What it is that Grips Us (Part 2)

With my voice revealing the nervous tension seated somewhere in my rib cage, I stood in front of a classroom full of undergraduate students for the first time in the fall of 2016. In the months leading up to the semester, I had idealized and imagined the lessons I would give as a professor. On the first day of class, however, I quickly learned that the idea of teaching and actually taking on the role, feeling the awesome responsibility of communicating a knowledge base in a manner that is both engaging and coherent, are two very different things. What makes sense in my head mentally preparing for a lesson does not always come out that way. I stumbled on occasion, lost my train of thought, or simply did not have adequate answers for some difficult questions. Yet on many days, I melded with the material, surprising even myself with the facility of my quick responses, direction of discussion, and recall of interesting and relevant facts during the lecture. Teaching I found, is just as much about continued improvement in classroom methods and ongoing learning of a subject, as it is about disseminating knowledge.

Defining "normal"

Because the subject of my class was the study of mental health, its history and situation within a culture and time period, we often touched on topics that blended the personal with the academic. After concluding the lecture one day, I opened up discussion with a simple but highly problematic question that hit a nerve (in a good way).

"We've talked a lot about abnormal psychology," I said, "But what is normal?"

I saw a few shoulders shrug, but no one volunteered a reply. I let the silence hang, eventually verging on awkwardness. Finally, a clever student with a sly look on his face ventured an answer: "Not abnormal" he said, then grinned as everyone looked his way. A few students chuckled before launching a volley of responses, arguments, and probing questions that lasted nearly an hour.

To directly answer the question "what is normal?" is an invitation to look foolish as the students likely foresaw. Psychologists and psychiatrists run the risk of imposing their own unquestioned beliefs, morals, and assumptions when they define normality. Yet, to the clever student's point, normality is inadvertently being defined when an abnormality is described, quantified, and categorized.

A simple dichotomy of normal and abnormal, however, is insufficient, though it makes a great entry point for classroom discussion. The words themselves are bothersome to many (self-included). Yet the term "abnormal psychology" refers partly to the fact that specific mental disorders are not common to the majority of people, and affect only small percentages of populations. Even that, however, is not so simple, with certain populations having higher rates of certain mental illnesses.

This brings up a pressing question: how common is it for someone living with rheumatoid arthritis to experience major depression compared to the general population?

Some Statistics on depression and RA

Major depressive disorder affects nearly 256 million people worldwide, about 3.6% of the global population¹. The percentage of people affected at least once in their lifetime ranges from 7-21%². In the United States, the twelve-month prevalence rate of major depressive disorder is "approximately 7%, with marked differences by age group such that the prevalence of 18-29-year-old individuals is three-fold higher than the prevalence in individuals 60 years or older³." Likewise, prevalence rates in women are higher than in men, though there are no "clear differences between the genders in symptoms, course, treatment response, or functional consequences⁴."

Importantly for the discussion here, the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition states, "Chronic or disabling medical conditions also increase the risk for major depressive episodes. Such prevalent illnesses as diabetes, morbid obesity, and cardiovascular disease are often complicated by depressive episodes, and these episodes are more likely to become chronic than are depressive episodes in medically healthy individuals⁵." In other words, having a chronic illness like rheumatoid arthritis increases the risk of depression, as well as the risk of depression lasting longer than what is common in the non-ill population.*

A systematic review and meta-analysis of the prevalence of depression in RA published in the Oxford Journal of Rheumatology in 2013 sums up some key points: "Depression is more common in RA than in the general population and has been associated with increased pain, fatigue, reduced health-related quality of life, increased levels of physical disability, and increased health care costs. Depressed RA patients have poorer long-term outcomes, including increased pain, more comorbidities, and increased mortality levels. Depression may, therefore, be a useful target for interventions aimed at improving subjective health and quality of life in RA patients. However, prevalence estimates for depression in RA range between 9.5% and 41.5%, making it difficult to establish the likely impact of depression in this patient group."

It is clear the intersection of depression and RA is important, and that addressing it holds the possibility of improving the quality of our lives, and potentially the course of the disease. It is, therefore, worthwhile to consider the nuances and particulars of depression weighed alongside life with RA, which will be addressed in the next two sections of this series.

* Consideration must also be given to risk. If someone had a previous episode of major depression, or a familial history of it, their risk of having a depressive episode with the life difficulties of RA will be increased compared to someone without that history.

Call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) or the National Hopeline Network at 1-800-SUICIDE (1-800-784-2433). These toll-free crisis hotlines offer 24-hour suicide prevention and support. Your call is free and confidential. To find a suicide helpline outside of the US, visit IASP or Suicide.org.