CHAPEL HILL, North Carolina—Depression should appear on the rheumatologist's radar screen when treating patients with rheumatoid arthritis (RA), according to a new study and an accompanying editorial in the February issue of Arthritis Care & Research.¹

RA patients are twice as likely as other individuals to experience depression, but rheumatologists rarely, if ever, broach this subject, according to the new findings.

"When patients go to the rheumatologist, the main focus of their visit is their RA, [however,] a chronic disease such as RA can greatly impact a patient's quality of life and psychosocial wellbeing," conclude researchers led by Betsy Sleath, PhD, of the University of North Carolina at Chapel Hill.

The rheumatologist serves as the primary care provider for many RA patients. As such, it is important for rheumatologists to consider addressing both the RA and the depression. Research in other chronic diseases has shown that depression can affect adherence to medication and self-care regimens, the authors write.

Rheumatologists missing the boat

The new study comprised 200 RA patients from four rheumatology clinics with eight participating doctors. Patient visits were audiotaped and patients were interviewed regarding their mental status after their doctor's appointments. The researchers assessed patient's functional status using American College of Rheumatology criteria.

About 11% of the patients showed moderately severe to severe symptoms of depression. Moreover, those RA patients rated as being more restricted in their normal activities were more than twice as likely to show depressive symptoms.

Only 1 in 5 of the patients who showed such symptoms actually broached the subject of depression with their rheumatologists. If depression did come up, it was always initiated by the patient. Of 200 office visits, the rheumatologist never once brought up the topic of depression.

In addition to screening for depression, the authors suggest it is important for patients to have access to appropriate treatment because "failure to detect and treat depression may compromise patients' adherence to regimens and, ultimately, their health outcomes."

Editorialist outlines practical solutions

In an editorial accompanying the study,² Perry M. Nicassio, PhD, of the University of California at Los Angeles, points out hurdles facing rheumatologists when it comes to identifying—and subsequently treating—depression in their RA patients.

While studies have shown how depression can affect the practice of rheumatology, these findings are not translated into clinical practice. System constraints also exist, Nicassio writes. "Rheumatologists may not be able to identify or manage [patients'] depression because time limitations, reimbursement and insurance coverage problems, and lack of personnel resources may prevent them from doing so in the clinical setting."

Also hard is distinguishing depression in RA patients, as the two diseases share similar symptoms namely fatigue, insomnia, and reduced motivation, Nicassio writes. In addition, some rheumatologists may feel uncomfortable asking patients personal questions required to determine depression.

Partnerships needed

These barriers can be overcome: better screening using self-report inventories can help identify depression in patients with RA, and more collaboration with behavioral medicine specialists so patients can access help.

"Through the adoption of effective screening and management strategies for depression, the practice of rheumatology can have an important and lasting impact on the emotional wellbeing of patients with RA."

Role model

Linda A. Russell, MD, assistant professor of medicine at Weill Medical College of Cornell University and assistant attending physician at Hospital for Special Surgery, both in New York City, tries to screen all of her RA patients for depression.

"Rheumatologists have to take the time and step back and ask patients how they are feeling," she told MSKreport.com. "It's OK to ask 'do you think you are depressed?'" Or, for example, "if patients say they are not taking their medication, you can look into why. It may be because they are depressed." Patients may provide subtle clues without coming out and saying they are depressed, she said.

If patients seem to be depressed, rheumatologists can work with them or refer them for psychological counseling. "Most rheumatologists would feel comfortable prescribing some of the common antidepressants, but if they are not working or become more depressed, it is time to refer," she ended.

References