Among adults with arthritis in the United States, anxiety and depression are twice as common compared to among the general population1; anxiety and depression prevalence are even higher in rheumatoid arthritis (RA). Likewise, psoriatic arthritis is associated with increased odds of anxiety and depression,2 a systemic lupus erythematosus metaanalysis reported prevalence around 25%,3 and in RA, anxiety and depression prevalence was ~37% in 1 study.4 Among patients with RA, comorbid anxiety and depression are associated with increased disease activity and reduced quality of life, making RA an important disease to study.5 Further, people with rheumatic diseases face a heightened risk of suicide. One study noted that patients with RA had 2.5 times increased risk of death by suicide,6 highlighting critical unmet mental health needs.
In this issue of The Journal of Rheumatology, Giblon and colleagues examined 30-year trends in the prevalence and incidence of depression and anxiety among people with RA in the Rochester Epidemiology Project, a population-based cohort of patients in Olmstead County, Minnesota.7 Across RA cohorts ending in 2014, followed through 2020, the authors observed a rising occurrence of anxiety, and concomitant anxiety and depression. The authors noted that this rise occurred despite advancements in disease-modifying antirheumatic drugs and improved RA management over this time period. Temporal trends of increasing anxiety and depression prevalence have also been observed in the general population, amid enhanced screening and despite advances in managing other chronic diseases.
Observed increases raise this question: What is causing the rise of anxiety and depression in the general population and, more specifically, in individuals with RA? The answers are likely multifactorial. Over the past few decades, there have been significantly expanded systematic screening efforts in primary care that have led to improved detection of depression and anxiety. Societal trends also include increased social media use, which has known negative effects on mental health and perceived decreases in social connectedness; the US Surgeon General has called this lack of social connection an “epidemic of loneliness and isolation,” which includes heightening feelings of isolation, anxiety, and depression.8-10 Such factors were likely further exacerbated by the coronavirus disease 2019 (COVID-19) pandemic.
Globally, rates of both anxiety and depression increased by at least 25% during the first year of the COVID-19 pandemic, with immunocompromised adults reporting higher odds of feeling nervous, anxious, or on edge compared to the general population.11,12 Factors of immunosuppression and worry could also play a role in the RA population. In RA, chronic pain, physical limitations, the unpredictable nature of the disease, and financial hardships also compound psychological distress. Both health-related and financial concerns might have increased among those with RA during the pandemic.
Interestingly, increases in anxiety and anxiety with depression were most pronounced in those with seropositive RA in the present study.7 Seropositive status was used as a surrogate for disease severity, suggesting a direct relationship between RA burden and comorbid mental health challenges. Others have shown that patients with RA and comorbid depression have worse clinical outcomes and lower likelihood of achieving disease control.13 Giblon and coauthors7 pointed out that several studies suggest a bidirectional relationship between RA and mental health concerns, with increased anxiety and depression both preceding and following the RA diagnosis.14 Investigating the proposed bidirectional relationship could strengthen a case for correlating between high inflammatory disease activity and increased anxiety and depression in future studies.
The present study by Giblon and colleagues7 has several strengths. Their unique longitudinal follow-up across 3 decades in a stable population-based cohort provides robust data on temporal changes of anxiety and depression in people with RA. Using matched controls for comparator data and adjusting for confounders such as socioeconomic status increases the internal validity of the study. Further, comparing seropositive status provides disease-specific insight into subgroups who might be at higher risk for developing anxiety and depression.
Limitations of the study include that data were abstracted only in Olmsted County, a predominantly White (> 90%) and highly educated (> 90% completed high school education or beyond) county in Minnesota. Elsewhere, adverse social determinants of health, including financial insecurity, food insufficiency, housing instability, employment difficulties, and discrimination can contribute significantly to the development and exacerbation of anxiety and depression,15,16 so rates might be even higher. Generalizability of this study to other populations could be limited. Further, the authors described that healthcare utilization differed between patients with seropositive and seronegative disease, which could contribute to differences in screening and detection.
The results from this study show the need to investigate and implement tailored interventions to identify and treat anxiety and depression in patients with RA. Given increasing rates in RA and other common rheumatology populations, and the effects on RA and well-being, rigorous detection and timely treatment of depression and anxiety might prove essential to improve outcomes in RA.
Rheumatologists can use a variety of resources to diagnose, treat, and collaboratively manage depression and anxiety in patients with RA. For diagnosis, validated screening tools include the 9-item Patient Health Questionnaire (PHQ-9; or PHQ-8 without suicide item), and 7-item Generalized Anxiety Disorder (GAD-7) for depression and anxiety disorders, respectively; only PHQ-9 and Patient Reported Outcomes Measurement Information System (PROMIS) tools have been validated and calibrated for use specifically in the RA population.17 The Multidimensional Health Assessment Questionnaire (MDHAQ) has items validated for screening both anxiety and depression in patients with inflammatory arthritis, including RA and PsA.18,19
Once depression or anxiety have been identified, treatment options may include pharmacological interventions, psychosocial interventions, and/or physical exercise regimens. Selective serotonin reuptake inhibitors and serotonin and norepinephrine reuptake inhibitors are commonly used medications that are effective for treating anxiety and depression. Denmark has simplified guidelines, recommending sertraline as first-line treatment for all patients.20 Developing similar simple, evidence-based recommendations for RA and anxiety or depression could also help to control both conditions. Psychological interventions can include cognitive behavioral therapy (CBT), social work, or health psychology referrals. CBT can be effective in managing anxiety and depression by helping patients identify and modify negative thought patterns and behaviors. Health psychologists can help patients manage stress, improve coping skills, and promote overall well-being by providing strategies to effectively cope with the challenges of chronic health conditions, such as pain, fatigue, and social isolation. In addition to pharmacotherapy and psychological interventions, exercise has been shown to be a powerful way to reduce disease activity, pain, and fatigue, while also improving physical function and mental health in patients with RA.21
Although many rheumatologists feel confident in identifying mental health disorders, few feel confident in their ability to manage them.22 Despite reservations, most rheumatologists will initiate treatment when they identify a mental health condition such as depression or anxiety.22 Anxiety and depression can be effectively treated in nonpsychiatric settings, with robust literature on guiding primary care clinicians.23 These conditions can be managed individually with mental health professionals or through integrated care models,24-26 such as Collaborative Care Models (CoCM). CoCM is an evidence-based team method of treating mental health conditions within primary care and other medical settings that has been shown to improve outcomes. Using a team-based approach, CoCM could involve collaboration among primary physicians, rheumatologists, mental health specialists, and other healthcare providers to provide comprehensive care for patients with RA and comorbid mental health conditions.
In summary, Giblon and colleagues7 offer a timely, well-constructed study and call to action regarding the increasing occurrence of anxiety and concomitant anxiety and depression, particularly among patients with seropositive RA. Further understanding regarding relationships between RA and anxiety and depression is crucial to develop interventions. The study by Giblon et al7 highlights temporal trends, risk factors including seropositivity, and calls for research on potential underlying mechanisms contributing to mental health comorbidities in RA. Potential negative clinical implications of untreated anxiety and depression among patients with RA include worse RA outcomes, poor quality of life, and suicide risk. With current trends worsening, timely and effective mental health screening, treatment, and monitoring are crucial. Integrated CoCMs can help overcome barriers facing busy rheumatologists to improve anxiety and depression care and outcomes in RA or other rheumatic conditions.
Footnotes
See Depression and anxiety in RA, page 210
FUNDING
The authors declare no funding or support for this work.
COMPETING INTERESTS
The authors declare no conflicts of interest relevant to this article.
- Copyright © 2025 by the Journal of Rheumatology
