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Arthritis and Depression:

When Physical Pain Can Have an Effect on Emotional Pain 

Introduction:

            According to the National Institute for Mental Health in 2005, approximately twenty million Americans or 10 percent of our population suffer from depression each year.  In the elderly population, both arthritis and depression has a high prevalence.  As many as one half to a third of the elderly population has arthritis and approximately 20 percent of the elderly population suffers with depression (Jeste, 2005).  The symptoms and disability commonly associated with arthritis may increase the vulnerability of those individuals with arthritis developing depression by increasing their number of risk factors.  It is important for patients with arthritis and their caregivers to become educated and monitor for warning signs of depression in order to assure patients are treated effectively. 

 

How Arthritis Can Lead to Depression:

            Patients diagnosed with either rheumatoid arthritis (RA) or osteoarthritis (OA) have a relatively high incidence of depression.  Rheumatoid arthritis is considered to be the most severe form of arthritis.  Patients with rheumatoid arthritis may experience debilitating symptoms characterized by severe joint deformation, anemia, weight loss, fatigue, and problems involving the heart, lungs, and eyes.  Approximately two million Americans have rheumatoid arthritis.  The disease predominately affects women more than men by 3:1.  Rheumatoid arthritis is caused by an adverse immune response attacking one’s own joint linings called the synovial membrane.

             People with osteoarthritis, also known as degenerative arthritis, also may have symptoms leading to decreased mobility and diminishing quality of life.  Approximately 15 million Americans above the age of 45 suffer from osteoarthritis (Arthritis-Symptom.com, 2004).  These individuals live with pain, diminished range of motion and function in the hands, spine, hips, knees, and feet resulting from progressive degeneration of cartilage in these joints. 

            Seeing how disabling severe arthritic symptoms can be, it is understandable how people who are enduring arthritis can develop symptoms of depression.  These individuals suffer from both physical pain and emotional pain having lost the ability to perform activities they once enjoyed and the level of mobility they once had.  The progressive joint destruction experienced not only limits joint motion but ultimately impacts an individual’s ability to function.  Patients may find it is harder to perform tasks at the workplace, harder to care for their children.  Symptoms can even impair one’s ability to accomplish activities of daily living such as dressing, and bathing.  These factors such as lost mobility, function and independence can all contribute to developing depression.

 

The Relationship Between Arthritis and Depression: A Self-Consuming Cycle

            Depression that is a result of an arthritic condition is a self-consuming cycle. One symptom feeds directly into another. It has been theorized that there is a cognitive component associated with depression for people who have arthritis.  In particular, the patients’ physical symptoms and major life changes, such as being diagnosed with an illness and disability, may affect mood. 

            For example, consider a person named Robert who has recently been diagnosed with rheumatoid arthritis.  He is enduring many physical symptoms of pain associated with rheumatoid arthritis, such as aching joints.  Robert is somewhat limited in his abilities to enjoy all of the activities that he was once able to partake in (for example, going for frequent runs or playing the piano).  He may feel that he has lost some of his freedom due to arthritis, and this feeling, coupled with his physical pain, may cause him to feel depressed.  Robert might think to himself, “I am hindered by arthritis.  I will never be able to do anything I enjoyed anymore.” These thoughts can lead to emotional symptoms of sadness, hopelessness and despair.  These emotional symptoms, in turn, can cause Robert to intensify his experience of physical symptoms, such as pain, fatigue, and low energy.  His lethargic feelings may accentuate and begin a downward spiral whereby he becomes even less active and more depressed.  Therefore, although depression cannot cause arthritis, it can exacerbate the symptoms.  It is important that Robert and his identify the warning signs of depression to initiate treatment and hopefully stop the cycle.

 

Symptoms, Warning Signs, and Diagnosis of Depression Associated with Arthritis

            According to the American Psychiatric Association Diagnostic and Statistical Manual – IV (American Psychological Association, 2000, 1994), in order to receive a diagnosis for a major depressive episode, a person must have “at least five of the following symptoms during the same two-week period, nearly every day:”

§         depressed mood most of the day

§         markedly diminished interest or pleasure in almost all activities most of the day

§         significant weight loss or weight gain, or decrease or increase in appetite

§         insomnia or hypersomnia

§         psychomotor agitation or retardation

§         fatigue or loss of energy

§         Anxiety

§         feelings of worthlessness or excessive guilt

§         reduced ability to think or concentrate, or indecisiveness” (Quoted in Comer, 2001; Based on APA, 2000, 1994).

In order to be diagnosed with major depressive disorder, one must have the presence of a major depressive episode and no history of a manic or hypomanic episode (APA, 2000, 1994).

 

Whom to Turn to When a Patient has Arthritis and Depression

            There are many sources of medical help and emotional support for patients who have both arthritis and depression.  While all of these are good sources, if you suspect that you or someone you know may have depression, a physician or other qualified health-care professional should be part of the treatment team.  Among the resources are:

§         Primary Care Physician – for preliminary screening or diagnosis of arthritis, depression, and overall medical care.  Primary care physicians can also prescribe antidepressants, which will allow, for some patients, the treatment of depression without having to visit a psychiatrist.

§         Rheumatologist – to treat symptoms of arthritis

§         Physical Medicine and Rehabilitation physician – to treat symptoms of arthritis and design an exercise program for you to follow with a physical and/or occupational therapist

§         Physical Therapist – to ameliorate the physical pain of arthritis by strengthening muscles and facilitating movement of the bones and joints

§         Psychiatrist – to treat depression, usually by prescribing medication

§         Clinical psychologist – to treat depression using psychotherapy, cognitive-behavioral therapy

§         Caregiver – can be a family member, friend, or hired caregiver to help with daily treatments as prescribed by doctors while the patient is at home

§         Family and friends – to provide emotional support and other needs of the patient

 

Treatments of Depression Related to Arthritis

Cognitive Therapy for Depression

            Because there is a possible cognitive component to comorbid arthritis and depression, one mode of treatment that can be beneficial is a form of psychological therapy called cognitive therapy.  In recent years, and after much research, cognitive therapy has been regarded as being one of the most effective treatments for depression because there is usually a component of cognition that causes depression (i.e. negative feelings or thoughts, whether induced by a physical or emotional response to pain or a change in way of life due to arthritis).

            In cognitive therapy, a psychologist works with a patient to analyze his own thoughts and what are termed “faulty” cognitions, which tend to be negative or pessimistic thoughts that are either exaggerated or untrue.  Consider the case of Robert.  Upon being diagnosed with rheumatoid arthritis, he made unrealistic assumptions:  “I will never be able to do anything I enjoyed anymore.”  Robert, like many people with depression, thinks in extremes and his belief that he will never be able to enjoy his life again is exaggerated to the point where his belief is untrue.  The psychologist would teach Robert how to identify these faulty cognitions and also how to evaluate his thoughts more realistically, so that his mood will improve.        
            The psychologist would also teach Robert a more positive and rational way to deal with his anxieties and cognitions, to reduce his depressive symptoms.  For example, the psychologist would reason out with Robert, “Is it true that you will never be able to do anything you enjoyed anymore?”  She would then point out that in fact, there are many things Robert can do, and would work with Robert to consider activities that he enjoys and is fully able of doing even though he has rheumatoid arthritis. For example, if Robert likes to run marathons, he could try similar activities like bicycling, going for brisk walks, or doing other lower impact activities.  Robert also likes to play the piano.  Although he may be limited in being able to play the piano, he can still pursue his love for music by teaching others how to play.  The psychologist could also point out that Robert’s physical pain does not prevent him from other pleasurable activities such as socializing with friends, going to the movies, or being active in a neighborhood club.  By teaching Robert how to reason out his negative cognitions, the psychologist shows Robert that there are still many ways he can enjoy his life.

 

Biological Causes and Treatments for Depression

Medical Treatments for Both Arthritis and Depression

            Although cognitive therapy is a highly effective method for treating depression, not all depression is caused by negative cognitions.  For some people, there is a significant biological component to depression, which can be inherited genetically.  Depression is frequently caused by a chemical imbalance in the brain, often with the neurotransmitters serotonin or norepinephrine.  Psychiatrists and other medical doctors frequently prescribe antidepressant medications to patients with depression, according to what neurotransmitters are suspected to cause the depression in each particular patient.  One of the most commonly prescribed antidepressant medications are selective serotonin reuptake inhibitors (SSRIs).  SSRIs are prescribed when decreased serotonin is thought to be responsible for causing depression.  This class of medication works by blocking the reuptake of serotonin and thereby increases serotonin activity in the brain (Comer, 2001).     Antidepressant drugs can also improve sleep for patients.

            Older forms of antidepressants, namely tricyclics, are effective in treating depression, but also have an analgesic effect.  Analgesic medications are effective at treating the pain that arises from arthritis.  Analgesics work by blocking the pain pathways to the brain. A common analgesic is acetaminophen.  Analgesics are beneficial because they do not induce stomach problems or aggravate ulcers, and they allow a patient to retain consciousness.  Although they have a beneficial analgesic effect, tricyclics are presently not prescribed with high frequency because of the negative side effects associated with them, such as dizziness, decreased blood pressure, and dry mouth.        

 

Medical Treatments for Arthritis Only

            Medications which may also be effective for reducing pain, swelling, and stiffness are nonsteroidal anti-inflammatory drugs such as aspirin and ibuprofen.  These drugs work by reducing the production of prostaglandins in the body.  Prostaglandins are responsible for sending messages of pain to the brain (Arthritis Foundation, 2005).  Another class of medications is disease-modifying antirheumatic drugs (DMARDs).  These drugs reduce inflammation in rheumatoid arthritis, and also suppress the immune system.  One important factor to be aware of is that one of the adverse side effects of these arthritis medications, such as chronic use of steroids like prednisone, may trigger depression (Arthritis Foundation, 2005).

 Exercise

            Exercise is an effective treatment for depression that is not pharmacological, but it works to help depression by physiological changes.  When a person exercises, the endorphin levels in the brain increase.  Endorphins are what is termed the brain’s “feel good” chemical, so as endorphin levels increase, mood improves.  Exercise is also beneficial for treating arthritis by maintaining range of motion of joints, overall cardiovascular fitness and most importantly preserving function and mobility.  Specific exercise regimens can be prescribed by a general physician or specialist such as a physiatrist (rehabilitation medicine doctor) or when working with a physical therapist or occupational therapist.  “New research [has shown] that exercise and diet together significantly improve physical function and reduce knee pain from osteoarthritis of the knee in people over age 60 who are overweight or obese compared with either therapy alone (Chicago Caregiver, 2005).”

 

Does Treating Depression also Treat Arthritis?

            In 2003, the Journal of the American Medical Association (JAMA) published a study led by Elizabeth Lin which examined whether treating depression was also able to treat the pain and suffering associated with arthritis.  Termed the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) study, 1,001 participants in 18 clinics in the United States were divided into an intervention group and a control group.  The participants in the intervention group could choose to be treated by either 6-8 psychotherapy sessions or by antidepressant medications. There was also a control group who was not treated for depression.

            The findings of the study were that after a year, the participants who were treated for depression, whether it was by medication or psychotherapy, were significantly improved in terms of their symptoms of not only depression but also arthritis.  Patients were surveyed on their amount of pain experienced and the amount of interference in their everyday activities.  The scale for pain was from 0-10, with 10 being the maximum amount of pain (Peterson, 2003). 

            “The researchers found that after one year, regardless of the type of treatment, the patients who received treatment for depression (the intervention group) not only had fewer symptoms of depression, but also experienced less pain (5.62 vs. 6.15), less interference with their daily activities due to arthritis (4.40 vs. 4.99), less interference with daily activities due to pain (2.92 vs. 3.17).”  The participants treated for depression were able to participate in their daily activities more fully and felt that their quality of life and health was significantly better (Peterson, 2003).  Researchers believe that the success of the treatment was due to both the use of antidepressant medications including SSRIs and a method of counseling called Problem-Solving Treatment in Primary Care which teaches patients how to solve problems that exist in their daily life (DeClaire, 2005).

 

The Importance of Seeking Help

            Depression can be treated successfully a majority of the time.  However, patients who have both arthritis and depression may not be treated for depression because its symptoms are, at times, neither recognized nor acknowledged.  Many resources are available to treat patients with arthritis and depression, such as health care professionals, who are willing and fully able to help.  Family and friends are also an invaluable resource because they can assist the patient with help in getting to appointments, caring for the patient while at home, and perhaps most importantly, lending emotional support.  There are many barriers to treatment that can occur, and it is important to be aware of these barriers so that a patient and his caregiver can overcome them.

            One major barrier is that people do not recognize depression because its symptoms, such as inattention, somatic pain, and insomnia, are also symptoms of arthritis.  Therefore, a patient and his caregiver may not be aware of the patient’s symptoms reflecting an underlying mood disorder rather than the physical manifestation of arthritis.  Even if the symptoms are clear to the patient or the caregiver, some still may not seek help because of the fear and the stigma associated with psychiatric illness.  However, depression is common today, and it is becoming increasingly well understood by both healthcare professionals and the general public.  The main challenge for the caregiver in this situation is finding a way to get the patient into treatment for depression in addition to arthritis. 

 

A Positive Outlook for Patients with Arthritis and Depression

            Today, with the advent of new medications and therapies to treat both arthritis and depression, the outlook for successful treatment is good.  As scientists, doctors, and other healthcare professionals discover new treatments, their level of understanding of arthritis and depression increases, and in turn, the public awareness also increases.  This is helpful for people with both arthritis and depression feel more comfortable seeking help rather suffering in silence.  What is important to remember is that, although arthritis can be disabling, by maintaining a positive outlook on life and treating signs and symptoms of depression, the cycle of depression and arthritis can be broken, enabling one to  improve their quality of life and return living.

 

Authors:  Theresa L. Kowalski, B.A., Princeton University, Princeton, NJ

  Victoria Chan Harrison, M.D., New York-Presbyterian Hospital, The University Hospital of Columbia and Cornell, New York City, NY

 

Resources for Patients with Arthritis and Depression

Arthritis:

ArthritisMD.com: www.ArthritisMD.com

National Institute of Arthritis and Musculoskeletal Skin Diseases:  www.niams.nih/gov 

Depression:

National Institute of Mental Health:  www.nimh.nih.gov/publicat/depression.cfm

American Psychological Association:  www.apa.org

American Psychiatric Association: www.psych.org

 

References:

APA (American Psychiatric Association).  (1994). Diagnostic and Statistical Manual of Mental Disorders, (4th ed.).  Washington, D.C.

Arthritis Foundation (2005).  “Making it Go Away.”  http://www.arthritis.org/resources/arthritistoday/2003_archives/

Arthritis Foundation (2005).  “Take Medicines Wisely.”  http://www.arthritis.org/conditions/pain_center/medications.asp

Arthritis-Symptom.com (2005).  “Arthritis Symptoms.”  http://www.arthritis-symptom.com

AssistPainRelief.com (2005).  “Analgesics.”  http://www.assistpainrelief.com/info/analgesics/

Clark, M. (2005).  “Management:  Chronic Pain, Depression and Antidepressants:  Issues and Relationships.”  Johns Hopkins Arthritis.  http://www.hopkins-arthritis.som.jhmi.edu/mngmnt/depression.html

Comer, R.J. (2001). Abnormal Psychology (4th ed.). New York: Worth Publishers.

DeClaire, J. (2005).  “Better Depression Care for Older Adults also Improves Arthritis Problems, Study Finds.”  Group Health Cooperative.

DeClaire, J. (2005).  “Key Findings and Q&A on the Arthritis and Depression Study (Project IMPACT).”  Group Health Cooperative.

Gilles, G., ed. (2005).  “Top 10 Research Advances and Self-Care Tips for Arthritis.”  Chicago Caregiver, May/June 2005.

Jeste, D.V.  (2005). “Depression in Older Persons.”  National Alliance for the Mentally Ill http://www.nami.org/Template.cfm?Section=By-Illness&template=/ContentMangagement . . .

National Institute of Mental Health (2005).  “Depression.”  Bethesda (MD):  National Institute of Mental Health, National Institutes of Health, US Department of Health and Human Services.

Peterson, E.A. (2005).  “Can Treating Depression Help Reduce Arthritis Pain and Suffering?”  EBSCO Publishing.

Pfizer Australia (2004).  “Silent Epidemic of Depression Associated with Arthritis.”  Pfizer Australia Health Report.  http://www.pfizer.com.au/Media/Arthritis1.aspx

 

 

 

 

 

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