Depression and rheumatoid arthritis

"Depressed....... me?"

What do J.K.Rowling, Agatha Christie, Marcus Trescothick, Mel C, Buzz Aldrin, Winston Churchill, Angelina Jolie, Stephen Fry, Hugh Laurie and Ruby Wax have in common? Well the eagle-eyed among you will have spotted that they are all noted in their field, but did you know that they have all spoken about their experiences of depression?

Depression can affect anyone regardless of age, gender, race, culture, level of wealth or profession. What is encouraging is that the people mentioned above have managed or continue to manage their condition, and have full and active lives.

Chronic health conditions and depression: some facts and figures

In 2007, the World Health Organisation (WHO) conducted a worldwide survey which looked at four chronic health conditions, including "arthritis". The result of this survey showed that average health scores were lower when people also had depression. This does not tell us whether people who have a chronic health condition are more depressed, but does indicate a strong relationship between mental health issues and physical health outcomes.

This year (2013) calls have been renewed to incorporate assessments, treatments and monitoring of mental health into primary and hospital care settings for people with chronic health conditions, which includes the training of health professionals in mental health care

Rheumatoid arthritis and depression

It has been suggested that depression in rheumatoid arthritis (RA) is nearly three times that of the general population, yet it often goes undiagnosed. One of the reasons for this is that some of the symptoms of RA, such as fatigue and poor sleep could easily be attributed to the disease, when they could also be an indicator of poor mood and/or anxiety. However, though people with RA are more susceptible to depression than the general population, many with RA will not experience this symptom and it is thought that it may only affect around 13-20% of RA patients.

Doctors may not do formal evaluations of a patient's mood state when they are attending clinic, perhaps due to lack of time, resources, training, or a belief that someone else, such as the General Practitioner (GP) should take responsibility for these assessments. Unfortunately undiagnosed 

depression can mean that a patient may find coping with the demands of suggested treatments, and the efforts required for effective self-management too hard to adhere to. Decisions about treatments may be particularly hard to make, and a patient may not avail themselves of potentially useful medications and interventions. Furthermore, if the symptoms being experienced are actually more to do with depression than the RA, patients can become disenchanted with treatments that apparently do not work, as they do not feel better.

People may also not realise that they are depressed, and so do not talk to their doctor about how they feel. Some people also still worry about the perceived 'stigma' of admitting to feeling low, and being diagnosed with a 'mental health' condition. The people mentioned at the beginning of this factsheet have spoken out because of this, and are trying to raise the profile of mental health issues both here and internationally.

The National Institute for Health and Care Excellence (NICE) do acknowledge that people with chronic health conditions may also experience depression at some point during their lifetime, and they have set out some clear guidelines for assessment and treatment. They have produced a useful booklet which you can download from the internet which tells you about this at: www.nice.org.uk/CG91publicinfo

Seeking help

Sometimes it is other people who notice that you aren't quite 'yourself' and may suggest you go to see your GP or talk to your rheumatologist or clinical nurse specialist. The important thing is that you seek help if you have been feeling low for some time or are very anxious about things. Don't worry, no-one will think you are 'mad'. Jot down how you have been feeling before you go to see the doctor so that you cover all the things you want to say. We can all experience the "rabbit in headlights" moment when we see the doctor, so it's best to go prepared. Don't minimise symptoms, if you feel grim, say so. Consider taking someone you trust with you. It can be very reassuring to have someone there with you. Generally speaking, if you have been feeling very down, low or depressed for most of the day, every day, for at least two weeks and you have lost interest in activities that you used to enjoy, you should talk to one of your health care team.

Your doctor will probably ask you two questions:

  • "During the last month, have you often been bothered by feeling down, depressed or hopeless?"
  • "During the last month, have you often been bothered by having little interest or pleasure in doing things?"

If you answered "Yes" to those questions, they would go on to find out a little more about how you have been feeling:

  • The doctor will ask you about your sleep patterns and whether you feel restless or particularly slowed down.
  • Whether or not your weight and appetite has changed (either increased or decreased)
  • what your fatigue levels are like
  • if you have been irritable or unable to concentrate
  • if you have been troubled by feeling worthless or guilty.

These questions may seem rather personal, but it is necessary to establish what other symptoms may be present, and what else is going on in your life. The doctor may ask you about your relationships, work and living conditions. They would also want to know if you have experienced depression in the past, perhaps before you were diagnosed with RA, and what treatments were used and how effective they were.

The doctor will also ask you if you have been thinking about or have any intentions to commit suicide. This may seem rather frightening, but people who are depressed (who also have a long-term health condition like RA) may be more likely to think about self-harm.

Caring for yourself

If you are diagnosed with depression, or you think you might be beginning to feel low, there are several things you can do to help yourself. 

  • Try to get enough sleep. Decide on a routine and stick to it; that means going to bed and getting up at roughly the same time each day. Our bodies do like routine!
  • If sleep is difficult, distraction from worrying or negative thoughts can be useful. Listen to the radio, read or listen to relaxing music. If the mind is occupied, it's less able to focus on worry.
  • Take a look at your diet and try to make one or two changes to make it healthier if you need to. A good 'heart healthy' diet may be especially good for people with RA. Try to include oily fish or omega-3 fatty acids in your diet.
  • If you're finding it hard to cope avoid alcohol, cannabis and other recreational drugs. They may appear to help, but in the long-term cause problems in themselves.
  • If you have a spiritual life, talk to your clergy or advisor, they may be able to help you with a range of supportive measures.
  • Concentrate on doing the activities that make you happy. One of the first ways of tackling low mood is to change behaviour, and increasing pleasurable activities gives you an immediate lift.
  • Spend time with other people, don't become isolated. Choose the friends and family that are likely to be supportive. It can help to talk things over, but don't dwell on the negative
  • A good relaxation and/or meditation routine can be key to reducing anxiety and feeling stressed. It takes practice, but can be worth it in the end. The Occupational Therapist at your local hospital may be able to show you some relaxation strategies, or you could check with your GP to see if they run any courses. Alternatively you might like to investigate a technique known as 'Mindfulness' Studies have indicated that Mindfulness-based interventions for people with physical health conditions can show benefit in improving psychological well-being.
  • Many people who feel depressed lose interest in how they look. Dressing every day and taking pride in your appearance can help raise your self-esteem.
  • Reward yourself with positive treats to remind yourself that you deserve good things.
  • Regular exercise can also improve mood, as well as having other health benefits, particularly in people with RA. Your rheumatology team or a physiotherapist might be able to help you with finding a suitable exercise programme. Self-help groups like www.mind.org.uk can be helpful; you may enjoy going to a local group if there is one in your area. It helps to remind yourself that you are not alone feeling like this.
  • You may also benefit from meeting other people with RA, through online forums or at group meetings, though this will not suit everyone and remember that everyone’s experiences will be different, so it’s not always easy to compare experiences.

- If you would like to join an online forum about RA, you can access the NRAS Members’ forum by joining the society, or register with HealthUnlocked, which has a forum on RA that is moderated by NRAS.
- Click here if you would like to look for an NRAS group in your area.

We know from research studies that people who feel depressed often feel quite helpless about life and the future. One of the most effective ways of combating this is to feel in control again, and this can be achieved by coping in a more active rather than passive way. If you feel you're doing something, this in itself can improve your mood.

Cognitive Behavioural Therapy (CBT)

When you have seen your doctor or other health care professional and they have made an assessment, or asked you to speak to a specialist who can make an assessment, they will discuss with you which treatments might be best for you. Many people are uncertain about taking antidepressant medication. The current guidelines suggest that where depression is thought to be mild or moderate, a 'talking therapy' like Cognitive Behavioural Therapy (CBT), (which can help you to manage your problems by changing the way you think and behave), or another problem-solving therapy might be as effective as an antidepressant, and you should be offered the option of this. In other cases where depression is more severe, your doctor may advise an antidepressant in the first instance, perhaps followed up with, or in conjunction with a talking therapy. It is true to say however, that in the UK there is often a long wait for access to psychological services. If budget permits, you can access a psychologist privately. If you do, make sure they carry the title "Chartered" which is the standard for practice in the UK. Psychologists can be found from a register that is maintained by the British Psychological Society (see www.bps.org.uk) or through organisations such as the British Association for Counselling and Psychotherapy (BACP) and United Kingdom Council for Psychotherapy (UKCP). If you have very strong views on medication or counselling, either for or against, do discuss these with your doctor so you can mutually agree a way forward that you are happy with.

CBT looks at how our thoughts, behaviours, emotions and physical feelings are all interlinked. In depression we can get stuck in very negative ways of thinking which impact on our behaviour, emotions and how we feel physically. This can lead to a negative downward spiral as one 'feeds' off the other. CBT helps you to identify those thoughts and behaviours that might be impacting on how you feel, and teaches you how to achieve a more balanced view of things.

When you have started treatment, it can be good to keep a simple record or chart of how you feel each day. Maybe a smiley face record, or a score from 1 to 10 to indicate how good or bad things are. These are useful as you can see over time whether a treatment is working or not. It's also useful because we forget very quickly how we feel. How did you feel on this date 2 months ago, exactly? Hmmm, hard isn't it? Take your record to your doctor at each appointment so they can see how things are going too, and discuss what happens next.

CBT diagram

Cognitive-behavioural type therapies have been shown to be one of the most useful therapies for people with long-term health conditions as they tend to focus on the 'here and now'. However, there are other types of therapy and therapists, who may be more appropriate for you. Psychotherapy for instance tends to look at events and experiences in your past to help you in the present. This kind of therapy usually lasts much longer than CBT, often for over a year, or longer.

Perhaps the most important thing to realise if you think you may have depression is that you do not have to cope with this on your own. As well as getting help from your healthcare team and help and support from friends and family there are many organisations who may be able to offer useful information, some of which are outlined below:

Some useful websites and resources

Expert advice from the Royal College of Psychiatrists
Mind offer support and advice so people don't feel alone.
The British Psychological Society has a register of Chartered psychologists (click on ‘Find a psychologist’).
The British Association for Counselling and Psychotherapy also has a directory (See BACP Services on the home page and ‘Find a therapist’).
The United Kingdom Council for Psychotherapy (UKCP) also has a directory (click on the ‘find a therapist’ button on the homepage).
British Heart Foundation dietary advice for a good heart healthy diet

A website with free downloadable resources on mindfulness meditations to listen to.
www.freemindfulness.org

Some useful contacts

www.nhs.uk or Dial 111 when your GP or out of hours service is not available. 24 hours a day, seven days a week, for urgent help or advice that is not an emergency

Samaritans
www.samaritans.org or Samaritans 08457 909090 call 116 123 (24 hours a day, seven days a week) to talk about anything that is troubling you

Saneline
www.sane.org.uk or call 0300 304 7000 between 4.30-10.30pm daily. 'Textcare' also available.

In urgent crisis your Community Mental Health Team may have a crisis support contact if needed, or you can ask to see the duty psychiatrist at your local A&E department.

References available on request

Elizabeth D.P Hale Chartered Health Psychologist, Department of Rheumatology, The Dudley Group of Hospitals NHS Foundation Trust

Original article: 23/09/2013
Reviewed: 05/02/2017
Next review due: 05/02/2020

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