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Rheumatoid arthritis (RA) is associated with severe and progressive disability. Over time most of the patients are severely crippled. This in turn has a severe impact on the quality of life and mental health of the patient.
There is evidence from several epidemiological studies that rheumatoid arthritis is associated with depression. In fact from most review of studies it is found that 13 to 20% of the patients diagnosed with RA suffer from clinical depression.
RA patients are thus twice as likely to suffer from depression as members of the general population. In addition depression among spouses and carers of RA patients is also a common finding.
Several factors may affect an RA patient and raise the risk of depression. Some of these are socioeconomic factors, care, degree of independence and some depend on the severity of the disease.
In addition in RA patients, depression contributes its own additional burden and also affects the way the patient perceives his or her ailment and how they intend to cope with the condition and how they interact with their rheumatologist and general practitioner.
One of the commonest triggering factors that raises the risk of depression among RA patients is the degree of pain. Depression in RA patients is associated with increased levels of pain. Patients, who when asked to describe their pain, described them in severe terms such as “excruciating” appear to suffer from higher degrees of depression.
Frequent occurrence of pain is not, however, a direct associated marker of depression. There are several studies that show that the association works both ways - pain increasing depression and depression increasing pain.
Depression is also associated with inability to perform activities that the person feels are necessary for daily living. These could be going on holidays or visiting neighbours. A 10% reduction in ability to perform these activities is followed by a seven‐fold increase in depression over the subsequent year find studies.
The exact mechanism in the brain that explains the association of pain and depression is poorly understood. Depression and psychological stress, however, have been seen to result in a poor immune function status. This could be a link between RA severity and depression.
Depression thus should be an important consideration while managing a patient with RA. In general Selective Serotonin Uptake inhibitors (SSRIs) such as fluoxetine or citalopram should be considered as first‐line treatment for depression in RA.
Tricyclic anti-depressants in low doses such as amitriptyline and dothiepin could be given for depression as well as pain relief.