CAB members Sharan Rai and Lianne Gulka interviewed Dr. Hiram Mok, a Consultant Psychiatrist and the Mary Pack Arthritis Centre Clinical Associate Professor of the UBC Department of Psychiatry, as well as Arthritis Research Centre of Canada trainee Ms. Lindsay Burns.  Ms. Burns conducts public health research on arthritis, pain, and mental health. Read on to find out what they had to say about depression and arthritis.

 

Sharan Rai: What is depression? How common is it, both in arthritis patients and in the general population?

 

Lindsay Burns: Depression is a medical condition characterized by extreme sadness, loss of interest in previously enjoyable activities, and feelings of worthlessness or guilt for a lengthy period of time (at least two weeks) that impairs normal functioning. It is a leading cause of disability worldwide, and 10-15% of Canadians experience depression in their lifetime.  In arthritis, the rate of depression is much higher, with up to half of patients experiencing depression over the course of their disease.

 

Sharan Rai: Are there any tips for a patient or care giver to catch early warning signs?

 

Dr. Mok: Depression is very common in patients with arthritis because of the pain, associated physical limitations, and loss of functioning. Patients are frequently coping with flare ups of chronic pain and the uncertainty of the illness. He/she constantly needs to make adjustments & concessions in their lives (work, family, child care, recreational pursuits) –  and they feel totally out of control. 

 

The typical diagnostic criteria are persistent depressed mood and/or loss of usual interests for more than two weeks, plus other symptoms such as difficulty with sleep, fatigue, poor concentration, feelings of hopelessness, psychomotor retardation or agitation, feelings of guilt, changes in appetite & thoughts of self harm. These symptoms must have affected areas of their life – whether it be school life, work life, or family/social life. Patients suffering from these symptoms should go to their family doctor or rheumatologist first, and then they can be referred on for psychiatric consultation if necessary. Please refer to the DSM-5 for further information on the diagnostic criteria for a Major Depressive Episode.*

 

Sharan Rai: How is depression related to arthritis? Is depression linked to inflammation?

 

Dr. Mok: This is really a question of the chicken or the egg. Surely, pain will affect mood, and mood will affect perception of pain. Clinically, it’s a vicious cycle of chronic pain, insomnia, anxiety and depression. There is extensive research into Central Nervous System biological markers and immunological factors and their relationships to Depression.

 

Lindsay Burns: Depression can lead to increased inflammation, pain, fatigue, and obesity, all of which can worsen the course of arthritis.  Further, depression can make it harder for people to properly manage a chronic disease (like remembering to take medications) or engage in healthy behaviours (like going for a walk or visiting with friends).  On the other hand, arthritis can lead to symptoms of depression by causing pain, inflammation, and feelings of loss due to a reduced ability to take part in everyday physical and social activities.  With the unpredictability of arthritis flares, it is also common to feel helpless.

 

Sharan Rai: Does depression result from arthritis pain, or does arthritis (pain) result from depression?

 

Lindsay Burns: It is a vicious cycle.  Living with chronic pain can cause individuals from all walks of life to become depressed.  Not only is it difficult to cope with pain on a daily basis, but pain can make you limit your physical and social activities which can harm your general health and weaken your support network.  On the other hand, depression affects brain chemistry leading to an increased perception of arthritis pain. 

 

In addition, certain autoimmune conditions such as Central Nervous System SLE (lupus) may attack organs including the brain, which may cause depression.  

 

Sharan Rai: How is depression treated? Are anti-depressant medications the first line treatment for depression, or are alternative therapies becoming more commonly used? If so, what non-prescription therapies available?

 

Dr. Mok: I will refer to the CANMAT (Canadian Mood & Anxiety Treatment) guidelines for treatment of Depression. Generally, there are two main treatment modalities: anti-depressant medications and psychotherapy. The three main validated first-line psychotherapies are: Cognitive Behavioral Therapy (CBT), Interpersonal Therapy (IPT), and Mindfulness-Based Cognitive Therapy (MBCT). People suffering from more severe depression will require both anti-depressants and psychotherapy.

 

Lindsay Burns: Also, beyond their effects on depression, antidepressants have the added benefit of reducing pain.  In fact, these drugs tend to act on pain symptoms even faster than depression symptoms.  That’s why many pain specialists often prescribe antidepressant drugs as pain relievers, even for people with no symptoms of depression.  

 

Moreover, the same pain relief benefits can be achieved with non-pharmacologic options for treating depression as well.  Physical activity, social support, sunlight (with UV protection), and psychotherapy are great ways to naturally boost levels of brain chemicals that jointly improve mood and decrease pain – so get out, get moving, and get together with friends and family!

 

Sharan Rai: Have any anti-depressants been found to be better tolerated in people with inflammatory arthritis?

 

Dr. Mok: I shall refer back to the CANMAT guidelines – all anti-depressants should work and are clinically efficacious.  SNRIs and SSRIs are the two main groups of anti-depressants, and there are novel antidepressants which are free from drug-drug interactions and major side effects. Patients should talk to their doctor.

 

Sharan Rai: Is depression something that is routinely screened for by a patient’s general practitioner/rheumatologist/dermatologist/other specialist?

 

Lindsay Burns: Unfortunately, research shows that not enough doctors are screening for depression in clinical practice.  Further, patients are often hesitant to discuss symptoms of depression for many reasons including social stigma, fear of medications, belief that mental health is not part of primary health care, or belief that treatment is hopeless.  

 

Sharan Rai: If somebody thinks that they have depression, what should they do?

 

Lindsay Burns: If you think you have depression, you should:

 

• Speak with your family doctor or rheumatologist about your symptoms to develop a treatment plan (you may be referred to a specialist)
• Seek support from trusted friends and family (ask them to check-in regularly and encourage you to participate in social and physical activities, even when you don’t feel like doing so)
• Join a support group
• Get out of the house, even if it’s just to walk around the grocery store

Remember, combined treatment of both arthritis and depression is essential to break the vicious cycle of disability and get you back on the road to living well.  

 

Sharan Rai:  Can depression put you at risk for other illnesses and why is it so important to seek assistance?

 

Lindsay Burns: In addition to increasing the risk of arthritis, research has shown that depression can increase the risk of several major illnesses like cancer, diabetes, and heart disease.  Thus, taking steps to improve your mental health could have major benefits for your general health as well.

 

Sharan Rai: If you had only one suggestion to give a patient about coping with arthritis-related depression, what would it be?

 

Dr. Mok: Depression is a very common problem and can affect within up to 50% of patients with arthropathies [diseases of the joints]. It needs to be addressed.  Self-acceptance, acknowledging the problem, and reaching out for help are very important. Unfortunately, it is often undiagnosed because of societal stigma. Depression itself also causes tunnel-vision (those afflicted often see treatment options as hopeless).

 

Lindsay Burns:  Depression is a real medical illness that can harm your long-term health and should therefore be screened for and appropriately treated.  While patients may feel there is no end in sight, it is important to remember that depression is treatable and recovery is expected.  Be sure to seek the care you need!

 

Dr. Hiram Mok, MA, MD, FRCPC, is a Consultant Psychiatrist and the Mary Pack
Arthritis Centre Clinical Associate Professor of the UBC Department of Psychiatry.

 

Lindsay Burns (MSc candidate) is an Arthritis Research Centre of Canada trainee and CIHR research scholar.

 

* The DSM-5 is the Diagnostic and Statistical Manual of Mental Disorders version 5 which is published by the American Psychiatric Association