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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.

This article represents the opinions, thoughts, and experiences of the author; none of this content has been paid for by any advertiser. The RheumatoidArthritis.net team does not recommend or endorse any products or treatments discussed herein. Learn more about how we maintain editorial integrity here.

  1. Diagnostic and statistical manual of mental disorders DSM-5. (2013). Arlington, VA: American Psychiatric Association.
  2. Diagnostic and statistical manual of mental disorders DSM-5. (2013). Arlington, VA: American Psychiatric Association.
  3. Semedo PDD. Weight Gain, Loss in Rheumatoid Arthritis Patients Influenced by Disease-Modifying Drugs. Rheumatoid Arthritis News. https://rheumatoidarthritisnews.com/2016/03/11/disease-modifying-antirheumatic-drugs-affect-weight-of-patients-with-ra/. Published March 11, 2016. Accessed May 14, 2017.
  4. Son C-N, Choi G, Lee S-Y, et al. Sleep quality in rheumatoid arthritis, and its association with disease activity in a Korean population. The Korean Journal of Internal Medicine. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4438293/. Published May 2015. Accessed May 14, 2017.
  5. Repping-Wuts H, Riel Pvan, Achterberg Tvan. Fatigue in patients with rheumatoid arthritis: what is known and what is needed. Rheumatology. https://academic.oup.com/rheumatology/article/48/3/207/1784966/Fatigue-in-patients-with-rheumatoid-arthritis-what. Published October 16, 2008. Accessed May 14, 2017.
  6. Diagnostic and statistical manual of mental disorders DSM-5. (2013). Arlington, VA: American Psychiatric Association.
  7. Diagnostic and statistical manual of mental disorders DSM-5. (2013). Arlington, VA: American Psychiatric Association.
  8. Timonen M, Viilo K, Hakko H, et al. Suicides in persons suffering from rheumatoid arthritis. Rheumatology. https://academic.oup.com/rheumatology/article/42/2/287/1788454/Suicides-in-persons-suffering-from-rheumatoid. Published February 1, 2003. Accessed May 14, 2017.

Comments

  • Michael Booth moderator author
    2 years ago

    Dear Jbubblee

    Apologies for the very late response. Many external life events kept me away from the site, and it also took me some time to process your feedback. Thank you for speaking to points missed and problems in my posts. I agree that mental health is a very important topic, and am happy to have contributed here. I intend to do much more on the subject in the future. Rheumatoidarthritis.net has also taken up a mental health initiative on the site with articles, the survey, and official content. I hope you have found this valuable.

    Undoubtedly treatment resistance depression must be very difficult. I can see how blanket generalizations about there being hope and help are ignorant of many things. I am sorry for any offense. Though my intention was to encourage people who have not sought help to give it a try, I agree that how I phrased it is not accurate and can be dismissive of those who are not helped by the available services. I can also see how it is infuriating. In writing about mental health in other areas since, I have incorporated more realistic wording on the reality of depression, its difficulties in treatment, and the fact that not everyone is helped by the available interventions. Thank you for pointing this out to me.

    As per the link between complex trauma, PTSD and autoimmune disease, I am not sufficiently familiar with the evidence to comment. I do know the body of literature you are referencing, so I’ll take a look at it. If things line up, I’ll make a future post on the subject.

    In terms of wordiness, looking back now, I agree that some of my posts are excessive. The divide of writing discipline specific jargon for academics, and writing content that is more blog like and public, has been hard to straddle. However, you made me realize the need to state things with less wordiness, while conveying meaningful ideas. It is a skill I have since been working on. I think doing so improved much of my writing, both academically and in pieces written for a larger audience. Thank you for the constructive feedback.
    I apologize again for the lack of response on my part. I hope you are doing well.
    Best wishes,
    Mike

  • Julie C.
    2 years ago

    Dear Mr. Booth,
    Thank you for contributing articles that help engage our community on the topics of mental health and mental illness. I believe any mention of depression is an important discussion. Personally I have been diagnosed with Major Depressive Disorder (MDD), severe and recurrent, since 8 years of age. I have received treatment for this in the form of individual therapy, medication, months of in-patient hospitalization at a time, to name a few. Panic Disorder and PTSD were later added to my “resume”.
    Almost 30 years later I was diagnosed with Rheumatoid Disease. I am fascinated to hear multiple medical clinicians claim that my diagnosis of Post Traumatic Stress Disorder (PTSD), in addition to MDD are “known” precursors to “my” developing an autoimmune disease/Rheumatoid Disease.
    ~First I would like to request future contributions to this forum on the relationship between an individual’s exposure to complex trauma/PTSD and the inevitable(?) diagnosis of an autoimmune disease.
    ~Second, I write this with the utmost respect: in response to your statement that, “Depression is a treatable condition, and there is help.” In my personal experience DEPRESSION IS NOT [ALWAYS] A TREATABLE CONDITION. There is a condition know as treatment-resistant depression. And sadly, there is a community of individuals that suffer from this condition despite the most modern, cutting edge medical treatment and intervention available. I continue to see writers state the very same as you and it truly infuriates me as it is a false statement. Depression is NOT always treatable. And there is NOT necessarily a “cure”.
    ~Lastly, and please forgive me, but despite having completed graduate school myself, and once employed actively as a Certified Public Accountant (CPA), I personally find your last 4-part series extremely verbose and difficult to comprehend. Please know that I have been genuinely looking forward to reading every part of your series!! Perhaps it’s my constant “brain fog” (lol). I sincerely respect your work as a professor at the university level. I have written and taught at that level myself. However, at this juncture in my RD journey, I simply struggle with how you present your contributions. Your statement: “Taken together, using these symptoms to gauge whether or not you or someone with RA may be depressed is highly confounded”. Ugh! D-: My friend, Mr. Booth, “confounded” makes no sense!!
    ~All that being said, PLEASE, please do NOT stop writing for our community Mr. Booth!! 🙂 I just beg you to perhaps simplify your discussion of such important subject matter in order to make it just a bit easier for your readers to remain engaged. Thank you so very much for all your hard work!!

  • Lauren Tucker moderator
    2 years ago

    Jbublee,

    Thank you so much for writing to Michael Booth and commenting on his article. We do appreciate you being so open and honest about your RD journey as well as the depression that you experienced.

    You do bring up some valid points, Michael does write from a higher level of thinking which is what makes us different from other communities and I am sure he will follow up with you in the future. Of course we will also consider your comment about future posts around this subject matter in a different layout and format, for our readers.

    Since you mention you would like to see more discussion around the topic I do encourage you to share your story if you wish (no obligation) here: https://rheumatoidarthritis.net/stories/

    We do thank you again for your comment and for being part of our community.

    Best Wishes, Lauren (RheumatoidArthritis.net Team)

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