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Salud mental

versión impresa ISSN 0185-3325

Salud Ment vol.37 no.3 México may./jun. 2014


Cartas del editor


Association between depression and parasuicidal behavior in rheumatoid arthritis's patient


Natalia Pinho de Oliveira Ribeiro,1 Alexandre Rafael de Mello Schier,1 Tamires Marinho,2 Sergio Machado,3 Antonio Egidio Nardi,4 Adriana Cardoso Silva5


1 Institute of Psychiatry / Universidade Federal do Rio de Janeiro (UFRJ). Laboratory of Panic and Respiration, Institute of Psychiatry (UFR). National Institute for Science and Technology - Translational Medicine (INCT-TM).

2 Laboratory of Panic and Respiration, Institute of Psychiatry (UFRJ). National Institute for Science and Technology - Translational Medicine (INCT-TM).

3 Panic and Respiration Laboratory, Institute of Psychiatry of Federal University of Rio de Janeiro (IPUB/UFRJ); National Institute for Translational Medicine (INCT-TM), Brazil; Quiropraxia Program of Faculty of Health Sciences, Central University (UCEN), Santiago, Chile; Institute of Phylosophy of Federal University of Uberlndia (IFILO/UFU), Brazil; Physical Activity Neuroscience Laboratory, Physical Activity Sciences Postgraduate Program of Salgado de Oliveira University, Niteri, Brazil.

4 Institute of Psychiatry, Medical School (UFRJ). Laboratory of Panic and Respiration. (INCT-TM).

5 Universidade Federal Fluminense (UFF). Laboratory of Panic and Respiration. Institute of Psychiatry (UFRJ. INCT-TM).


Natalia Pinho de Oliveira Ribeiro.
Universidade Federal do Rio de Janeiro.
Instituto de Psiquiatria.
Laboratório de Pânico e Respiração. Rua Visconde de Piraja,
407/702. Rio de Janeiro.
RJ, CEP: 22410-003 Brasil.
Conselho Nacional de Desenvolvimento Científico e Tecnológico.
Tel: (5521) 2521-6147
Fax: (5521) 2523-6839.


Received: May 2, 2013.
Accepted: January 17, 2014.



Rheumatoid arthritis (RA) is an autoimmune, progressive, inflammatory, and systemic disease that causes pain and deformities in the bones and cartilages, leading to joint destruction.1 It may eventually cause depression and anxiety due to its consequences2 and this could be also explained by its progressive origin with possible deformities and thus excluding expectations for cure or improvement.3,4 In addition to depression, the severe pain that is common in RA may lead to suicidal thoughts and actions.5

Here, we report a case of an association between depression and parasuicidal behavior in a patient with RA. The patient signed a consent form and was aware of the experimental protocol (approved by the Ethics Committee at the Federal University of Rio de Janeiro) before her participation.



Female patient, 74, third degree with two full university courses (psychology and mathematics), retired. RA was diagnosed in a advanced stage in 1998, and wrists, knees, and ankles were the main affected regions.

Last year, she also developed symptoms of chronic obstructive pulmonary disease and heart failure resulting not only from arthritis, but also from the use of a wide variety of drugs too.

Drug treatment involved: prednisolone 10mg twice a day, paracetamol and codeine phosphate 30mg and 500mg, respectively, three times a day, gabapentin 300mg twice daily, hydroxy chloroquine 400mg daily, amitriptyline 25mg twice a day, fluoxetine 20mg twice a day, clonidine hydrochloride 0.100mcg at night, metformin 500mg three times daily, in-dapamide 1.5mg, bromazepam 3mg once a day, bamifilina 300mg three times daily, xinafoate and salmoterol 36.25mcg, fluticasone 50 and formoterol 112mcg + budesonide 400mcg.

She was recommended by her rheumatologist for psychological evaluation due to the possible presence of depression. In the first contact, the patient was analized based on the following instruments: Mini International Neuropsychiatry Interview (MINI), version 5.0.0, that showed an absence of any psychiatric disorder, except depression; and Beck Depression Inventory (BDI), where the patient reached 25 points (moderate depression). Subsequently, a new assessment was conducted, considering the MINI (presented risk of suicide), BDI went for 33 points (severe depression) and including the Beck Hopelessness Scale (BHS), where the patient reached the highest score; and the Beck Suicide Ideation (BSI) that proved the MINI result.

She was assigned to a psychiatrist and asked to remain in psychological care, having rejected both possibilities. The patient died a few months later due to acute pulmonary edema, one week after showing signs of shortness of breath, fainting, arrhythmia, and refusing to take medication or to be taken to the hospital.



This case is a warning to the role of depression and hopelessness in patients with chronical diseases, emphasizing the importance of early detection and appropriate treatment. Prophylactic measures taken in mental health to improve the quality of life and reduce the signs and symptoms of depression, when it is still in its early stages, may contribute to the avoidance of outcomes that, although they can not be classified as actively suicidal, generate tragic consequences for the patient's life.



1. Klippel J, Weyand C, Stone J, Arthritis Foundation. Primer on the Rheumatic Diseases, 12th ed. Arthritis Foundation, 2001.         [ Links ]

2. Gettings L. Psychological well-being in rheumatoid arthritis: a review of the literature. Musculoskeletal Care 2010;8:99-106.         [ Links ]

3. Duarte MB, Rego MAV. Depression and clinical illness: comorbidity in a geriatric outpatient clinic. Cad Saúde Pública 2007;23:691-700.         [ Links ]

4. Berber JSS, Kupek E, Berber SC. Prevalence of depression and its relationship with quality of life in patients with fibromyalgia syndrome. Rev Bras Reumatol 2005;45:47-54.         [ Links ]

5. Ratcliffe GE, Enns MW, Belik SL, Sareen J. Chronic pain conditions and suicidal ideation and suicide attempts: an epidemiologic perspective. Clin J Pain 2008;24:204-210.         [ Links ]

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