People living with rheumatoid arthritis not only grapple with physical symptoms and impaired ability to perform ordinary tasks, they also have higher reported rates of anxiety and depression, according to a 2012 study led by researchers at the Centers for Disease Control and Prevention (CDC) in Atlanta. 

The study, which was published in the medical journal Arthritis Care & Research in April, looked at rates of anxiety and depression among U.S. patients with arthritis as a whole, not just RA. Researchers used the emotional well-being questions from the Arthritis Impact Measurement Scales, a respected measurement tool, to determine rates of mood disorders. Among 1,793 adults age 45 or older with doctor-diagnosed arthritis or rheumatic conditions, 31 percent had anxiety and 18 percent had depression, notes Louise Murphy, PhD, the epidemiologist who led the study.

“This is not a surprise to people with arthritis,” says Murphy. It’s hard to pinpoint the exact cause of anxiety or depression, but RA pain and inflammation can cause life-disrupting problems. “People with arthritis experience a higher degree of work limitation once symptoms start, and that is a huge source of anxiety. If a person becomes unable to work, then the path is clear.”

What remains unclear: Whether RA’s physical symptoms cause increased anxiety and depression, or if depression is just another RA symptom sparked by systemic, chronic inflammation. Regardless, health care professionals can do more to identify anxiety and depression in RA patients and either treat the conditions, or refer the patient to a mental health professional for counseling and treatment, says Murphy.

She and her colleagues at CDC recommend a three-pronged approach to the problem: Encourage more health-care professionals to identify and diagnose anxiety or depression in patients with RA, either treat the disorder with medications or refer the patient for mental-health counseling, and encourage the patient to get more physical activity to improve physical function and boost mood. She also recommends people with RA who have mood disorders enroll in an arthritis self-management course to learn coping skills, and to talk with others experiencing the same issues.

Half the patients in the study who reported anxiety or depression were not seeking treatment for these conditions, says Murphy. “Maybe they are apprehensive about talking about it. But they’re not alone, and it would be helpful if they were talking about it, and knowing that there are things they can do about it.”

Losing Valued Activities

RA destroying one’s ability to perform “valued life activities” may contribute to depression, says Mary Margaretten, MD, a rheumatologist at the University of California at San Francisco (UCSF). “Like no longer being able to pick up your children at school because you have trouble driving,” she explains. “It’s not surprising that the inability to do those things makes a person feel sad or depressed.”

As part of UCSF’s Rheumatoid Arthritis Cohort, Dr. Margaretten has studied patients with RA and collected data on their symptoms. She and other researchers are now looking into possible causes of depression and how it may be better addressed by health-care professionals. Patients may be talking about their physical symptoms but not bringing up emotions, she says.

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.”