Depression and Chronic Illness

Being bummed out is not in your head and you’re not crazy — if you have arthritis or another chronic illness, there’s a very good chance you could be clinically depressed. According to a study in the International Journal of Clinical Rheumatology, patients with a chronic illness like rheumatoid arthritis (RA), ankylosing spondylitis (AS), or psoriatic arthritis (PsA) are two to four times more likely than those in the general population to experience depression. It’s estimated that a whopping 13 to 42 percent of us are beyond just having “the blues” — we’re legit depressed.

I’ve battled depression myself — before, during, and after my RA diagnosis and for reasons both related to and totally separate from my chronic illness. Depression was hard enough when I was otherwise physically healthy. The added physical and emotional strains of RA made my mental stability an uphill battle at times.

Several studies also show that depression and chronic illness feed off each other in the worst ways. Chronic pain itself can cause anxiety and depression, as well as related issues like economic hardship, sexual dysfunction, and fatigue. Then depression and anxiety lower our pain threshold and/or contribute to more pain and health problems. It’s a vicious cycle that seems impossible to escape.

“Depression is crushing me,” admits Jeff B., who has AS. “I have my family counting on me and I’m scared.”

If you think you might be depressed, it’s crucial to recognize it and get ahold of it as soon as possible. The first step is to talk to your primary care doctor or rheumatologist, who can refer you to a mental health professional. There is zero shame in this.

The Importance of Professional Mental Health Treatment

“If you can’t sleep, you can’t eat, or you can’t get out of bed, you should be evaluated for medication,” explains Katie Willard Virant, MSW, JD, LCSW, a psychotherapist in St. Louis and author of Psychology Today blog Chronically Me: The Emotional Landscape of Chronic Illness.

There are many reasons people may be reluctant to see a psychiatrist or a psychologist, such as social stigma, cost, limited availability of providers, or having the time or mobility to see a mental health expert regularly

But Willard Virant points to new research that shows there is a biological link between inflammation and depression.

“People may sort of poo-poo the psychosocial factors,” she says, but knowing that having depression could make inflammation worse, or that having inflammation from arthritis could be triggering the depression “might get more people into treatment. If patients knew that there could be a biological reason for their depression, and that therapy can reduce disease symptoms, they might be more willing to try therapy.”

RA patient Tracey R. knows that addressing her mental health is as important as physical health. “I was going down a very dark road I didn’t want to be on, but didn’t know how to turn off of,” she says. “In my case I not only needed intense therapy to deal with my own thoughts and emotions, but some medications as well to balance me out. It took awhile but I’m glad I got help. Please talk to your doctor and perhaps a counselor. The right therapy [can make] a big difference.”

Willard Virant, who herself has Crohn’s disease, specializes in treating patients with chronic illness. She helps them address the grief and other emotions that comes with having chronic conditions like arthritis or related autoimmune diseases, which can turn your whole life upside down. “We really take stock of the losses, grieving what can’t be, but also start building a new way of living.”

AS patient Emily L., who has also had Crohn’s disease since the age of 6, has been battling depression her whole life. She found a therapist who specializes in chronic illness and she says it was life-affirming and life-changing. “My depression and AS are so interconnected,” she says. “My therapist really understands this relationship so much more. Like when I talk about relationship issues and talk about how my AS impacts them. She really gets it in a way that no one else does and I don’t have to explain why things are hard. I feel validated.”

To find a therapist who specializes in chronic illness, you can start by ask your doctor for a referral, check with local arthritis groups in your community, or use the Find a Therapist tool on PsychologyToday.com, which lets you use “chronic illness” in the search filter. (Once you add your state or zip code, you can click on “chronic illness” in the left-hand navigation of the tool.)

Medication and/or therapy are often a necessary part of managing depression and anxiety, but there are also many other things you can do alongside them to help you cope with depression and we talked to fellow patients coping with depression for the habits and activities that they say have helped them the most.

We’re not suggesting these are a replacement for mental health care or a magic solution, but rather part of a well-rounded approach to a healthy lifestyle for your mental health (as well as for chronic pain, fatigue, and other arthritis symptoms).

Join a support group

According to the Mayo Clinic, “a support group among people with shared experiences may function as a bridge between medical and emotional needs.” Warning: Support groups can go sideways if one person dominates or the group gets too negative. Willard Virant says the secret to a successful support group is a good facilitator. “A good facilitator will cycle back and forth between grieving but also being proactive and finding ways to live meaningfully.”

You can find support groups online through social media platforms like Facebook or Reddit or you may find that you prefer an in-person group that meets regularly.

“Having a chronic illness can be very isolating,” Willard Virant says. We might not be working or working from home, which means seeing people less and less. Having in-person human interaction with other people who are in the exact same boat and empathize can be really helpful. Ask your doctor or a local hospital or check with a community center to see if there are any near you.

Make your diet more anti-inflammatory

A new study in the journal PLOS ONE found that symptoms of depression “dropped significantly” among a group of young adults after they cut down on processed foods, sugar, and carbs, and tried a produce-heavy Mediterranean diet for just three weeks. In the study, people were randomized to eat a diet that had about six extra servings of fruits and vegetables a week and their depression scores were compared to that of a control group that continued to eat their usual diet, which had more processed and sugary foods and drinks.

“I try to keep my diet strictly anti-inflammatory foods and it helps my mental health greatly,” says RA patient Rebecca J. “It’s not perfect, but it helps.”

John S., who was diagnosed with RA nine months ago, went through severe depression. “Pain defined my existence and I almost lost myself,” he says. He stopped consuming sugar, alcohol, and red meat, and lost 10 percent of his body weight, giving him more energy, reducing his pain and more importantly improving his overall outlook. He was able to be more physically active and continue the activities he used to love, like hiking. “I’m crawling out of my hole.”

Find a ‘pocket of goodness’ in your day

It’s really important to “feed your soul” at least once a day, says Willard Virant. She asks patients to talk about the parts of their lives where they feel contentment and build on that. For example, that could be losing yourself in a book, sitting in your garden or baking cookies. Some people will be so depressed, they’ll say, “’I don’t have any of that.’ And that’s okay. We’ll work from the ground up.”

It’s also important to “keep your senses alive,” she adds. Pain has a way of sitting with us and it can feel like it’s taken over everything. Willard Virant is a big proponent of using meditation, mindfulness, deep breathing, and guided imagery to allow your mind to enjoy your senses, which in turn can help create a better quality of life. “These are the tools I give to my patients that they can practice and rely upon.”

Adopt a pet

Of course, caring for animals — especially certain kinds — can be too much work for people with chronic pain and limited mobility. (Think walking dogs multiple times a day, lifting heavy bags of pet food, changing kitty litter, or taking pets to the groomer or the vet.) But if you think you can physically manage it, the emotional benefits of caring for furry, feathery, or other types of animal friends may help improve your mental outlook.

According to a survey of 2,000 pet owners conducted by the Human Animal Bond Research Institute, three-quarters of pet owners reported a mental health improvement from having a pet.

“Positive human-animal interaction is related to the changes in physiological variables both in humans and animals, including a reduction of subjective psychological stress (fear, anxiety) and an increase of oxytocin levels in the brain,” according to the Anxiety and Depression Association of America. The organization notes that pets and therapy animals can help promote less stress, anxiety, depression, and feelings of loneliness and isolation.

Becky L., who has PsA, is on antidepressant medication and has four dogs, including one emotional support animal. Valjene P., who also has PsA, calls herself “a crazy bird lady.” “I have two parrots and I feed about 50 lorikeets!” Another PsA patient named Amanda K. fosters kittens. “It gets me out of my head and caring for someone else,” she explains. “It motivates me to move more. And I get more time with the family in my room where I rest, because who can resist kittens?”

Spend time in nature

Ann, who has RA, likes to spend time in nature, especially around trees, and indeed, there is “a strong connection between time spent in nature and reduced stress, anxiety, and depression” according to Jason Strauss, MD, director of geriatric psychiatry at Harvard-affiliated Cambridge Health Alliance, in an article for Harvard Health Publishing.

In a growing area of research called ecotherapy, multiple studies have reported mental health benefits from being in soothing natural settings. One 2015 study, for example, found that people had reduced brain activity in an area where repetitive negative thoughts (called ruminations) tend to occur after they walked for 90 minutes in a natural setting.

“Calming nature sounds and even outdoor silence can lower blood pressure and levels of the stress hormone cortisol, which calms the body’s fight-or-flight response,” according to the Harvard article. Having visually pleasing things to look at can distract your mind from negative thinking.

Do something to stoke your creativity

Often, living with chronic pain diseases like arthritis remind us of everything that has been taken away from our lives — from our mobility to our ability to live without pain and worry. Artistic hobbies are an antidote to that feeling of being robbed — they help us focus on creating, doing, and accomplishing something cool.

“Creative engagement can decrease anxiety, stress, and mood disturbance,” reports a study in the American Journal of Public Health. “Through creativity and imagination, we find our identity and our reservoir of healing.”

Creativity is “super important,” confirms Willard Virant, whether it’s writing, painting, dancing, taking photographs, or other hobbies. She asks patients having a hard time connecting to the world to use their iPhones and take some pictures and bring them in to discuss. “It gets people to live outside their heads more.”

In fact, the World Health Organization (WHO) recently examined over 900 publications on the arts and health and concluded that engaging with the arts can be beneficial for both mental and physical health.

And lest you think that “arts” means something very visual and specific, like painting, the WHO report defined it more broadly, including such categories as performing arts (music, dance, singing, theater, film); visual arts (crafts, design, painting, photography); literature (writing, reading, attending literary festivals); culture (going to museums, galleries, concerts, the theater); and online arts (including animation and digital arts).

RA patient Camilla A. has struggled with depression since the age of 8. She has found music and painting to be effective coping mechanisms. Tina P. and Gina P., who also have RA, find solace in journaling. Diana R. colors, often on apps on her tablet, while Tina makes collages. Shawna E. has re-launched a craft business making jewelry. “To help myself through a flare, depression and anxiety, I started making my gemstone bracelets again,” she says. “It’s a much-needed confidence boost.”

Find a ‘spiritual’ practice that works for you

Many fellow patients I spoke with mentioned aspects of spirituality and religion as ways to prevent and cope with their depression. Willard Virant is a big proponent of mediation, mindfulness, guided imagery, and deep breathing exercises — and recommends different techniques to her patients.

Ann A., who has RA, copes with her depression with prayer and daily gratitude work. RA patient Kimberly R. listens to spiritual teachings on You Tube and in various podcasts, including Eckhart Tolle, Brene Brown, and Oprah’s Super Soul Sunday.

“Even if I don’t share [the same] beliefs [as the hosts], I continue to learn about gratitude and staying in the moment with acceptance,” she says.

Rethink your approach to napping

Chronic illness can cause intense fatigue, and yet many of us get depressed if we lie around too much. We feel isolated and lazy. Napping can be good for us, but it can also make us feel guilty.

Remember this: “Rest is not a punishment,” Willard Virant says. “You’re not doing nothing, you’re in a lot of pain. What you’re doing is actually really, really, really important. You’re replenishing your body.”

To make naps feel less depressing, Willard Virant asks her patients to imagine what they can do to make their resting space feel good to them. That could mean a soft blanket, lavender aromatherapy, or listening to classical music. “It’s amazing,” she beams. “People really brighten up when we start talking about how we make rest not be a punishment and something that feeds you.”

Let it out

This is easier said than done, but don’t bottle up your feelings — whether that’s sadness, grief, frustration, or anger. “I let myself be sad sometimes instead of fighting it,” says RA patient Meaghan S.

“Holding it in and pretending everything is fine is also problematic. Sometimes I let myself cry just to get it out, then I pick myself up, dust myself off, go for a walk or just go sit in a hot tub.”

“I curse. A lot,” adds Tami S. “Probably enough to make a sailor blush.”

Not Sure What’s Causing Your Pain?

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Keep Reading

Bratman GN, et al. Nature experience reduces rumination and subgenual prefrontal cortex activation.Proceedings of the National Academy of Sciences of the United States of America. July 2015. doi: https://doi.org/10.1073/pnas.1510459112.

Breton A, et al. Enhancing the sexual function of women living with chronic pain: A cognitive-behavioural treatment group. Pain Research and Management. May/June 2008. doi: http://dx.doi.org/10.1155/2008/369382.

Can you dance your way to better health and well-being? For the first time, WHO studies the link between arts and health. World Health Organization. November 2019. http://www.euro.who.int/en/media-centre/sections/press-releases/2019/can-you-dance-your-way-to-better-health-and-well-being-for-the-first-time,-who-studies-the-link-between-arts-and-health.

Feldman, S. Alleviating Anxiety, Stress and Depression with the Pet Effect. Anxiety and Depression Association of America. November 2018. https://adaa.org/learn-from-us/from-the-experts/blog-posts/consumer/alleviating-anxiety-stress-and-depression-pet.

Francis HM, et al. A brief diet intervention can reduce symptoms of depression in young adults – A randomised controlled trial. PLOS One. October 2019. doi: https://doi.org/10.1371/journal.pone.0222768.

 Interview with Katie Willard Virant, MSW, JD, LCSW, a psychotherapist in St. Louis

Lee CH, et al. The Role of Inflammation in Depression and Fatigue. Frontiers in Immunology. July 2019. Doi: http://dx.doi.org/10.3389/fimmu.2019.01696.

Margaretten M, et al. Depression in patients with rheumatoid arthritis: description, causes and mechanisms. International Journal of Clinical Rheumatology. December 2011. doi: http://dx.doi.org/10.2217/IJR.11.6.

Pain, anxiety, and depression. Harvard Health Publishing. https://www.health.harvard.edu/mind-and-mood/pain-anxiety-and-depression.

Sheng J, et al. The Link between Depression and Chronic Pain: Neural Mechanisms in the Brain. Neural Plasticity. June 2017. doi: http://dx.doi.org/10.1155/2017/9724371.

Sour mood getting you down? Get back to nature. Harvard Health Publishing.https://www.health.harvard.edu/mind-and-mood/sour-mood-getting-you-down-get-back-to-nature.

Stuckey HL, et al. The Connection Between Art, Healing, and Public Health: A Review of Current Literature. American Journal of Public Health. February 2010. doi: http://dx.doi.org/10.2105/AJPH.2008.156497.

Support groups: Make connections, get help. Mayo Clinic. https://www.mayoclinic.org/healthy-lifestyle/stress-management/in-depth/support-groups/art-20044655.

Survey: Pet Owners and the Human-Animal Bond. Human Animal Bond Research Institute. https://habri.org/2016-pet-owners-survey.