Depression and Autoimmune and Chronic Illnesses

[Bens_Friends]

Sascha Gallardo – November 18, 2020

One of the things the Ben’s Friends team always tries to emphasize in the communities is to never to feel guilty for being depressed. Instead, members are encouraged to seek help from medical experts as well as ask and provide support to others including their fellow patients.

Our Co-EDs have always promoted the concept of “to get support, one must give support.” This was explained in detail by Clasina in a previous blog titled Hanging Out is Helping Out: The Cycle of Helping Each Other at Ben’s Friends.

Promoting this kind of attitude towards depression is based on a discussion that has long been going on in many of our communities: depression is a common comorbidity in many autoimmune and chronic diseases. Studies show such is actually the case.

This blog will present findings from recent studies regarding the relationship between depression and autoimmune and chronic diseases.

Depression prevalence among patients with autoimmune diseases

A study by Yanjun Liu and Xiangqi Tang titled Depressive Syndromes in Autoimmune Disorders of the Nervous System: Prevalence, Etiology, and Influence, “systematically reviewed the current literature to highlight the prevalence, etiology and influence of depressive manifestation in ADNS.” [1]

The authors covered many autoimmune disorders of the nervous system such as multiple sclerosis, Guillain-Barré syndrome (GBS), chronic inflammatory demyelination polyradiculoneuropathy (CIDP), and myasthenia gravis.

Even though they’re looking at different autoimmune diseases, a common finding of the many studies is that these patients have a higher risk of suffering depression. For instance, it was found that GBS patients have a higher risk of having depression by 4.8 fold, while among MS patients, “the frequency of depressive disorders rang[e] from 17 to 50%.” [2]

Another article titled Depression in Psoriatic Arthritis: Dimensional Aspects and Link with Systemic Inflammation by Ashish J. Mathew and Vinod Chandran reviewed previous studies on psoriatic arthritis and depression to “explore existing evidence on the burden of depression in PsA patients, the link between inflammation and depression in these patients and the screening tools used to evaluate the subdomains of depression.” [3]

Mathew and Chandran looked at various studies that examined the prevalence of depression among PsA and/or psoriasis patients. The common finding is that depression and anxiety are quite common among PsA patients.

These studies include a 2014 study conducted by McDonough, et. al. where they found a 36.6% and 22.2% prevalence rate for anxiety and depression in a cohort involving 306 PsA patients and 105 psoriasis patients. A study involving 495 PsA patients in Spain, on the other hand, revealed a 17.6% prevalence for depression while a 2017 study found that patients with psoriatic arthritis have a higher risk of depression by 22% compared with the general population. [4]

Causes of depression

There are different factors that may be causing or contributing to the prevalence of depression among patients with autoimmune and chronic diseases.

Liu and Tang found four possible causes. These are: (1) psychological factors, (2) immunological dysregulation, (3) structural brain damage, and (4) drug-related depression.

The authors recognize that “it has proven difficult to conclude the subjective experience” but the different constraints resulting from chronic illnesses were found to be related to the patient’s depression in one way or another. Some of these constraints are poor treatment procedures, deteriorating relationships, and high levels of stress. [5]

Aside from the psychological factors, several studies Liu and Tang reviewed found that immunological response or the release of cytokines as well as damage in the brain such as in multiple sclerosis are factors contributing to depression among patients. Moreover, certain substances in the medications such as interferon and corticosteroids were hypothesized to be causing depression among multiple sclerosis and myasthenia gravis patients respectively. [6]

When it comes to psoriatic arthritis, Mathew and Chandran’s review of previous studies show that “pain from PsA and depressive symptoms are inter-connected and point to a common inflammatory etiology for both.” [7]

And, similar to Liu and Tang’s findings “Pro-inflammatory cytokines associated with PsA are associated with symptoms of depression and anxiety.” [8]

How depression affects autoimmune patients

Needless to say, depression significantly affects patients’ quality of life. According to Liu and Tang, 40-50% of the lowering health-related quality of life (HRQL) was due to neurological changes. The rest of it is caused by other factors including depression, pain, fatigue and cognitive impairment. [9]

Beyond this, however, depression can also have a direct impact on the disease itself. For instance, depression is found to prevent patients’ positive response to PsA treatments. Such is the case of 566 patients in a British study where comorbidities like depression were related to the discontinuance of TNF inhibitors. Mathew and Chandran therefore suggest that physicians should be aware of this correlation when designing patients’ treatment plans. [10]

Moreover, some symptoms related to depression may cause delays in diagnosing autoimmune diseases like myasthenia gravis. For example, muscle weakness, low energy levels, and breathlessness, which are symptoms of MG, are also related to depression and may cause misrecognition of the former. [11]

Summary

Our society may have biases against certain behaviors. It is common to hear comments like “toughen up” or “snap out of it” so it is not unusual for people including patients with chronic autoimmune illnesses to feel guilty whenever they exhibit depression symptoms. But as the studies reveal, depression is prevalent among autoimmune patients.

Not only should patients avoid feeling guilty for being depressed, it is highly recommended that they seek help from medical experts. This is both to address the depression as well as to factor that in in their treatment plans as advised in the study above.

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NOTES:

[1] Yanjun Liu, Xiangqi Tang (2018 September). Depressive Syndromes in Autoimmune Disorders of the Nervous System: Prevalence, Etiology, and Influence. Front. Psychiatry 9:451.

[2] Liu and Tang.

[3] Ashish J. Mathew and Vinod Chandran (2020 Jun). Depression in Psoriatic Arthritis: Dimensional Aspects and Link with Systemic Inflammation. Rheumatol Ther*;* 7(2): 287–300.

Published online 2020 Apr 22.

[4] Mathew and Chandran

[5] Liu and Tang

[6] Liu and Tang

[7] Mathew and Chandran

[8] Mathew and Chandran

[9] Liu and Tang

[10] Mathew and Chandran

[11] Liu and Tang

[tamac]

As one that has dealt with depression for over 30 years, this advice is sound.

If you are dealing with it, stop worrying about what other people think, and ignore most of their suggestions. Find a good psychiatrist, not a therapist at first. If it is bad enough you are needing or seeking help, let a psychiatrist help you with the meds. Not a GP. Psychiatrist know their meds. They are like our rheumies. If the first meds do not work well enough, there are others they can change to.

Ask for a referral for a psychiatrist from a good primary care good. When you see that doc the first time make sure you feel comfortable with them. If they recommend medications discuss any and all side effects. If they seem unwilling to discuss potential side effects with you, find another psy doc.

It is not that side effects can be bad, just don’t let a doc ignore your concerns. This will be sort of a test for you to see if the doc you are talking to is going to listen to you.

Once the meds begin helping, you should find a talk therapist. Psychiatrists do not have the time, nor will insurance usually pay, for you to talk to them for an hour. My first one did talk therapy with me for nearly four years, but this was a long time ago when that was what psy docs did.

Depression is chemical, but from my studies and talking to my docs, it seems us humans can be triggered by something in life that sets off the chemical imbalance. That has to be addressed or all the talk in the world will not help.

Over thirty years I have educated myself about depression, mental health, and medications. My second psychiatrist asked me to go back to school and become his NP so I could prescribe meds for him all day when he couldn’t meet with patients. He said I knew as much about them as he did. You don’t have to learn all this, but the more you educate yourself the more you will feel as if you can put a handle on what is going on.

Depression is a hideous disease. It takes your life away if you are suffering badly (much like our PsA). Until you feel it is getting better and you have some handle on the why and causes, it is hard to understand. After all my years I now feel that my understanding of life triggers and how the meds work has helped me a lot. Not everyone will want to study all that, but that is my personality.

Unfortunately, the form of depression I have is what they now call drug-resistant or treatment-resistant. It is a subset that is difficult to treat. I went through many different meds for 20 years. All they could do at that time was keep me from going over into the abyss. In 2008 they approved an electrical device that is implanted in my chest that stimulates my brain. Without getting deep into how it works, for drug-resistent forms the SSRI drugs (serotonin reuptake inhibitors) do not work as well as they should because I do not have enough serotonin for them to work with. There is no medications that will increase brain serotonin levels. The implant stimulates my vagal nerve and that makes more serotonin. Now the medications I still have to take work.

It can be a long road to recovery. Get good doctors and good therapists. I do have to say you need a good support system at home. This is very important. Depression is not only hard on you, it is hard on your family. it is very hard on a marriage. Without a good support system, recovery will be hard and long. I often took my wife with me to see my psychiatrist so she could ask questions. Often I just let the two of them meet without me in the room. Dealing with this is a family affair.

As a lost word…there may be people in your life that you have to distance yourself from. It may be your parents, it may be your spouse. I have lost too many friends my age that did not have a support system. Two of them had well-meaning Christian parents. Unfortunately, their advice too often was that my friends were not praying enough or not going to church, etc. One of these I talked to and told them that God was an important part of the healing, but God helps those that help themselves. They knew they could not pray their way out of the depression, but I lost one of them because of their well-meaning parents.

With depression, you doubt yourself. You do not need anyone around you that is fueling that doubt. Understanding this is an important part of the road to recovery. If you and your doctor(s) is trying everything they can, you do not need to go home and have that work destroyed. If that is happening a serious sit down and tough love to those destroying your recovery will be needed.