Prevalence of mood and anxiety disorders in women with systemic lupus erythematosus

Immune mechanisms of stress susceptibility and resilience: Lessons from animal models

Stress has an impact on the brain and the body. A growing literature demonstrates that feedback between the peripheral immune system and the brain contributes to individual differences in the behavioral response to stress. Here we examine preclinical literature to demonstrate a holistic vision of risk and resilience to stress. We identify a variety of cellular, cytokine and molecular mechanisms in adult animals that act in concert to produce a stress susceptible individual response. We discuss how cross talk between immune cells in the brain and in the periphery act together to increase permeability across the blood brain barrier or block it, resulting in susceptible or stress resilient phenotype. These preclinical studies have importance for understanding how individual differences in the immune response to stress may be contributing to mood related disorders such as depression, anxiety and posttraumatic stress disorders.

Non-pharmacologic therapies for systemic lupus erythematosus

BACKGROUND

Non-pharmacologic therapies have been deemed as potentially beneficial for patients with systemic lupus erythematosus. We conducted an updated review to determine the effects of these therapies to inform practice.

METHODS

A literature search was performed using PubMed (MEDLINE), EMBASE, Cochrane, PsychINFO, the Cumulative Index to Nursing and Allied Health Literature, Web of Science, and Google Scholar from inception until August 2018. We included randomized controlled trials of non-pharmacologic therapies in systemic lupus erythematosus patients with sample size ≥10. Systemic lupus erythematosus was defined by 1982 or 1997 American College of Rheumatology criteria. Studies were synthesized separately by patient-reported outcomes and disease activity. Due to the heterogeneity of interventions and comparisons, a meta-analysis was not performed.

RESULTS

A total of 15 randomized controlled trials involving 846 participants met the inclusion criteria. Of the 15 trials, eight used exercise interventions, six used psychological interventions (one group psychotherapy, three cognitive behavioral therapies, one psychoeducation, one mindfulness-based cognitive therapy) and one used electro-acupuncture. Five of 15 studies utilized control groups consisting of usual medical care. Other studies included control interventions of relaxation, attention placebo, symptom monitoring support, education, minimal needling, isotonic and resistance exercise. Compared with the control conditions, non-pharmacological interventions were associated with a significant improvement in fatigue in three out of six studies. Three out of eight studies reported improved anxiety and depression, and one study reported improved pain after interventions. Seven out of 11 studies reported improvement in overall quality of life in at least one domain of the Short-Form Health Survey. Of note, no studies demonstrated an improvement in disease activity after 5-52 weeks of non-pharmacological therapies.

CONCLUSION

This review showed promising results for physical exercise and psychological interventions as adjuncts to traditional medical therapy for improvement in fatigue, depression, pain and quality of life for systemic lupus erythematosus. Further high-quality randomized controlled trials with longer follow-up periods are warranted.

Lipidomic and metabolomic profiling reveals novel candidate biomarkers in active systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is a challenging disease caused by both genetic and environmental influences. Symptoms of SLE vary and they may come and go, therefore diagnosis and treatment of the disease is difficult. Serum metabolites can not only serve as biomarkers of the disease but also can reveal the pathogenesis. Thus, it is important to find reliable biomarkers for early diagnosis and treatment of the disease, which would greatly benefit SLE patients. Our purpose was to study the metabolite profiles in active systemic lupus erythematosus and to identify metabolites that are significantly altered. Serum samples from 34 participants (17 SLE and 17 healthy) were collected and analyzed. Untargeted lipidomics and metabolomics were used to study the metabolite profiles in serum by high-performance liquid chromatography-tandem mass spectrometry. Serum enzyme-linked immunosorbent assay was performed to validate differentially expressed metabolites. We identified differential expression of over 50 metabolites. These metabolites include several new SLE related metabolite species such as ceramide, trimethylamine N-oxide, xanthine, which were significantly elevated in the serum of active systemic lupus erythematosus patients. Some other metabolites include acylcarnitine, caffeine, hydrocortisone, itaconic acid and serotonin were down-regulated. Our study characterizes the circulating metabolites in active systemic lupus erythematosus and provides several candidate biomarkers for the diagnosis and potential therapeutic targets of the disease.

Prevalence of sexual dysfunction in women with systemic lupus erythematosus and its related factors

Objectives

Systemic lupus erythematosus (SLE) affects all body organs. This disease has marked physiological, mental, and cognitive effects on the patient and results in sexual dysfunction, depression, and decreased self-confidence. This study was conducted to compare sexual function, depression, anxiety, stress, and the related factors in women suffering from SLE.

Material and methods

In this cross-sectional study, 340 women (170 with SLE and 170 healthy) aged 18–49 years were investigated. Convenience sampling was used to select the participants. In this study, a demographic questionnaire, the Depression, Anxiety, and Stress Scales – 21 Items (DASS-21), and the Female Sexual Function Index (FSFI) were applied. Data were analyzed with SPSS 16 using Spearman’s correlation, χ², Mann-Whitney, covariance, and multiple regression statistics; p-values less than 0.05 were considered significant.

Results

The results showed a significant difference in sexual function between the SLE and healthy groups. According to covariance analysis, the difference remained significant after controlling for confounding factors (stress, depression, anxiety). Moreover, the effect of SLE on the sexual function had a significant correlation with age, life status, number and age of children, economic status, menstruation, duration of marriage, age at diagnosis, disease duration and activity, stress, anxiety, and depression. The results of multiple regression analysis showed that age, disease activity, depression, and life status had the highest correlation with sexual dysfunction in women with SLE.

Conclusions

The results of this study indicated that more attention should be paid to the sexual health of women suffering from SLE as a neglected aspect of their treatment, which requires an interdisciplinary approach to shift the care of these patients from a biomedical model to a biopsychosocial model.

Relationships among organ damage, social support, and depression in African American women with systemic lupus erythematosus

OBJECTIVES

Systemic lupus erythematosus (SLE) disproportionately strikes African American women. Social support can potentially reduce disease impact. The purpose of this study is to understand the relationship between organ damage and depression in African American women and how social support influences this relationship.

METHODS

We used a mixed methods design, analyzing self-reported data on lupus-related organ damage, depression, and social support in 437 African American women with SLE recruited in the Georgians Organized Against Lupus (GOAL) cohort. Moreover, we conducted interviews among 15 GOAL participants to gather patients' perspectives about the role of social support in people who live with lupus.

RESULTS

We found a significant association between organ damage and depression ( r = 0.163, p = 0.001), as well as between depression and social support ( F = 17.574, p < 0.001). The quantitative analysis did not render social support as a significant moderator in the organ damage-depression relationship. Interviews, however, revealed that African American women with the most severe organ damage have the greatest need for support.

CONCLUSIONS

Social support is a key resource for lupus patients with high disease burden. Overall, these findings highlight the importance of monitoring depressive symptoms in this population and developing interventions aimed to increase social support available to lupus patients.

Lipocalin-2 is a pathogenic determinant and biomarker of neuropsychiatric lupus

Neuropsychiatric manifestations in lupus (NPSLE) affect ∼20-40% of patients. In the central nervous system, lipocalin-2 (LCN2) can promote injury through mechanisms directly linked to NPSLE, including brain barrier disruption, neurotoxicity, and glial activation. Since LCN2 is elevated in lupus and has been implicated in neuroinflammation, we investigated whether LCN2 is required for the pathogenesis of NPSLE. Here, we investigated the effects of LCN2 deficiency on the development of neurobehavioral deficits in the B6.Sle1.Sle3 (Sle1,3) mouse lupus model. Sle1,3 mice exhibited depression-like behavior and impaired spatial and recognition memory, and these deficits were attenuated in Sle1,3-LCN2KO mice. Whole-brain flow cytometry showed a significant increase in brain infiltrating leukocytes in Sle1,3 mice that was not reduced by LCN2 deficiency. RNA sequencing on sorted microglia revealed that several genes differentially expressed between B6 and Sle1,3 mice were regulated by LCN2, and that these genes are key mediators of the neuroinflammatory cascade. Importantly, LCN2 is upregulated in the cerebrospinal fluid of NPSLE patients across 2 different ethnicities. Our findings establish the Sle1,3 strain as an NPSLE model, demonstrate that LCN2 is a major regulator of the detrimental neuroimmune response in NPSLE, and identify CSF LCN2 as a novel biomarker for NPSLE.

Systemic Lupus Erythematosus: Symptoms and Signs at Initial Presentations

BACKGROUND

Systemic Lupus Erythematosus (SLE) is an autoimmune multisystem inflammatory condition that causes microvascular inflammation with the production of various auto-antibodies that play a major role in its pathogenesis. SLE can affect both sexes, all ages, and all ethnic groups with widespread geographical and socioeconomic backgrounds. Asia encompasses people of many sociocultural backgrounds with diverse ethnic.

OBJECTIVE

Due to a lack of national epidemiological research, the incidence and prevalence of SLE in Middle Eastern and Arab countries, have only recently been studied. This article aims to explore the status of SLE in Oman and to record symptoms and signs of SLE at first presentation.

METHODOLOGY

Medical records of all patients diagnosed with SLE at the Royal Hospital from 2006 to 2014 were reviewed for information recorded at first visit. SLE diagnosis was based on the American College of Rheumatology classification criteria; ACR97 (which includes the clinical manifestation and laboratory evidence). Patients with SLE disease manifestations extrapolated and analyzed. There were 966 patients diagnosed with SLE during the period from 2006 to 2014. Mean (SD) age at presentations was 35.5 (11.5) years. Majority of patients were female which constitutes 88.7% of the total SLE patients with mean age 27.6 (1.4) years.

RESULTS

Constitutional symptoms were found in 48.68 of SLE population including fatigue in 35.22%, and weight changes in 13.43%. The cutaneous manifestations that were present included malar rash 37.69%, photosensitivity 35.10%, discoid lupus 17.63%, and hair loss 39.29%. Musculoskeletal manifestations were commonly seen among the studied population including arthralgia in 68.75%, myalgia in 55.65%, arthritis in 48.31%, whilst myositis, tendon abnormalities and avascular necrosis were found in only 2.47%, 0.31% and 1.98%. respectively.

CONCLUSION

This is the first study of the symptoms and signs at initial clinical presentation of SLE patients compared to other studies done regionally where most have focused on clinical manifestations during the progression course of SLE. SLE manifestations may be related to the differences in the genetic make-up of the patients who come from various ethnic groups despite similar geography or sociocultural background, or to referral bias, as some studies were performed in the nephrology units and others in the rheumatology units. There is a pressing need to establish a nationwide and regional collaboration to establish LUPUS and to put forward a strategic planning with each MOH to provide an easy and efficient report of SLE cases and provide various effective management for such a debilitating syndrome.

Effects of Aspirin in Rats With Ouabain Intracerebral Treatment-Possible Involvement of Inflammatory Modulation?

Bipolar disorder (BD) is a chronic and refractory disease with high probability of morbidity and mortality. Although epidemiological studies have established a strong association between BD and immune dysfunction, the precise etiology is still debatable, and the underpinning mechanism remains poorly investigated and understood. In the present study, manic-like symptoms of BD were induced in rats after intracerebroventricular administration of ouabain. Aspirin, a commonly used anti-inflammatory agent, was used to treat the induced manic-like symptoms and inflammation. Concentrations of a spectrum of inflammatory cytokines were examined by enzyme-linked immunosorbent assay in both plasma and brain tissues, and expression of Toll-like receptors 3 and 4 were determined in rat brains. Locomotor activity was monitored with open-field test to assess the effects of ouabain challenge and to evaluate the treatment efficacy of aspirin. Ouabain administration recapitulated many mania-like features such as increased stereotypic counts, traveling distance in open-field test, and decreased expression of brain-derived neurotrophic factor, interferon gamma, and Toll-like receptor 3, which were frequently found in patients with BD. These abnormalities could be partially reversed by aspirin. Our findings suggest that aspirin could be used as a promising adjunctive therapy for BD.

Fatigue in systemic lupus: the role of disease activity and its correlates

OBJECTIVES

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that leads to a variety of negative health outcomes resulting from inflammation in various organ systems. Although treatment continues to advance, fatigue remains one of the most salient, poorly understood and addressed patient complaints. Understanding the mechanisms of fatigue can help guide the development of interventions to improve health outcomes. The aim of this research was to evaluate the contribution of six variables (disease activity, insomnia, depression, stress, pain and physical health) to fatigue in SLE without concomitant fibromyalgia (FM).

METHODS

A total of 116 ethnically diverse, primarily female participants (91%) with SLE, receiving care at university medical centers, completed assessments of disease activity and quality of life outcomes (FACIT-FT, Insomnia Severity Index, Perceived Stress Scale (PSS-4), Pain Inventory, Depression-PHQ-9, and LupusPRO-physical function). All patients met the American College of Rheumatology classification criteria for SLE and did not have a known diagnosis of FM. Multivariate linear and stepwise regression analyses were conducted with fatigue (FACIT-FT) as the dependent variable, and the above six variables as independent variables.

RESULTS

Mean (SD) age was 39.80 (13.87) years; 50% were African American, 21% Caucasian, 13% Hispanic, 9% Asian and 8% other. Mean (SD) FACIT-FT was 20.09 (12.76). Collectively, these six variables explained 57% of the variance in fatigue. In the multivariate model, depression, stress and pain were significantly and independently associated with fatigue, but not disease activity, sleep or physical health. Stress had the largest effect on fatigue (β 0.77, 95% CI 0.17-1.38, p = 0.01), followed by depression (β 0.66, 95% CI 0.21-1.10, p = 0.005). On stepwise regression analysis, only stress, depression and pain were retained in the model, and collectively explained 56% of the variance in fatigue. All three remained independent correlates of fatigue, with the largest contribution being stress (β 0.84, 95% CI 0.27-1.42, p = 0.005), followed by depression (β 0.79, 95% CI 0.44-1.14, p < 0.001) with fatigue.

CONCLUSION

Stress, depression and pain are the largest independent contributors to fatigue among patients with SLE, without concurrent FM. Disease activity, sleep and physical health were not associated with fatigue. The evaluation of stress, depression and pain needs to be incorporated during assessments and clinical trials of individuals with SLE, especially within fatigue. This stress-depression-fatigue model requires further validation in longitudinal studies and clinical trials. Significance and innovation: • Disease activity, sleep, pain, stress, depression, and physical health have been reported individually to be associated with fatigue in lupus. This analysis evaluated the role of each and all of these six variables collectively in fatigue among patients with SLE without a known diagnosis of FM. • Disease activity, sleep and physical health were not significantly related to fatigue, but depression, stress and pain were. • The results emphasize the need to evaluate and treat fatigue in individuals with SLE utilizing a biopsychosocial approach, particularly in the realm of clinical trials. Behavioral medicine interventions are shown to be most effective for the treatment of depression, stress and pain.

Association of Depression With Risk of Incident Systemic Lupus Erythematosus in Women Assessed Across 2 Decades

IMPORTANCE

It has long been hypothesized that depression may increase the risk of developing autoimmune disease; however, rigorous empirical evidence is sparse.

OBJECTIVE

To evaluate whether an association exists between depression and risk of incident systemic lupus erythematosus (SLE), a paradigmatic, systemic autoimmune disease.

DESIGN, SETTING, AND PARTICIPANTS

This 20-year prospective, longitudinal cohort study evaluated data collected from 2 cohorts of women participating in the Nurses' Health Study (1996-2012) and the Nurses' Health Study II (1993-2013). Data analyses were conducted from August 2017 to May 2018.

MAIN OUTCOMES AND MEASURES

Incident SLE with 4 or more American College of Rheumatology criteria was ascertained by self-report and confirmed by medical record review. Depression was assessed repeatedly throughout follow-up according to whether women reported having received a clinician's diagnosis of depression, regular antidepressant use, or a score of less than 60 on the 5-item Mental Health Inventory (MHI-5). Whether longitudinally assessed health risk factors (eg, cigarette smoking, body mass index, oral contraceptive use, menopause or postmenopausal hormone use, alcohol use, exercise, or diet) accounted for increased SLE risk among women with vs without depression was examined. Cox proportional hazards regression models were used to estimate risk of SLE. In addition, the association of depression lagged by 4 years, and depression status at baseline with incident SLE throughout follow-up was assessed.

RESULTS

Data from 194 483 women (28-93 years of age; 93% white) were included. During 20 years of follow-up, 145 cases of SLE occurred. Compared with women with no depression, women with a history of depression had a subsequent increased risk of SLE (HR, 2.67; 95% CI, 1.91-3.75; P < .001). Adjustment for body mass index, cigarette smoking, and oral contraception and postmenopausal hormone use slightly attenuated associations (adjusted HR, 2.45; 95% CI, 1.74-3.45; P < .001). The SLE risk was elevated with each of the 3 following depression indicators modeled separately: clinician's diagnosis of depression (HR, 2.19; 95% CI, 1.29-3.71), antidepressant use (HR, 2.80; 95% CI, 1.94-4.05), and MHI-5 scores indicating depressed mood (HR, 1.70; 95% CI, 1.18-2.44). Associations remained strong when depression status was lagged by 4 years with respect to the outcome (HR, 1.99; 95% CI, 1.32-3.00) and when depression status at baseline was used as the exposure (HR, 2.28; 95% CI, 1.54-3.37).

CONCLUSIONS AND RELEVANCE

This study contributes to increasing evidence that depression may be associated with increased risk of SLE and suggests that the association is not fully explained by measured health factors or behaviors.

Current and up-and-coming pharmacotherapy for obsessive-compulsive disorder in adults

INTRODUCTION

Only 40-60% of obsessive-compulsive patients respond to first line treatments, such as selective serotonin reuptake inhibitors (SSRIs) and cognitive-behavioral therapy. Several second-line treatments have been investigated in the last two decades, and most of them seem to work, at least in a subset of patients. However, since there is still a lack of treatment predictors, the treatment of obsessive-compulsive disorder (OCD) is still empirical and non-evidence based.

AREAS COVERED

In this paper, we review current and up-and-coming pharmacotherapy for OCD in adults, focusing on two emerging fields of research, inflammation and glutamate systems, since they have attracted the greatest attention in recent years in OCD pharmacological research.

EXPERT OPINION

Most of the investigated second-line agents seem to work at least in a subset of patients with OCD. These results raise an open question: what works for who? In our opinion, this question should be answered in a precision medicine perspective or, in other words, individualizing diagnostic processes and treatment approaches. In a precision medicine approach, OCD treatment should be sub-type specific, phase specific, multimodal and sequential, and, more importantly, dimensional.

Neuropsychiatric Systemic Lupus Erythematosus Is Dependent on Sphingosine-1-Phosphate Signaling

About 40% of patients with systemic lupus erythematosus experience diffuse neuropsychiatric manifestations, including impaired cognition and depression. Although the pathogenesis of diffuse neuropsychiatric SLE (NPSLE) is not fully understood, loss of brain barrier integrity, autoreactive antibodies, and pro-inflammatory cytokines are major contributors to disease development. Fingolimod, a sphingosine-1-phosphate (S1P) receptor modulator, prevents lymphocyte egress from lymphoid organs through functional antagonism of S1P receptors. In addition to reducing the circulation of autoreactive lymphocytes, fingolimod has direct neuroprotective effects such as preserving brain barrier integrity and decreasing pro-inflammatory cytokine secretion by astrocytes and microglia. Given these effects, we hypothesized that fingolimod would attenuate neurobehavioral deficits in MRL-lpr/lpr (MRL/lpr) mice, a validated neuropsychiatric lupus model. Fingolimod treatment was initiated after the onset of disease, and mice were assessed for alterations in cognitive function and emotionality. We found that fingolimod significantly attenuated spatial memory deficits and depression-like behavior in MRL/lpr mice. Immunofluorescent staining demonstrated a dramatic lessening of brain T cell and macrophage infiltration, and a significant reduction in cortical leakage of serum albumin, in fingolimod treated mice. Astrocytes and endothelial cells from treated mice exhibited reduced expression of inflammatory genes, while microglia showed differential regulation of key immune pathways. Notably, cytokine levels within the cortex and hippocampus were not appreciably decreased with fingolimod despite the improved neurobehavioral profile. Furthermore, despite a reduction in splenomegaly, lymphadenopathy, and circulating autoantibody titers, IgG deposition within the brain was unaffected by treatment. These findings suggest that fingolimod mediates attenuation of NPSLE through a mechanism that is not dependent on reduction of autoantibodies or cytokines, and highlight modulation of the S1P signaling pathway as a novel therapeutic target in lupus involving the central nervous system.

Manic Episodes Due to Medical Illnesses: A Literature Review

The body of evidence for mania as a secondary syndrome due to organic diseases is small. The clinical diagnosis and management of these patients are mainly based on clinical experience and on some case reports. Treatment should be focused on both the underlying medical illness and the control of acute symptoms. Mania due to a medical condition is relevant in the clinical setting, and thus more research is needed to add evidence-based recommendations to the currently available clinical knowledge. In this review, we summarize the latest information on the etiology, epidemiology, diagnostic aspects, and management of secondary mania.

Physical-psychiatric comorbidity: patterns and explanations for ethnic group differences

OBJECTIVE

This paper examines ethnic differences in the co-occurrence of physical and psychiatric health problems (physical-psychiatric comorbidity) for women and men. The following ethnic groups are included: Non-Latino Whites, African Americans, Caribbean Blacks, Spanish Caribbean Blacks, Mexicans, Cubans, Puerto Ricans, Other Latinos, Chinese, Filipinos, Vietnamese, and Other Asian Americans. In addition, the study assesses the extent to which social factors (socioeconomic status, stress exposure, social support) account for ethnic differences in physical-psychiatric comorbidity (PPC).

DESIGN

This study uses data from the Collaborative Psychiatric Epidemiology Surveys (CPES) (N = 12,787). Weighted prevalence rates of physical-psychiatric comorbidity (PPC) - the co-occurrence of physical and psychiatric health problems - are included to examine ethnic group differences among women and men. Multinomial logistic regression analysis was used to determine group differences in PPC before and after adjusting for social factors.

RESULTS

Puerto Rican men have significantly higher risk of PPC in comparison to Non-Latino White men. Among women, Blacks and Cubans were more likely than Non-Latino Whites to experience PPC as opposed to 'Psychiatric Only' health problems. Social factors account for the Puerto Rican/Non-Latino White difference in comorbid health among men, but have little explanatory power for understanding ethnic differences in comorbidity among women.

CONCLUSION

These findings have implications for medical care and can guide intervention programs in targeting a specific constellation of co-occurring physical and psychiatric health problems for diverse ethnic groups in the United States. As comorbidity rates increase, it is crucial to identify the myriad factors that give rise to ethnic group differences therein.

Bipolar Disorder Associated with Another Autoimmune Disease-Pemphigus: A Population-based Study

OBJECTIVES

Recent evidence suggests a notable role for inflammation and immune dysregulation in the neuroprogression of bipolar disorders (BD). Several autoimmune comorbidities have been reported in association with BD. However, the epidemiological relationship between pemphigus and BD has not yet been elucidated. We aimed to estimate the association between pemphigus and BD using a large-scale, real-life computerized database.

METHODS

Data for this study were retrieved from the database of the Clalit Health Services, the largest, state-mandated, health service organization in Israel. This study was designed as a cross-sectional study. The proportion of patients with BD was compared between patients diagnosed with pemphigus and age-, sex-, and ethnicity-matched control subjects. A logistic regression model was performed to estimate how pemphigus and other covariates contributed as risk factors for BD.

RESULTS

A total of 1,985 pemphigus cases and 9,874 controls were included in the study. The prevalence of BD was greater in cases with pemphigus than in controls (1.0% v. 0.5%, respectively; P = 0.023). This coexistence was more prominent among patients of Jewish ethnicity. After controlling for confounders, such as age, sex, ethnicity, socioeconomic status, drug abuse, alcohol abuse, smoking, healthcare utilization, and comorbidities, pemphigus demonstrated a substantial independent association with BD (OR, 1.7; 95% CI, 1.0 to 2.9).

CONCLUSIONS

Pemphigus is significantly associated with BD. Patients with pemphigus should be assessed for comorbid BD. Experimental research is needed to better recognize the biological mechanisms underlying this observation.

Variation in pain related to systemic lupus erythematosus (SLE): a 7-year follow-up study

We have previously shown that most patients with systemic lupus erythematosus (SLE) reported low degree of SLE-related pain. However, 24% of the patients reported high degree of SLE-related pain, more fatigue, anxiety and depression, and worse health-related quality of life (HRQoL). To explore SLE-related pain, the presence of long-standing widespread pain, and patient-reported outcomes (PROs) after 7 years. Sixty-four out of 84 patients participated in a 7-year follow-up of the original survey and completed the same questionnaires answered at inclusion: pain (VAS 100 mm), fatigue (MAF), HRQoL (SF-36), anxiety and depression (HADS), and, if appropriate, a pain-drawing. Differences between inclusion and follow-up (change) were calculated. The patients with a low degree of SLE-related pain at inclusion reported no changes at follow-up in pain and PROs except for worsening in physical function in SF-36, median change (IQR) 0 (- 10 to 5), p = 0.024. Half of the patients with high degree of pain at inclusion reported decreased pain at follow-up, median change (IQR) 45 (35 to 65), p = 0.021; fatigue, 8 (8 to 17), p = 0.018; anxiety, 4 (1 to 4), p = 0.035; and depression, 4 (2 to 5), p = 0.018 and improvements in most dimensions of SF-36. The remaining half of the patients reported no changes regarding pain and PROs except for a worsening in vitality in SF-36, 20 (15 to 35), p = 0.0018. All patients with remaining high level of pain indicated long-standing widespread pain. After 7 years, a subgroup of patients with SLE reported remaining high level of SLE-related pain and a high symptom burden, including long-standing widespread pain. Such patients require more observant attention to receive appropriate treatment.

Research Ethics in Behavioral Interventions Among Special Populations: Lessons From the Peer Approaches to Lupus Self-Management Study

BACKGROUND

Research involving a homogenous cohort of participants belonging to a special population must make considerations to recruit and protect the subjects. This study analyses the ethical considerations made in the peer approaches to lupus self-management project which pilot tested a peer mentoring intervention for African American women with systemic lupus erythematosus.

METHODS

Considerations made at the outset of the project are described and their justifications and reasoning are given. Through analysis of feedback from a postintervention focus group and mentors' logs, implications on program outcomes and participant satisfaction are discussed.

RESULTS

Feedback indicated the importance of recruiting and training capable mentors, consistent contact from study staff to avert adverse events and avert fear or mistrust and careful consideration that must go into the pairing of mentors and mentees. Participant feedback also indicated that sensitive topics must be addressed carefully to prevent distress and dissatisfaction.

CONCLUSIONS

Applying the lessons learned from this work as well as the considerations that proved successful may improve the contextualization and ethical conduct of behavioral interventions in special populations resulting in improved tailoring and acceptability toward historically underserved individuals.

Feasibility, Validity, and Reliability of the 10-item Patient Reported Outcomes Measurement Information System Global Health Short Form in Outpatients with Systemic Lupus Erythematosus

OBJECTIVE

To assess the feasibility, validity, and reliability of the Patient Reported Outcomes Measurement Information System Global Health Short Form (PROMIS10) in outpatients with systemic lupus erythematosus (SLE).

METHODS

SLE outpatients completed PROMIS10, Medical Outcomes Study Short Form-36 (SF-36), LupusQoL-US, and selected PROMIS computerized adaptive tests (CAT) at routine visits at an SLE Center of Excellence. Construct validity was evaluated by correlating PROMIS10 physical and mental health scores with PROMIS CAT, legacy instruments, and physician-derived measures of disease activity and damage. Test-retest reliability was determined among subjects reporting stable SLE activity at 2 assessments 1 week apart using intraclass correlation coefficients (ICC).

RESULTS

A diverse cohort of 204 out of 238 patients with SLE (86%) completed survey instruments. PROMIS10 physical health scores strongly correlated with physical function, pain, and social health domains in PROMIS CAT, SF-36, and LupusQoL, while mental health scores strongly correlated with PROMIS depression CAT, SF-36, and LupusQoL mental health domains (Spearman correlations ≥ 0.70). Active arthritis, comorbid fibromyalgia (FM), and anxiety were associated with worse PROMIS10 scores, but sociodemographic factors and physician-assessed flare status were not. Test-retest reliability for PROMIS10 physical and mental health scores was high (ICC ≥ 0.85). PROMIS10 required < 2 minutes to complete.

CONCLUSION

PROMIS10 is valid and reliable, and can efficiently screen for impaired physical function, pain, and emotional distress in outpatients with SLE. With strong correlations to LupusQoL and SF-36 but significantly reduced responder burden, PROMIS10 is a promising tool for measuring patient-reported outcomes in routine SLE clinical care and value-based healthcare initiatives.

Systemic autoimmune diseases are associated with an increased risk of bipolar disorder: A nationwide population-based cohort study

BACKGROUND

Studies suggested autoimmunity plays a role in the etiology of bipolar disorder (BD). This study aimed to investigate the association between systemic autoimmune diseases (SADs) and the subsequent development of BD, and examine the potential risk factors for developing BD.

METHODS

Patients with SADs were identified in the Taiwan National Health Insurance Program (NHIP). A comparison cohort was created by matching patients without SADs with age. The SADs cohort consisted of 65,498 while the comparison cohort consisted of 261,992 patients. The incidence of BD was evaluated in both cohorts.

RESULTS

The major finding was the discovery of a higher incidence of subsequent BD among patients with SADs (adjusted hazard ratio: 1.98). Specifically, the risk of BD was observed to be significant increase in systemic lupus erythematosus, rheumatoid arthritis, autoimmune vasculitis, Sicca syndrome and Crohn's disease. Furthermore, our study revealed some potential risk factors for developing BD including female, younger age and patients who lived in eastern Taiwan. Also, some comorbidities including dyslipidemia, chronic obstructive pulmonary disease, diabetes mellitus, asthma, cerebrovascular disease, alcohol used disorder, liver cirrhosis, and malignancies were potential risk factors for incident BD.

LIMITATIONS

The diagnosis of SADs was based on the catastrophic illness certificate defined by Taiwanese NHIP. Thus, not every form of SADs was explored for subsequent developing BD.

CONCLUSION

This study confirms that SADs are associated with higher incidence of BD, suggesting that abnormal autoimmune process is associated with increased expression of psychiatric disturbances.

The mediational role of helplessness in psychological outcomes in systemic lupus erythematosus

Objective Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that can result in disability and psychological distress. Although pain has been associated with depressive symptomatology and stress in SLE, a paucity of theoretical models have been used to explain the relationship between pain and psychological distress in this population. Thus, the present study examined helplessness as a mediator of the relationship between pain and psychological distress among patients with SLE. Methods Multiple mediation analysis was used to examine the hypothesis that learned helplessness mediates the relationship between pain and symptoms of anxiety, depression, and stress in a sample of patients with SLE ( N = 136) receiving medical care at Cedars Sinai Medical Center. Results The mean score on the Helplessness subscale was 14.5 ( SD = 5.4). Helplessness fully mediated the relationship between pain vitality and symptoms of anxiety (BCa 95% CI (-0.073, -0.015)), depression (BCa 95% CI (-0.502, -0.212)), and stress (BCa 95% CI (-0.063, -0.027)). Conclusion Participants reported a high level of perceived inability to control one's disease. Helplessness fully mediated the relationship between pain and measures of anxiety, depression, and perceived stress among patients with SLE.

Socioeconomic Predictors of Incident Depression in Systemic Lupus Erythematosus

OBJECTIVE

To assess different measures of socioeconomic status (SES) as predictors of incident depression among women with systemic lupus erythematosus (SLE).

METHODS

Data were derived from the 2010-2015 waves of the Lupus Outcomes Study, where individuals with confirmed SLE were interviewed annually by telephone. Depression was assessed using the Center for Epidemiologic Studies Depression Scale, using a validated lupus-specific cutoff (≥23) for major depressive disorder. Women interviewed in ≥2 consecutive waves, with scores <23 in the first wave (T1), were included. The level of financial strain was classified as high, moderate, or none based on responses to 3 questions. Generalized estimating equations were used to assess the impact of poverty status, income, education, and financial strain at T1 on the risk of incident depression the next year (T2), with adjustment for sociodemographic and disease status measures. Individuals could contribute more than one 2-year dyad to the analysis.

RESULTS

In total, 682 women contributed 2,097 observations, with 19% having high financial strain, 47% moderate strain, and 34% no strain. There were 166 women who had 184 episodes of incident depression (rate = 8.8/100 person-years). In bivariate analysis, poverty, lower income and education, disease activity, and high financial strain were associated with depression onset; race/ethnicity was not. Poverty, income, and education were not significant in multivariate analyses, but disease activity and high financial strain were (odds ratio 1.85 [95% confidence interval 1.06-3.23]).

CONCLUSION

High financial strain was a significant predictor of new-onset depression in women with SLE, controlling for disease factors and other SES measures. Determining specific, modifiable sources of financial strain may help prevent the development of depression.

Bipolar Disorder and Immune Dysfunction: Epidemiological Findings, Proposed Pathophysiology and Clinical Implications

Bipolar disorder (BD) is strongly associated with immune dysfunction. Replicated epidemiological studies have demonstrated that BD has high rates of inflammatory medical comorbidities, including autoimmune disorders, chronic infections, cardiovascular disease and metabolic disorders. Cytokine studies have demonstrated that BD is associated with chronic low-grade inflammation with further increases in pro-inflammatory cytokine levels during mood episodes. Several mechanisms have been identified to explain the bidirectional relationship between BD and immune dysfunction. Key mechanisms include cytokine-induced monoamine changes, increased oxidative stress, pathological microglial over-activation, hypothalamic-pituitary-adrenal (HPA) axis over-activation, alterations of the microbiome-gut-brain axis and sleep-related immune changes. The inflammatory-mood pathway presents several potential novel targets in the treatment of BD. Several proof-of-concept clinical trials have shown a positive effect of anti-inflammatory agents in the treatment of BD; however, further research is needed to determine the clinical utility of these treatments. Immune dysfunction is likely to only play a role in a subset of BD patients and as such, future clinical trials should also strive to identify which specific group(s) of BD patients may benefit from anti-inflammatory treatments.

Prevalence and severity of depression among Iraqi patients with systemic lupus erythematosus: A descriptive study

BACKGROUND:

Systemic lupus erythematosus (SLE) patients have high risk for depression which is a potentially life-threatening disorder.

OBJECTIVES:

To evaluate the prevalence and severity of depression in a sample of Iraqi patients with SLE if present.

PATIENTS AND METHODS:

This cross-sectional study involved 60 patients with SLE diagnosed according to revised American College of Rheumatology (ACR) classification criteria. Demographics and clinical data were collected. All patients were screened for depression by using the diagnostic and statistical manual of mental disorders-5 (DSM5) diagnostic criteria of depression. Severity of their depression was determined by using the Beck Depression Inventory criteria.

RESULTS:

The prevalence of depression was 31.7%. A severe form of depression was observed in 13.3% of SLE cases, moderate depression in 10%, and a mild degree of depression was 8.3% of the cases. Patients with high SLE disease activity index (SLEDAI score >12) had an obviously higher rate of depression (40%) compared to 20% among those with mild or moderate disease. There was no important or statistically significant difference in median SLEDAI score between depression severity categories (p > 0.05).

CONCLUSIONS:

Prevalence of depression in SLE patients was relatively high. SLE disease activity increase depression rate.

The Effectiveness of Mindfulness-based Cognitive Therapy on Psychological Symptoms and Quality of Life in Systemic Lupus Erythematosus Patients: A Randomized Controlled Trial

OBJECTIVES

This study was conducted to determine the efficacy of mindfulness-based cognitive therapy (MBCT) on psychological symptoms and quality of life (QoL) in patients with systemic lupus erythematosus (SLE).

METHODS

We conducted a randomized single-blind clinical trial in patients with SLE referred from the Imam Ali Clinic in Shahrekord, southwest Iran. The patients (46 in total in two groups of 23 each) were randomly assigned into the experimental and control groups. Both groups underwent routine medical care, and the experimental group underwent eight group sessions of MBCT in addition to routine care. The patient^,s QoL was assessed using the General Health Questionnaire-28 and 36-Item Short Form Health Survey before, after, and six months after intervention (follow-up).

RESULTS

A significant difference was seen in psychological symptoms and QoL between MBCT and control groups immediately after the intervention and at follow-up (p ≤ 0.050). However, the difference was not significant for the physical components of QoL (p ≥ 0.050).

CONCLUSIONS

MBCT contributed to decreased psychological symptoms and improved QoL in patients with SLE with a stable effect on psychological symptoms and psychological components of QoL, but an unstable effect on physical components.

Cytokine balance and behavioral intervention; findings from the Peer Approaches to Lupus Self-Management (PALS) project

The Peer Approaches to Lupus Self-Management program sought to address the disparate impact of systemic lupus erythematosus (SLE) on African American women through a peer mentoring intervention with aims of reducing stress, anxiety, and depression. Given the association between psychological health and immune function this study examines the relationship between patient reported outcomes (PROs) in these domains and immunologic indicators of disease activity. Twenty-three African American women with SLE served as mentees in the intervention from whom PRO measures were collected at the outset, midpoint, and end of the 12week pilot study. Blood samples were collected pre- and post-intervention. Plasma was collected from the samples and cryopreserved for subsequent analyses. The strongest correlations were between the Generalized Anxiety Disorder measure and Th1/Th2 cytokine balance. Weaker correlations existed between depression and the Th1/Th2 cytokine balance. Assessment of fresh versus cryopreserved samples revealed that changes in Th1/Th2 cytokine balance within the intervention were generally equivalent, regardless of sample type. The PALS intervention resulted in significant improvements to anxiety and depression levels which were significantly associated with positive changes in Th1/Th2 cytokine balance indicating a possible underlying mechanism of action. The nature of this relationship warrants further study.

Inflammation in the Neurocircuitry of Obsessive-Compulsive Disorder

IMPORTANCE

For a small percentage of obsessive-compulsive disorder (OCD) cases exhibiting additional neuropsychiatric symptoms, it was proposed that neuroinflammation occurs in the basal ganglia as an autoimmune response to infections. However, it is possible that elevated neuroinflammation, inducible by a diverse range of mechanisms, is important throughout the cortico-striato-thalamo-cortical circuit of OCD. Identifying brain inflammation is possible with the recent advance in positron emission tomography (PET) radioligands that bind to the translocator protein (TSPO). Translocator protein density increases when microglia are activated during neuroinflammation and the TSPO distribution volume (VT) is an index of TSPO density.

OBJECTIVE

To determine whether TSPO VT is elevated in the dorsal caudate, orbitofrontal cortex, thalamus, ventral striatum, dorsal putamen, and anterior cingulate cortex in OCD.

DESIGN, SETTING, AND PARTICIPANTS

This case-control study was conducted at a tertiary care psychiatric hospital from May 1, 2010, to November 30, 2016. Participants with OCD (n = 20) and age-matched healthy control individuals (n = 20) underwent a fluorine F 18-labeled N-(2-(2-fluoroethoxy)benzyl)-N-(4-phenoxypyridin-3-yl)acetamide PET scan. It is a high-quality second-generation TSPO-binding PET radiotracer. All participants were drug and medication free, nonsmoking, and otherwise healthy.

MAIN OUTCOMES AND MEASURES

The TSPO VT was measured in the dorsal caudate, orbitofrontal cortex, thalamus, ventral striatum, dorsal putamen, and anterior cingulate cortex. Compulsions were assessed with the Yale-Brown Obsessive Compulsive Scale.

RESULTS

In the OCD and healthy groups, the mean (SD) ages were 27.4 (7.1) years and 27.6 (6.6) years, respectively, and 11 (55%) and 8 (40%) were women, respectively. In OCD, TSPO VT was significantly elevated in these brain regions (mean, 32%; range, 31%-36% except anterior cingulate cortex, 24%; analysis of variance, effect of diagnosis: P < .001 to P = .004). Slightly lower elevations in TSPO VT (22%-29%) were present in other gray matter regions. The Yale-Brown Obsessive Compulsive Scale measure of distress associated with preventing compulsive behaviors significantly correlated with TSPO VT in the orbitofrontal cortex (uncorrected Pearson correlation r = 0.62; P = .005).

CONCLUSIONS AND RELEVANCE

To our knowledge, this is the first study demonstrating inflammation within the neurocircuitry of OCD. The regional distribution of elevated TSPO VT argues that the autoimmune/neuroinflammatory theories of OCD should extend beyond the basal ganglia to include the cortico-striato-thalamo-cortical circuit. Immunomodulatory therapies should be investigated in adult OCD, rather than solely childhood OCD, particularly in cases with prominent distress when preventing compulsions.

Comorbid Conditions are Associated With Emergency Department Visits, Hospitalizations, and Medical Charges of Patients With Systemic Lupus Erythematosus

BACKGROUND/OBJECTIVES

In addition to increase mortality, comorbidities can increase medical costs for systemic lupus erythematosus (SLE). Healthcare utilization can dramatically increase medical costs. It is essential to better understand the comorbidities that can lead to healthcare utilization, such as emergency department visit and/or hospitalization, for SLE patients. Therefore, the objective of this study was to examine the associations between comorbidities and healthcare utilization and medical charges of patients with SLE.

METHODS

Nebraska statewide emergency departments (ED) discharge and hospitals discharge data from 2007 to 2012 were used to study the comorbid conditions of patients with SLE. SLE was defined using the standard International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis codes (710.0).

RESULTS

There were more comorbid conditions in patients with SLE than patients without SLE. Comorbid conditions were majorly related to ED visits and hospitalizations of patients with SLE. Chest pain, abdominal pain, injury, acute respiratory infections, symptoms of digestive systems, headache, myalgia and myositis, noninfectious gastroenteritis and colitis, and symptoms of skin and other integumentary systems are common comorbid conditions for ED visits. Infections, cardiovascular diseases, fractures, chronic obstructive pulmonary disease (COPD) and allied conditions, cerebrovascular diseases, and episodic mood disorder are common comorbid conditions for hospitalizations of patients with SLE. In addition, the numbers of comorbid conditions were significantly associated with the length of hospital stay and hospital charges for SLE patients.

CONCLUSION

The findings in this study indicated that comorbid conditions are associated with healthcare utilization and medical charges of patients with SLE.

Depression in systemic lupus erythematosus: gender differences in the performance of the Beck Depression Inventory (BDI), Center for Epidemiologic Studies Depression Scale (CES-D), and Hospital Anxiety and Depression Scale (HADS)

The prevalence of depressive symptoms in patients with systemic lupus erythematosus (SLE) varies widely between different cohorts (17-75%), primarily due to factors such as the heterogeneity of the samples and the instruments used to detect depressive symptoms. Most of these instruments are self-administered questionnaires that have different characteristics and approaches to depressive symptoms. This study aimed to evaluate gender differences in the performance of three questionnaires used to assess depressive symptoms in patients with SLE: the Beck Depression Inventory (BDI), Center for Epidemiologic Studies Depression Scale (CES-D), and Hospital Anxiety and Depression Scale (HADS). This study included 54 male and 54 female SLE patients. Depressive symptoms were assessed using BDI (cutoffs 13 and 15), CES-D and HADS. The gold standard method used was the diagnostic criteria of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. Regarding the performance of the BDI questionnaire, no significant differences in sensitivity or specificity were found between the genders. The specificity of the CES-D questionnaire was significantly greater for the male group (83% vs. 62.5%, p = 0.0309), and its sensitivity was non-significantly higher for the female group (92.9% for women and 71.4% for men; p = 0.2474). Regarding the performance of the HADS, we found similar sensitivities between the genders (71.4%) but a higher specificity among the men (95.7% in men and 82.5% in women, p = 0.0741). In conclusion, our results suggest the presence of gender differences in the performance of the questionnaires in SLE patients. The BDI had the most similar performances between the male and female groups. In contrast, the CES-D and HADS-D showed considerable variation in performances between men and women with SLE.

Effective Self-Management Interventions for Patients With Lupus: Potential Impact of Peer Mentoring

Systemic lupus erythematosus (SLE) is associated with significant mortality, morbidity and cost for the individual patient and society. In the United States, African Americans (AAs) have 3-4 times greater prevalence of lupus, risk of developing lupus at an earlier age and lupus-related disease activity, organ damage and mortality compared with whites. Evidence-based self-management interventions that incorporate both social support and health education have reduced pain, improved function and delayed disability among patients with lupus. However, AAs and women are still disproportionately affected by lupus. This article presents the argument that peer mentoring may be an especially effective intervention approach for AA women with SLE. SLE peers with a track record of success in lupus management and have a personal perspective that clinicians often lack. This commonality and credibility can establish trust, increase communication and, in turn, decrease disparities in healthcare outcomes.

Serum levels of brain-derived neurotrophic factor are associated with depressive symptoms in patients with systemic lupus erythematosus

OBJECTIVE

The aim of this study was to explore potential relationships between serum BDNF levels and depression in systemic lupus erythematosus (SLE) patients.

METHODS

We included 208 consecutive SLE patients and 100 age-and sex-matched healthy controls. The presence of depressive symptoms was determined through the Beck Depression Inventory-II (BDI-II) score.

RESULTS

The serum BDNF levels were significantly (P<0.0001) higher in SLE patients as compared to normal controls. There was a negative correlation between levels of BDNF and the SLE disease activity index 2000 (SLEDAI-2K) (r=-0.349, P<0.0001). Depression (defined as BDI-II score≥18) was identified in 54 SLE patients (26.0%, 95%CI: 20%-31.9%). The serum BDNF levels were significantly lower in depression patients at the time of admission as compared with patients without depression [27.6(IQR, 23.2-30.4)ng/ml vs. 36.2(IQR, 31.7-42.3)ng/ml; P<0.0001]. Compared with the first quartile of serum BDNF levels, the second quartile OR for depression was 0.72 (95% CI, 0.61-0.80, P=0.033). For the third and fourth quartiles, it was 0.42 (95% CI, 0.33-0.52, P=0.002) and 0.16 (95% CI, 0.09-0.24; P<0.001).

CONCLUSION

Serum BDNF levels are decreased in SLE patients with depressive symptoms. In SLE, serum BNDF levels are independently associated with depressive disorders, suggesting the role of neurotrophic factors in depression.

Neuropsychiatric symptoms in systemic lupus erythematosus: impact on quality of life

Objective

Assess quality of life in patients with systemic lupus erythematosus (SLE) presenting with neuropsychiatric symptoms (neuropsychiatric SLE, NPSLE).

Methods

Quality of life was assessed using the Short-Form 36 item Health Survey (SF-36) in patients visiting the Leiden NPSLE clinic at baseline and at follow-up. SF-36 subscales and summary scores were calculated and compared with quality of life of the general Dutch population and patients with other chronic diseases.

Results

At baseline, quality of life was assessed in 248 SLE patients, of whom 98 had NPSLE (39.7%). Follow-up data were available for 104 patients (42%), of whom 64 had NPSLE (61.5%). SLE patients presenting neuropsychiatric symptoms showed a significantly reduced quality of life in all subscales of the SF-36. Quality of life at follow-up showed a significant improvement in physical functioning role (p = 0.001), social functioning (p = 0.007), vitality (p = 0.023), mental health (p = 0.014) and mental component score (p = 0.042) in patients with neuropsychiatric symptoms not attributed to SLE, but no significant improvement was seen in patients with NPSLE.

Conclusion

Quality of life is significantly reduced in patients with SLE presenting neuropsychiatric symptoms compared with the general population and patients with other chronic diseases. Quality of life remains considerably impaired at follow-up. Our results illustrate the need for biopsychosocial care in patients with SLE and neuropsychiatric symptoms.

Prevalence of depression and anxiety in systemic lupus erythematosus: a systematic review and meta-analysis

BACKGROUND

Systemic lupus erythematosus (SLE) patients are at high risk for depression and anxiety. However, the estimated prevalence of these disorders varies substantially between studies. This systematic review aimed to establish pooled prevalence levels of depression and anxiety among adult SLE patients.

METHODS

We systematically reviewed databases including PubMed, Embase, PsycINFO, and the Cochrane database library from their inception to August 2016. Studies presenting data on depression and/or anxiety in adult SLE patients and having a sample size of at least 60 patients were included. A random-effect meta-analysis was conducted on all eligible data.

RESULTS

A total of 59 identified studies matched the inclusion criteria, reporting on a total of 10828 adult SLE patients. Thirty five and thirteen methods of defining depression and anxiety were reported, respectively. Meta-analyses revealed that the prevalence of major depression and anxiety were 24% (95% CI, 16%-31%, I² = 95.2%) and 37% (95% CI, 12%-63%, I² = 98.3%) according to clinical interviews. Prevalence estimates of depression were 30% (95% CI, 22%-38%, I² = 91.6%) for the Hospital Anxiety and Depression Scale with thresholds of 8 and 39% (95% CI, 29%-49%, I² = 88.2%) for the 21-Item Beck Depression Inventory with thresholds of 14, respectively. The main influence on depression prevalence was the publication years of the studies. In addition, the corresponding pooled prevalence was 40% (95% CI, 30%-49%, I² = 93.0%) for anxiety according to the Hospital Anxiety and Depression Scale with a cutoff of 8 or more.

CONCLUSIONS

The prevalence of depression and anxiety was high in adult SLE patients. It indicated that rheumatologists should screen for depression and anxiety in their patients, and referred them to mental health providers in order to identify effective strategies for preventing and treating depression and anxiety among adult SLE patients.

TRIAL REGISTRATION

Current Meta-analysis PROSPERO Registration Number: CRD 42016044125 . Registered 4 August 2016.

Early onset of inflammation during ontogeny of bipolar disorder: the NLRP2 inflammasome gene distinctly differentiates between patients and healthy controls in the transition between iPS cell and neural stem cell stages

Neuro-inflammation and neuronal communication are considered as mis-regulated processes in the aetiology and pathology of bipolar disorder (BD). Which and when specific signal pathways become abnormal during the ontogeny of bipolar disorder patients is unknown. To address this question, we applied induced pluripotent stem cell (iPSC) technology followed by cortical neural differentiation on adipocyte-derived cells from BD type I patients (with psychotic episodes in psychiatric history) and healthy volunteers (controls). RNA sequencing in iPSC and cortical neural stem cell (NSC) lines were used to examine alterations between the transcriptomes from BD I and control samples during transition from the pluripotent stage towards the neural developmental stage. At the iPSC stage, the most highly significant differentially expressed gene (DEG) was the NLRP2 inflammasome (P=2.66 × 10^-10). Also among 42 DEGs at the NSC stage, NLRP2 showed the strongest statistical significance (P=3.07 × 10^-19). In addition, we have also identified several cytoskeleton-associated genes as DEGs from the NSC stage, such as TMP2, TAGLN and ACTA2; the former two genes are recognised for the first time to be associated with BD. Our results also suggest that iPSC-derived BD-cortical NSCs carry several abnormalities in dopamine and GABA receptor canonical pathways, underlining that our in vitro BD model reflects pathology in the central nervous system. This would indicate that mis-regulated gene expression of inflammatory, neurotransmitter and cytoskeletal signalling occurs during early fetal brain development of BD I patients.

Depressive and Anxiety Disorders in Systemic Lupus Erythematosus Patients without Major Neuropsychiatric Manifestations

Depressive and anxiety disorders are frequently observed in patients with Systemic Lupus Erythematosus (SLE). However, the underlying mechanisms are still unknown. We conducted this survey to understand the prevalence of depression and anxiety in SLE patients without major neuropsychiatric manifestations (non-NPSLE) and to explore the relationship between emotional disorders, symptoms, autoantibodies, disease activity, and treatments in SLE. 176 SLE patients were included, and SLE disease activity index (SLEDAI), Hamilton Depression Rating Scale (HAMD), and Hamilton Anxiety Rating Scale (HAMA) were recorded to evaluate their disease activity and emotional status. We found that depressive and anxiety disorders were common among SLE patients: 121 (68.8%) patients were in depression status while 14 (8.0%) patients could be diagnosed with depression. Accordingly, 101 (57.4%) were in anxiety status and 21 (11.9%) could be diagnosed with anxiety. Depression was associated with disease activity, and anxiety was associated with anti-P0 antibody, while both of them were associated with proteinuria. HAMA and HAMD scores were in strong positive correlation and they were independent risk factors of each other. We concluded that the high prevalence of depression and anxiety and the association between depression and SLE disease activity might reveal the covert damage of central nervous system in SLE. The role of anti-P0 antibody in SLE patients with emotional disorders warrants more researches.

Lupus brain fog: a biologic perspective on cognitive impairment, depression, and fatigue in systemic lupus erythematosus

Cognitive disturbances, mood disorders and fatigue are common in SLE patients with substantial adverse effects on function and quality of life. Attribution of these clinical findings to immune-mediated disturbances associated with SLE remains difficult and has compromised research efforts in these areas. Improved understanding of the role of the immune system in neurologic processes essential for cognition including synaptic plasticity, long term potentiation and adult neurogenesis suggests multiple potential mechanisms for altered central nervous system function associated with a chronic inflammatory illness such as SLE. This review will focus on the biology of cognition and neuroinflammation in normal circumstances and potential biologic mechanisms for cognitive impairment, depression and fatigue attributable to SLE.

Prevalence and risk factors of anxiety and depression in patients with systemic lupus erythematosus in Southwest China

Systemic lupus erythematosus (SLE) patients have high risk for anxiety and depression. We aimed to investigate the prevalence and risk factors of anxiety and depression in SLE patients in Southwest China. Participants were recruited by convenience sampling from Rheumatic Outpatient Clinic of West China Hospital Sichuan University between August and October 2014. The prevalence of anxiety and depression was evaluated using Hospital Anxiety and Depression Scale (HADS). Risk factors were explored by multiple logistic regression analyses. A total of 352 participants were enrolled, of who 64 (18.2 %) met the HADS criteria for anxiety and 82 (23.3 %) for depression. In multivariable analysis, higher levels of pain (OR = 1.17, P = 0.02) and fatigue (OR = 1.19, P < 0.01) predicted a higher risk of anxiety. Similarly, a higher level of fatigue (OR = 1.2, P < 0.01) was associated with a higher risk of depression. The results suggest that anxiety and depression are common in patients with SLE in Southwest China. Health care providers and SLE patients should take some measures to cope with them as early as possible. Strengthening management of pain and fatigue may be useful. But further studies are needed to verify these findings.

Bipolar I and II Disorders; A Systematic Review and Meta-Analysis on Differences in Comorbid Obsessive-Compulsive Disorder

CONTEXT

More than half of the bipolar disorder (BD) cases have an additional diagnosis; one of the most difficult to manage is obsessive-compulsive disorder (OCD). Although some authors recently investigated the co-occurrence of anxiety and BD, the topic remains insufficiently studied. The current study aimed to investigate differences in comorbid OCD between BD-I and BD-II.

EVIDENCE ACQUISITION

A systematic review and meta-analysis was conducted on the prevalence and predictors of comorbid BD-I/BD-II and OCD. Relevant papers published until June 30, 2015 were identified searching the electronic databases MEDLINE, Embase, PsycINFO and the Cochrane Library.

RESULTS

Fourteen articles met the inclusion criteria. The pooled prevalence of BD-I in OCD was 3.9% (95% confidence interval (CI), 2.4 to 6.4, I2 = 83%, Q = 56) while that of BD-II in OCD was 13.5% (95% CI, 9.3 to 19.3, I2 = 89%, Q = 91). The pooled prevalence of OCD in BD-I was 21.7 (95% CI, 4.8 to 60.3, I2 = 84%, Q = 95). With regard to OCD-BD predictors, mean age and rate of males did not predict the prevalence of BD-I (β = 0.0731, 95% CI, -0.1097 to 0.256, z = 0.78; β = 0.035, 95% CI, -0.2356 to 0.1656, z = 0.34) and BD-II (β = 0.0577, 95% CI, -0.1942 to 0.0788, z = 0.83; β = -0.0317, 95% CI, -0.1483 to 0.085, z = 0.53) in OCD. The mean age explained some of the observed heterogeneity (R2 = 0.13; R2 = 0.08).

CONCLUSIONS

This first systematic review and meta-analysis of the prevalence and predictors of comorbid BD-I/BD-II and OCD suggests that BD-OCD comorbidity is a common condition in psychiatry. However, the available evidence does not allow to assess whether BD-I or BD-II are more common in patients with OCD.

Intervention to Improve Quality of life for African-AmericaN lupus patients (IQAN): study protocol for a randomized controlled trial of a unique a la carte intervention approach to self-management of lupus in African Americans

BACKGROUND

Systemic Lupus Erythematosus (lupus) is a chronic autoimmune disease that can impact any organ system and result in life-threatening complications. African-Americans are at increased risk for morbidity and mortality from lupus. Self-management programs have demonstrated significant improvements in health distress, self-reported global health, and activity limitation among people with lupus. Despite benefits, arthritis self-management education has reached only a limited number of people. Self-selection of program could improve such trends. The aim of the current study is to test a novel intervention to improve quality of life, decrease indicators of depression, and reduce perceived and biological indicators of stress in African-American lupus patients in South Carolina.

METHODS/DESIGN

In a three armed randomized, wait list controlled trial, we will evaluate the effectiveness of a patient-centered 'a-la-carte' approach that offers subjects a variety of modes of interaction from which they can choose as many or few as they wish, compared to a 'set menu' approach and usual care. This unique 'a-la-carte' self-management program will be offered to 50 African-American lupus patients participating in a longitudinal observational web-based SLE Database at the Medical University of South Carolina. Each individualized intervention plan will include 1-4 options, including a mail-delivered arthritis kit, addition and access to an online message board, participation in a support group, and enrollment in a local self-management program. A 'set menu' control group of 50 lupus patients will be offered a standardized chronic disease self-management program only, and a control group of 50 lupus patients will receive usual care. Outcomes will include changes in (a) health behaviors, (b) health status, (c) health care utilization, and (d) biological markers (urinary catecholamines).

DISCUSSION

Such a culturally sensitive educational intervention which includes self-selection of program components has the potential to improve disparate trends in quality of life, disease activity, depression, and stress among African-American lupus patients, as better outcomes have been documented when participants are able to choose/dictate the content and/or pace of the respective treatment/intervention program. Since there is currently no "gold standard" self-management program specifically for lupus, this project may have a considerable impact on future research and policy decisions.

TRIAL REGISTRATION

NCT01837875 ; April 18, 2013.

Gender differences in systemic lupus erythematosus concerning anxiety, depression and quality of life

Several studies have demonstrated a high prevalence of depression and anxiety in patients with systemic lupus erythematosus (SLE); however, few data address gender differences regarding these manifestations. This study aimed to investigate gender differences in the prevalence of depressive and anxiety symptoms, and their effect on the quality of life (QOL) of male and female SLE patients. This study included 54 male SLE patients, 54 female SLE patients, 54 male controls and 54 female controls. Depressive symptoms were assessed using the Beck Depression Inventory (BDI), the Center for Epidemiologic Studies Depression Scale (CES-D) and the Hospital Anxiety and Depression Scale (HADS); the anxiety symptoms were examined using HADS. We used the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) to assess QOL. Depressive symptoms were found in 22.2% of BDI respondents, 24.1% of CES-D respondents and 13% of HADS-D respondents who were male SLE patients; while in the female SLE patient group, they were found in 38.9% of BDI respondents ( p = 0.063), 51.9% of CES-D respondents ( p = 0.653) and 31.5% of HADS-D respondents ( p = 0.003). Anxiety symptoms were found in 16.7% of the male SLE patients and 38.9% of the female SLE patients ( p = 0.024). Lower scores on the SF-36 (for QOL) were found in both male and female SLE patients with depression and anxiety symptoms. In conclusion, we observed significant gender differences regarding the prevalence of depressive and anxiety symptoms in patients with SLE, with significantly higher values in the female group. The presence of these symptoms appears to have a negative effect on the QOL of patients of both genders.

Identifying Targets for Improving Mental Healthcare of Adolescents with Systemic Lupus Erythematosus: Perspectives from Pediatric Rheumatology Clinicians in the United States and Canada

OBJECTIVE

To identify targets for improving mental healthcare of adolescents with systemic lupus erythematosus (SLE) by assessing current practices and perceived barriers for mental health intervention by pediatric rheumatology clinicians.

METHODS

Members of the Childhood Arthritis and Rheumatology Research Alliance (CARRA) completed a Web-based survey assessing current mental health practices, beliefs, and barriers. We examined associations between provider characteristics and the frequency of barriers to mental health screening and treatment using multivariable linear regression.

RESULTS

Of the 375 eligible CARRA members, 130 responded (35%) and 119 completed the survey. Fifty-two percent described identification of depression/anxiety in adolescents with SLE at their practice as inadequate, and 45% described treatment as inadequate. Seventy-seven percent stated that routine screening for depression/anxiety in pediatric rheumatology should be conducted, but only 2% routinely used a standardized instrument. Limited staff resources and time were the most frequent barriers to screening. Respondents with formal postgraduate mental health training, experience treating young adults, and practicing at sites with very accessible mental health staff, in urban locations, and in Canada reported fewer barriers to screening. Long waitlists and limited availability of mental health providers were the most frequent barriers to treatment. Male clinicians and those practicing in the Midwest and Canada reported fewer barriers to treatment.

CONCLUSION

Pediatric rheumatology clinicians perceive a need for improved mental healthcare of adolescents with SLE. Potential strategies to overcome barriers include enhanced mental health training for pediatric rheumatologists, standardized rheumatology-based mental health practices, and better integration of medical and mental health services.

Bipolar Disorder and Inflammation

The pathophysiology of bipolar disorder (BD) remains poorly understood. Current psychopharmacologic treatments are often poorly tolerated and carry high rates of treatment resistance. Mounting evidence has suggested that innate immune system dysfunction may play a role in the pathophysiology of BD. Elevated proinflammatory cytokine levels have been identified. The innate immune system is a novel therapeutic target in BD. Lithium has been shown to have antiinflammatory properties. Further research is needed to establish the role of antiinflammatory agents in the treatment of BD; however, evidence from several clinical trials indicates that antiinflammatory agents may be incorporated into clinical practice soon.

Depressive symptoms are associated with tumor necrosis factor alpha in systemic lupus erythematosus

BACKGROUND

Tumor necrosis factor alpha (TNF-α) is deeply related to pathogenesis of neurodevelopmental disorders, especially depression. The aim of this study was to explore potential relationships between sera TNF-α levels and mood and anxiety disorders in systemic lupus erythematosus (SLE) patients.

METHODS

We included 153 consecutive SLE patients (women 148; median age 30; range 10-62) and 40 (women 37; mean age 28.5; range 12-59) age- and sex-matched healthy controls. Mood and anxiety disorders were determined through Beck Depression and Beck Anxiety Inventory. SLE patients were further assessed for clinical and laboratory SLE manifestations. TNF-α levels were measured by enzyme-linked immunosorbent assay using commercial kits.

RESULTS

Depressive symptoms were identified in 70 (45.7 %) SLE patients and in 10 (25 %) healthy controls (p < 0.001). Anxiety symptoms were identified in 93 (60.7 %) SLE patients and in 16 controls (40 %) (p < 0.001). Sera TNF-α levels were increased in SLE patients with depressive symptoms (p < 0.001) and with anxiety symptoms (p = 0.014). A direct correlation between the severity of depressive symptoms and sera TNF-α levels (r = 0.22; p = 0.003) was observed. TNF-α levels were significantly increased in patients with active disease (p = 0.012). In addition, we observed a correlation between sera TNF-α levels and disease activity (r = 0.28; p = 0.008). In the multivariate analysis, sera TNF-α levels were independently associated with depressive symptoms (t = 3.28; 95 % CI 1.08-2.2; p = 0.002).

CONCLUSIONS

Sera TNF-α levels are increased in SLE patients with mood and anxiety disorders. In SLE, sera TNF-α levels are independently associated with mood disorders. The etiology of mood disorders is still debated in SLE, but our findings suggest the presence of immunological basis for depression in SLE.

Depression in Autoimmune Diseases

Up to 50% of patients with autoimmune diseases show an impairment of health-related quality of life and exhibit depression-like symptoms. The immune system not only leads to inflammation in affected organs, but also mediates behavior abnormalities including fatigue and depression-like symptoms. This review focuses on the different pathways involved in the communication of the immune system with the neuronal network and the body's timing system. The latter is built up by a hierarchically organized expression of clock genes. As discussed here, the activation of the immune system interferes with high amplitude expression of clock genes, an effect which may play a pivotal role in depression-like behavior in autoimmune diseases.

Inflammation as a neurobiological substrate of cognitive impairment in bipolar disorder: Evidence, pathophysiology and treatment implications

BACKGROUND

Bipolar disorder (BD) has been associated with cognitive impairment during depressed, manic and euthymic periods. Inflammation has been shown to be involved in the pathophysiology of BD and cognitive impairment.

METHODS

For this systematic review, the MEDLINE/PubMed, Embase, Google Scholar and ClinicalTrials.gov databases were searched for relevant articles assessing the association between cognitive function and inflammatory markers in BD subjects. A discussion of potential mechanisms and therapeutic implications is also included to provide further context to the subject matter.

RESULTS

Eight studies, including a total of 555 BD subjects, assessing the association between cognitive function and inflammatory markers were identified. Cognitive dysfunction was associated with elevated levels of pro-inflammatory markers YKL40, IL-6, sCD40L, IL-1Ra, hsCRP and TNF-α. Mechanistically, elevation in inflammatory cytokines alters monoamine levels leading to cognitive and affective dysfunction. Neuro-inflammation, manifesting as microglial activation, leads to increased oxidative stress, pathologic synaptic pruning and impaired neuroplasticity in key brain regions sub-serving mood and cognition. Immune dysfunction also activates the hypothalamic-pituitary-adrenal (HPA) axis leading to hypercortisolemia and metabolic dysfunction, further promoting neuronal dysfunction. Anti-inflammatory agents are therefore currently being investigated in the treatment of BD and appear to exert an antidepressant effect; however, cognitive outcomes have yet to be reported.

CONCLUSION

Several studies suggest that immune dysfunction is associated with cognitive impairment in BD. Several neurobiological pathways have been identified whereby immune dysfunction may promote cognitive impairment in BD. Future investigations of anti-inflammatory agents targeting cognitive function as a treatment outcome are merited.

Depression and the risk of autoimmune disease: a nationally representative, prospective longitudinal study

BACKGROUND

Autoimmune diseases are associated with substantial morbidity and mortality, yet the etiology remains unclear. Depression has been implicated as a risk factor for various immune-related disorders but little is known about the risk of autoimmune disease. This study examined the association between depression and the risk of autoimmune disease, and investigated the temporal and dose-response nature of these relationships.

METHOD

A prospective population-based study including approximately 1.1 million people was conducted using linked Danish registries. Depression and autoimmune diseases were diagnosed by physicians and documented in medical records. In total, 145 217 individuals with depression were identified between 1995 and 2012. Survival analyses were used to estimate the relative risk of autoimmune disease among those with, compared to without, depression. Analyses were adjusted for gender, age, and co-morbid mental disorders.

RESULTS

Depression was associated with a significantly increased risk of autoimmune disease [incidence rate ratio (IRR) 1.25, 95% CI 1.19-1.31], compared to those without a history of depression. Results suggest a general increased risk of autoimmune diseases following the onset of depression during first year (IRR 1.29, 95% CI 1.05-1.58), which remained elevated for the ensuing 11 years and beyond (IRR 1.53, 95% CI 1.34-1.76). Findings did not support a dose-response relationship.

CONCLUSIONS

Depression appears to be associated with an increased risk of a range of autoimmune diseases. Depression may play a role in the etiology of certain autoimmune conditions. If replicated, findings could highlight additional clinical implications in the treatment and management of depression. Future studies are needed to investigate the possible social, genetic, and neurobiological underpinnings of these relationships.

Identifying Differences in Risk Factors for Depression and Anxiety in Pediatric Chronic Disease: A Matched Cross-Sectional Study of Youth with Lupus/Mixed Connective Tissue Disease and Their Peers with Diabetes

OBJECTIVE

To investigate differences in risk factors for depression and anxiety, such as central nervous system involvement in systemic lupus erythematosus (SLE)/mixed connective tissue disease (MCTD), by comparing youth with SLE/MCTD to peers with type 1 diabetes mellitus (T1D).

STUDY DESIGN

We conducted a cross-sectional study of 50 outpatient pairs, ages 8 years and above, matching subjects with SLE/MCTD and T1D by sex and age group. We screened for depression, suicidal ideation, and anxiety using the Patient Health Questionnaire-9 and the Screen for Childhood Anxiety Related Emotional Disorders, respectively. We collected parent-reported mental health treatment data. We compared prevalence and treatment rates between subjects with SLE/MCTD and T1D, and identified disease-specific risk factors using logistic regression.

RESULTS

Depression symptoms were present in 23%, suicidal ideation in 15%, and anxiety in 27% of participants. Compared with subjects with T1D, subjects with SLE/MCTD had lower adjusted rates of depression and suicidal ideation, yet poorer rates of mental health treatment (24% vs 53%). Non-White race/ethnicity and longer disease duration were independent risk factors for depression and suicidal ideation. Depression was associated with poor disease control in both groups, and anxiety with insulin pump use in subjects with T1D.

CONCLUSION

Depression and anxiety are high and undertreated in youth with SLE/MCTD and T1D. Focusing on risk factors such as race/ethnicity and disease duration may improve their mental health care. Further study of central nervous system and other disease-related factors may identify targets for intervention.