As of 2021, about 17.9 million people globally were living with rheumatoid arthritis — an autoimmune type of arthritis that causes inflammation in the joints.
Past studies show that rheumatoid arthritis can negatively impact a person’s health by increasing their risk for irreversible joint damage, osteoporosis, heart disease, eye issues, sleeping problems, obesity, and mental health conditions like anxiety and depression.
Now, two new papers — a perspective paper published in the journal Nature Reviews Rheumatology, and a commentary in The Lancet Rheumatology — have concluded that some of these health issues, such as depression, may not only be complications of rheumatoid arthritis, but may also help maintain the disease especially in people with difficult-to-treat rheumatoid arthritis.
In these two papers, the authors reflect on how certain health problems, such depression, smoking, obesity, and sleep disorders, may impact rheumatoid arthritis and its symptoms.
“Historically, treating [rheumatoid arthritis] meant focusing almost exclusively on physical joint inflammation,” György Nagy, MD, PhD, head/director of the Department of Rheumatology and Immunology at Semmelweis University in Hungary, senior and corresponding author for the Nature Reviews Rheumatology perspective peace, and co-lead author of The Lancet Rheumatology commentary, told Medical News Today.
“Yet, in daily clinical practice, we frequently see patients whose blood work looks completely normal, but who are still experiencing pain, fatigue, and whose everyday functioning is limited,” Nagy added.
“Lifestyle factors like smoking and obesity, and coexisting health conditions like depression and fibromyalgia disproportionately skew the patient-reported metrics used to calculate [rheumatoid arthritis] severity scores. If a patient’s pain is amplified by depression or a sleep disorder rather than active joint swelling, traditional arthritis drugs simply won’t touch it. A recent meta-analysis by Xie et al. [on which the paper in The Lancet provides commentary] systematically identifies different lifestyle factors as major drivers of treatment failure.”
– György Nagy, MD, PhD
Nagy said that the most crucial finding is that these health issues do not just casually exist alongside rheumatoid arthritis; they feed into it bidirectionally, trapping the patient in a grueling “vicious circle.”
“For example, a patient with severe [rheumatoid arthritis] pain may become physically inactive, leading to obesity,” he detailed.
“Obesity generates low-grade systemic inflammation, which further worsens the [rheumatoid arthritis] trajectory. Similarly, failing multiple medications lowers mood and motivation, triggering depression; that depression then amplifies pain perception in the brain and lowers the patient’s ability to rigidly adhere to their treatment plan,” Nagy explained.
“Recognizing that these factors actively maintain the disease state is revolutionary because it means we can break the cycle by targeting the modifiable lifestyle factors directly, sometimes without even needing a new drug,” the researcher added.
Nagy and his team developed a model that could potentially improve the treatment options for people with difficult-to-treat rheumatoid arthritis.
“Currently, [rheumatoid arthritis] care is treated as a linear, ‘one-size-fits-all’ escalator,” he explained. “If a drug fails, the clinician automatically steps up to the next, stronger drug. Our model introduces a smart triage layer.“
“Instead of universally escalating medication when standard care under-performs, the clinician halts to perform a ‘structured multi-domain reassessment.’ We treat the patient’s unique condition like a puzzle, evaluating four specific zones: disease biology, clinical conditions (comorbidities), behavioral habits (adherence), and contextual realities (such as sleep or social support),” Nagy told us.
“Instead of just changing the prescription, our model might pivot a patient toward a multidisciplinary roadmap: engaging pain specialists, psychologists for mental well-being, or personalized nutrition and lifestyle coaching to address weight or smoking,” he continued. “It shifts medicine from rigidly treating a generic disease to flexibly treating an individual human being.”
Nagy said that finding new avenues for “difficult-to-treat” rheumatoid arthritis patients is vital because blindly escalating powerful immunomodulatory medications doesn’t work for everyone.
“Unnecessary drug escalation can expose patients to unwanted side effects and rising healthcare costs without actually relieving their symptoms,” he added. “We must understand the deeper, non-inflammatory drivers to alleviate this impactful clinical and socioeconomic burden.”
MNT spoke with Erica Frenkel, NBC-HWC, FMCHC, functional medicine-certified and a nationally board-certified health and wellness coach, and owner of Erica Frenkel Health Coaching, about these findings.
“We’ve long known about the mind-body connection,” Frenkel, who was not an author on either of the papers, commented. “Generally it is discussed as a one way relationship — illness, pain, or other physical ailments can lead to depression and other mental health issues. What’s less frequently discussed is that the mind-body connection is actually a two-way relationship.”
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“So I’m glad to see research that illustrates the reality that our physical health and wellbeing can be impacted when we are not mentally well,” she added. “My hope is that it leads to more integrative care where we don’t silo mental health and physical health but rather care for the whole person.”
MNT also spoke with Neha Patil Kumar, a licensed marriage and family therapist (LMFT) and owner of Prose & Psyche Counseling, about the findings regarding depression and difficult-to-treat rheumatoid arthritis.
“I’m not at all surprised that depression can sustain persistent rheumatic symptoms,” Patil Kumar, who was likewise not involved in authoring the recent papers, told us.
“We know that depression can negatively impact an individual’s ability to perceive and process pain, which can result in poor treatment adherence and worse outcomes overall. The links between mental health conditions and chronic conditions need to be studied to ensure that clinicians are aware of every possible factor contributing to a patient’s pain in order to provide the most effective, comprehensive treatment possible,” she noted.
Patil Kumar further said that it would be encouraging to see future research evaluate multidisciplinary treatment models that incorporate mental health care into the management of rheumatoid arthritis.
“If depression contributes to persistent symptoms, addressing psychological well-being alongside medical treatment may improve patients’ quality of life and overall health outcomes,” she added.
