What it is That Grips Us (Part 3)

The evaluation of the symptoms of a major depressive episode is especially difficult when they occur in an individual who has a general medical condition. — The Diagnostic and Statistical Manual of Mental Disorders Fifth Edition.

Looking for peace

Running away from family, friends, and everyone I knew at the age of twenty-one, I lived for almost a year in a tent amidst haunting memories of the past. I spent my days rock climbing and slacklining, caring little for my life and taking extraordinary risks. Dangling a thousand feet above the ground, secured by nothing more than a rope and a few pieces of climbing gear, I felt truly alive. Moments of adrenaline shocked me out of a pervasive numbness and rumination. A need to distance myself from painful events, the reminders of which permeated what I had previously called home, drove me into a self-imposed exile. Thereafter, and for the majority of my twenties, I tried to come to some internal peace, to find stability, and to create a life I could call my own. Sports became my lifeblood, the only thing that kept me striving and anchored. Eventually, education filled my mind with thoughts that seemed worth thinking. I fell in love with school in my late twenties, a thirst for knowledge bringing a sense of purpose and meaning.

By my early thirties, I had found consistent stability. I graduated from college, married a wonderful and adventurous woman, became a stepfather, and reached the height of an athletic career spanning two decades. I came to know contentment, a foreign emotion that gradually seeped in under the doorways and through the cracks, filling me with calm. Yet, the peaceful respite did not last.

A phone call burst through the silence one morning, plummeting me into another period of emptiness and grief. Smiling and laughing would come to feel like betrayal. My best friend had died suddenly. He was young and full of life. The loss left me stranded in a desert of misery, the dry sands of the past and endless stretch of the future isolating me in a nihilism and sadness so profound that it was both human, and other worldly.

An RA diagnosis

While still submerged in mourning, but slowly emerging to the surface, the words, "You have the signature distribution of swelling and blood markers characteristic of rheumatoid arthritis," fell from a doctor's lips and plunged me back into the depths. Looking at my newborn son and seeing our future threatened by my now rogue immune system brought devastation. I remember driving at night shortly after my diagnosis and amid months of debilitating pain and fatigue, shouting repeatedly as loud as I could, "Not now!" I felt I was shattering under the sheer weight of life and loss, crumbling and breaking, collapsing into nothing.

***

Making sense of an RA diagnosis

To the outsider, the emotional reaction to the diagnosis of a major and potentially debilitating chronic illness may appear unreasonable. However, there is no one way to respond to such life events and experiences.* What emotionally follows the onset of a chronic illness can take myriad forms based on the meaning of the disease for the individual, their life history, and the particular context in which it occurs. Some may be relieved to finally have a name and treatment plan for pain that has been constant and ongoing. Others may experience a feeling of injustice like they have been robbed of something dear and precious. Many are too young to fully understand the implications. In my case, sadness and grief tinged by frustration arrived in waves.

RA and depression

Importantly for the discussion of RA and depression, grief due to the onset of a chronic illness can resemble a major depressive episode with "feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss...¹ This makes unraveling depression and the onset of RA difficult, as grief surrounding the experience may be an appropriate and reasonable response, and not reflective of a cluster of symptoms qualifying diagnosis.

Disentangling the emotional response of grief is only one of many ways in which understanding depression and RA is complicated. In the second part of this series, various statistics on the prevalence rate of depression for individuals with rheumatoid arthritis were cited. The range noted is rather broad, between 9.5% and 41.5%. The authors of the review provide an explanation for the wide estimate: "There are various reasons why this variation in prevalence estimates may exist. First, the term depression is not clear-cut. Making sense of depressive symptoms in the context of chronic physical disease is challenging—it may be difficult to distinguish between patients with a depressive disorder, as opposed to those demonstrating a normal reaction to living with a chronic, debilitating condition. Further, a number of somatic symptoms of depression (e.g. fatigue, poor sleep and loss of appetite) might be expected to occur in RA as part of the disease process.²"

It has also been hypothesized that the pathophysiology of rheumatoid arthritis may be linked to depression. The evidence for this possibility, of depression as a direct result of the biological abnormalities of RA, is not definitive but ongoing. The curious reader can find an overview of that research and evidence here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3247620/

Side effects of treatment must also be considered for their impact on fatigue, insomnia, lack of mental clarity, and changes in weight that are also considered symptoms of depression. Additionally, physical impairment, loss of employment, inability to enjoy once pleasurable activities and changes to relationships due to the disease must also be considered. These themes will be taken up in the next part of the series.

Taken together, there is a lot of overlap between possible grief reactions to the onset of a potentially debilitating disease, as well as overlap in many common aspects of life with RA that can mirror depressive symptoms. Perhaps you are wondering if you or a loved one with RA is experiencing depression, and whether or not seeking help is warranted and potentially beneficial. It is reasonable to question whether or not one is having mental health issues or simply responding to the reality of the disease. The decision to seek help is a personal one. My motivation is to provide information so that the reader can make the most informed choice possible. The next article in this series will look closer at the symptoms of depression and specific warning signs that may indicate a threshold has been crossed.

*The popular and often cited Kübler-Ross model of the stages of grief (denial, anger, bargaining, depression, and acceptance) as a response to illness or death has been the subject of research controversy since publication in 1969. The argument is whether or not the stages are universal and common to different time periods and cultures, are inherent to all grief processes and/or death, and how the stages might be affected by other variables like the context of death or disease. Likewise, there is an argument about whether or not the absence of grief is common in death and other losses, and a healthy response to certain people and situations. For an interesting and easy read on some of the controversy and criticism surrounding stage theories of grief, see the this Times article: http://content.time.com/time/magazine/article/0,9171,2042372-1,00.html

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.