Depression and heart problems in

rheumatoid arthritis: The way you think

about the future is important

Dr Gareth Treharne PhD (previously of the School of Psychology, University of Birmingham; currently of the Department of Psychology, University of Otago, New Zealand &

Professor George Kitas MD PhD FRCP (Consultant Rheumatologist and Director of Research & Development, Dudley Group of Hospitals NHS Foundation Trust, Russells Hall Hospital, Dudley
Original article: 22/03/2006
Reviewed: 06/02/2010
Next review due: 06/02/2012

When someone is depressed, they feel down most of the time and no longer look forward to events or enjoy things. It is also common for someone experiencing depression to turn away support from other people and feel bad about themselves for no apparent reason. In the worst scenario, depressed people feel that life is no longer worth living and may harm themselves. There are many different factors that may relate to feelings of depression for people with rheumatoid arthritis and these were looked at in a study carried out as a collaboration between the Rheumatology Unit at the Dudley Group of Hospitals and the School of Psychology at the University of Birmingham.

Participants completed a questionnaire on their background (age, sex, whether they were married and whether they were employed), their rheumatoid arthritis (how long they had been diagnosed and how much pain, fatigue and disability they had) and their psychological status (including whether they felt optimistic and whether they were experiencing symptoms of depression). More than 10% of people with rheumatoid arthritis reported considerable symptoms of depression in this study. Depression was assessed using a questionnaire that can give a good indication of whether someone is depressed or not. Beyond a certain score, this questionnaire is nearly as accurate as a doctor’s diagnosis of depression after interviewing someone.

Heart problems are also more common for people with rheumatoid arthritis than the general population. The inflammation that causes your joints to be swollen and painful when you have rheumatoid arthritis may also affect your blood vessels and contribute to heart disease. In this study nearly 30% of the people with rheumatoid arthritis also had a heart problem listed in their hospital records. The majority of these people had high blood pressure (which can be controlled by medicines to reduce the risk of having a heart attack or stroke, as described in national guidelines detailed in the links section). Several factors related to having heart problems for people with rheumatoid arthritis in this study:

• Older people were more likely to have heart problems than younger people.

• More men (41%) had heart problems, although heart problems were still quite common among women (24%).

• People who were not in paid employment were more likely to have a heart problem (36%) than people who were still employed (9%).

People who had been diagnosed with rheumatoid arthritis for more than a year were only very slightly more likely to have heart problems than people who had been diagnosed for less than six months. There also did not seem to be any relationship of current inflammation, pain, fatigue or disability with heart disease.

The study found that people with rheumatoid arthritis who also had a heart problem were more likely to report depression than people with rheumatoid arthritis but no heart problems. Over 25% of people with rheumatoid arthritis and a heart problem reported considerable levels of depression. This is likely to be due to the double-whammy of having two serious illnesses, both of which cause stress and require visits to your doctor and medicines.

However, when all of the important factors were considered at once, two different factors explained whether people with rheumatoid arthritis reported depression or not:

• People who were not in paid employment were more likely to report depression (18%) than people who were still employed (9%).

• People who were optimistic about their future were less likely to report depression than people who were not optimistic.

The findings of this study show that:

• Heart disease is very common for people with rheumatoid arthritis even straight after being diagnosed, not only years down the line.

• Depression is also common for people with rheumatoid arthritis.

• People with rheumatoid arthritis who also have heart disease are most at risk of depression.

• This association of heart disease with depression when you have rheumatoid arthritis is actually explained by being out of employment and not feeling optimistic, which are also common when you have rheumatoid arthritis.

Depression is not something to be ashamed of. Asking for help is one of the first steps out of depression. There are many  things  that can help you when you feel depressed. Antidepressant medicines can lift the worst feelings but are not a permanent solution. Cognitive behavioural therapy (or CBT) is a psychological therapy that can help address the way you feel and how you think about the future when you are experiencing depression. Cognitive behavioural therapy usually involves around six to 10 weekly sessions that can be delivered to groups, one-on-one or even over the internet.

It is now recommended that antidepressant medicines and cognitive behavioural therapy are combined to combat depression (as described in national guidelines detailed in the links section). If you feel you are depressed, then it is worth mentioning this to your general practitioner, your rheumatologist or your rheumatology nurses so they can help you overcome these feelings and enjoy your life. If you have been taking antidepressants for a while without any cognitive behavioural therapy and do not yet feel completely better then ask for an update. Some form of therapy may now be available for you locally. Exercise is also recommended (within your ability range). Regular exercise can improve your mood and strengthen your muscles, including the most important muscle, your heart.

Links (verified 6th February 2010):

National Institute for Health and Clinical Excellence (NICE) guidelines on identifying your risk of heart disease.

National Institute for Health and Clinical Excellence (NICE) guidelines on reducing your cholesterol levels when you have a risk of heart disease.

National Institute for Health and Clinical Excellence (NICE) guidelines on treating high blood pressure

National Institute for Health and Clinical Excellence (NICE) guidelines on treating depression

Birmingham Arthritis Resource Centre, for local support & information (with national links): email: barccentre@bham.ac.uk (Tel:0121 464 2708)

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