Understanding Ankylosing Spondylitis and Depression

Ankylosing spondylitis and depression often coexist and impact each other. The link is often due to the loss of control that people feel when they have pain they can't manage.

Ankylosing spondylitis is a chronic inflammatory disease that causes pain in your back, hips, and other joints. As the illness becomes worse, it can make it hard to drive, work outside your home, or keep up with your social life. There is no cure for the disease, but you can manage it with treatment.

This article describes the link between the two diseases, complications, diagnosis, and treatment. It also provides help with ways to cope when both problems occur at the same time.

The Connection Between Ankylosing Spondylitis and Depression

Ankylosing spondylitis is a chronic inflammatory disease that usually strikes young adults before 30 years of age. The disease causes progressive deterioration of your physical function and professional capacity. The result can impact your social relationships and overall quality of life.

Living with chronic pain and the knowledge that the disease is irreversible, incurable, and progressive can generate feelings of despair, anxiety, and loneliness. Though estimates of the incidence of depression with this disease vary widely, the highest calculations link people with ankylosing spondylitis to having a 51% higher risk of depression versus that of the general population.

Research indicates that people with ankylosing spondylitis have the following characteristics and may be more likely to have depression with this disease:

• A higher disease activity
• A higher degree of functional impairment
• A delay in disease diagnosis from the onset of symptoms
• A co-occurring condition like diabetes or heart disease
• Lack of control over their disease

Inflammation is also an important link between depression and many chronic diseases like ankylosing spondylitis. The elevated levels of proinflammatory factors common in people with depression may be an important link in the progression of this inflammatory disease.

Latest Research

Not all types of exercise provide the same benefits for people with ankylosing spondylitis. A study of people with ankylosing spondylitis concluded that those who participated in an eight-week Pilates group training program lowered disease activity. This group also improved functional capacity, spinal mobility, core endurance, and quality of life, all of which can help reduce feelings of depression. Research indicated that the Pilates training program was more effective in improving patients' symptoms than a home-based exercise program assigned to a control group.

Fatigue, which is linked to depression and anxiety, is the third most common complaint of people with ankylosing spondylitis. Improving fatigue is a key priority in the treatment of physical symptoms of the disease. In two Phase 3 clinical trials, treatment with Cosentyx (secukinumab)reduced fatigue in people with active ankylosing spondylitis for up to three years.

Complications of Ankylosing Spondylitis and Depression

Though depression isn't identified as a cause of ankylosing spondylitis, it can affect the disease experience. Having a mental disorder can produce chronic joint pain, back pain, and gastrointestinal problems. This can aggravate symptoms and lower your pain threshold.

As depression weakens your ability to cope with pain, your perception of pain can become skewed. The result can leave you less likely to adhere to your treatment regime or follow through with movement and exercise programs. This effect can increase your risk of more severe symptoms and loss of mobility. The process can become a cycle that accelerates disease progression while more severe symptoms intensify feelings of depression.

Diagnosis of Ankylosing Spondylitis and Depression

If your general healthcare provider suspects that you have ankylosing spondylitis, you may be referred to a rheumatologist to confirm your diagnosis. This type of physician specializes in diagnosing and treating arthritis and other autoimmune disorders that affect the muscles, joints, tendons, connective tissue, ligaments, and bones.

Early symptoms of ankylosing spondylitis include:

• Pain and stiffness in the lower back that worsens with inactivity and improves with movement
• Back pain that begins between your pelvis and spine (sacroiliac joint)
• Loss of flexibility in the lower spine
• Hyperkyphosis (spine curvature)
• Swelling or pain in other joints or your heel
• General fatigue
• Kyphosis (forward head posture)

There is no conclusive test to diagnose ankylosing spondylitis. Instead, your rheumatologist will likely perform the following procedures to determine the source of your pain and other physical symptoms:

• Physical exam, with special attention to the back, pelvic bones, sacroiliac joints, chest, and heels
• Personal medical history
• Family medical history
• X-ray or magnetic resonance imaging (MRI) of the sacroiliac joints to show erosion or inflammation
• Complete blood count (CBC)
• Blood test for C-reactive protein (CRP)
• Blood test for erythrocyte sedimentation rate (ESR)
• Blood test for the HLA-B27 gene (a gene that is present in a large percentage of people with a White racial background who have ankylosing spondylitis)

If your healthcare provider determines that depression may be contributing to your symptoms, they will conduct one or more screenings to diagnose your condition. A diagnosis of depression is based on criteria included in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).

Based on criteria from the DSM-5, depression is a clinical diagnosis in which a person has a loss of interest or pleasure nearly all day, every day for at least two weeks. They also have at least four of the following symptoms:

• Persistent sad, anxious, or "empty" mood
• Feelings of worthlessness
• Difficulty making decisions
• Slowing down or speeding up physical movements
• Difficulty sleeping
• Decreased energy or fatigue
• Sudden changes in appetite or weight
• Recurrent thoughts of suicide or death
  

Self-Test for Depression

Only a qualified healthcare provider can make a definitive diagnosis of depression. However, you can find out whether your symptoms align with signs of depression by conducting the following self-tests:

• Depression Test (Mental Health America)
• Depression Self-Assessment (Kaiser Permanente)
  
• Screening for Depression (Anxiety & Depression Association of America)

Treatment of Ankylosing Spondylitis and Depression

There is no cure for ankylosing spondylitis, but your healthcare provider can establish a treatment plan to help you relieve symptoms, maintain proper posture, and slow disease progression.

Most people with ankylosing spondylitis follow a therapy plan that includes a combination of physical therapy, medication, and occasionally, surgery. Treatment for depression usually involves a combination of psychotherapy and medications.

It's important to realize that taking medications for both conditions may cause interactions that could interfere with your results. You can avoid your risk of drug interactions by ensuring that your pharmacist and all your healthcare providers are aware of every medication you take.

Medications

The following medications can treat ankylosing spondylitis:

Non-steroidal anti-inflammatory drugs (NSAIDs) are the first-line treatment for treating the pain and stiffness of ankylosing spondylitis. These over-the-counter drugs include:

• Bayer, Bufferin, Ecotrin, St. Joseph (aspirin)
• Advil, Motrin (ibuprofen)
• Aleve, Anaprox DS, Naprosyn (naproxen)
• Celebrex (celecoxib)

Disease-modifying anti-rheumatic drugs (DMARDs) decrease inflammation by changing the way your immune system works. This can reduce symptoms and slow down disease progression. DMARDs interact with many other medications and can have serious side effects. These drugs include:

• Rheumatrex (methotrexate)
• Azulfidine (sulfasalazine)

Corticosteroids act on the immune system by blocking the production of substances that promote inflammation. This can relieve swelling and pain.

Tumor necrosis factor (TNF) inhibitors are biologics, a class of drugs created from living cells. These drugs can have serious side effects and are contraindicated for pregnant women. The drugs used to treat ankylosing spondylitis include:

• Enbrel, Erelzi, Eticovo (etanercept)
• Remicade (infliximab)
• Humira, Amjevita, Cyltezo, Hadlima (adalimumab)
• Cimzia (certolizumab pegol)
• Simponi (golimumab)

Interleukin (IL-17) Inhibitors are biologics that target inflammatory proteins to reduce inflammation. These drugs include:

• Cosentyx (secukinumab)
• Taltz (ixekizumab)

Janus kinase (JAK) inhibitors hinder the activity of one or more of the JAK enzymes that promote inflammation. These drugs include:

• Xeljanz (tofacitinib)
• Olumiamt (baricitinib)
• Jakafi (ruxolitinib)
• Rinvoq (upadacitinib)

The following drugs are for treating depression and chronic pain. Their use for pain is often considered adjuvant treatment, which is used in combination with other pain medications. These drugs include:

Tricyclic antidepressants treat depression while also improving nerve pain. The most common tricyclic antidepressant prescribed for neuropathic, or nerve-related chronic back pain is Elavil (amitriptyline).

Serotonin-norepinephrine reuptake inhibitors increase the amount of both serotonin and norepinephrine in your brain by slowing down a process called reuptake. These drugs include:

• Cymbalta (duloxetine)
• Effexor (venlafaxine)

Selective serotonin reuptake Inhibitors (SSRIs) increase the amount of serotonin available to your brain. Common SSRIs for pain include:

• Celexa (citalopram)
• Lexapro (escitalopram)
• Paxil (paroxetine)
• Zoloft (sertraline)

Psychotherapy

Research indicates that the following types of psychotherapy can help reduce symptoms of depression:

• Cognitive behavioral therapy (CBT) is considered a common form of psychotherapy. It is a form of talk therapy in which you work to identify and change dysfunctional thought patterns and emotions.
• Interpersonal therapy treats mood disorders by improving the quality of your interpersonal relationships and social functioning. It provides strategies to resolve problems related to current rather than past relationships. It aims to change thoughts and behaviors as they apply to interpersonal relationships.
• Supportive therapy relies on an alliance between therapist and client to improve self-esteem, reduce symptoms, and reinforce your ability to cope with the challenges and stressors of life.
  

Coping With Ankylosing Spondylitis and Depression

Coping with ankylosing spondylitis and depression requires taking steps to support your physical and mental well-being. It's important to follow your healthcare provider's recommendations for medication and lifestyle changes throughout your lifetime.

Addressing the causes of pain and stiffness can help you live more fully and avoid the feelings of loneliness and isolation that often occur with ankylosing spondylitis and other diseases that cause chronic pain.

Lifestyle Changes

Research indicates that taking part in your own care can help reduce pain and require fewer visits to your healthcare provider. Follow these lifestyle changes and strategies to improve your quality of life:

• Stay active: Exercise and stretching can help you maintain joint function and movement. It can also help reduce inflammation and reduce pain. Other benefits of exercise, which include improved sleep and a positive attitude, can help prevent feelings of depression.
• Stand up straight: Good posture can help you avoid some of the complications that are common to ankylosing spondylitis. Advanced stages of the disease can lead to changes in which your neck becomes stiff and your spine and upper back curve forward.
• Manage stress: Depression and other negative emotions can increase your stress level. The effect can make it harder to handle disease flares, pain, or any other type of problem the disease causes. Practice meditation, yoga, or other types of relaxation techniques to maintain calm.
• Consume a healthy diet: Eating a healthy, well-balanced diet can help decrease inflammation and relieve pain and fatigue. Avoid foods high in sugars, fat, and salt, and increase your consumption of foods rich in antioxidants like fruits and vegetables.
  
• Limit alcohol use: Research suggests that alcohol may worsen the symptoms of ankylosing spondylitis. Alcohol consumed in combination with certain medications can cause serious side effects to your gastrointestinal tract, liver, and kidneys. It can also increase your risk of falling by making you less stable when you walk.
• Quit smoking: If you smoke, take the steps necessary to quit. Smoking is linked to more aggressive spinal damage, more severe disease, and poorer overall health versus people who have the disease and don't smoke.
• Consume calcium and vitamin D: Having ankylosing spondylitis increases your risk of osteoporosis. Consuming adequate amounts of calcium and vitamin D can improve bone strength and reduce your risk of fractures from osteoporosis, which can complicate your condition.
  
• Address feelings of depression: Don't ignore feelings of loneliness, anxiety, or hopelessness, which often occur among people dealing with chronic pain. Talk to your healthcare provider about ways to treat depression and follow through with their recommendations.

Support Groups

Depending on your condition and concerns, you may benefit from participating in a support group directed at people with ankylosing spondylitis. Your healthcare provider can help you determine which type of group may be most appropriate for your needs.

The following organizations sponsor support groups for people with ankylosing spondylitis:

• MySpondylitisTeam.com (online only)
• Spondylitis Association of America (SAA) (in-person and online)
• Patient: Ankylosing Spondylitis Forum (online only)
• Arthritis Foundation (in-person and online)
  

The following organizations sponsor support groups for people with depression:

• Substance Abuse and Mental Health Services Administration (SAMHSA) (national referral service for mental disorder support groups)
• Depression and Bipolar Support Alliance (DBSA) (in person and online)
• Mental Health America (MHA) (in person and online)
• Anxiety & Depression Association of America (ADAA) (in person and online)
  

Summary

Living with a chronic disease like ankylosing spondylitis can almost double your risk of having a mental disorder like depression. Symptoms of pain in your back, hips, and other joints can make it hard to live a normal life.

Feelings of worry and isolation, which can progress to depression, are common in people with chronic diseases. The effect also works in reverse. Feeling depressed can worsen chronic symptoms and disease outcomes.

Though there is no cure for the disease, people who have it can manage it with proper treatment and lifestyle changes. Most people with this disease can lead a full life with the right medical treatment. Treatment can also improve mental health and reduce the chances of depression.

A Word From Verywell

Living with ankylosing spondylitis requires lifelong treatment. However, you can expect to lead a normal and productive life if you follow your recommended treatment regimen.

Medication, exercise, and a healthy diet can reduce symptoms of pain and stiffness. These approaches can also provide mental health benefits because they can allow you to live more fully. The result can improve your quality of life and restore the control you may have lost due to physical limitations. This can help prevent feelings of helplessness and loneliness that can lead to depression.

Joining an in-person or online support group for people with ankylosing spondylitis can provide the support you need when your symptoms flare up. In addition to the benefits of meeting with others who understand your condition, you may also gain helpful insights on coping with this condition's challenges as it changes throughout your lifetime.