Psychological Aspects of Rheumatic Diseases: Psychorheumatology in Clinical Practice

Abstract

Rheumatic diseases (RDs) significantly impact patients’ physical, psychological, and social well-being, yet psychological dimensions remain inadequately addressed in routine clinical practice. In this commentary, we examine psychological manifestations and mental health comorbidities in RDs, such as systemic lupus erythematosus, systemic sclerosis, Sjögren’s disease, vasculitis, rheumatoid arthritis, juvenile idiopathic arthritis, psoriatic arthritis, axial spondyloarthritis, osteoarthritis, and fibromyalgia. Patients demonstrate high rates of depression (up to 90% lifetime prevalence), anxiety (18–65%), sleep disturbances (19–90%), chronic fatigue (31–89%), and alexithymia (25–59%). The prevalence of anxiety and depression is nearly double in RDs compared to the general population, whereas health-related quality of life is inferior to that in chronic conditions. These manifestations are bidirectionally linked to disease activity, pain intensity, and functional impairment. We propose the utilization of psychorheumatology, integrating psychological assessment, targeted interventions, and coordinated care between rheumatologists and mental health professionals.

Key Summary Points

Patients with rheumatic diseases (RDs) have approximately double the prevalence of depression and anxiety compared to the general population.

There is a bi-directional influence of psychological factors and disease activity in RDs.

Psychorheumatology integrates psychological assessment and interdisciplinary care to improve patient outcomes and quality of life.

Introduction

Rheumatic diseases (RDs) encompass a broad and heterogeneous group of conditions characterized by diverse clinical and laboratory features. They primarily affect the musculoskeletal system, but also often impact other organs and tissues, including lungs, kidneys, skin, gastrointestinal tract, and blood vessels, leading to organ impairment [1]. These manifestations significantly impact multiple areas of patients’ lives, including physical and mental health, social relationships, career, and finances [2]. Patients with RDs frequently report reduced health-related quality of life (HRQoL) [3, 4]. In fact, patients report that their HRQoL is lower compared to other chronic conditions, such as cardiovascular disease, cancer, neurological disease, and chronic kidney disease [5]. In addition, the prevalence of anxiety and depression is nearly double compared to the general population [6]. In a recent rheumatoid arthritis (RA) study with 18 months of follow-up, stress was independently associated with greater self-reported disease activity, more pain, more fatigue, and lower physical function [7].

The high frequency of psychological manifestations is linked to several factors, including inflammatory cytokines, reduced functionality, a sense of lack of control, due to the chronicity and uncertain prognosis of RDs, and the emotional burden arising from physical appearance and symptoms [6]. A meta-analysis showed a strong association between interleukin (IL)-6, C-reactive protein (CRP), and major depression [8], whereas a Mendelian randomization analysis revealed a causal effect of soluble IL-6 receptor (sIL-6R) on depression [9]. CRP levels were also associated with depression and anxiety [10], whereas higher CRP levels were detected even in otherwise healthy middle-aged individuals with a recent negative affect and pain [11]. The relationship between biological mechanisms of disease and psychosocial processes is complex. Behaviors, such as avoiding physical activity, cognitive attitudes, such as pessimism, and emotional states, like depression, can directly influence the intensity of pain and fatigue. These same factors may also indirectly affect disease progression by impacting medication adherence and the pursuit of medical help [12].

This commentary highlights the substantial psychological burden of various RDs and emphasizes the urgent need for targeted psychological interventions. Such strategies are essential for the improving patients’ HRQoL and mitigating the debilitating effects of symptoms on daily functioning. This article is based on previously conducted studies and does not contain any new studies with human participants or animals performed by any of the authors; formal ethics approval was not required.

Psychological Burden of Rheumatic Diseases: The Size of the Problem

Systemic Lupus Erythematosus

Systemic lupus erythematosus (SLE) is a prototype of systemic autoimmune inflammatory diseases, affecting many organs/tissues and impairing HRQoL [13]. The disease affects mostly women, and organ damage, fibromyalgia, and mood disorders are the main determinants for reduced quality of life in these patients [14]. Fatigue and sleep disorders are the most prevalent symptoms, affecting up to 85% of patients, and may have a multifactorial origin, including psychosocial factors and disease activity [15, 16]. Joint pain and muscle pain are reported in 72.8% and 62.6% of patients, respectively [17]. Depression affects approximately 24–57% of patients with SLE, one of the highest prevalence rates observed among RDs [18]. Anxiety impacts 24% to 40% of patients and often flares alongside disease activity [19]. Some patients (20–40%) develop neuropsychiatric lupus (NPSLE), which can either mimic or worsen mood disorders and cognitive dysfunction [20]. Approximately 51% of patients with SLE exhibit alexithymia [21], and high levels of alexithymia are strongly associated with an increased tendency to express emotional distress through somatic symptoms, independent of disease severity [22]. Most concerning of all is the increased suicide risk among patients [23].

Systemic Sclerosis

Systemic sclerosis (SSc) is a complex autoimmune disease, affecting mostly women, and characterized by extensive fibrosis of skin and internal organs, and microvasculopathy. These changes can cause organ insufficiency, leading to impairment of functional status and HRQoL, and reduced survival [24]. Current therapies are largely ineffective, and 36% to 65% of patients exhibit depression, often linked to the severity of skin involvement, pain, fatigue, social support, coping, helplessness, and fear of progression [25]. Severe pain (10%) significantly contributes to the overall disease burden [26]. Fatigue, reported by 31% to 89% of patients, is closely associated with multiple factors, including pain, depression, sleep disturbance, impaired physical function, reduced self-efficacy, and parenting challenges [27]. Anxiety, affecting 18% to 65% of patients, is associated with disability and psychological characteristics [28]. Reduced sleep quality, reported by 54.6% of patients, is linked to digital ulcers, dyspepsia, low back pain, and depression [29]. Patients also face cognitive difficulties [30, 31], reduced participation in daily activities, and social isolation [32–34], often attributed to body image discomfort [35]. Additionally, alexithymia, affecting more than 40% of patients, is strongly related to depressive symptoms [36].

Sjögren’s Disease

Sjögren’s disease (SjD) is a chronic autoimmune inflammatory disorder affecting mostly women. It is characterized by epithelitis involving most frequently salivary and lacrimal glands and manifesting with dry mouth and dry eyes [37]. Patients with severe dry eye disease have lower HRQoL in all scales of the short-form (SF)-36 [38]. Functional impairment is common, and many patients often experience a psychological burden that profoundly impacts HRQoL. Patients often report chronic pain (65–75%), which is frequently of neuropathic etiology [39], depression (8–75%) [40], and anxiety (34%) [41]. Chronic fatigue, reported by up to 75% of patients, represents one of the most debilitating symptoms and correlates with poor HRQoL [42, 43]. Patients may have an alexithymic profile (27%) [44], and sleep disturbances (46%) [45] and many patients report cognitive dysfunction, social isolation, sexual dysfunction from vaginal dryness, and diminished self-efficacy [46].

Vasculitis

Systemic vasculitis is an idiopathic inflammation of the arterial wall and encompasses various entities affecting different organs/tissues. Anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitis is a prototype of systemic small vessel vasculitis. The disease is relatively common and most frequently affects the upper and lower respiratory tract and kidneys [47], leading to renal and lung impairment and requiring strong immunosuppressive therapy to achieve remission [48]. In a systematic review, patients with ANCA vasculitis frequently have fatigue and anxiety, mood disorders, and sleep disturbances, and a marked decrease in HRQoL [49]. Patients with systemic vasculitis commonly experience depression and anxiety, with prevalence rates reaching 55% and 43%, respectively [49, 50]. Depression and anxiety are risk factors for poor HRQoL, whereas corticosteroid use was found to be independently associated with worse SF-36 scores [51]. Chronic fatigue (75%) significantly impacts HRQoL and daily functioning [49, 52], whereas pain (62%), sleep disorders (57%) [53], and alexithymia (52%) further complicate psychological adjustment in systemic vasculitis. Patients also often face other psychological difficulties, including decreased participation in social activities and friendships [54].

Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a systemic autoimmune inflammatory arthritis causing joint pain and swelling, stiffness, and functional impairment, progressively leading to joint destruction with decreased HRQoL. Nowadays, biological and targeted synthetic disease-modifying antirheumatic drugs, although effective, leave a proportion of patients with inadequate response. In a recent study of patients with RA-receiving biological therapy, substantial disability (Health Assessment Questionnaire [HAQ] score ≥ 1) was observed at 8 years of follow-up in 32% of women and 21% of men [55] and it tended to increase over time [56]. Psychological distress correlates with increased pain perception and disease activity, whereas depression was found to be an independent predictor of high disease activity [57]. Depression (16% to 38.8% of patients), particularly during flares and higher functional impairment [58], often coexists with anxiety disorders, which are reported in 20% of patients [59]. This psychological burden operates bi-directionally, with depression predicting worse disease activity and vice versa [60]. Sleep disturbances, reported by 50% to 75% of patients, exacerbate psychological distress and potentially contribute to inflammatory dysregulation [61]. Pain and catastrophizing act as mediators between disease activity and psychological distress [62], whereas alexithymia, affecting 25–30% of patients, further impairs emotional processing and pain management [63]. Fatigue, reported by 41% of patients [64], and emotional ambiguity are associated with perceived higher disease activity [65]. Notably, 44% of patients with RA and low disease activity and 12% of patients in DAS28 remission report significant pain (pain score ≥ 4/10) [66, 67]. Negative body image concerns are particularly prevalent among women with RA and correlate with reduced HRQoL [68].

Juvenile Idiopathic Arthritis

Juvenile idiopathic arthritis (JIA) is a chronic inflammatory joint disease that afflicts children of 16 years of age or less. Patients, apart from peripheral arthritis, may have spondylitis, uveitis, and high fever. The disease results in functional impairment through persistent joint inflammation, contractures, growth limb abnormalities, and delayed somatic development, while joint deformities and muscle atrophy exacerbate body image disturbances, negatively influencing psychological health [69]. Children experience some degree of pain even with biological agents [71] while pain intensity directly correlates with increased risk of depression, poor sleep quality, reduced social participation, and reduced HRQoL [71]. Elevated rates of depression, anxiety, and emotional distress are well documented in JIA [72]. Depression is more frequent in females (30%) than males (13%), while anxiety is also more frequent in female (30%) than male (16%) patients [73]. Fatigue is very frequent (up to 76%) and relates to daytime pain, disease activity, sleep disturbances, and psychosocial factors, negatively impacting daily functioning and HRQoL [74, 75]. The disease often disrupts the sense of normality, affecting identity formation and peer relationships [76].

Psoriatic Arthritis

Psoriatic arthritis (PsA) is a chronic inflammatory arthritis associated with psoriasis. Patients have skin lesions, peripheral joint or spinal pain, fatigue, impaired physical function, and reduced HRQoL [77]. Moderate-to-severe joint pain, present in 69% of patients, and moderate-to-severe skin lesions, present in 30% of patients, both contribute to emotional distress and reduced HRQoL [78]. Patients also have sleep disturbances, anxiety, and depression [79]. Recent systematic reviews show that PsA patients experience significantly elevated rates of depression (up to 20%) and anxiety disorders (up to 61%) compared to the general population [80, 81]. Poor sleep quality, reported by 72.9% of patients, is linked to pain, fatigue, reduced physical functioning, emotional distress, and joint inflammation [82]. Fatigue, reported by 49.5% of patients, is associated with fibromyalgia tender points, physical impairment, and psychological distress [83], and is influenced not only by disease activity but also by education level and female sex [84]. Also, alexithymia affects approximately 38% of patients [81]. There is a bidirectional association between pain and depressive symptoms [85], whereas body image makes patients feel rejection, shame, and guilt [86].

Spondyloarthritis

Spondyloarthritis (SpA) is a chronic inflammatory arthritis of the axial skeleton and encompasses ankylosing spondylitis (AS) (the prototype of SpA), psoriatic spondyloarthritis, reactive arthritis, and inflammatory bowel disease-associated SpA. AS causes functional disability through pain, progressive spinal fusion with reduced mobility, and postural abnormalities [87]. The disease inflicts a significant psychological burden, permeating multiple dimensions of patients’ lives. Chronic pain is a prominent feature, with 44% of patients reporting chronic widespread pain (CWP) and 33% reporting chronic regional pain, both of which contribute to emotional disturbance and diminished HRQoL [88]. Depression and anxiety affect up to 40% [89, 90], while alexithymia affects 31% of patients with SpA [91]. Fatigue correlates with depressive symptoms and substantially impairs HRQoL in up to 73% of patients [92]. Sleep disorders are reported in 19–90% of patients with AS [93], and visible physical changes affect body image, leading to increased psychological burden.

Osteoarthritis

Osteoarthritis (OA) is the most common form of arthropathy affecting middle-aged and older individuals. It affects many joints and may lead to functional impairment through progressive joint pain and restricted range of movement, both of which can lead to joint replacement [94]. Disability-adjusted life years (DALYs) rate was 311 per 100,000 population in the USA and 245 per 100,000 population in China, with an increasing trend year by year [95]. As the older population grows, OA is becoming a major concern for health systems worldwide. Pain varies and is constant or intermittent. In a systematic review, 15% to 76% of patients with knee pain had radiographic OA, and 15% to 81% of patients with radiographic knee OA had pain [96]. In hand OA, pain is up to 53% of cases, with pain intensity reaching 62 out of 100 [97]. Structural joint deformities, malalignment, and compensatory gait adaptations in OA not only increase pain and impair physical function but also negatively affect body image, contributing to psychological distress. Pain contributes to depressed mood by increasing fatigue and disability, which in turn exacerbate both pain and functional decline [98]. Fatigue is also a common complaint, affecting approximately 35% of individuals with OA [64]. Among the most prevalent psychological and somatic symptoms are alexithymia (58%) and sleep disturbances (77%) [99, 100]. Alexithymia correlates with increased pain sensitivity and catastrophizing [101], while sleep disturbances are closely associated with increased pain perception, largely mediated by depressive symptoms [100]. Sleep problems amplify pain by affecting mood, disrupting natural pain modulation mechanisms, and impairs physical functioning [102]. Anxiety affects up to 21% of patients, while depression (up to 20% of patients) has been identified as a stronger predictor of disability than radiographic joint damage [103].

Fibromyalgia

Fibromyalgia (FM) is a chronic condition characterized by widespread pain and often accompanied by fatigue, cognitive dysfunction (“fibro fog”), and sleep disturbances, leading to substantial functional and psychological impairment [104]. Sleep disturbances are among the most prevalent symptoms, affecting up to 90% of patients and contributing to a cycle of pain amplification and emotional distress [105]. Depressive symptoms are highly common (40% at any time prevalence to 90% lifetime prevalence) [106], while anxiety disorders affect approximately 30% of patients [107], and widespread chronic pain accompanied by significant fatigue is reported by up to 50% of patients [108]. In a study, patients with FM reported higher rates of widespread pain, sleep disturbances (85%), and depression (53%) than patients with RA on low-disease activity and/or remission [109]. Alexithymia is also common, affecting approximately 39–44% of patients with FM [110, 111]. Notably, the association between alexithymia and pain intensity is often mediated by depressive symptoms, suggesting a complex interplay between emotional processing difficulties and pain perception [112, 113].

The prevalence of psychological manifestations across the rheumatic disease spectrum is summarized in Table 1.

Table 1.

Prevalence of psychological manifestations in rheumatic diseases

Disease	Depression (%) [ref]	Anxiety (%) [ref]	Fatigue (%) [ref]	Alexithymia (%) [ref]	Sleep disorders (%) [ref]	Pain (%) [ref]
SLE	24–57 [18]	24–40 [19]	Up to 85 [15]	51 [21]	55–85 [16]	62–73 [17]
SSc	36–65 [25]	18–65 [28]	31–89 [27]	> 40 [36]	55 [29]	83 [26]
SjD	8–75 [40]	34 [41]	Up to 75 [42]	27 [44]	46 [45]	65–75 [39]
Vasculitis	Up to 55 [50]	Up to 43 [49]	Up to 75 [49, 52]	52 [115]	57 [53]	62 [53]
RA	16–39 [58]	20 [59]	Up to 41 [64]	25–30 [63]	50–75 [61]	12–44* [67, 116]
JIA	26 [73]	26 [73]	Up to 76 [74]	–	44[75]	100 [70]
PsA	Up to 20 [81]	61 [80]	49 [83]	38 [81]	73 [82]	30–69 [78]
SpA	Up to 40 [89]	Up to 40 [90]	Up to 73 [92]	32 [91]	19–90 [93]	33–44 [88]
OA	Up to 20 [103]	Up to 21 [103]	35 [67]	58 [99]	77 [100]	Intermittent or constant
FM	90** [106]	30 [107]	Up to 50 [108]	39–44 [110, 111]	Up to 90 [105]	Up to 50 [108]

SLE systemic lupus erythematosus, SSc systemic sclerosis, SjD Sjögren’s disease, RA rheumatoid arthritis, JIA juvenile idiopathic arthritis, PsA psoriatic arthritis, SpA spondyloarthritis, OA osteoarthritis, FM fibromyalgia

*12% of patients with DAS28 remission and 44% with low disease activity

**Lifetime prevalence

The Need for Psychorheumatology

It is well established that RDs deeply affect a person’s HRQoL and emotional well-being. On the other hand, emotional distress can make physical symptoms more difficult to manage. For instance, 17% of patients with PsA experienced multiple biological/targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) failures, and female sex, axial disease, depression, and obesity were risk factors for multiple b/tsDMARDs failures [114].

Despite the growing understanding of the connection between mental and physical health, psychological support is not generalized in rheumatological care, although a multidisciplinary team is in place in some centers. The present article advocates for psychorheumatology, an interdisciplinary field aimed at recognizing and addressing the psychological aspects of RDs, i.e., an integrative understanding of the psychological and social determinants shaping the experience of individuals living with the physical burden of these conditions. Psychological interventions are expected to improve psychological distress treatment adherence and disease outcomes [6]. In a recent randomized clinical trial of patients with RA, PsA, or SLE who reported psychological distress, digital psychological intervention led to greater reduction of psychological distress and greater improvement of HRQoL [115]. Psychorheumatology will also investigate biological mechanisms through which psychological stress and emotional states influence immune system activity and apply these to the specific context of RDs. Within this framework, Psychorheumatology will focus on the bidirectional relationship between psychological factors and RDs. In this way, we will improve comprehensive care and provide a more holistic therapeutic approach for patients with RDs. Thus, there is a need for incorporating psychorheumatology into the rheumatology curriculum, in the same way as musculoskeletal ultrasound works.

Implementing Psychorheumatology

We propose a stepwise framework for Psychorheumatology integrating early screening with interdisciplinary management. Patients with RDs may complete brief patient-reported outcome measures (PROMs) in the waiting room, assessing HRQoL, depression, anxiety, sleep disturbances, and pain. A pragmatic composite screening strategy may include the PHQ-4 (Patient Health Questionnaire-4) for depression and anxiety (total score 0–12; scores ≥ 6 indicating moderate-to-severe psychological distress; subscale scores ≥ 3 indicating probable anxiety or depressive disorder) [116], the ISI-3 (3-item Insomnia Severity Index) to assess sleep disturbance (total score range 0–12; scores ≥ 6 indicating clinically significant insomnia symptoms) [117], and the Numeric Rating Scale (0–10 Numeric Rating Scale) for pain severity (scores ≥ 4 indicating moderate pain and ≥ 7 severe pain). In addition, a single-item global health measure, conceptually aligned with the EQ-5D, may be used to capture overall HRQoL (self-rated health < 60/100 indicating impaired perceived health status) [118]. The selection of ultra-brief instruments aims to maximize feasibility and completion rates in routine clinical settings while maintaining adequate screening performance. Completed questionnaires can be reviewed during the rheumatology outpatient visit, and patients meeting predefined cut-offs may be referred to an interdisciplinary clinic involving both a rheumatologist and a mental health professional with expertise in RDs (Fig. 1). This model enables the delivery of targeted psychological interventions, like stress management, coping strategies, cognitive behavioral therapy and psychoeducation, addressing both physical and psychological dimensions of disease and leading to better outcomes. This pathway, comprising systematic screening, integrated assessment, and interdisciplinary care, represents a feasible and scalable approach for embedding Psychorheumatology into routine clinical practice.

Fig. 1.

Stepwise framework for psychorheumatology integrating early screening with interdisciplinary management. Patients with rheumatic disease (RD) complete PROMs in the waiting room, facilitating rapid identification of psychological distress. Patients with significant psychological distress are referred to an interdisciplinary clinic for integrated medical and psychological care, including CBT (cognitive behavioral therapy) and psychoeducation. This pathway efficiently incorporates psychorheumatology into routine clinical practice. Figure created with BioRender.com

Conclusions

Recognizing psychorheumatology as a distinct interdisciplinary field is expected to advance both clinical practice and research. Such recognition would facilitate the development of standardized training pathways for rheumatology professionals, covering areas such as palliative care and empathetic communication with patients, as well as competency frameworks for psychology professionals, including skills like providing psychoeducation in emotion regulation. This emerging field could also contribute to the creation of evidence-based clinical guidelines tailored to specific rheumatic conditions. Furthermore, it may support the implementation of appropriate reimbursement models for integrated care and strengthen advocacy for patient-centered approaches.

Author Contributions

Domniki M. Karagianni conceptualized and prepared the initial draft; Lazaros I. Sakkas contributed to writing and revised the draft; Christina G. Katsiari designed Fig. 1 and revised the draft. Konstantinos Bonotis revised the draft. All authors reviewed the manuscript and approved the final version.

Funding

No funding or sponsorship was received for this study or publication of this article. The Rapid Service Fee was funded by the Special Account for Research Grants, University of Thessaly.

Data Availability

Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.

Declarations

Conflict of Interest

Domniki M. Karagianni has nothing to disclose. Christina G. Katsiari received honoraria for lectures from UCB, GSK, Boehringer Ingelheim, AstraZeneca, congress travel expenses from UCB, GSK, Novartis, Viatris, Boehringer Ingelheim, AstraZeneca, AbbVie, and VIANEX. Konstantinos Bonotis has nothing to disclose. Lazaros I. Sakkas received congress travel expenses from AbbVie and Faran. Lazaros I. Sakkas is an Editorial Board member of Rheumatology and Therapy. Lazaros I. Sakkas was not involved in the selection of peer reviewers for the manuscript nor any of the subsequent editorial decisions.

Ethical Approval

This article is based on previously conducted studies and does not contain any new studies with human participants or animals performed by any of the authors; formal ethics approval was not required.