Treatment of Mood Disorders: Rheumatoid Arthritis
Depressive symptoms occur in 17%-27% of patients with rheumatoid arthritis. One study compared the prevalence of a psychiatric diagnosis in patients with musculoskeletal complaints evaluated in a primary care clinic versus those referred for rheumatology consultation . More than 40% of the patients in the rheumatology clinic were diagnosed with a psychiatric disorder, whereas only 29% of those patients seen in the primary care clinic fulfilled criteria for an active psychiatric diagnosis. Complex diagnostic issues often complicate depression seen in patients with rheumatic illness. Many factors such as functional impairment, chronic pain, systemic involvement, loss of independence, and psychosocial difficulties clearly affect the neurovegetative symptoms that lead to the DSM-IV (American Psychiatric Association 1994) diagnosis. The origin of the psychiatric morbidity remains unclear.
Treatments, in particular the use of corticosteroids, in connective tissue disorders often lead to neuropsychiatric symptoms. Also, some evidence suggests that younger cohorts with rheumatoid arthritis have higher rates of depression. From a clinical perspective, one might assume that adequate treatment of the depressive symptomatology would lead to better outcomes, but presently little treatment data exist. For many years the treatment of the chronic pain in rheumatological illness consisted of nonsteroidal medication, narcotics as necessary, and low-dose TCAs, in particular amitriptyline. The doses used were far too low for adequate treatment of a true major depressive episode and were initiated for sleep improvement and treatment of anxiety. Recommendations for use of any particular agent at this point still lacks clinical trial research endorsement. Because of their favorable side-effect profile, the SSRIs are more likely to be the treatment of choice. The newer antidepressants may offer an additional benefit with both serotonin reuptake and norepinephrine reuptake inhibition, which would combine low-dose pain relief offered by the TCAs and the effective depressant treatment by the SSRIs. A clinical trial investigating the use of bupropion in patients with rheumatoid arthritis has been proposed to assess its effectiveness.
Psychotherapeutic intervention for patients with rheumatoid arthritis remains a viable option. The biopsychosocial model highlights the mind-body interactions leading to depressive symptoms. Several studies have shown a significant correlation between depression and illness perception in rheumatoid arthritis. Social factors such as isolation, denial, and conflict have been shown to predict depression in this group. Items such as subjective illness, negative or maladaptive coping strategies, and other cognitive variables can affect the depressive symptoms reported by the patient. The primary care provider as well as a consulting psychiatrist can initiate supportive therapy. However, all therapeutic measures must be tailored to each patient and be based on a comprehensive understanding of that person’s illness and illness dynamics.
Revision date: July 3, 2011
Last revised: by Jorge P. Ribeiro, MD