Apply your psychiatric skills to managing rheumatoid arthritis

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Joint disease is the most common cause of disability and the source of considerable psychological distress. In the United States, 50 million adults complain of joint pain; in 2007, 1.5 million people suffered from rheumatoid arthritis (RA). A chronic inflammatory autoimmune disease of joints, RA can involve almost all organs.1

The link to mental illness

Mental illness in RA patients often is underdiagnosed and undertreated. These missed opportunities contribute to poor compliance with medical therapy, suboptimal therapeutic response, greater disability, and diminished quality of life.2

Limited mobility, chronic pain, sleep disturbance, fatigue, and immunological factors predispose RA patients to depression and anxiety.3 The proinflammatory cytokines, tumor necrosis factor-α (TNF-α), interleukin 1 (IL-1), IL-6, and interferon-g have a role in inducing affective symptoms. There also is a relationship between an elevated IL-17 level and anxiety.

Research substantiates a relationship between RA and depression.3 The prevalence of affective illness is approximately 6% among the general population, and 13% to 30% among RA patients.4 In arthritic populations, 52% exhibit depression and anxiety; joint discomfort contributes to insomnia in 25% to 42% of cases.4

Arthritic pain persists despite suppressed inflammation, which suggests involvement of the CNS.5 Increased levels of IL-6 and TNF-α can cause insomnia and affect pain perception.6 Decreased conditioned pain modulation, a lower pain threshold, and pressure pain intolerance lead to increased pain awareness and heightened discomfort.

How can you help your patient who has RA?

Because the focus of care in RA is on the disease’s physical attributes, psychiatric symptoms sometimes receive less attention.7 And because arthritic symptoms overlap with anorexia, weight loss, fatigue, pain, and insomnia, affective illness can go unrecognized.

Depression rating scales can overestimate affective illness, but a history and follow-up questionnaire can facilitate an accurate diagnosis of depression and help determine the need for, and type of, intervention.

Selective serotonin reuptake inhibitors (SSRIs) are considered first‐line treatment of depression associated with RA.7 Although SSRIs for RA can be administered to the maximum recommended dosage, titration is advised in accordance with patient response and tolerance.

Tricyclic antidepressants are not as well tolerated in RA, especially in older patients; however, they have more of an analgesic effect, even at lower dosages.

Joint disease activity and mood are associated with sleep disturbance, and vice versa.5 Insomnia calls for patient education about sleep hygiene, avoiding caffeine and other stimulants, and an individualized appraisal of options for pharmacotherapy.

Alleviating RA pain is important for psychosocial health.8 Although the medical team’s emphasis should be on controlling inflammation to minimize joint damage and pain, be sure to address your RA patients’ mood symptoms to improve the quality of their life.


The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

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