You’re listening to ReachMD. This episode of Living Rheum, titled “Managing Mental Health in SpA” is sponsored by Novartis US Clinical Development and Medical Affairs. The host and speaker have been compensated for their time. This program is intended for health care professionals.
Here’s your host, Dr Anisha Dua.
Living with a chronic illness or disease is not only physically, but also mentally taxing. The prevalence estimates of depression across the spondyloarthritis spectrum range from 11% to 64%, and so these issues need to be recognized, discussed, and managed, to improve the overall health of our SpA patients.1
This is ReachMD, and I’m Dr Anisha Dua. Joining me to discuss the role of mental health in SpA is Dr Elaine Husni. Dr Husni is an associate professor and director of the Arthritis and Musculoskeletal Center at the Cleveland Clinic. Dr Husni, thanks so much for coming here today to speak with me.
Thanks, Dr Dua. Very exciting topic on mental health and managing this in our SpA patients.
Yeah, absolutely. So, before we dive into the role of mental health in our SpA patients, can you give us your perspective on what it means to address your patients’ mental health? I know this is a big question.
Yes, it is a big question. But we really know that it does affect the way that we are able to treat our patients, and the way that they can get down to low disease activity, and possibly remission, is really influenced by their mood and mental health.2 And we really may not be doing as good a job as we want to because it’s sort of a two-way street, right? Mental illness is something that not only do we have to ask and pick up, but patients have to be willing to tell us in order for us to work as a team to really understand how much of their mental illness might be affecting them. So, it really takes a lot of communication both ways, and sometimes that doesn’t happen in just one visit.
Yeah. No, that’s a good point. I mean, the communication between patients and the physician, and establishing that rapport is so important. And then, of course, there’s so many factors that are barriers, right, to mental health that have become increasingly aware about recently, and hopefully we’ll talk about some of those as we go through this. So, based on your experience, do you think that SpA patients are at a greater risk of mental health issues? And if so, are there any features that might make them more susceptible?
Yeah, so I think having a chronic illness unfortunately does probably put more of a mental toll on a patient because this is something that they know is a lifelong issue, something that most likely doesn’t have an immediate cure. And so, I think that alone adds to some of the anxiety around having a chronic illness. Specifically in SpA, there has been a recent study in 2021 which showed that up to 60.7% were at risk of having a mental health disorder.3 So, more than half our patients that walk in our door are going to have something that needs to be addressed in order for them to feel well. I know in this particular study that younger patients, female gender, patients who are unemployed were probably most vulnerable in this particular group.
Yeah, I think that’s interesting to note that more than half of our patients—I mean, that’s a lot, that’s something we definitely need to be aware of—pick up on, and you were mentioning, having a chronic illness, and then of course, that disability, or unpredictability of whether you can make it to work or lose your job. I mean, those are major causes of stress and anxiety for anyone and when it’s the chronic disease that’s kind of impacting that, it’s gonna take a toll. So, while fibromyalgia, it’s not necessarily labeled a mental health disorder, but it clearly plays a role in overall wellness. So, can you tell us a little bit about the relationship between fibromyalgia syndrome and axSpA?
Yes, I’m always a little tentative to put fibromyalgia in a talk with mental health disorders, but I agree with you. This is definitely, comorbid fibromyalgia is well-recognized in our SpA patients, so hard for us not to talk about it. There are some studies that show it ranges from 12% to 60% of our patients with SpA can be affected by fibromyalgia.4 So it’s hard not to talk about it, and we know itself that about 1 in 5 patients with SpA can meet the diagnostic criteria for fibromyalgia as well.
So, this is a significant part of our population, but at the same time I think it’s really important to understand that fibromyalgia probably falls more into a central sensitization pain issue as opposed to having a true sort of mood disorder, whether it be depression or anxiety, or a combination of that.
Yeah, and I think another interesting thing is just the overlap between some of the symptoms, right? Low back pain, not sleeping well—these are things that you see in fibromyalgia. You also see them in axSpA, so trying to tease out what’s comorbid, what needs more immunosuppression, what needs targeting from a central sensitization perspective.5,6 There’s just so much overlap in terms of mimics, and so it can be definitely difficult to tease out what’s actually active in those patients who have both or might be developing one with a background of the other. Yeah. So, we talked a little bit about the prevalence of mental health issues and fibromyalgia in our patients. But let’s talk a little bit about how we can address some of the challenges. So, what role do you think transparency and ownership play in addressing mental health concerns for our patients with SpA?
Yeah, that’s a tough question. I think how I think about it in our role, is that we need to help empower our patients. Empower them to speak up, empower them to have the education behind what’s going on, and the associations that, we know in our research. We need to destigmatize the conversations about mental health. Make it safe for them to be able to talk to us about it, because as I said, at the beginning if they don’t really share with us it’s really hard for us to treat them as a whole patient if we’re only knowing, you know, 70% of what’s going on. So I do think some responsibility falls on the patient’s side to be reporting some of these things that are occurring with them, but it’s also our job to empower and to create a safe environment for them to be able to give us some of this information.
Yeah, it’s so much a two-way street. We have to ask some of those difficult questions, and they have to feel comfortable enough to bring it up or answer them. So to bring all this together, what are some of the wellness strategies you recommend to help address these mental health challenges and how do you incorporate them into your clinical practice?
So, we have a couple of things that we do in clinical practice. One is, there is something a PHQ-9, that we use for most patients that come for a visit at the Cleveland Clinic.7 So that’s sort of a nice screening measure.
It does ask a bunch of questions that they can do on their own time, in the waiting room, so sometimes they might not want to just come out and tell us that they’re feeling down and depressed and have thoughts of harming themselves, and so the screening measures where they can do on their own time and then we can look at their scores, sometimes is a sort of a noninvasive way to get a sense of what’s going on in their mind. And some, I do look at those questions, and sometimes I’ll pick a question out that they answered poorly, and I say, “Hey, is it okay if I address this question? I see that you answered that you think about sad mood all the time,” and try to get permission to open them up. That’s one way that we can incorporate into practice. The second is just to help them with education, right? So a couple of the statistics that we talked about that patients with chronic disease, more than half of them do have problems with mental health conditions and that you are wondering if, is SpA getting you down? Does this diagnosis bother you in more ways than you’d like it to? Are there things that you were doing a year ago that you’re not doing now? And I think those are really nice, sort of open-ended, but yet safe ways to try to empower our patients to tell us more about how it’s bothering them.
Yeah, those are great points—you know, trying to destigmatize, normalize, and ask are just such important things that you brought up, that we need to be doing to try to open that communication and address some of those significant issues. So that is a great way to round out our discussion on this important topic, and I want to thank my guest for helping us better understand the role of mental health in SpA. Dr Husni, it was wonderful again to speak with you today.
Yeah, thanks for a great conversation. I think this is something we all kinda learned in medical school, and now we have to really bring it up when you’re caring for a chronic disease patient. So, I think it’s always important to hear about it again.
This industry podcast was sponsored by Novartis US Clinical Development and Medical Affairs. If you missed any part of this discussion or to find others in this series, visit reachmd.com/living-rheum.
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- Zhao SS, Thong D, Miller N, et al. The prevalence of depression in axial spondyloarthritis and its association with disease activity: a systematic review and meta-analysis. Arthritis Res Ther. 2018;20(1):1-9. doi:10.1186/s13075-018-1644-6
- Lwin MN, Serhal L, Holroyd C, Edwards CJ. Rheumatoid arthritis: the impact of mental health on disease: a narrative review. Rheumatol Ther. 2020;7(3):457-471. doi:10.1007/s40744-020-00217-4
- Garrido-Cumbrera M, Gálvez-Ruiz D, Delgado-Domínguez CJ, et al. Impact of axial spondyloarthritis on mental health in Europe: results from the EMAS study. RMD Open. 2021;7(3):1-7. doi:10.1136/rmdopen-2021-001769
- Alunno A, Carubbi F, Stones S, Gerli R, Giacomelli R, Baraliakos X. The impact of fibromyalgia in spondyloarthritis: from classification criteria to outcome measures. Front Med. 2018;5(290):1-8. doi:10.3389/fmed.2018.00290
- Fibromyalgia: understand how it’s diagnosed. Mayo Clinic. Published 2017. Accessed May 18, 2022. https://www.mayoclinic.org/diseases-conditions/fibromyalgia/in-depth/fibromyalgia-symptoms/art-20045401
- Strand V, Singh JA. Patient burden of axial spondyloarthritis. J Clin Rheumatol. 2017;23(7):383-391. doi:10.1097/RHU.0000000000000589
- Kroenke K, Spitzer RL, Williams JBW. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606-613. doi:10.1046/j.1525-1497.2001.016009606.