2 "Your state of mind matters."

When your rheumatologist starts your appointment with "How are you?" and you reflexively respond "fine" or start explaining the new pain in your left knee, you may be missing your chance to let your doctor know how you're coping. For many doctors, that routine question is their only chance to glimpse the inner workings of your emotional health.

Studies show that people with chronic pain are at increased risk for depression, and depressed people are twice as likely as men to experience chronic pain. Moreover, anywhere from eight to 50 percent of people living with chronic pain currently have major depression, but diagnosing depression in people with chronic pain is a complex process. Many of the factors doctors commonly use to evaluate depression - weight loss and fatigue, for example -- overlap with the symptoms of arthritis and chronic pain. And people may be reluctant to admit to depression -- one study found that 21 percent of patients met the criteria for depression, but only one percent described their problem as depression. The most vulnerable are men and younger patients -- they are likely to slip through the cracks, especially if their doctor is older. The New England Research Institutes in Watertown, Mass., and Boston University School of Medicine found younger doctors and black doctors of any age were more likely to diagnose depression in men and younger people than their older, white counterparts. Older doctors were more likely than younger doctors to diagnose depression in women and older people. Complicating the issue even more is the fact that some doctors -- as many as half in one study - recognize depression but give patients a different symptom-related diagnosis. Reasons why ranged from worry that a patient's insurance wouldn't cover depression treatment to concern about the stigma of a depression diagnosis.

Identifying and treating depression isn't just a nice extra your doctor can perform. One study found that depressed people with RA had poorer prognoses and overall health than people with the same degree of RA who weren't depressed. Chronic stress, often a precursor of depression symptoms, can actually increase your chances of developing an inflammation-related condition or exacerbate your pain and possibly accelerate joint damage if you already have one. 

What can you do? There are a lot of points on the continuum between unhappiness and true depression, but early intervention is key. It's not unusual to feel uncomfortable bringing up emotional issues with your doctor, but you must speak up if you feel that you are experiencing undue stress or depression. Next time your doctor asks "How are you feeling?" take a deep breath and tell him: "You know, I've been feeling sad" or "My husband's having surgery next week, and I'm worried about him and whether I'll be able to take care of him." There's no one-size-fits-all method for dealing with emotional concerns: your doctor may prescribe a medication, refer you to a specialist or suggest you join a support group or participate in an Arthritis Foundation Self-Help course.

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