What to do about unrecognized depression and anxiety in RA patients

As many as 20% to 39% of patients with rheumatoid arthritis (RA) also have anxiety or depression, yet many patients avoid talking about mental health symptoms with their general practitioner. As a result, anxiety and depression may go unrecognized and untreated in many patients with RA, researchers described in a study in the British Journal of General Practice.

Participants in the qualitative study said that good communication with their GP and encouragement to attend follow-up would make discussing their psychological concerns much easier, noted lead author Annabelle Machin, MBChB, a GP and researcher at Keele University in Staffordshire, UK, who was funded by the UK’s National Institute for Health Research (NIHR).

For this study, Dr. Machin and colleagues recruited participants through a rheumatoid arthritis annual review for patients, performed at nurse-led clinics at two Staffordshire community hospitals. After patients were screened by questionnaire, the researchers interviewed those who scored high for anxiety and depression. They asked patients about their previous experiences of care, their understanding of anxiety and depression, and their preferences for the management of mood problems.

From these interviews, Dr. Machin and colleagues learned that some patients perceived their GP to prioritize physical health problems over mental health concerns. Lack of time and poor continuity of care appeared to confound this problem.

“Some patients normalized their mood problems as something expected with RA, though the patients I interviewed did not perceive their GP to do the same,” Dr. Machin said. Other participants described appointments with their GP as anxiety-provoking, which further discouraged them from seeking help for mental health problems.

Patients with severe anxiety and depression felt that mental health symptoms themselves could be a barrier to self-referral for psychological therapy, which suggests that a GP referral could improve access to care.

Regarding treatment for comorbid mood problems, patients often preferred the idea of talk therapy over medication. “I was surprised that some participants perceived antidepressants to be offered as a ‘quick fix’ by their GP. Others feared potential drug interactions with their existing medication, hence participants expressed an overall preference for psychological therapies,” Dr. Machin said.

Participants also had different perceptions about how their RA related to their mood problems. “Whilst several perceived RA-related pain to precipitate their anxiety and depression, others described flares of their RA being triggered by low mood or anxiety,” Dr. Machin described. “In contrast, some participants felt their mood problems were completely separate from their RA, often due to social circumstances.”

Although some patients recognized their arthritis was related to their mood problems, others only made this link when a clinician highlighted it. “Therefore, it is important that mood is explored as part of an annual review for RA patients,” Dr. Machin said.

Because patients accepted the case-finding questions in this study, perhaps a case-finding approach could improve the recognition of mood problems, she suggested.

“GPs need to give equal priority to mental and physical health problems to facilitate disclosure of distress,” Dr. Machin added. “Provision of time during individual appointments and encouragement to attend follow-up with the same GP to support continuity of care could be integral to the disclosure of mood concerns.”