate earlier treatment, which may improve clinical outcomes. And there are many resources available; it’s just a matter of finding a good fit.

Thank you very much to Dana for sharing her thoughts with us on this topic. You can find links to the resources mentioned in this podcast, as well as other podcasts in this series on Medicine Matters rheumatology. Join us for the next podcast in this series, when we will be discussing exercise in patients with rheumatic diseases.