The Relationship Between Depression and Arthritisby Lindsay Myers, MBA, MPH | August 8, 2014
Both arthritis and depression are common in the United States, with age and obesity trends likely to increase the number of people who suffer from both conditions simultaneously.
Studies have repeatedly demonstrated an association between arthritis symptoms and major depression. Of concern, research has shown that among patients with both conditions, the result is not merely the sum of the suffering and disability associated with each independent illness; when depression coincides with arthritis, studies have found that the conditions are multiplicative rather than additive, amplifying each other.
Arthritis and depression are but one example of the increasingly frequent overlap between medical and behavioral health, and evidence suggests that treating depression reduces arthritis-related healthcare expenditures, increases compliance with arthritis treatment plans, and alleviates physical symptoms.
The Arthritis Problem
According to the CDC’s 2013 Morbidity and Mortality Weekly Report, one in five adults in the United States has physician-diagnosed arthritis. For the past 15 years, arthritis has been the most common cause of disability among U.S. adults. Ten years ago, just under 10 percent of U.S. adults, approximately 19 million people, said their activities of daily living were limited by this chronic condition. The number is projected to reach 25 million by 2030.
In older populations, arthritis is widespread: by age 65, at least a third of people in the U.S. have osteoarthritis, and the majority, approximately 80 percent, experience degenerative changes or joint disease. The costs associated with this are enormous: The American Academy of Orthopedic Surgeons (AAOS) reported an estimated annual cost for medical care to treat arthritis and joint pain of $281.5 billion in 2004. Prescription drugs accounted for 23 percent of the expenditures.
The Depression Problem
The Morbidity and Mortality Weekly Report also notes that depression is more common among people with chronic diseases such as diabetes, asthma, cancer, and arthritis. Citing the Behavioral Risk Factor Surveillance System (BRFSS) survey conducted from 2006 to 2008, 9 percent of U.S. adults, of any health status, met the criteria for depression.
Depressive symptoms have been identified as an independent risk factor for all-cause mortality. A study by Wells et al. found an association between depression and disability where the effects of depression were comparable to several major medical conditions.
When Arthritis and Depression Overlap
When arthritis and depression overlap, studies have shown a synergism resulting in worse suffering and disability than that which would be associated with each condition independently. A 1998 study found that osteoarthritis-related knee pain was associated with depression. Other studies demonstrate worse outcomes, lack of adherence to treatment plans, and increased cost of care in patients suffering from both illnesses.
In addition to increased use of pain medication, a bidirectional relationship exists between the two conditions: Yohannes and Canton describe how the fatigue that accompanies depression results in activity avoidance, which decreases muscle conditioning, resulting in increasing arthritis pain while also leading to social isolation, thereby perpetuating depression. They also note that “a previous history of depression is a better predictor of utilizing healthcare than the severity of osteoarthritis symptoms,” which implies that the financial burdens of arthritis could be mitigated to some extent by addressing coinciding depression.
While osteoarthritis is the most common form of arthritis, another form, rheumatoid arthritis, shows an even more significant link with depression. The National Institute of Mental Health (NIMH) Catchment Area program reports that the lifetime prevalence of psychiatric disorders among patients with rheumatoid arthritis is 63 percent. “Indeed,” state the researchers, “approximately 20 percent of patients with RA are found to have current major depression with potential impact on RA symptoms.”
Devellis and Devellis summarize the implications of these studies, stating that “helping arthritis patients obtain relief from their depression promises both to mitigate the added risk associated with depression and to enable the patient and physician to manage the arthritis itself more effectively. A first step to optimal treatment may simply be an awareness of the role that depression can play in the course of arthritis and its treatment.” Primary care physicians could screen arthritis patients for depression and refer them for treatment.
The long term effects of medication, as well as interactions between medications, should be cause for concern among patients afflicted with multiple conditions. Non-steroidal anti-inflammatory and other drugs for arthritis are associated with gastrointestinal issues, renal toxicity, and other side effects.
Breedveld notes that among American adults over the age of 35 with osteoarthritis, 41 percent were also receiving pharmacotherapy for hypertension. As other chronic diseases join the mix of arthritis and depression, the potential for activity-limiting, undesirable medication side effects increases. According to the CDC, 57 percent of those with heart disease also have arthritis, and 52 percent of diabetics have arthritis.
The CDC’s Arthritis Program recommends self-management education and physical activity programs, noting that some of the barriers to self-management through physical activity include lack of time, competing responsibilities, lack of motivation, difficulty finding an enjoyable activity, and fear of exacerbating pain or further damaging joints. Barriers to treating depression often include cost of drugs, side effects, stigma, and the patient-provider relationship.
Studies have shown that older people with osteoarthritis could benefit from combination therapy utilizing medication and cognitive behavioral therapy, however copays are frequently a barrier to treatment for elderly patients on a fixed income. Consistent with the CDC’s recommendations, Yohannes and Canton concluded that self management techniques, medical information, assistance with pain coping skills, and exercise would be beneficial. Cognitive behavioral therapy has been used to cultivate the belief that the patient is equipped to effectively cope with the condition, resulting in increased activity and improvement in depressive symptoms. Aerobic exercise programs have decreased depression in adults with arthritis.
Depression exacerbates the manifestations of joint disease. Recognition of this relationship by family members and providers can lead to better support for the increasing number of people suffering from overlapping medical and behavioral health issues. Counseling, education, and exercise programs have shown the potential to mitigate symptoms and reduce health care spending while improving quality of life and daily functioning.
Agarwal P, Pan X, & Sambamoorthi U (2013). Depression treatment patterns among individuals with osteoarthritis: a cross sectional study. BMC psychiatry, 13 (1) PMID: 23607696
Behnam, B. (2013). The Frequency and Major Determinants of Depression in Patients with Rheumatoid Arthritis Turkish Journal of Rheumatology, 28 (1), 32-37 DOI: 10.5606/tjr.2013.2599
Breedveld, F. (2004). Osteoarthritis–the impact of a serious disease Rheumatology, 43 (90001), 4-8 DOI: 10.1093/rheumatology/keh102
Current Depression Among Adults, 2006-2008. (2010). Morbidity and Mortality Weekly Report
Parmelee PA, Harralson TL, McPherron JA, & Schumacher HR (2013). The structure of affective symptomatology in older adults with osteoarthritis. International journal of geriatric psychiatry, 28 (4), 393-401 PMID: 22653754
Prevalence of Doctor-Diagnosed Arthritis and Arthritis-Attributable Activity Limitation – United States, 2007-2009. Morbidity and Mortality Weekly Review, 59(139).
Yohannes AM, & Caton S (2010). Management of depression in older people with osteoarthritis: A systematic review. Aging & mental health, 14 (6), 637-51 PMID: 20686976
Mental Context – A Delicate Subject
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