Osteoarthritis and Depression

Chronic joint pain or osteoarthritis sometimes go hand-in-hand with depressed mood. But which comes first, the depression or the osteoarthritis? Understanding more about this answer could possibly change your life.

Symptoms of depression can include:

Persistent sad, anxious or "empty" mood
Feelings of hopelessness or pessimism
Feelings of guilt, worthlessness or helplessness
Loss of interest or pleasure in hobbies and activities that were once enjoyed, including sex
Decreased energy or fatigue
Difficulty concentrating, remembering or making decisions
Insomnia, early-morning awakening or oversleeping
Appetite and/or weight changes
Thoughts of death or suicide or even suicide attempts
Restlessness or irritability

A better understanding of how depression and arthritis may be linked, will help you establish a direct plan of action as you embark on a path to raise your level of health and vitality.

Osteoarthritis and Depression

"Depression is significant among patients with arthritis and musculoskeletal illnesses." This is a statement by physicians writing in the American Journal of Medicine in 2008. In their paper, they discuss evidence highlighting the close links between depression and arthritis. What is most promising about this report is the finding that "a focused, collaborative depression care intervention not only decreased depression, but also improved arthritis-associated outcomes, such as pain severity and arthritis-related limitations in daily activities. Relative to patients given usual care, patients receiving [depression] intervention also reported better health status and higher quality of life." In other words, managing the depressive condition not only improved depressive symptoms, but joint-related pain and limitations, as well. They go on the write that "An integrated depression and pain program using evidenced-based pharmacologic and nonpharmacologic treatments is needed to achieve optimal depression and pain outcomes."

A brief note about "non-pharmacologic" (non-drug) treatments of depression will be explored later in this article.

[Lin, EH. Depression and osteoarthritis. Am J Med 2008;121(11 Suppl 2):S16-9.]

Depression and Pain Perception

One way that depression may act to worsen arthritis is through pain perception. More precisely, doctors have long noticed that people with depression often have a heightened sensitivity to pain. Recently, doctors writing in the journal Pain Medicine carefully studied the factors associated with pain intensity in more than 1,000 patients with osteoarthritis. Severity of depression was the single most important factor linked to pain intensity. Disability of a lower limb was the next most important factor. Fourth on the list was social isolation or a "weak social network." [Rosemann, T, et al. Pain and osteoarthritis in primary care: factors associated with pain perception in a sample of 1,021 patients. Pain Med 2008;9(7):903-10.]

These findings would suggest that managing depression is one way to improve mobility and quality of life in people with osteoarthritis. I would also seem to suggest that the severity of symptoms is not always related to the amount of injury or damage within the joints. This has been verified in other studies. But it is important to understand, because part of the difficulty of living with arthritis is the belief that nothing can be done to improve it or that it will simply get worse with time. New evidence clearly shows that this is not the case--there is much that can be done.

Isolation and Loneliness

The link between social isolation and osteoarthritis is being increasingly noticed by doctors. If you have arthritis, you may reduce your interactions with other people, because of limitations in your mobility and your lowered ability to comfortably go places and do things. This is according to Dr. Jamila Bookwala of Lafayette College in Pennsylvania. She is the lead author of a study distinguishing the physical impairment caused by OA of the knee from the social impairments caused by the disease --Psychology and Aging, December 2003.

Overweight and Depression

Int J Obes (Lond). 2009 Jan 6. [Epub ahead of print]

Related Articles,

Links

Depression and anxiety among US adults: associations with body mass index.

Zhao G, Ford ES, Dhingra S, Li C, Strine TW, Mokdad AH.

1Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA.

Background:Obesity is associated with an increased risk of developing a variety of chronic diseases, most of which are associated with psychiatric disorders. We examined the associations of depression and anxiety with body mass index (BMI) after taking into consideration the obesity-related comorbidities (ORCs) and other psychosocial or lifestyle factors.Methods:We analyzed the data collected from 177 047 participants (aged>/=18 years) in the 2006 Behavioral Risk Factor Surveillance System. Current depression was assessed by the Patient Health Questionnaire-8 diagnostic algorithm. Lifetime diagnoses of depression, anxiety and ORCs were self-reported. The prevalence of the three psychiatric disorders was age standardized to the 2000 US population. Multivariate-adjusted prevalence ratios were computed to test associations of depression and anxiety with BMI using SUDAAN software.Results:The age-adjusted prevalence of current depression, lifetime diagnosed depression and anxiety varied significantly by gender. Within each gender, the prevalence of the three psychiatric disorders was significantly higher in both men and women who were underweight (BMI<18.5 kg/m(2)), in women who were overweight (BMI: 25-<30 kg/m(2)) or obese (BMI>/=30 kg/m(2)), and in men who had class III obesity (BMI>/=40 kg/m(2)) than in those with a normal BMI (18.5-<25 kg/m(2)). After adjusting for demographics, ORCs, lifestyle or psychosocial factors, compared with men with a normal BMI, men with a BMI>/=40 kg/m(2) were significantly more likely to have current depression or lifetime diagnosed depression and anxiety; men with a BMI<18.5 kg/m(2) were also significantly more likely to have lifetime diagnosed depression. Women who were either overweight or obese were significantly more likely than women with a normal BMI to have all the three psychiatric disorders.Conclusions:Our results demonstrate that disparities in the prevalence of depression and anxiety exist among people with different BMI levels independent of their disease status or other psychosocial or lifestyle factors.International Journal of Obesity advance online publication, 6 January 2009; doi:10.1038/ijo.2008.268.

Depression and Metabolic Syndrome

It is now well known that there is a link between depression and a pre-diabetic state known as the metabolic syndrome (this used to also go by the name syndrome X). Metabolic syndrome is also linked to osteoarthritis, suggesting that there are some common features to all these conditions. Doctors writing in Diabetes Care in 2008 summarized their analysis of 5,232 people who were assessed beginning in 1991, then again six years later. They found that having the metabolic syndrome predicted who would get depression in later years. This is a very important studies. Doctors have not be entirely clear on whether depression leads to metabolic syndrome or metabolic syndrome leads to depression. Many doctors have thought is was a two-way street, so to speak.

While it still has two-way components, this finding that the metabolic syndrome leads to depression is very important to understand. Doctors also found something very interesting. They observed that the strongest contributors (from the metabolic syndrome) to depression was increased belly fat, high triglyceride levels, and low HDL cholesterol. As the authors state: "Our results suggest that the metabolic syndrome, in particular the obesity and dyslipidemia components, is predictive of depressive symptoms." In other words, the part of the metabolic syndrome that predicted whether someone would get depression later on are:

1) belly fat

2) high triglycerides

3) low HDL cholesterol

So, what of the two-way street? In another study, women were followed for 15 years. They were assessed for both diabetes and mood-related factors, such as depressive symptoms, stressful life events, feeling angry, tense, or stressed. Those women who, at the beginning of the study, reported feeling frequently intensely angry, tense, or stressed had an increased risk for developing the metabolic syndrome. Those women with more severe depressive symptoms were also more likely to develop metabolic syndrome.

According to the doctors conducting this study, “These are the first data to demonstrate that psychosocial factors predict the risk for developing the metabolic syndrome by multiple definitions. Psychosocial factors may play a causal role in the chain of events leading to the metabolic syndrome.”

[Räikkönen, K, Matthews, KA, Kuller, LH. Depressive symptoms and stressful life events predict metabolic syndrome among middle-aged women: a comparison of World Health Organization, Adult Treatment Panel III, and International Diabetes Foundation definitions. Diabetes Care. 2007;30(10):2761.]

Ok. This all sounds like a lot of complicated stuff to keep track of. What does it mean for osteoarthritis? Put simply, there seems to be a messy relationship between weight gain, belly fat, blood sugar, depression, and arthritis. Put another way, metabolic syndrome, depression, and osteoarthritis appear to interact, where one may lead to another. While they might all seem unrelated, they are joined by their common biochemistry. As a practical matter, it means that if you gain control of your diet, lifestyle, and physical activity, you have a resounding chance to gain control of your joints, your pain perception, and your quality of life.

[Akbaraly, TN, Kivimaki, M, Brunner, EJ, et al. Association between metabolic syndrome and depressive symptoms in middle-aged adults: Results from the Whitehall II study. Diabetes Care 2008;Dec 23.]

Non-Drug Support for Depression

In the article above from the American Journal of Medicine, doctors wrote about the importance of pharmacologic and non-pharmacologic interventions for depression in people with joint pain. We would like to explore evidence for one form of non-drug intervention here, because this type of data lies, in part, behind our enthusiasm for a self-care program that supports healthy joints. As we've noted previously, the Insulite System for Healthy Joints incorporates elements of diet, nutrition, and lifestyle that have been shown in previous studies to have an influence on both depression and on osteoarthritis. One intervention with a fair amount of evidence is a nutrient molecule called SAMe.

The United States Department of Health and Human Services has a department called the Agency for Health Care Research and Quality (AHCRQ). They undertook an investigation that examined the benefits of SAMe (S-adenosyl-methionine) on depression and on osteoarthritis (SAMe Treats Osteoarthritis, Depression, and Liver Disease, Agency for Healthcare Research and Quality. 2002;64:1–3). SAMe is a compound made in the body from the dietary amino acid methionine. It is crucial to processes in the brain called methylation reactions, which help make our neurotransmitters. It is also important in joint function. In all, SAMe influences some 100 metabolic reactions in the human body.

The Agency for Health Care Research Quality identified 47 studies involving SAMe for depression and 14 studies for SAMe for osteoarthritis.

Twenty eight of these studies were included in an analysis of the benefits of SAMe to decrease symptoms of depression.

SAMe vs. Placebo. Compared to placebo, treatment with SAMe was associated with an improvement of approximately 6 points in the score of the Hamilton Rating Scale for Depression measured at 3 weeks. This degree of improvement is statistically as well as clinically significant and is equivalent to a partial response to treatment. According to the researchers, “The results generally favored SAMe compared to placebo.”
SAMe vs. Antidepressant Drugs. Use of SAMe resulted in outcomes similar to that achieved by antidepressant drugs.

Ten studies were included in an analysis of the benefits of SAMe to decrease pain of osteoarthritis.

SAMe vs. Placebo. One large randomized clinical trial showed an effect size in favor of SAMe of 0.20 compared to placebo, thus demonstrating a decrease in the pain of osteoarthritis.
SAMe vs. Anti-inflammatory Drugs. Use of SAMe resulted in outcomes similar to that achieved by anti-inflammatory drugs (such as ibuprofen, indomethacin, aspirin, and others).

Depression may also be linked to development of another factor that is often linked to osteoarthritis—the metabolic syndrome. Recall that the term metabolic syndrome is often used to describe disturbances in blood glucose, blood insulin, and blood fats that falls short of true diabetes.

The relationship between disease symptoms, life events, coping and treatment, and depression among older adults with osteoarthritis