Psychosocial resources, including coping style, self-efficacy, and cognitive schemas—influenced by cultural and social norms—contribute to emotional functioning. As an example, Covic, Adamson, Spence, and Howe (2003) used path analysis to determine whether physical disability, helplessness, and passive coping would predict pain and depression in a sample of 157 patients in both cross-sectional and longitudinal models. Findings revealed that helplessness and passive coping mediated the relationship between physical disability and future depression and pain. Both cross-sectional and longitudinal models accounted for significant variability in pain and depression, illustrating the central roles of illness beliefs and coping in depression among arthritis patients.

Chronic disease is a stressor that can leave patients feeling depleted cognitively, behaviorally, emotionally, and socially. Over a period of time, chronic stress strains the biological system and social relationships (Kiecolt-Glaser, 1999; Kiecolt-Glaser et al., 2003). For instance, in addition to the interruptions caused by medical difficulties, marriages and romantic partnerships become strained as a result of numerous changes in family and social systems, thereby amplifying the perception of stress and inducing feelings of social disconnectedness. For example, disability and health care costs create financial burdens for families: patients experience changes in sexual desire and functioning; and irritable mood and inability to complete household chores require other family members to take on additional responsibilities, thus, rearranging family dynamics. Chronic stress alters the sympathetic, neuroendocrine, and immune response to acute stress (Pike et al., 1997). Chronic psychological stress has been linked to negative affective states and clinical depression, along with increased disease risk and negative health-related outcomes in several diseases, including HIV/AIDS, cardiovascular disease, and cancer, which are likely the result of physiological and behavioral responses in adjusting to, and coping with, stress (Cohen et al., 2012; Cohen, Janicki-Deverts, & Miller, 2007). Moreover, disruptions in sleep, common among arthritis patients, further contribute to fatigue, inflammation, increased pain intensity, alterations in dietary habits, and depression (Irwin et al., 2012; Nicassio et al., 2012).

Depression affects more than 350 million people worldwide and is an independent risk factor for early death and the second leading cause of disability (Symmons et al., 2000). Depression is usually recurrent and can present with somatic, behavioral, cognitive, and emotional symptoms. Individuals with early childhood adversities are more vulnerable to developing depression because early life experiences may interact with other psychological, biological, and environmental factors that diminish patients’ resilience over the lifespan (McEwen, 2012).

Not surprisingly, depression exacerbates disease severity, interferes with medical adherence, nutrition, and quality of life, and compromises the response to medical treatments. Depression, along with ethnicity, has been found to significantly predict self-reported disease states among patients with SLE (Carr et al., 2011). Moreover, disease status among those with lupus predicts fatigue with helplessness and depression mediating the association (Tayer, Nicassio, Weisman, Schuman, & Daly, 2001). Overall, empirical data demonstrating that disease activity, health behaviors, and mood have direct and indirect associations with patient outcomes are robust and indicate the importance of assessment and treatment of these factors in clinical practice.

In addition to mood and immune factors, depression has molecular, genetic, social, and physiologic correlates and is associated with chronic exposure to stress (Slavich & Irwin, 2014). Patients at risk for depression may have some protective factors in reducing both risk and severity that can be targeted in treatment. For example, those with higher self-efficacy, social support, and social integration are less likely to become depressed than those who do not have these resources. However, perceived chronic stress heightens inflammation and may play a role in the onset of arthritis and depression (Slavich & Irwin, 2014).

What might explain the underlying mechanisms between psychosocial factors, especially depression and disease course? Recent theories on depression and inflammation integrate research findings on the social–environmental experiences to advance conceptualizations of the immunologic pathways and risk factors for depression. At the forefront of these theories is the social signal transduction theory of depression, which asserts that biological responses from social–environmental threats and lifelong exposure to stress in particular can result in changes in pro-inflammatory cytokines that can affect behavior, depression, and disease (Slavich & Irwin, 2014). Such changes further contribute to a patients’ risk of withdrawing from their social network, which intensifies depressive symptoms (Eisenberger, Inagaki, Mashal, & Irwin, 2010). Relative to patients from upper socioeconomic backgrounds, those from socially and economically impoverished backgrounds, as well as those with histories of oppression and marginalization, are likelier to have had fewer educational and occupational opportunities for economic and social advancement, experience greater levels of chronic stress and trauma exposure, and reside in environments in which resources are lacking that could potentially act as stress buffers.

In addition to emotional distress and major depression, anxiety is common among populations afflicted with arthritis and may be even more prevalent than depression (Murphy, Sacks, Brady, Hootman, & Chapman, 2012). Negative affective states such as anxiety and depression are associated with increased pain severity, functional limitations, disrupted sleep cycles, maladaptive coping strategies (e.g., denying the severity of illness, smoking, alcohol, and sedentary lifestyle), decreased levels of self-efficacy and control of their medical condition, and increased utilization of health services. Unfortunately, despite the prevalence of depression and anxiety and their impact on health outcomes, most patients do not pursue treatment for these symptoms and they are not routinely assessed for these symptoms by their providers (Ang et al., 2005; Dickens, McGowan, Clark-Carter, & Francis, 2002; Gatchel, 2004; Matcham, Rayner, & Hotopf, 2013; Murphy et al., 2012; Nicassio, 2008). Thus, depression and anxiety often go undetected in clinical care.

Health behaviors and coping mechanisms may play important roles in immune function in arthritis. Maladaptive coping and health behaviors , such as smoking, physical inactivity, overconsumption of alcohol, and high-fat processed foods have all been found to demonstrate direct and indirect relationships with disease risk, disability, pain sensitivity, and disease activity. For example, smoking causes inflammation and alters immune function (Arnson, Shoenfeld, & Amital, 2010). RA is substantially more common among smokers than nonsmokers , and individuals who smoke are at increased risk for developing a range of medical conditions, including rheumatoid arthritis, cancer, and cardiovascular disease (Costenbader, Feskanich, Mandl, & Karlson, 2006; U.S. Department of Health and Human Services, 2014). Recent findings indicate that smoking, along with genetic factors, increases vulnerability to developing arthritic conditions, exacerbates sleep problems, and also impairs the immune response (Arnson et al., 2010).

Lazarus and Folkman (1984) cite two major styles of coping when faced with a stressor, emotion-focused and problem-focused coping that can have a significant impact on psychosocial adjustment. People often choose which type of coping to use in response to a stressor based on several factors: the level of threat posed by the stressor, the type of stressor they are facing, level of arousal, the duration of the stressor, and perception of control of the stressor (Penley, Tomaka, & Wiebe, 2002). Emotion-focused coping is based on employing strategies, such as denial, distancing, avoidance, and wish-fulfillment fantasies, to minimize the deleterious effect of a stressor. While using these coping styles may be advantageous in minimizing emotional distress for a short period of time, the use of these strategies over the course of an illness can be maladaptive. For example, patients with arthritis who rely on denial may delay treatment seeking or fail to appreciate the severity of their condition.

Importantly, emotion-focused coping is associated with the development of depression and other forms of emotional distress and negative health outcomes (Penley et al., 2002). In problem-focused coping , individuals tend to acknowledge and confront a stressor directly before exploring its sources and ways of modifying the stressor. While problem-focused coping strategies may not always be feasible if the stressor is not controllable, in general, patients who adopt a problem-focused approach are likely to have better health outcomes (Penley et al., 2002).

In addition to structural pathology and tissue damage, disease detection, assessment, management, and treatment outcomes may be further affected by numerous factors: individual material, and psychological resources, environmental exposure to toxins, patient–provider relationships, divergent perspectives of health and etiology of symptoms embedded through cultural and social norms, and medical knowledge and treatment expectations (Carr & Donovan, 1998; Felson, 1996; Kiecolt-Glaser, 1999; McEwen, 2012). Patients with arthritis often have comorbid medical problems such as diabetes, lung complications, and heart disease, all of which may be adversely impacted by emotional distress. Not surprisingly then, multidisciplinary approaches are needed to optimize treatment outcomes. Even with the advent of increasingly effective medications that can slow deterioration of the joints and tissues and provide pain relief, the side effects of disease-modifying medications can be serious and create other health risks. Moreover, a considerable percentage of patients do not respond effectively to disease-modifying medications. This knowledge further underscores the complexities of arthritic conditions and the need to broaden traditional treatment approaches that rely solely on medication.

Because psychosocial (e.g., emotion, cognition), socio-demographic factors (e.g., socioeconomic status, ethnicity), and health behaviors (e.g., nutrition, physical activity, smoking, sleep) have both emotional and physiological consequences, the reliance on medication alone to treat depression and anxiety is insufficient. There is already compelling evidence that psychological and stress management interventions and other mind-body therapies can lead to improvements in both psychological well-being and health outcomes (Hewlett et al., 2011; Morgan, Irwin, Chung, & Wang, 2014; Nicassio, 2010).

Due to the high degree of psychiatric comorbidity in arthritis, it is important for clinicians to evaluate the psychosocial functioning of patients in the rheumatology setting during the first visit and on an ongoing basis thereafter (Harris et al., 2013). Even if symptom severity does not meet diagnostic criteria for a psychiatric disorder, screenings for sleep quality, sexual functioning, and levels of depression and emotional distress will highlight the need for potential psychological interventions and provide essential data for identifying barriers to effective medical treatment.

In conclusion, arthritic conditions have the potential to interfere with virtually every domain of patients’ lives and exert a stressful impact on their families. The biopsychosocial model has advanced our ability to develop more sophisticated formulations of our patients, appreciate variability in their subjective experiences and outcomes, and increase awareness on the part of health professionals that transdisciplinary care is a vital component to restoring functioning, decreasing disability, and improving health outcomes. We recognize, more than ever, that medical treatments, while imperative, are insufficient to address all the factors that affect health outcomes in arthritis or the impact of having arthritis. In an effort to help patients maximize their functioning and lead productive lives, health professionals must embrace and investigate the interactions of biological, social, psychological, and cultural systems related to arthritis and identify factors within those systems that should be targeted for treatment through a multidisciplinary approach .