What it is That Grips Us (Part 4)

Parts two and three of this series have addressed the prevalence of depression in RA, as well as various factors like grief from disease onset that make differentiating depression from responses to RA difficult. This part of the series is a closer examination of the symptoms of depression and concludes with some warning signs to look for as well as advice to loved ones, family members, and caregivers who may be worried about the emotional health of someone with RA.

To preface, the following information is not for self-diagnosis or the diagnosis of another. Rather, it is meant to illuminate some of the hidden struggles of those who live with RA, as well as show where the line is between realistic response to the disease and potential depression that warrants seeking help. The gold standard for a diagnosis of depression is an in-person interview with a qualified mental health or medical professional.

Depression in Focus

Major Depression, whether recurrent or a single episode, is more than just a downcast or gloomy mood. To differentiate it from sadness characteristic of the vicissitudes of life, depression requires that five or more of nine possible symptoms be ongoing (two weeks or more), persist for most of the day nearly every day, be newly present or a change from previous functioning, and be accompanied by clinically significant distress or impairment in social, occupational, or other important areas of functioning.1

Let's take a look at these nine symptoms as described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), followed by consideration of how RA fits in. The symptoms are:

  1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)
  2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation.)
  3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.)
  4. Insomnia or hypersomnia nearly every day.
  5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
  6. Fatigue or loss of energy nearly every day.
  7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
  8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
  9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.2

When considering these symptoms alongside RA, it is important to realize that many are characteristic of the disease process or treatment, and may not be indicative of depression.

Changes in weight can be due to the direct effects or side effects of medication, as well and changes in activity level due to physical impairments. For those taking methotrexate, prednisone, or a TNF inhibitor, weight gain is on average seen at six months following treatment initiation; with prednisone having the highest rate of weight gain, whereas leflunomide-treated patients on average may show weight loss.3

Insomnia can be due to discomfort, pain, disease activity, and mood. In a study comparing sleep quality of RA patients to healthy matched peers, it was shown that poor sleep quality was higher in RA patients and that sleep problems and their related symptoms occurred in 54% to 70% of RA patients.4

Fatigue likewise is a well-documented aspect of autoimmune diseases, with 42-80% of RA patients reporting fatigue, and 40% reporting severe persistent fatigue.5

A diminished ability to think or concentrate could also be caused by the disease or medication, a phenomenon many of us refer to as brain fog. This aspect of the disease is not clearly understood, however, patients frequently report it, and various studies have shown cognitive impairment in RA patients on a range of measures compared to matched peers. A thorough analysis of brain fog and RA, as well as the studies and factors supporting that association can be found here: http://blog.arthritis.org/rheumatoid-arthritis/rheumatoid-arthritis-brain-fog/

Taken together, using these symptoms to gauge whether or not you or someone with RA may be depressed is highly confounded.

Moving Beyond a Checklist of Symptoms

To view depression in more descriptive terms, the DSM-V states, "The mood in a major depressive episode is often described by the person as depressed, sad, hopeless, discouraged, or 'down in the dumps.' [Additionally] many individuals report or exhibit increased irritability." Likewise, "Loss of interest or pleasure is nearly always present, at least to some degree. Individuals may report feeling less interested in hobbies, 'not caring anymore' or not feeling any enjoyment in activities that were previously considered pleasurable. Family members often notice social withdrawal or neglect of pleasurable avocations. In some individuals, there is a significant reduction from previous levels of sexual interest or pleasure."6

The difficulty again becomes differentiating these descriptions of depression and life with RA. The disease can lead one to discouragement or irritability in the face of ongoing pain, sad at the loss of ability, empty at the loss of meaningful employment, worried or frustrated over the increased financial strain, incapable of enjoying previous activities due to physical or mental impairments, and uninterested or avoidant of sex due to physical limitations or changes in relationships due to RA. The qualitative impact of RA is broad, as the functional impairments and disease process can range from mild to severe, as well as episodic to progressive.

So where does this leave us?

My intention is not to overcomplicate depression and RA, but rather to show that what may appear like depression to an outsider may, in fact, be a reasonable response to the lived difficulties of the disease. The DSM acknowledges this: "Some of the criterion signs and symptoms of a major depressive episode are identical to those of general medical conditions." In addressing this difficulty, the recommendation of the DSM is to focus on the non-somatic symptoms: "dysphoria, anhedonia, * guilt or worthlessness, impaired concentration or indecision, or suicidal thoughts..." Interestingly, when these symptoms alone are the focus, the same individuals are generally identified as occurs using the full criteria.7

Some Warning Signs to Look For

Depression is an emotionally painful, difficult, and potentially debilitating condition that may have onset or been exacerbated by RA. For individuals living with RA, the intensity, duration, and content of the depressed thoughts and emotions are the key factors to focus on:

Do you feel detached, numb, empty, and "blah" most of the day nearly every day, for weeks or more, and regardless of what is going on in your life?

Do you feel hopeless, sad, or incapable of enjoying pleasure most of the day nearly every day, for weeks or more?

Do you feel excessively guilty or worthless?

Do you think of suicide, fantasize about it, or are planning on it, or have recurrent thoughts of your own death?

If you are answering yes to some or all of these questions, it is possible you are suffering from depression. Seeking help and a professional opinion from a mental health professional, or discussing depression with your doctor, is warranted. Depression is a treatable condition, and there is help. The next part of this series will address the myriad professionals, licenses, and mental health services available, followed by another part of non-professional resources and interventions.

Advice for caregivers, family members, friends, and loved ones

Perhaps you may have noticed that depressed moods are more common than before in someone you know with RA. After reading the complications of disentangling many of the common signs of depression from RA, I hope I have shown that some responses to the disease mirror depression but are realistic responses to RA and that this brings some context and insight.

If you are worried that someone you know with RA may be dealing with depression and not just the difficulties of the disease, my recommendation is to inquire openly and compassionately about the intensity and extent of the types of feelings and thoughts listed in the section on warning signs (assuming the person with RA is willing to talk about it). In particular, do not be afraid to ask about suicidal ideation, thoughts, or fantasies. The risk of suicide amongst individuals with RA is significantly greater than the non-ill population.8 Please do not underestimate your possible positive influence in speaking about difficult topics and showing a willingness and compassion in listening.

*Anhedonia is the inability to feel pleasure.

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.

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