Fostering Mental Health in Rheumatic Disease

By Linda Rath | Dec. 10, 2024

Some signs of autoimmune arthritis are obvious: swollen joints, skin rash, limited mobility. But other symptoms, particularly pain, are unseen. Chronic pain – defined as pain that lasts three months or more – affects about 20% of adults in U.S. at any given time and is a defining feature of autoimmune disease. It can limit a person’s work and social life and is associated with depression, dementia, a higher suicide rate and substance misuse. Chronic pain is also on the rise, increasing faster than diabetes and depression.

Afton Hassett, PhD, an associate professor in the Chronic Pain and Fatigue Research Center at the University of Michigan, spoke at the 2024 American College of Rheumatology Convergence conference about ways to improve mental health in people with arthritis.

According to Hassett, chronic pain doesn’t occur in a vacuum; it’s usually part of a constellation of symptoms that includes sleep problems, impaired cognition and fatigue. The same symptom cluster is found in most chronic conditions, including cancer, she said. “Not everyone has all three [symptoms],” she added, “but you rarely see just one.” 

In addition to these symptoms, people with autoimmune conditions often experience depression, anxiety and loneliness. “They become pessimistic and passive, don’t take care of themselves, and have a decreased sense of self and self-efficacy and a poor self-image,” Hassett said.

The goal should be to treat some of these unseen processes, not just the disease, she emphasized. “We want to turn depression into joy, loneliness into connection and most of all get them moving again, because then they do better in all spheres.”

This may seem like a tall order, but Hassett said it can be accomplished by building resilience. “Adversity is part of the human condition; what matters is how you respond to it. The unifying principle of resilience is that when someone experiences adversity, they can recover, can bounce back.”

She described the four elements of resilience – psychological, social, biological and healthy lifestyle – as occurring on a continuum, depending on where a person is in life. But she maintained that resilience can be taught.

“Most people are moderately resilient, while some are highly resilient and can bounce back from anything. Then there are people who thrive, who go through a traumatic event and come out the better for it. This is the place we want to help people with arthritis get to – not helpless, not hopeless, but thriving.”

She outlined three factors that help build resilience: healthy, positive emotions; mental and emotional flexibility; and strong social support. Many studies show a clear connection between a positive emotion, like optimism, and less pain and disability and the need for less medication. In high-quality studies, the connection is as high as 92%. 

Hassett said it’s not clear why there is such a strong link between optimism and better health. Optimism may strengthen the brain’s reward system. Or it may affect the body’s endogenous opioids – signaling molecules that play a key role in how people perceive and experience pain.

On the other hand, loneliness and depression correlate with more pain and disability and a worse quality of life. Hassett sees loneliness as a particular problem that until recently has gone unacknowledged as a major contributor to poor health.

What can we do about it?

Hassett proposed prescribing what she calls positive activity interventions (PAIs) to help build resilience. They are rooted in behavioral cognitive therapy (CBT), a short-term talk therapy that helps people change negative thoughts, feelings and behaviors. 

One powerful PAI is to schedule time for something a person loves three or four times a week, even if it’s outside what is usually recommended for their particular disorder – for example, jogging for someone with back pain. Then they have to commit to it just as they would to a job or doctor appointment. Consistency and commitment are key.

Other PAIs include volunteering, performing random acts of kindness and savoring moments of joy and beauty. Even a gratitude diary – an idea whose time has pretty much come and gone – can be helpful, Hassett said. “If you have to write down three things you’re grateful for every single day, you run out of big things pretty quickly. Once you have to dig deeper and look for little things, it helps broaden your world and keeps you more focused on things beyond yourself.”

PAIs are simple, scalable, and cost little or nothing. They also offer psychological solutions for people who might not want or can’t afford therapy. 

“PAIs are powerful because they’re not stigmatizing; they’re not about sending people to a therapist,” Hassett said. 

They also work. Studies show that people who engage in PAIs have less pain, depression and anxiety, and the benefits can last for months. 

Her takeaway for people living with arthritis pain is that they have the power to change how they feel and process pain. The intervention that works best for them is the one that helps and that they are willing to stick with. She advised providers to promote interventions that build strength and resilience rather than those that limit patients. 

“Don’t focus on the disease,” she said. People who have a chronic illness or chronic pain have lost their sense of self. Helping them find a life that is purposeful and meaningful should be a priority.