EVALUATING AND TREATING DEPRESSION IN PATIENTS WITH RHEUMATOID ARTHRITIS
Objectives:
This poster presentation represents a paper and clinical protocol that were created from the available literature to inform the provider on relevant clinical issues regarding depression in a patient with rheumatoid arthritis and to guide the provider in identifying, diagnosing, and treating depression in this population.
Introduction:
Rheumatoid arthritis and depression are widespread diseases associated with poor health outcomes. Evidence exists throughout the literature to support depression as a co-morbid condition in patients with rheumatoid arthritis. Depression among patients with rheumatoid arthritis is associated with worsening of symptoms, increased disease activity, a decrease in functional ability and quality of life, and a decrease in treatment response. As a result of the negative outcomes related to depression, it is important for a provider to effectively detect and treat depression in patients with rheumatoid arthritis
Discussion:
The 2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis, while comprehensive, does not address the management of depression in this population. No other guideline was found regarding the assessment and management of depression in a patient with rheumatoid arthritis. While the major objective of rheumatology care importantly remains reducing inflammatory disease activity and controlling difficult symptoms, it should also embrace the challenge of helping patients achieve optimal psychosocial function in the face of their medical condition. As a result, this clinical protocol was created from the available literature to inform the provider on relevant issues and guide them in the decision-making process.
Summary:
Rheumatoid arthritis is a chronic, progressive disease and it is the most common autoimmune inflammatory arthritis in adults (Singh et al., 2015). Rheumatoid arthritis is associated with a significantly greater burden of comorbidity, health-care resource utilization, and cost (Chen et al., 2018). Patients with rheumatoid arthritis experience significant negative impacts on their ability to perform daily activities, including work and household tasks, and health-related quality of life (Singh et al., 2015). As a result, depression frequently co-occurs in patients with rheumatoid arthritis. Similarities in the pathophysiology and psychosocial factors have been hypothesized throughout the literature to explain the association. An inflammatory hypothesis can explain the relationship between the systemic inflammation seen in rheumatoid arthritis and its subsequent effect on the brain and its function. During the rheumatoid arthritis inflammatory response, pro-inflammatory cytokines are circulating systemically. An increase in these peripheral cytokines is thought to directly activate pathways affecting brain structures known to be altered in depression.
The relationship between depression and rheumatoid arthritis is bidirectional (Withers, 2017). The impact of rheumatoid arthritis on a patient’s pain and functioning can contribute negatively to their depression, while chronic depression can also be exacerbated by rheumatoid arthritis (Nicassio, 2008). A 2017 study illuminated this bidirectional relationship. Throughout the study, the researchers found that poorer mental health was associated with more active disease. They also found the reverse to be true: more active disease was associated with poorer mental health. Their findings suggest that pain may be the cause of the bidirectional relationship between depression and rheumatoid arthritis.
The first step in the assessment and diagnosis of depression in a patient with rheumatoid arthritis is to identify all predisposing factors for depression. Some predisposing factors include advanced age (>65 years old), female, low socioeconomic status, past history of depression, poor social support, and high disease activity defined in rheumatology as DAS 28 >5.1. Next, the evaluation of depressive symptoms is needed. The symptomatology of depression among this population includes sadness, lack of interest in daily activities, weight loss or gain, sleeplessness, excessive sleepiness, lack of energy/fatigue, feelings of guilt/worthlessness, lack of control/powerlessness, and recurrent thoughts of death/suicide. Providers may find it difficult to recognize the symptoms of depression in their patients with rheumatoid arthritis because the symptoms of both rheumatoid arthritis and depression overlap and can create diagnostic confusion. As a result, providers who care for these patients should include screening for depression to improve treatment adherence, patient quality of life, and clinical outcomes such as pain and fatigue.
Providers can identify depressive symptoms among their patients with rheumatoid arthritis by using self-rated screening tools. The Beck-Depression Inventory II (BDI-II), the Patient Health Questionnaire (PHQ-9), the Hospital Anxiety Depression Scale (HADS), and the Geriatric Depression Scale (GDS) have been validated in the literature and can be used in clinical practice.
There is a significant lack of evidence regarding the treatment of depression among patients with rheumatoid arthritis. Selective serotonin re-uptake inhibitors (SSRIs) are likely the best choice because of their efficacy and low rate of side effects. Clinical trials have demonstrated the safety and effectiveness of Sertraline (Zoloft) and Paroxetine (Paxil) for use in this population. Cognitive behavioral therapy, mindful meditation, physical activity, and exercise have also been shown to be effective in the treatment of depression among this population. Overall, more research is needed to determine the most effective treatment regimen for depression among patients with rheumatoid arthritis.
Erica Dougherty, MSN, RN is a recent graduate of the Adult-Gerontology Primary Care Nurse Practitioner Program at the University of Pennsylvania. She currently works as a nurse at Penn Medicine’s Dermatology Oncology Center. She has a great interest in the convergence of Dermatology and Rheumatology and, as a result, chose to explore the evaluation and treatment of depression among patients with rheumatoid arthritis for her graduate poster presentation.