Depression in the patient with rheumatologic disease.

Although depression often goes undetected and untreated in practice, 29,32 there are compelling reasons for rheumatologists to be familiar with its recognition and management. Medically ill patients have a higher prevalence of depression than those who report good health. 8 Chronic medical conditions such as rheumatologic disease are associated with increased risk of concomitant psychological disorders. 41 One study of 2552 patients with chronic illnesses, such as arthritis, diabetes, hypertension, cardiac disease and pulmonary disease, revealed that the prevalence of affective diseases (such as depression) was higher in these groups than in individuals without such illnesses. 46 In addition, the prevalence of psychiatric illness among patients referred to a rheumatologist is significant. A recent study of 185 patients referred for musculoskeletal complaints revealed that 40% had a specific psychiatric diagnosis, in contrast to 29% of patients with musculoskeletal complaints seen in a primary care practice. 26 Depressive symptoms not only impact on functional status and well-being more than most medical illnesses, 28,47 but their effects are additive when combined with other chronic medical conditions. 27 In patients with rheumatologic disease, factors such as functional impairment, chronic pain, disfigurement, systemic involvement, work or livelihood difficulties, and loss of independence represent constant sources of psychological stress. These stresses may predispose patients to depressive disorders. Patients with rheumatologic disease have disease-specific risks for depression 25 and the increased risk that accompanies chronic illness in general. There is also emerging evidence that psychological variables may affect the activity of rheumatologic disease as well, making early detection and treatment essential. 24 Rheumatic diseases are often chronic and require ongoing medical care, so that many patients have more frequent contact with their rheumatologist than with other medical providers. Many patients will identify their rheumatologist as the clinician in whom they trust most. This places the rheumatologist in a unique position to identify changes in their patients' physical and mental health, facilitating early recognition and treatment of disease. In addition to rendering rheumatologic care to their patients, rheumatologists are increasingly called upon to treat general medical problems and provide primary care to their patients. Familiarity with the diagnostic criteria and treatment approaches for depression is therefore essential. Moreover, knowledge of side effects and potential drug interactions will ensure proper choices in therapy, thereby sparing the patient adverse outcomes. The course of a major depressive episode cannot be changed by the will of the patient, any more than wishful thinking alters the course of rheumatoid arthritis. They are both serious medical problems that have a major impact on quality of life and have significant morbidity and mortality. This article primarily addresses the detection and treatment of major depressive disorder because it exacts the highest cost in both dollars and suffering. Other commonly encountered depressive disorders, adjustment disorder with depressed mood, dysthymia, and minor depression, are also presented.