Depression is a common symptom of rheumatoid arthritis (RA). As many as 41 percent of people with RA experience depression, more than twice the rate in the general population, according to the Arthritis Foundation. Depression is related to increased RA disease activity, which worsens pain and other physical symptoms, according to a 2019 meta-analysis in the International Journal of Rheumatic Diseases. Coping with both physical and emotional pain can greatly reduce quality of life for people with RA.

How Is Depression Different From Feeling Sad?

Sadness is a temporary feeling that can arise from disappointment or loss. Depression, on the other hand, is a serious mood disorder that affects daily functioning and can last much longer.

According to the National Institute of Mental Health, you may have clinical depression if you’ve experienced at least five of the following symptoms of depression for most of the day, nearly every day, for more than two weeks.

• Sadness, irritability, anxiety, or an “empty” feeling
• Loss of interest or pleasure in activities you usually enjoy
• Hopelessness or pessimism
• Changes in appetite
• Sleep problems
• Fatigue
• Feelings of worthlessness or guilt
• Cognitive problems, such as difficulties thinking or concentrating
• Persistent thoughts of death or suicide

Many people with RA may not realize they're depressed or may be too embarrassed to talk to their doctors about how they feel. Other people’s symptoms may be overlooked because doctors don’t typically screen for depression with RA.

A study reported in Arthritis Rheumatology confirmed that rheumatologists rarely discuss depression during appointments. Less than 20 percent of people with moderate-to-severe depressive symptoms raised the issue during an RA medical visit.

Left untreated, depression can make RA harder to manage. Depression can also increase the risk of developing other chronic diseases — such as cardiovascular disease — and may even be life threatening, according to a 2011 study reported in the International Journal of Clinical Rheumatology.

Understanding the difference between a major depressive disorder and “the blues” can help people with RA get the proper diagnosis and treatment. If you think you might be clinically depressed, talk to your doctor.

What Causes Depression in People With Rheumatoid Arthritis?

One of the most common inflammatory diseases for which there is no cure, RA attacks more than just the body’s joints. Systemic inflammation caused by this autoimmune disease may affect the brain as well, leading to cognitive impairment (also known as “brain fog”) and major depressive disorders.

A 2019 review published in Current Opinion in Rheumatology suggested that inflammation can change the way brain cells function, triggering a response that increases depression risk. Another study in The British Journal of Psychiatry discussed the link between levels of C-reactive protein (CRP) — an inflammation biomarker in the blood that may indicate RA — and depression.

Just the stress of a rheumatoid arthritis diagnosis can trigger depression. A 2017 British study of 4,187 people with RA found 30 percent developed depression within five years of diagnosis. Women, who have a higher risk of RA than men, are more likely to develop RA-related depression in that time frame.

It’s not unusual to feel depressed when living with a painful, chronic illness such as RA. Daily struggles with pain and loss of mobility, and worry about disease progression, can make it hard to cope. Not only that, depression can affect self-esteem and work and personal relationships.

Some medications can cause depression, too. While many RA treatments may help lift mood disorders, other drugs prescribed for inflammation — such as Prednisone and Betamethasone — may worsen depression symptoms. Talk to your doctor if you’ve experienced mood changes since starting RA medications.

Researchers have found that women with a history of depression are more likely to develop seronegative RA later on. In the Nurses’ Health Study II, the risk of developing seropositive RA — the most common type of RA, caused by certain antibodies in the blood — increased by 76 percent among those who showed at least four symptoms of post-traumatic stress disorder (PTSD).

Treating Depression in Rheumatoid Arthritis

The good news is that depression can be treated. Lifestyle changes can ease some symptoms of depression, and antidepressants are often prescribed for people with both RA and depression. The best place to start is by talking to your doctor.

Antidepressants

The most commonly prescribed antidepressants for RA are selective serotonin reuptake inhibitors (SSRIs). They include Celexa (Citalopram), Lexapro (Escitalopram), Prozac (Fluoxetine), Paxil (Paroxetine), and Zoloft (Sertraline). SSRIs work by altering levels of brain chemicals, such as serotonin and dopamine, and by changing the way nerve cells communicate. These drugs have been found to be highly effective against depression, and may also have some benefit in treating rheumatoid arthritis.

Tricyclic antidepressants — another class of medications — have been used to treat mood, as well as reduce pain in people with RA. They include Elavil (Amitriptyline) and Pamelor (Nortriptyline). Selective serotonin-noradrenaline reuptake inhibitors (SSNRIs), such as Cymbalta (Duloxetine) and Effexor XR (Venlafaxine), treat both depression and chronic pain. They work as neuromodulators, reducing pain by modifying the number of chemical messengers — such as serotonin and norepinephrine — transmitted between nerves.

Antidepressants have side effects that should be discussed with your doctor.

Lifestyle Changes

Although different medications may be prescribed to treat RA and depression, lifestyle changes and complementary therapies can be helpful in addressing the physical and emotional effects of both conditions.

Counseling

If you’re experiencing mood disorders, your doctor may refer you to a mental health professional, such as a psychologist or counselor. There are many types of psychotherapy — including traditional talk therapy and cognitive behavioral therapy — which can help you work through difficult emotions and develop healthy coping mechanisms for stress.

Sleep

Getting a good night’s sleep can be challenging for people with RA. Those who toss and turn tend to have more trouble with depression. Better sleep habits include avoiding caffeine or alcohol, taking a hot shower or bath before bedtime, and using pain relievers to reduce joint pain. Sleep medications, when used under the supervision of a physician, can help you fall and stay asleep. They include Lunesta (Eszopiclone) and Ambien (Zolpidem).

Exercise

A 2018 review of 17 studies published in the Annals of the Rheumatic Diseases found that exercise remains an important part of RA treatment and significantly reduces depression symptoms. The study included a mix of aerobic and resistance training, yoga, dance, and tai chi. If mobility is a concern, gentle stretching can be helpful. Check with your doctor before starting any exercise program.

Meditation and Stress Reduction

A 2018 review examining the effects of mindfulness meditation in people with RA found a 35 percent reduction in psychological distress after six months. The Arthritis Foundation also recommends conscious breathing, visualization, tai chi, and journaling — as well as creative activities such as pottery, needlework, or sketching — to reduce stress that can trigger depression.

Diet

While there are no dietary guidelines for RA, many people with the condition can benefit from eating a nutritious, balanced diet and maintaining a healthy weight. The Mediterranean diet — a type of anti-inflammatory diet — has been shown to reduce inflammation associated with RA. This can improve RA symptoms, including depression.

Complementary Therapies

A 2018 literature review confirmed that acupuncture, alone or combined with other treatments, can reduce RA inflammation, regulate immune functioning, and improve quality of life. Other studies have shown that cannabinoids, the active chemical in medical marijuana, may also ease inflammation, but more research is needed.

Members Share Ways They Manage Depression

By joining MyRATeam, members gain a community of more than 126,000 people living with RA who understand their challenges, including depression. Members support each other and share ways they have found to manage their depression and live their best lives with RA.

Do you live with RA and depression? What has worked to help you manage depression? Share below in the comments or post on myRAteam.