Painting shows the outline of a woman in pain holding her head. The image is hazy with a gray and purple scale. The woman has red spots on her wrists and elbows indicating joint pain. She looks exhausted

There’s plenty of evidence that people who have chronic conditions including inflammatory arthritis are more apt than others to also have depression. Now researchers are attempting to determine whether there are pivotal moments in the course of rheumatic disease — what we sometimes call the patient journey — that coincide with an increased risk of mental health issues.

According to a new study, published in the journal RMD Open, inflammatory arthritis patients who escalate their current treatment — either by adding a biologic drug to their regimen or switching from one biologic drug to another (likely because the first option was not effective) — are more apt to be taking antidepressant or anti-anxiety medication at the same time.

To conduct the study, Greek researchers used data from the country’s Government Center for Social Security Services medical database. They identified nearly 24,000 people with inflammatory arthritis between 2016 and 2018. Inflammatory arthritis patients included people with rheumatoid arthritis (RA), psoriatic arthritis (PsA), and ankylosing spondylitis (AS).

While the use of antidepressant and anti-anxiety medication was relatively common among all inflammatory arthritis patients, those who had recently starting taking a biologic or switched to a new biologic were substantially more likely than those whose treatment remained stable to be taking a mood-related medication.

“To the best of our knowledge, this is the first study to show a positive association between the use of medications for depression or anxiety and both introduction and switching of [biologics], in a large, real-world population of patients with [inflammatory rheumatic disease],” the researchers wrote. “Notably, these associations were independent of age, gender, underlying disease, and concomitant glucocorticoid or [traditional disease modifying antirheumatic drug] use.”

Understanding the Depression/Anxiety/Biologic Link

Why is starting a biologic or switching to a new linked to an uptick in depression and anxiety?

For starters, these kind of treatment changes indicate that a patient’s rheumatic disease is not being well-controlled on their previous regimen — or at least that the patient (and/or doctor) did not think it was being sufficiently controlled.

The study authors noted that “increased pain and physical disability, subsequent loss of social roles and employment, as well as medication side effects at higher disease activity, may predispose to depression,” adding that severe inflammation has been connected to higher levels of inflammatory cytokines (proteins) that research has separately been linked to depression.

The authors also said that depression and anxiety might lead to worse inflammatory rheumatic disease activity or vice versa. Someone who is already depressed or anxious might find that their mood problems exacerbate their joint pain and other arthritis symptoms. Or, severe joint pain and other arthritis symptoms could cause someone to become more depressed and anxious, triggering the need for both an arthritis treatment change and depression or anxiety medication.

Lastly, it’s also possible that “depression distorts subjective components of commonly used disease activity indices, thus misleading physicians to upscale treatment,” the researchers theorized.

In other words, patients who are depressed might perceive their pain as being worse, even if objective measure of disease activity do not reflect this.

The key takeaway, according to the authors, is that health care providers should factor in depression and anxiety when considering whether to prescribe more aggressive therapy for rheumatic disease.

“Mood disorders should be always considered by practicing rheumatologists upon the decision to propose to an ‘inadequately treated’ patient the introduction or switching of a biologic agent,” they concluded.

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Bournia V-K, et al. Introduction and switching of biologic agents are associated with antidepressant and anxiolytic medication use: data on 42,815 real-world patients with inflammatory rheumatic disease. RMD Open. October 2020; doi:

Walsh N. Depression and Biologic Use in Arthritis: Chicken or Egg? MedPage Today. October 2, 2020.

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