When arthritis and depression coexist: Tips for the clinician

By Naveed Saleh, MD, MS
Published February 21, 2022

Key Takeaways

  • Research shows that 26% of American adults with arthritis experience depression which, in turn, can decrease response to arthritis treatment and compromise quality of life.

  • Clinicians are advised to screen arthritis patients for anxiety/depression, and offer treatment and referrals for psychotherapy, if indicated.

  • Clinicians can also counsel patients to remain physically active, and practice self-management, stress reduction, and other coping skills to decrease depression and arthritis symptoms.

Arthritis, which comes in more than 100 different forms, affects millions of Americans. For many, the disease extends beyond pain, stiffness, and swelling, taking a psychological toll as well.

Depression and anxiety are common comorbidities. In total, 43.2% of Americans have arthritis-induced activity limitations, and 26.2% of adults with arthritis struggle with depression, compared with 10.7% of those without arthritis.

Depression in different arthritis types

In a 2017 article published in Expert Review of Pharmacoeconomics & Outcomes Research, authors expatiate the relationship between depression and different types of arthritis.[] They cited that the prevalence of depression varied from 4.0% to 66.2% in those with rheumatoid arthritis (RA).

Researchers noted that depression is more common with RA than with osteoarthritis (OA). Although fewer studies have been performed with other types of arthritis, the authors cited research demonstrating that depression may be slightly more common in those with systemic lupus erythematosus (SLE) arthritis vs. RA.

The authors qualified their findings by mentioning that studies examining the prevalence of comorbid OA and depression were inconclusive. They also noted that overall, depression rates varied widely.

"These differences in rates may be due to many factors: differences in defining depression, type of arthritis, tools used to detect depression, use of different thresholds with the same tools, and country of residence."

Researchers publishing in Expert Review of Pharmacoeconomics & Outcomes Research

“These differences in rates may be due to many factors: differences in defining depression, type of arthritis, tools used to detect depression, use of different thresholds with the same tools, and country of residence,” the authors wrote.

The CDC noted that in addition to depression symptoms being more than twice as common in adults with arthritis, one of five patients with arthritis had anxiety symptoms compared with one of nine adults without arthritis.[]

Morbidity and mortality

Those with arthritis alone compared with those with comorbid depression and arthritis were less likely to engage in physical activity, as well as more likely to have joint limitations, work limitations, and social-activity limitations. Taken alone, depressive symptoms can affect the functional ability in those with arthritis.

The authors pointed to various studies that highlighted the increased risk of all-cause mortality correlated with depression. In those with RA and depression, the death risk was 2.2 times higher compared with those with RA and without depression.

In the US, suicidal thoughts in those with arthritis affected 5.6% of a National Health and Nutrition Examination Survey (NHANES) cohort compared with 5.1% of those with cancer. Of note, there is a paucity of literature on the association between mortality risk and OA.

Underlying mechanisms

Results from a 2016 Scientific Reports longitudinal study indicated that in the case of RA, there may be a bidirectional relationship underlying its association with depression.[]

Neurotransmitter deregulation and impaired intracellular signaling could bridge psychological stress and immune-related disease. Of note, chronic negative mood has been related to dysfunction of the hypothalamic-pituitary adrenal (HPA) axis and peripheral release of glucocorticoids, as well as increased sympathetic and decreased parasympathetic activation. These autonomic triggers induce inflammatory markers, which advance autoimmune disease.

“Conversely, a growing body of evidence has also indicated that these pro-inflammatory cytokines, such as TNF-α and some interleukins, may mediate the HPA activation in response to various threats to homeostatic balance, and could, therefore, play a decisive role in the generation of major depression,” they wrote.

Recommendations for the clinician

The CDC stressed that depression symptoms can decrease response to arthritis treatment and result in decreased quality of life.

"Improving mental health can even reduce pain, independent of other pain management strategies."

The Centers for Disease Control and Prevention

“Improving mental health can even reduce pain, independent of other pain management strategies,” they wrote.

The CDC's recommendations

The CDC offers two strategies to help patients with arthritis pain. First, screen patients for anxiety/depression per USPSTF guidance. Second, physicians should offer treatment and referrals as necessary. You can refer patients to self-management education workshops, which help with symptom management and stress reduction.

Physicians should also motivate patients to remain physically active. Self-management and physical activity enhance mood, boost energy, and decrease symptoms of arthritis, depression, and anxiety.

The Arthritis Foundation wrote that SSRIs and SNRIs are first-line treatments for depression and anxiety.[] Buspirone may also be used long-term to help curb anxiety. Importantly, benzodiazepines are habit forming and should be used only short-term.

In addition to psychotherapy, other treatment options include yoga, massage, visualization, nutrition, meditation, and support groups.

Early control

In a 2018 study published in the Journal of Rheumatology, authors found that high-disease activity (HDA) could lay the foundation for depressive symptoms in early rheumatoid arthritis (ERA).[5][] This risk appears highest in women with active disease and comorbidity. These patients should be a population of targeted focus, screening and research, according to the authors.

“Our findings suggest that controlling disease activity over time to the lowest possible state may have the added benefit of limiting psychiatric comorbidity. Future studies on the optimal evaluation and treatment of depression, and how this may coincide or complement the management of patients with ERA, is needed,” they wrote.

What this means for you

The close relationship between arthritis and mental health warrants special attention. Patients with arthritis are at high risk of depression and anxiety and should be screened and referred out as necessary. In addition to medication and psychotherapy, other interventions such as self-management workshops and exercise may be of benefit. 

Related: Psychological, communication, and logistical factors influence treatment adherence in patients with rheumatoid arthritis
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