Over time, a cursory overview of PUBMED, the world’s leading and most comprehensive medical repository shows the combined topic of osteoarthritis and depression emerged as a theme on its data base in 1954 and since then has slowly been increasing to reach 1967 items as of June 2022. Of these are 202 clinical trials, 171 randomized trials, and 34 meta analyses of which only one directly addresses depression and was published in 2016.

Yet, even though the rate of publications has increased quite substantively in the past two years in particular, many gaps remain with few well-informed empirically validated intervention solutions and almost no uniform study design, and assessment procedures. Nonetheless, among the 167 currently listed studies as of June 9, 2022, one noteworthy study is that by Parmelee et al. 7 who sought to examine the main and moderating effects of global depressive symptoms upon in-the-moment associations of pain and affect among individuals with knee osteoarthritis (N=325) who completed a baseline interview tapping global depressive symptoms showed the construct of global depression as measured in the study predicted current pain, as well as both positive and negative emotional affect, in addition to changes in pain and affect over a 3-8 hour period. This observed association between the measures made of pain and negative affect was stronger in those cases who documented higher rates of depressive symptoms as far as both momentary pain experiences, as well as those occurring over short time periods. While no moderating effect for any positive affect-pain association was found, the presence of depressive symptoms, which correlated with pain variability as well as negative affect, led the authors to conclude that previous work on the relationship of chronic pain and global depressive symptoms are valid for explaining short term and momentary osteoarthritis pain experiences. How many subjects had clinically verifiable depression, the accuracy of the pain estimates, and how severe or protracted this was, was not clearly established, however.

As identified though in an article designed to examine correlations between pain severity and levels of anxiety and depression in adults with osteoarthritis patients, Fonseca-Rodrigues et al. 8 using four databases from inception up to 14 January 2020 including 12 original articles and 121 studies, with a total of 38 085 participants, mean age 64.3 years old showed a moderate positive correlation between pain severity and depressive symptoms that cannot be readily overlooked. In addition, Schepman et al. 9 who employed a nationally representative survey to generate data concluded that cases reporting moderate to severe pain on a daily basis often exhibited signs of depression, while Furlough et al. 10 found a correlation between osteoarthritis disease duration and depression symptoms in cases with either hip or knee osteoarthritis. Barowsky et al. 11 show that osteoarthritis and major depression appear to share common genetic risk mechanisms, one of which centers on the neural response to the sensation of mechanical stimulus that should be explored further. As well, this research points to the strong impact of depression on the health status and general condition of the adult with osteoarthritis, that occurs more often in the case where the adult feels helpless and unconfident 12, and may induce a deleterious impact on management in general, as well as on surgery outcomes where this is needed 313.

In fact several papers stress a highly negative role for pre surgical depression as this impacts the extent of recovery post joint replacement surgery significantly and predictably 14, even if the affected adult is not considered at all ‘old’ 12. As well, those suffering from a long standing or chronic major depressive disorder 11 may encounter an unrelenting cycle of pain and disability rather than any simple unidirectional cause effect association 15. Other research shows that delaying the opportunity to intervene on the presence of depression regardless of cause or type is likely to do more harm than good in as many as 50 percent or more of osteoarthritis cases 16, especially where perceptions of any cumulative or perceived discrimination prevail 25. Those cases who present with comorbid insomnia 12 or a newly diagnosed joint lesion may be especially vulnerable 17.

Wang and Ni 18 concluded that depression, one of the most common comorbidities in people with osteoarthritis is important because it clearly affects patient prognosis and quality of life, plus the overall disease burden. Moreover, it is a key contributor to pain, poorer health status and life quality, productivity and activity impairments. In addition, the presence of depression, often linked to pain, and more evident in the face of severe pain 1920 may increase the risk for restless sleep among cases with osteoarthritis of the knee 21, and according to Furlough et al. 10 many reports state that osteoarthritis, the most common joint disease, often produces lengthy periods of chronically intractable joint stiffness and swelling, as well as multiple functional, social, occupational, and emotional challenges and restrictions, as well as feelings of depression that flow from this 1920. Depressive presence may also impact surgical outcomes negatively 6, as well as sleep disturbances, overweight or obesity, pain, plus the presence of comorbid health conditions 22, hence surgeons and others have been increasingly encouraged not to neglect to screen for any undue depressive manifestations in their osteoarthritis clients 23, especially in light of the possible associations between a subject’s psychological profile and their somatosensory function and brain structure 30.

As noted by Jeong et al. 24 adults with arthritis who become worse or stay the same over time are more likely than not to develop depressive symptoms than those who are disease free, regardless of cohort studied, or younger age 25. Therefore, even if not associated with pain exacerbations 26, timely mental health evaluations and appropriate management interventions are highly recommended for those patients with arthritis who do not improve or who undergo changes in their disease status, as well as those who desire their clients to experience a high rather than a low life quality 27. More specifically, as per Rathburn et al. 28 depression interventions if required or indicated could be optimized by targeting the specific symptomology that these subtypes exhibit.

As well, efforts that focus on this high risk group as far as increasing functional exercise, positive social interactions and support, and lower limb muscle strength training could help towards addressing both depression 29 along with other physical health and mental health risks 30 even if quite recent data fail to include depression among the personal modifiable risk factors for osteoarthritis disability or any osteoarthritis phenotype ^eg.3132, even though this common psychological attribute of suffering cannot be discounted. The role of the provider in this regard, which appears of key import 18 is also not widely highlighted. In addition, the fact that one or more forms of long standing clinical depression can induce several chronic health conditions that might predispose to joint derangement, as well as detrimental post operative outcomes has been poorly studied. Regardless of depression category and its origin, a wealth of research predicts unrelieved feeling of depression, may not only be expected to foster negative health and life quality outcomes, but may be especially harmful if this engenders a predictable increase in central nervous system sensitivity to incoming neural stimuli among cases with intractable osteoarthritis that is found to have the potential to greatly amplify the pain experience of the depressed individual 3334, even if the actual extent of joint pathology itself is not striking. Similarly, even if receiving prompt medical care, a negative set of provider beliefs concerning osteoarthritis, can be expected to heighten the risk of acquiring persistent and incremental feelings of depression or helplessness as well as negative patient beliefs that are not commensurate with the prevailing degree of osteoarthritis joint damage, but which the sufferer feels unable to deal with or alleviate. At the same time, even if only moderate, the prevailing state of joint pathology can be expected to worsen over time, along with an increase in adverse reactions to any persistent impairments and possible spread of the disease to other joints, along with a low life quality, and an increased need for more radical rather than conservative intervention approaches 36 and worse than anticipated outcomes of function 37.

As a result, there can be no question as to whether averting rather than unravelling this cycle of deleterious interactive health events and examining what specific interventions may be most beneficial to the individual patient with this condition is likely to be strongly warranted in most older adults suffering from advanced osteoarthritis. Unfortunately, even though more than 80 percent of this older osteoarthritis population may be in constant pain and have difficulty in accomplishing everyday tasks, current treatment approaches often fail to mitigate this, as evidenced by persistent high rates of joint replacement surgery and evidence of substantive pre surgical depressive symptoms 37, and in many cases associated feelings of sadness, loss of interest and pleasure in daily activities 36 even when surgery is successfully enacted.

Fortunately, depression can be reasonably well diagnosed by taking a careful history, and by applying one or more validated scales to examine if indeed the individual is depressed, and if so, how severe the condition is. It can be treated to some effect by efforts to minimize stress, chronic unrelenting pain and inflammation by employing counselling, psychotherapy, medications, cognitive behavioural therapy, exercise, and social support among other approaches. Treating any prevailing comorbid conditions, while enhancing coping skills may also be beneficial.

Indeed, the proactive willingness and desire of the primary caregiver to take the time to examine the personal situations facing their older clients who may be experiencing or exhibiting depressive symptoms, and intervening thoughtfully and empathetically upon discovering any presiding or probable risk of incurring these symptoms, may be expected to not only assist in alleviating immense degrees of suffering due to pain in this sub group, but impairments due to excess stiffness, low levels of vitality, excess fatigue and lack of motivation. Moreover, research strongly supports the likelihood of better patient outcomes if patients feel more optimistic than not, and believe they can care for themselves successfully, and discussions about any unrealistic expectations and the importance of maximizing mental health and avoiding distress are forthcoming 3839.

In the struggle for practitioners and patients to achieve successful osteoarthritis outcomes, as outlined above, psychological attributes such as feelings of depression are undoubtedly a highly salient explanatory factor of excess osteoarthritis disease manifestations and severity and a lower than desirable life quality 39. In this regard, prior and current literature describing the prevalence and impact of co-occurring depressive symptoms among older adults with osteoarthritis, supports a role for the idea of preventing or treating the presence of depression in a population even though the key pathological explanation for osteoarthritis is commonly accepted as a physical one. As such, it appears that ignoring the presence of any co occurring mood disorder or reactive depression can no longer be considered a dispensable consideration in efforts to ameliorate or avert severe disabling osteoarthritis among a fair percentage of the older population. As shown by Taveres et al. 40 who advocated treating multiple neural targets especially in the case of the older adult suffering from osteoarthritis with intractable pain, this approach is likely to help improve rather than hinder the affected adult s sleep and activity practices, morale, anxiety, and self efficacy for coping with their osteoarthritis disability, while raising their self-worth. Moreover, since the patient s negative perceptions and reactions to their impairment may reinforce pain, efforts to mitigate persistent feelings of distress also predict fewer coping challenges, inflammatory responses, excess medication needs, excess eating or appetite losses, plus increased chances of acquiring or exacerbating an array of co existing physical illnesses, memory challenges, weakness, social implications and an excess need for existing health services.

Unfortunately, although a scan of the currently available data show the presence of unwanted depressive symptoms appears to be present quite commonly in many older adults diagnosed as having osteoarthritis especially among those cases requiring total joint replacement surgery, showing the degree of depression is substantial in many cases, very few articles to date have tested the idea of preventing this state, which tends to persist in many post surgical cases. Moreover, little attention appears to be directed to the fact older adults may already be suffering from long standing trait based depression, rather than reactive depression, or both, and multiple co existing illnesses associated with depression. At the same time, even if treatable, unless sought by the provider, emotional attributes such as depression may be overlooked due to false beliefs stemming from the mythology that nothing can be done for osteoarthritis, that osteoarthritis is a biomechanical disease, not a psychosocial disease, or that mental health issues are highly stigmatized in society, thus not put forth by the patient proactively, and are thus not reported. Yet, current data reveal that the caregiver should be suspicious in this regard especially if their clients seek help more often than anticipated, and describe an increase in sleep disturbances, activity avoidance practices, a low sense of morale, anxiety, and diminished self efficacy for coping with their disability, plus a low self-worth and persistent feelings of distress, and fatigue. Those who exhibit excessive inflammatory responses, excess medication needs, excess eating or appetite losses should also be more carefully evaluated in efforts to reduce reliance on harmful medications and existing health services, while aiming to foster a high rather than a low life quality plus a strong degree of satisfaction 40. As well, and in the context of osteoarthritis, a disease frequently associated with obesity and cardiovascular problems including diabetes 41, those with functional impairments and depression 42 may exhibit high levels of non-compliant behaviors, activity avoidance, catastrophizing, and passive coping styles 43, plus higher levels of psychopathology than non-distressed controls 4445, especially in cases with marked joint destruction and poor walking ability 46.

These potentially modifiable disease associated factors not only predict future depression and/or pain onset or worsening 4748, but adverse or delayed outcomes following either hip or knee total joint replacement surgery 40. Moreover, they may explain why those with generalized osteoarthritis suffer more losses in leisure time activity performance than controls 49, and why they exhibit greater rates of disease-associated consequences with relatively lower health than those with knee or hip problems alone 50, along with greater disability, a reduced ability to cope, further depression, and more pain (p<.05) 5152.

At the same time, those experiencing psychological distress may be less motivated towards self-care, as well as less optimistic about engaging in treatments deemed crucial for minimizing their disability such as exercise 5354, and may yet have a lower life quality, higher pain and body mass scores plus more stiffness than desirable in spite of receiving a surgical joint replacement to counter this 1354.

In any event, current research as well as multiple observations carried out over the past 40 years among a fairly representative sample of osteoarthritis cases have specifically shown a relationship to exist between depression and osteoarthritis, including less effective cognitive coping strategies 55 that would strongly support the possible added value of improved routine efforts to identify, study, and treat this psychosocial factor.

Moreover, it seems safe to say older adults with osteoarthritis and concomitant depression who remain untreated are more likely to require high doses of pain relieving medications, as well as more health services than those with no depression 56. They may also have fewer social contacts, a poor life quality, and excessively high body mass indices compared to those osteoarthritis cases not experiencing depression 5758.

To this end, efforts to impact depression directly, including some form of cognitive behavioral therapy, emotional and social support, plus a combination of adequate nutrition, exercise, stress control strategies, weight management, and sleep, plus efforts to minimize inflammation and negative beliefs would all appear promising (Box 1). Minimizing the extent of any comorbid condition, such as cardiovascular disease, insofar as these conditions can heighten the risk for excess feelings of depression can potentially help affected individual s to experience less pain, and suffering. Finally, reducing the stigma of depression may be helpful as well, as may addressing any prevailing perceptions of disadvantage rather than omitting to do this. Importantly, even though poorly studied, or discussed during training of medical providers, it is clear thoughtful patient oriented provider approaches are strongly indicated 1.

It is also argued that because stress and depression are both associated with the development of later life medical co-morbidities, as well as the possible onset and worsening of osteoarthritis pain, disability, and poor health, plus possible excess opioid usage 66, very careful evaluation to tease out the presence of physical symptoms, versus emotional distress, followed by interventions such as relaxation, is strongly indicated 67, and may be especially helpful in reducing osteoarthritis related disability, among those who are over-anxious and/or chronically ill. In turn, therapies that foster feelings of efficacy and confidence and engage the mental and social capacities of the arthritis sufferer are expected to positively impact overall well-being, including walking ability as well as mental health status 68697071. Educational approaches that can foster both a more positive outlook, as well as an individual's self-management capacity, may similarly heighten the life quality of the individual osteoarthritic patient who feels sad and distressed, especially those older adults with little social support or negative views, those with a family history of psychiatric problems, those with long standing medical conditions, those experiencing prolonged stress, and those with limited resources.

As per Sanftennerg et al. 58, in light of the finding that most forms of depression can clearly decrease health-related quality of life, while compounding the severe disability experienced by many older adults suffering from osteoarthritis, the presence or tendency towards any co occurring depression should not be disregarded or overlooked in the context of health care delivery for this patient group that seeks to maximize this, as well as health care utilization and costs. In this regard, the application of multi-pronged interventions that specifically target both pain-related physical as well as psychological risk factors that can accompany other medical challenges commonly faced by people with osteoarthritis, such as obesity, sleep apnoea, pain in other joints 59 pain sensitivity 73, lower levels of brain derived pain mediators than healthy adults 74, appear strongly indicated, and can possibly help allay, rather than heighten fears about undertaking recommended activities or rehabilitation directives, as well as any provider related confusion 60. This approach may also encourage a more active, rather than a sedentary lifestyle 61, while mitigating non-specific somatic symptoms other than pain, such as fatigue, and sleeplessness that tend to compound the extent of any existing health complaints as well as the overall disease prognosis 62, as well as narcotic usage 75, even if this only minimally measurable 6370 and needs to be further explored in the future.