The problem of detecting and managing depression in the rheumatology clinic.

Psychiatric comorbidity in arthritis can be surprisingly high. For example, Wells et al (1) reported a lifetime psychiatric prevalence rate of 64% and a recent prevalence rate of 42% (last 6 months) in persons with arthritis drawn from a community sample. Depression is one of the most common psychiatric conditions found in patients with arthritis. Frank et al (2) reported that as many as one-third of patients with rheumatoid arthritis (RA) have been found to experience major depression or dysthymia, according to objective diagnostic criteria. In contrast, the prevalence of depression in nonmedical populations is estimated to be between 5% and 8%. Thus, while depression is one of the most common psychiatric conditions in the general population, it is clear that arthritis increases the risk for depression. Patients are very likely to have difficulty with depression while managing their arthritis and, therefore, to experience symptoms of depression during rheumatology visits. Depression includes a spectrum of disorders that vary in severity and associated impairments. Patients with a history of major depression typically have a chronic course that requires effective monitoring and management. Chronic depression may exist independently of, but can also be exacerbated by, disease flares and other illnessrelated obstacles. Patients with minor depression, or who have an adjustment disorder with depressed mood, experience fewer symptoms and generally have less social, occupational, and functional impairment from their condition than patients with major depressive disorder. In contrast, moderate to severe depression can adversely affect health outcomes and quality of life in a manner similar to that of other chronic medical conditions. In addition, depression may contribute to inflammation, interfere with medical adherence, and thus compromise medical treatment and management. In this regard, a longitudinal study by Ang et al (3) found that clinical depression resulted in a 2-fold increase in the likelihood of early mortality in a cohort of patients with RA followed over a 12-year period. In addition to negative health consequences, depression may contribute to unemployment, loss of work productivity, and increased health care costs in persons with arthritis (4). All of these factors heighten the importance of detecting and managing depression in patients with arthritis. When rheumatologists do not recognize depression, the risks to patients, their families, and the health care system can be severe. In light of the above findings, the article by Sleath et al (5) in this issue of Arthritis Care & Research provides evidence of a significant clinical problem in the care of patients with RA. Three important findings stand out in this research. First, the authors found that patients who were rated by their rheumatologists as having worse functional status were more than twice as likely to have moderately severe to severe depression. Second, only 4 (19%) of the 21 depressed patients had the opportunity to discuss their depression during medical visits. Third, when depression was addressed, the patient initiated the discussion each time. Not once during 200 office visits did a rheumatologist bring up the topic of depression to the patient. Because the study focused only on moderately severe to severe depression, the prevalence of minor depression was not assessed. Many more patients could have been afflicted with less severe forms of depression in the sample.