In a study published online this month in Arthritis Care & Research, the authors demonstrated that psoriatic arthritis patients with depression and anxiety were about 70 percent less likely than those without these mental-health issues to achieve “minimal disease activity,” or MDA — a state where pain, tenderness, and swelling is drastically reduced. “We all want our patients to get to remission or have minimal disease activity, but depression and anxiety are important factors that prevent that from happening,” says study author Vinod Chandran, MD, PhD, a rheumatologist and clinician-scientist at the University of Toronto and the co-director of the psoriatic arthritis program at the University Health Network. For this investigation, Dr. Chandran and his colleagues evaluated 743 patients (mean age 50) from the University of Toronto Psoriatic Arthritis Clinic. Clinicians conducted a complete physical exam on subjects at 6- to 12-month intervals, including a detailed joint and skin evaluation. Patients provided self-reported details regarding their well-being and mental health through a health assessment questionnaire and the Medical Outcomes Short Form (SF)-36 Health Survey. RELATED: 7 Things You Should Know About Psoriatic Arthritis and Emotional Health
The Toll on Emotional Well-Being May Be Underdiagnosed
Mental health problems are all too common among individuals with psoriatic arthritis. It’s estimated that about one third of patients with this autoimmune condition struggle with depression and anxiety. The University of Toronto study suggests that the actual number may be even higher. About 45 to 49 percent of study participants self-reported that they were experiencing depression or anxiety, depending on the definition used. But clinicians identified only 28 percent of study participants as having depression or anxiety. This discrepancy aligns with research presented at the American College of Rheumatology conference last fall. In that study, conducted in the United States and Europe, scientists found that 14 percent of doctors observed anxiety, depression, or both in their patients, while 36 percent of patients indicated they were experiencing anxiety or depression. Taken together, the research suggests that physicians may be unaware of the extent to which PsA patients face mental heath challenges. “These issues should be addressed by clinicians when managing patients with psoriatic arthritis,” says Chandran. Brett Smith, DO, a rheumatologist who practices at the Blount Memorial Physicians Group, East Tennessee Children’s Hospital in Knoxville, agrees that rheumatologists probably don’t pay enough attention to depression and anxiety. “I think that we tend to focus on the physical aspect rather than the psychological aspects,” he says. “I don’t know that it’s common practice for rheumatologists to administer mental health questionnaires or address depression and anxiety with patients because patients may not necessarily bring it up, and we’re not mental health specialists.” RELATED: Social Anxiety: The Invisible Symptom of Psoriasis
How Depression and Anxiety May Fuel Psoriatic Arthritis Pain
Dr. Smith believes clinicians could be more proactive about assessing their patients’ mental health, especially because psoriatic arthritis and depression seem to make each other worse. As a 2017 investigation published in the journal Neuropsychiatry put it, “Evidence is accumulating to show that depression and inflammation are closely connected and may fuel each other.” Although no research has definitively proved a cause-and-effect relationship between depression and psoriatic arthritis, PsA pain can heighten depression. Conversely, when a person is depressed, he or she may not take care of their health by exercising, for instance, which can make psoriatic arthritis symptoms worse. “I tell people that depression and anxiety are not the only reason for their pain, but it’s like squirting fluid on a campfire — it just makes the flame grow bigger,” Smith says. Stanford Shoor, MD, a clinical professor of medicine and rheumatology at Stanford Health Care in Palo Alto, California, explains that depression and anxiety can also lower a patient’s pain threshold. “Pain is in the mind of the beholder,” he says, “and depression and anxiety can make the same amount of inflammation present in a joint feel worse. It’s very important to determine whether the discomfort a person feels is actually from the inflammation or if it’s more related to processing the pain — and depression and mood play a role in that.” RELATED: What Psoriatic Arthritis Really Feels Like
Recognizing Serious Mental Distress and Getting Help
Smith notes that he sometimes works with a psychologist who can provide specialized support for patients who are grappling with mental health or psychological issues. “We have to address the patient as a whole person rather than just a handful of joints and some skin changes,” he says. While Dr. Shoor emphasizes that psoriatic arthritis is “not just a body disease — the mind plays a role,” he points out that rheumatologists are not experts in the treatment of depression. If he believes a person needs mental help, Shoor may suggest they see a therapist or possibly a psychiatrist. Patients who are proactive may also find emotional support among social groups of other psoriatic arthritis patients. The Centers for Disease Control and Prevention provides links to self-management education workshops that can help. For a patient, the first step in overcoming a mental health challenge may be recognizing the symptoms. The Anxiety & Depression Association of America says that signs of depression may include the following:
Persistent sad, anxious, or “empty" moodFeelings of hopelessness, pessimismLoss of interest or pleasure in hobbies and activitiesLower energy, fatigue, feeling “slowed down”Difficulty concentrating, remembering, or making decisionsInsomnia, early-morning awakening, or oversleepingDecreased appetite and weight loss or overeating and weight gainRestlessness or irritability
Including Mental Health as Part of Comprehensive Care
Chandran and his collaborators suggest that attitudes and practices may be shifting in regard to depression and anxiety as they relate to psoriatic arthritis. In their study, they highlight that both depression and anxiety were identified as key health factors in the development of the 2014 Psoriatic Arthritis Impact of Disease (PsAID) questionnaire, and emotional well-being is now strongly recommended to be included in the updated PsA Core Domain Set, an assessment used in research trials. Chandran believes clinicians need to not only focus on therapies that can suppress joint inflammation, but also expand treatment to a more multidisciplinary approach. “Comprehensive management of PsA should include measures for addressing anxiety and depression so that more patients achieve a state of MDA,” the study authors concluded. The Arthritis Foundation says that treating mental health conditions should be regarded as a fundamental part of managing arthritis symptoms. The organization offers advice on when to see a mental-health specialist as well as information on healthy lifestyle choices and self-care options that can help ease symptoms, especially when used alongside psychotherapy or medication.
