The Interconnection Between Rheumatoid Arthritis and Mental Health

What is Rheumatoid Arthritis?

Our body has an autoimmune function, a system that protects itself from invading agents, including bacteria and viruses. An autoimmune disorder is a condition in which the body’s immune system mistakenly attacks its own tissues.

Rheumatoid arthritis (RA) is an autoimmune disorder in which the immune system targets the synovium (synovial membrane), the connective tissue that forms the lining of the joints. This targeted attack triggers inflammation, resulting in swelling, pain, and stiffness in the affected joints. If these initial symptoms are overlooked, chronic inflammation results, leading to damage of the joints, deformity, and loss of function.

Individuals affected by unmanaged RA may suffer from chronic pain, fatigue, sleep disturbances, and emotional distress. As a result, they develop the risk of mental health issues such as anxiety, depression, and mood disorders. These issues are said to worsen the physiological symptoms, causing further escalation of pain, inflammation, and impaired mobility. A comprehensive treatment plan for RA should address both physical and mental health aspects.

Although the precise cause of this autoimmune response (RA) is still unknown, a combination of genetic predisposition, lifestyle, dietary, and environmental factors can be responsible.

Rheumatoid arthritis can happen at any age, but individuals aged between 30 and 60 are more prone to it.

Rheumatic Arthritis and Mental Health Challenges

Individuals suffering from RA experience a decreased quality of life (QoL) due to pain, fatigue, and mobility impairments. These conditions can lead to anxiety, depression, and mood changes. A 2020 review suggests a link between local and systemic inflammation and the development of anxiety and depression. The review highlights that 17% of RA patients developed major depressive disorders (MDDs). This interconnection between RA and mental health issues can be attributed to two factors: impaired coping mechanisms due to chronic inflammation and a worsening of RA activity, causing increased body pain, fatigue, and early morning stiffness. The researchers suggest that these mental health issues arise from either biological mechanisms involving cytokines or the psychological impact on the individual’s well-being.

Another 2022 review assigned a bidirectional relationship between the impact of RA and the associated psychological issues. Mental health issues such as anxiety and depression result from evolving perceptions of pain, disability, and impaired well-being. These psychological challenges can further worsen RA symptoms. While chronic stress can contribute to mental health issues, individuals with RA may experience unique psychological stressors related to their condition.

How Depression and Anxiety Worsen RA Symptoms

A 2016 study suggests that mental health comorbidities, such as anxiety and depression, can exacerbate RA. These comorbidities can lead to dysregulated inflammatory responses, increased pain and fatigue, and impaired cognitive and behavioral functions, further worsening the overall impact of the disease.

The worsening of RA symptoms progresses through two prominent pathways: behavioral and physiological.

Behavioral Pathways

Living with rheumatoid arthritis requires significant mental strength, courage, and determination. Motivation and perseverance are essential for consistently adhering to treatment plans, maintaining physical and psychological well-being, and seeking support from social networks. Depression and anxiety can diminish these qualities, and individuals with RA may experience negative behavioral patterns that can exacerbate their symptoms.

The following are some examples of behavioral risk factors:

1. Non-adherence to treatment due to demotivation and loss of hope can negatively impact the management of inflammation and other symptoms, worsening the disease.
2. Reduced physical activity due to psychological distress and lack of energy may worsen joint stiffness, pain, and overall mobility.
3. Social withdrawal due to feelings of isolation and social anxiety prevents RA patients from seeking support or medical advice, delaying intervention and preventing treatment outcomes.

Physiological Pathways

Depression and anxiety can significantly impact the physical well-being of individuals with RA. This bidirectional relationship between mental and physical health can exacerbate RA symptoms.

The following physiological processes may be impaired:

1. Elevated systemic inflammation and immune dysregulation, triggered by the release of stress hormones like cortisol and adrenaline in response to chronic stress, can exacerbate RA symptoms.
2. Immune system dysregulation, caused by the overactivation of the immune system, which is triggered by depression and anxiety.
3. Pain sensitization, a condition where the nervous system becomes more sensitive to pain signals, can be exacerbated by long-term psychological distress in RA patients.

Comprehensive Treatment Approach: Addressing Rheumatoid Arthritis and Mental Health Together

Due to the multidimensional impact of RA, a comprehensive treatment strategy combining pharmacological, psychological, and supportive modalities and lifestyle modifications is essential for managing the disease and improving the quality of life for individuals with it.

Pharmacological Approaches

Several classes of drugs are utilized for RA treatment, targeting various aspects of the disease, including autoimmune dysfunction, inflammation, pain, and joint damage. Concurrently, medications for mental health conditions like depression and anxiety are also prescribed to address the psychological impact of RA. These are:

1. Disease-Modifying Antirheumatic Drugs (DMARDs) are the cornerstone and first-line prescriptions for RA that are intended to provide anti-inflammatory effects, reduce joint inflammation and swelling, and regulate immune response. In this drug class, several subtypes exist that treat specific issues accompanying the disease. Conventional Synthetic DMARDs (csDMARDs) treat inflammation and swelling, while Targeted Synthetic DMARDs (tsDMARDs) are prescribed to block specific enzymes involved in the immune response.
2. Biologic DMARDs (bDMARDs) are usually prescribed as second-line treatment options when conventional DMARDs are ineffective. These medications target specific immune system components involved in RA, such as inflammation and autoimmunity reductions.
3. Corticosteroids, due to their potent anti-inflammatory effects, are used for short-term relief from flares (surges in the symptoms of RA).
4. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) are prescribed to reduce pain, swelling, and stiffness.
5. Selective Serotonin Reuptake Inhibitors (SSRIs) are used to treat depression and anxiety.
6. Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) for comprehensive treatment of depression, neuropathic pain, and fibromyalgia, which are common in RA patients.
7. Tricyclic Antidepressants (TCAs) for chronic pain and sleep disorders.
8. Anxiolytics (Anti-Anxiety) for anxiety, panic attacks, and emotional distress. These include the subclasses Benzodiazepines for short-term relief of chronic anxiety and Non-Benzodiazepines for long-term anxiety management.
9. Mood stabilizers are explicitly used when RA patients exhibit mood swings, emotional instability, or symptoms of bipolar disorder triggered by chronic illness.
10. Atypical Antipsychotics are prescribed at critical stages when RA patients experience severe depression, mood disorders, bipolar disorder, or stress-induced psychosis-related symptoms.
11. Sleeping Aids (Hypnotics) and Over-the-Counter Sleep aids such as melatonin supplements are prescribed for insomnia caused by chronic pain and emotional distress.
12. Occasionally and rarely, psychostimulants are prescribed for RA patients suffering from fatigue and mental sluggishness resulting from overlapping conditions such as fibromyalgia or chronic fatigue syndrome.

Psychological Interventions

According to a 2016 review, psychological interventions that equip RA patients with robust coping mechanisms can alleviate emotional distress, enhance mental resilience, and increase supportive social networks. These interventions can ensure optimal treatment outcomes. The following are prominent psychological therapies that aid recovery and overall life management:

1. Cognitive-Behavioral Therapy (CBT) helps patients identify negative behavioral and thought patterns, enables them to develop coping strategies, and overcome pain-related stress.
2. Acceptance and Commitment Therapy (ACT) trains RA patients to focus on accepting chronic pain and discomfort and enables them to take actions aligned with their values and commitments despite ongoing symptoms.
3. Mind-body therapies, such as yoga, tai chi, meditation, and mindfulness, help RA patients reduce stress, improve emotional regulation, and decrease perceived pain levels.
4. Pain management programs (psychological counseling integrated with physical therapies) are used to help individuals with RA to improve daily functioning and reduce reliance on pain medications.

Supportive Therapies

These therapies aim to improve quality of life, manage pain and inflammation, improve mobility, and overcome the physiological, psychological, and social barriers to recovery. Some of these therapies are:

1. Physical therapy helps RA patients to improve joint mobility, reduce inflammation, and enhance overall physical function.
2. Occupational therapy helps to adapt to joint limitations, manage daily activities, and maintain independence.
3. Assistive devices such as braces, splints, and mobility aids support mobility.
4. Support groups and community resources provide caregiving, emotional support, and venues for social sharing.

Lifestyle Modifications

A healthy lifestyle that manages weight, fitness, mobility, and wellness is essential for ensuring optimal treatment effectiveness in individuals with RA. Lifestyle modifications complement medical therapies and support patients in overcoming difficulties naturally and independently. These modifications include:

1. Low-impact exercise for mobility and pain relief.
2. Dietary adjustments to accommodate anti-inflammatory diets such as omega-3-rich foods.
3. Stress management routines like deep breathing and relaxation to overcome pain-induced stress and improve overall well-being.

Final Thoughts

Rheumatoid arthritis (RA) significantly impacts both physical and mental health. Chronic pain, fatigue, and functional limitations associated with RA can lead to depression, anxiety, and other mental health issues. These psychological challenges, in turn, can exacerbate RA symptoms, creating a vicious cycle.

A comprehensive treatment approach for RA should address both physical and mental health aspects. Pharmacological interventions, combined with psychological therapies and lifestyle modifications, can help manage symptoms, improve quality of life, and reduce the impact of the disease on overall well-being.

References

1. Lwin, M. N., Serhal, L., Holroyd, C., & Edwards, C. J. (2020). Rheumatoid Arthritis: The Impact of Mental Health on Disease: A Narrative Review. Rheumatology and Therapy, 7(3), 457–471. https://doi.org/10.1007/s40744-020-00217-4
2. De Cock, D., Doumen, M., Vervloesem, C., Van Breda, A., Bertrand, D., Pazmino, S., Westhovens, R., & Verschueren, P. (2022). Psychological stress in rheumatoid arthritis: a systematic scoping review. Seminars in Arthritis and Rheumatism, 55, 152014. https://doi.org/10.1016/j.semarthrit.2022.152014
3. Sturgeon, J. A., Finan, P. H., & Zautra, A. J. (2016). Affective disturbance in rheumatoid arthritis: psychological and disease-related pathways. Nature Reviews Rheumatology, 12(9), 532–542. https://doi.org/10.1038/nrrheum.2016.112