Mental Health Screening in Rheumatology: The Overlooked Connection

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Rheumatology, being a medical specialty that deals with the diagnosis and treatment of rheumatic diseases, has for a long time incorporated the importance of musculoskeletal pain, particularly arthritis and autoimmune diseases. However, one of the usual and frequently neglected aspects of rheumatology is the high rate of psychiatric diseases in patients with musculoskeletal pain. It is established that mental health and physical health are correlated; however, assessment of mental health is seldom incorporated into the routine rheumatologic patient examination. Such omissions result in wrong diagnoses, delayed treatment, and therefore unsatisfactory client results. Regarding rheumatology, special emphasis should be placed on the significance of mental health assessment since it is instrumental in the general approach to patients, the identification of correct diagnoses, and in enhancing the quality of life in identified individuals. This blog aims to bring attention to the association between psychiatric disorders and rheumatologic conditions and to stress the importance of introducing systematic mental health assessment in rheumatology practice.

The Epidemiology of Psychiatric Diagnosis in Rheumatology

Many who attend rheumatology clinics have chronic pain in the joints and muscles, which is often undiagnosable, thus being a source of frustration to the patient and the healthcare provider. Some past research has demonstrated that a large number of these patients also have psychiatric disorders; increased rates are recognized in comparison to those observed in general medical clinics. Such patients often have anxiety disorders, depression, and somatoform disorders. Depression and other psychiatric disorders’ incidence in rheumatology patients with BPMs may be as high as 40%, 2–3 times higher than in similar patients in primary care.

It may be postulated that symptoms of psychiatric disorders may enhance rheumatology patients’ perception or reporting of musculoskeletal pain and disability. For example, pain may affect those patients who have anxiety or symptoms of depression, as these patients would have higher pain sensations, more pain, and disability interfering with their quality of life. Moreover, psychiatric disorders interfere with rheumatologic diagnosis, which relates to signs of a diseased mind as being an indication of an underlying rheumatologic condition. This has often made it difficult to disentangle between isolated primary rheumatologic conditions and musculoskeletal manifestations due to psychiatric disorders.

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Impact on Diagnosis and Treatment

They pointed out that those patients who come to the rheumatologist complaining of musculoskeletal pain and other complaints often have psychiatric disorders that complicate the diagnosis. In their clinical practice, rheumatologists can come across situations when it is challenging to establish whether the symptoms that the patient complains of are predominantly of rheumatic origin or are substantially colored by psychiatric disease. Consequently, GP decision-making may become protracted, costly, and potentially misleading, and a spectrum of diagnostic uncertainty appears or diagnostic confusion or diagnostic imprecision seems to occur.

Furthermore, there is always the predisposing factor of different psychiatric disorders that may affect the outcome of the treatment. For example, patients with comorbid depression and/or anxiety may show lesser treatment compliance, worse coping behaviors, and a higher probability of continuing self-report of symptomatology even when on appropriate treatments. These factors can often interfere with the management of rheumatologic conditions and can cause persistent or aggravated symptoms, which in turn add to the patient’s psychological issues.

The Demand for Standardized Psychiatric Examination

Due to this, it is clear that among rheumatology patients, a large proportion suffer from psychiatric disorders and should therefore be screened for these conditions. Mental health screening in rheumatology clinics may identify patients who will require early intervention, thus increasing patient prognosis. PRIME-MD has been used effectively to detect psychiatric disorders in primary care settings, and its use in rheumatologic practice can be easily envisaged.

It will also ensure that rheumatologists and mental health caregivers are regularly in touch, and hence the patients have a better chance of being managed holistically. He or she can diagnose and treat a patient’s mental health disorder early enough, thus enabling the rheumatologist to possibly come up with relevant treatment plans that would leave those suffering from rheumatic diseases with relatively low levels of both physical and psychological dysfunction.

Barriers to Implementation

That is why there are several barriers to the implementation of mental health screening in rheumatology, as follows: The most difficult of these is the small amount of time one is likely to spend with the patient during consultations. The major areas of concern in rheumatology clinics involve the evaluation of multiple aspects of complicated musculoskeletal complaints, which often afford restricted opportunities for performing comprehensive psychiatric assessments. Also, the rheumatologists’ may not be well-trained and may not be fully confident in identifying and treating psychiatric disorders, and therefore they may not incorporate adequate mental health screening.

One of them is cultural; decisions based on culture still frown at people with such disorders, thus discouraging the patient from revealing signs of a malfunctioning mind or seeking help. A sub-theme is the feeling of rejection that patients have for seeking help from a different doctor for mental problems; a worry that their physical symptoms will be regarded as fabricated or overstated if they come out and admit to having mental problems. These kinds of stigma can be a major barrier to the adoption of mental health screening as part of the usual rheumatologic practice.

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Strategies for Overcoming Barriers

To eradicate such barriers, the following can be employed: Several strategies can be put into practice. Firstly, rheumatology practices can incorporate standardized brief mental health questionnaires that have been shown to take little time to complete and score and can often be done within the time available usually utilized for an average consultation. For a depression assessment, the Patient Health Questionnaire (PHQ-9) is one of the brief instruments that can be used even in a busy clinical setting; another is the Generalized Anxiety Disorder 7-item (GAD-7) scale for testing for anxiety.

Secondly, rheumatology training programs should include knowledge about diagnosing and managing psychiatric disorders, which should prepare rheumatologists to act competently and confidently in managing mentally ill patients. CME programs can also be used to provide practicing rheumatologists with new information on mental health screens and treatment.

In third place, it is recommended to encourage synergy between rheumatologists and mental health practitioners for better client outcomes. Creating referral linkage systems and care coordination plans in which mental health professionals are easily reachable within rheumatology clinics can help in the early identification and management of psychiatric disorders among patients.

The Role of Integrated Care

Treatment programs that are a combined delivery of mental health services and rheumatology have been reported to produce better results. In such models, mental health specialists collaborate with rheumatologists in the integrated management of patients who seek to treat the physical as well as psychological well-being of the patients. Besides increasing the efficiency of recognizing and addressing patients with psychiatric disorders, it also provides a better understanding and handling of rheumatological diseases.

The analysis of the literature review showed that integrated care provides patient satisfaction and treatment compliance, as well as the prevention of the worsening status of physical and mental health conditions. Engaging with the issues related to the delineation of mental health within rheumatology, integrated care models are beneficial for offering a considerably longer and more reframed approach to healthcare, thus corresponding to the patient’s needs better in the long run.

Conclusion

Mental health screening in rheumatology is a well-established, significant, yet underappreciated aspect of the evaluation and management of rheumatology patients. The prevalence of psychiatric disorders in patients with rheumatology was significantly high, and this warranted screening for such disorders so that patients gain the correct diagnosis, treatment, and better prognosis. Despite such challenges, they can be hardly an insurmountable obstacle if and when brief screening tools are used, rheumatologists are trained adequately, and mental health support is provided within rheumatology practice.

This not only represents a huge missed opportunity to address the obvious mental health concerns of these patients, but it also undercuts rheumatology practices’ ability to provide comprehensive, patient-centered care that is so desperately needed to improve the quality of life of these patients and, indeed, their overall health. It has become high time for rheumatology to embrace the concept of mental health and musculoskeletal health and ensure patients get the attention they deserve.

References

  1. O’Malley, P.G., Jackson, J.L., Kroenke, K., Yoon, I.K., Hornstein, E. and Dennis, G.J., 1998. The value of screening for psychiatric disorders in rheumatology referrals. Archives of Internal Medicine, 158(21), pp.2357-2362.
  2. Parker, T., May, P.A., Maviglia, M.A., Petrakis, S., Sunde, S. and Gloyd, S.V., 1997. PRIME-MD: its utility in detecting mental disorders in American Indians. The International Journal of Psychiatry in Medicine, 27(2), pp.107-128.
  3. Valenstein, M., Kales, H., Mellow, A., Dalack, G., Figueroa, S., Barry, K.L. and Blow, F.C., 1998. Psychiatric diagnosis and intervention in older and younger patients in a primary care clinic: effect of a screening and diagnostic instrument. Journal of the American Geriatrics Society, 46(12), pp.1499-1505.
  4. Katon, W., Von Korff, M., Lin, E., Walker, E., Simon, G.E., Bush, T., Robinson, P. and Russo, J., 1995. Collaborative management to achieve treatment guidelines: impact on depression in primary care. Jama, 273(13), pp.1026-1031.
  5. Nease, D.E., Volk, R.J. and Cass, A.R., 1999. Investigation of a severity-based classification of mood and anxiety symptoms in primary care patients. The Journal of the American Board of Family Practice, 12(1), pp.21-31.
  6. Kobak, K.A., Dottl, S.L., Greist, J.H., Jefferson, J.W., Burroughs, D., Mantle, J.M., Katzelnick, D.J., Norton, R., Henk, H.J. and Serlin, R.C., 1997. A computer-administered telephone interview to identify mental disorders. Jama, 278(11), pp.905-910.
  7. Ormel, J., VonKorff, M., Ustun, T.B., Pini, S., Korten, A. and Oldehinkel, T., 1994. Common mental disorders and disability across cultures: results from the WHO Collaborative Study on Psychological Problems in General Health Care. Jama, 272(22), pp.1741-1748.

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