Doctors may not be asking patients about depression or anxiety, adds Murphy. “People are dealing with the physical consequences of arthritis, but the emotional consequences are high as well,” she says. Doctors can identify and diagnose mood disorders in RA patients through either dialogue or by using the Hospital Anxiety and Depression Scale questionnaire, she says.

How high are those emotional consequences? People with RA who are depressed often have worse health outcomes, says Dr. Margaretten. In a recent article she co-wrote in the International Journal of Clinical Rheumatology, she notes that depression, which is treatable, increases a person’s risk of cardiovascular disease and heart attacks even if their RA pain and disease activity is controlled by medications. Depression can contribute to loss of work productivity or unemployment for people with RA, and it increases mortality risk, she says.

Her research also finds that people with RA who have lower socioeconomic status may have even higher rates of depression. Lower-income people with RA may struggle to afford RA drugs, have less access to health-care treatment, and feel the burden of lost income due to time off from work for RA-related illness or medical appointments more intensely. “Access to specialists is a key factor. Are you seeing an internist or a rheumatologist? Patients who are unable to work are often more depressed,” says Dr. Margaretten.

Possible Causes

Could depression or anxiety be symptoms of RA’s systemic inflammation, an unchecked autoimmune response triggering a chemical imbalance that leads to mood disorders? Researchers can’t say yet, but that possibility is being studied, says Dr. Margaretten.

People with clinical depression who do not have rheumatoid arthritis often have evidence of systemic inflammation, like elevated levels of inflammatory cytokines on blood tests, says Dr. Margaretten. “It’s thought that systemic inflammation in patients with rheumatoid arthritis may contribute to depressive symptoms. The answer is unknown, but we are in the process of trying to answer it,” she says. Obviously, patients whose inflammation is well controlled may feel better physically and have better physical function, allowing them to do more or keep working, so this can boost their mood, she says. “But it’s unknown if there is a direct link. We don’t know if there’s a direct effect on mood by controlling inflammation.”

Controlling depression in people with RA may be as important to their health as controlling inflammation. RA patients who are depressed tend not to respond as well to anti-TNF therapy to control their inflammation, according to research conducted in England and published in 2009 in the journal Rheumatology. In addition, some studies of people with depression who do not have arthritis but received anti-inflammatory drugs along with the common antidepressant drug fluoxetine (Prozac) had better results than those who took fluoxetine alone. These studies are intriguing, notes Dr. Margaretten, and further research may one day reveal some connections between inflammation and mood disorders.

Regardless, there are many things rheumatologists and their support staff can do now to identify and diagnose anxiety or depression in their RA patients, and put patients on the path to treatment, she says.

“Our patients think it’s important. Patients feel better when they feel they’re working with their physicians and not alone. Recognizing that a patient feels depression is a huge sense of relief, a feeling that we’re in this together.”