Major depressive disorder and disease activity in systemic lupus erythematosus

Neuropsychiatric systemic lupus erythematosus: association with global disease activity

Objective

To determine whether patients with neuropsychiatric (NP) events attributed to systemic lupus erythematosus (SLE) have more global disease activity than patients with NP events not attributed to SLE.

Methods

Patients were recruited from an academic lupus clinic. Global disease activity was measured with the SLE Disease Activity Index 2000 (SLEDAI-2K) and organ damage with the Systemic Lupus International Collaborating Clinics (SLICC)/American College of Rheumatology (ACR) damage index (SDI). NP disease was defined using the ACR case definitions and decision rules for attribution of NP events to SLE and non-SLE causes.

Results

There were 68 patients (age (mean ± SD) 40.8 ± 15.2 years, 85% female, 94% Caucasians) with 126 NP events. SLEDAI-2K scores in patients with NP events attributed to SLE were higher than in patients with NP events attributed to non-SLE causes even when NP variables were removed from the SLEDAI-2K (mean ± SD: SLE NP = 7.36 ± 5.42 vs non-SLE NP = 5.53 ± 4.57, P = 0.042). Patients with CNS and diffuse NP events, rather that PNS and focal events, accounted for the group differences in SLEDAI-2K scores. There were no significant differences in total SDI scores comparing NP events due to SLE vs. non-SLE causes (mean ± SD: 2.1 ± 1.8 vs. 1.7 ± 1.7; p = 0.28) even when NP variables were omitted.

Conclusions

Increased global SLE disease activity is associated with concurrent NP events attributed to SLE, particularly for diffuse NP and CNS NP events. The findings have diagnostic and therapeutic implications for SLE patients with NP events and inform pathogenetic mechanisms underlying NPSLE.

Irritable bowel syndrome-type symptoms in female patients with mild systemic lupus erythematosus: frequency, related factors and quality of life

BACKGROUND

Irritable bowel syndrome (IBS) impairs quality of life (HRQOL), as does systemic lupus erythematosus (SLE). Both are more common in women and are associated with fibromyalgia (FM). However, the relationship between IBS and SLE and its impact on HRQOL has not been explored. Therefore, we aimed to study the frequency and features likely to influence the presence of IBS-type symptoms in SLE and their impact on HRQOL.

METHODS

Female patients with SLE were studied. The presence of IBS-type symptoms and bowel habit subtype were established by Rome III criteria and HRQOL was assessed using the SF-36. Fibromyalgia and depression were assessed using the American College of Rheumatology criteria and CES-D scale, respectively.

KEY RESULTS

A total of 105 consecutive patients (43.62 ± 11.34 years old) were included; 48.6% had IBS-type symptoms (SLE+IBS) and were classified as IBS-C: 23.5%, IBS-D: 37.3%, and IBS-M: 39.2%. In addition, 23.8% had FM. SLE+IBS vs Non-IBS SLE patients had higher SLE activity scores (2.55 ± 1.65 vs 1.74 ± 2.19; p = 0.03), were more likely to have FM (33.0% vs 14.8%; p = 0.02) and depression (41.1% vs 25.9%, p = 0.04). Logistic multivariate analysis showed that IBS-type symptoms were associated with FM (OR = 2.85, 95% CI: 1.11-7.43) and depression (OR = 1.07, 95% CI: 1.02-1.13). Finally, SLE+IBS vs Non-IBS SLE patients had lower SF-36 scores (49.65 ± 18.57 vs 62.67 ± 18.14; p = 0.02).

CONCLUSIONS & INFERENCES

IBS-type symptoms are highly prevalent among women with SLE and are associated with FM and depression. SLE+IBS patients had worse HRQOL vs Non-IBS SLE, independently of FM status. We suggest that treating IBS symptoms may improve HRQOL in women with SLE.

Associated factors and psychotherapy on sleep disturbances in systemic lupus erythematosus

Sleep disturbance is a common problem in systemic lupus erythematosus (SLE) patients. This study was performed to determine the prevalence of sleep disturbance in SLE, the factors that might be associated with sleep disturbance, and the correlation between changes in clinical parameters and sleep quality over time. Fifty-six female SLE patients from a total of 497 SLE patients (11.3%) agreed to join the study. The demographic data were recorded at baseline and the clinical data, the Pittsburgh Sleep Quality Index (PSQI) and other standardized assessment tools, disease activity index, quality of life (QoL), damage index, depression, anxiety and fatigue score, were assessed three times: the first visit was at baseline, the second time was one month later, and the third time was three months after the baseline. Thirty-one of these 56 patients (55.36%) were found to have sleep disturbances. All were females with their mean ± SD age of 37.5 ± 12.3 years, and disease duration at study entry of 8.6 ± 7.3 years. There was no association between sleep disturbances and demographic data, disease activity, clinical symptoms, the presence of autoantibodies and current steroid use. In multiple logistic regression analyses, only moderate to severe depression was the independent determinant of sleep disturbances, p = 0.036. During the three-month observation, with the treatment, the changing of total PSQI score showed a significantly positive correlation with depression, anxiety, pain and QoL. Sleep disturbances in Thai SLE patients were not uncommon but a correctable condition. Depression was strongly associated with sleep disturbances. Awareness of underlying depression as well as sleep disturbances in SLE patients and treating them properly improve QoL in SLE.

Depression in systemic lupus erythematosus patients is associated with link-polymorphism but not methylation status of the 5HTT promoter region

A higher prevalence of depression in systemic lupus erythematosus (SLE) patients has been reported, though the mechanism underlying this phenomenon remains unclear. The present study was conducted to explore whether the polymorphism and methylation status of the serotonin transporter gene (5HTT) promoter region (PR-5HTT) contribute to depression in SLE patients from both genetic and epigenetic perspectives. In this study, 96 SLE patients and 96 healthy controls (HCs) were recruited. Depression levels of all subjects were evaluated using the Hamilton Depression Rating Scale (HDRS). The serotonin transporter-linked polymorphism (5HTTLPR) and the DNA methylation status of PR-5HTT were detected in peripheral lymphocytes of SLE patients and HCs. The differences in 5HTTLPR and DNA methylation of PR-5HTT between SLEs and HCs were compared. In SLE patients, the frequencies of short allele (S) and SS genotype of 5HTTLPR were higher in depressive SLE (SLE-D) patients than in non-depressive SLE (SLE-ND) patients. The mean HDRS score of SS homozygote patients was higher than that of patients with SL/LL genotypes. Conversely, PR-5HTT was hypomethylated in HCs as well as SLE patients. There was no difference in the methylation status between HCs and SLEs. Thus, the functional expression of PR-5HTT may be primarily regulated by gene polymorphism and not by DNA methylation. The risk allele of 5HTTLPR appears to be a major contributor to depression in SLE patients.

The inflammasome: pathways linking psychological stress, depression, and systemic illnesses

Stress is a common occurrence in everyday life and repeated or traumatic stress can be a precipitating factor for illnesses of the central nervous system, as well as peripheral organ systems. For example, severe or long-term psychological stress can not only induce depression, a leading illness worldwide, but can also cause psychosomatic diseases such as asthma and rheumatoid arthritis. Related key questions include how psychological stress influences both brain and peripheral systems, and what detection mechanisms underlie these effects? A clue is provided by the discovery of the pathways underlying the responses to host "danger" substances that cause systemic diseases, but can also contribute to depression. The inflammasome is a protein complex that can detect diverse danger signals and produce the accompanying immune-inflammatory reactions. Interestingly, the inflammasome can detect not only pathogen-associated molecules, but also cell damage-associated molecules such as ATP. Here, we propose a new inflammasome hypothesis of depression and related comorbid systemic illnesses. According to this hypothesis, the inflammasome is a central mediator by which psychological and physical stressors can contribute to the development of depression, and as well as a bridge to systemic diseases. This hypothesis includes an explanation for how psychological stress can influence systemic diseases, and conversely how systemic diseases can lead to psychiatric illnesses. The evidence suggests that the inflammasome may be a new target for the development of treatments for depression, as well as psychosomatic and somato-psycho diseases.

The correlations of disease activity, socioeconomic status, quality of life, and depression/anxiety in Chinese patients with systemic lupus erythematosus

The prevalence of psychological problems is frequent in systemic lupus erythematosus (SLE) patients and appears to be increasing. The current study investigated the relationship among disease parameters, quality of life, and the psychological status in Chinese patients with SLE. A self-report survey design was administered to 170 SLE patients and 210 healthy individuals using the Self-Rating Anxiety Scale, the Self-Rating Depression Scale, and the Short Form 36 health survey (SF-36). Our results showed that 20.3% SLE patients had anxiety, and 32.9% had depression, which were significantly higher than the control group (7.1%, 14.3%, resp.). And there were significant correlations among socioeconomic status (SES), disease activity, and anxiety/depression in SLE patients. Meanwhile, SF-36 analysis results revealed that VT, PF, and RP scales were the most powerful predictors of anxiety of SLE patients, and SLEDAI, VT, PF, SF, and RE domains were significantly accounted for anxiety. In summary, there were significant relationships among disease parameters, quality of life, and anxiety/depression in Chinese SLE patients. Therefore, it is necessary to have psychiatric and psychological evaluations and formulate an integrated approach for managing mental health in Chinese lupus patients, especially those who have high disease activity, low SES, and poor quality of life.

Mood, anxiety and personality disorders in patients with systemic lupus erythematosus

OBJECTIVE

This study presents the current prevalence of mood, anxiety and personality disorders and factors associated with the existence of psychiatric disorders in patients with systemic lupus erythematosus (SLE).

METHODS

The study sample was comprised of 45 patients with SLE and 60 control subjects. Mood and anxiety disorders were ascertained by means of the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition/Clinical Version. Personality disorders were diagnosed with the Structured Clinical Interview for DSM, Revised Third Edition Personality Disorders. The disease activity was assessed with SLE Disease Activity Index.

RESULTS

Of the 45 patients, 21 (46.7%) had at least one mood or anxiety disorder, and 16 (35.6%) had at least one personality disorder. The most common Axis I and Axis II diagnoses in the patient group were major depression (22.2%) and obsessive-compulsive personality disorder (20.0%), respectively. Specifically, major depression, generalized anxiety disorder and obsessive-compulsive personality disorder were more prevalent in the SLE group compared to the control group. The existence of Axis I disorders was associated with a more severe disease activity of SLE.

CONCLUSION

Mood and anxiety disorders, particularly major depression and generalized anxiety disorder, are frequently observed in patients with SLE.

The health education for lupus study: a randomized controlled cognitive-behavioral intervention targeting psychosocial adjustment and quality of life in adolescent females with systemic lupus erythematosus

INTRODUCTION

To examine in a randomize controlled feasibility clinical trial the efficacy of a cognitive-behavioral intervention designed to manage pain, enhance disease adjustment and adaptation and improve quality of life among female adolescents with systemic lupus erythematosus.

METHODS

Female adolescents (n = 53) ranging in age from 12 to 18 years were randomly assigned to 1 of 3 groups including a cognitive-behavioral intervention, an education-only arm and a no-contact control group. Participants were assessed at baseline, postintervention and at 3- and 6-month intervals after completion of the intervention.

RESULTS

No significant differences were revealed among the 3 treatment arms for any of the dependent measures at any of the assessment points. For the mediator variables, a posthoc secondary analysis did reveal increases in coping skills from baseline to postintervention among the participants in the cognitive-behavioral intervention group compared with both the no-contact control group and the education-only group.

CONCLUSION

Although no differences were detected in the primary outcome, a possible effect on coping of female adolescents with systemic lupus erythematosus was detected in this feasibility study. Whether the impact of training in the area of coping was of sufficient magnitude to generalize to other areas of functioning, such as adjustment and adaptation, is unclear. Future phase III randomized trials will be needed to assess additional coping models and to evaluate the dose of training and its influence on pain management, adjustment and health-related quality of life.

Incidence and risk of mood disorders in patients with breast cancers in Taiwan: a nationwide population-based study

OBJECTIVE

The objective of this study is to assess the incidence and risk of mood disorders, including major depression, anxiety, and bipolar disorders, in Taiwanese patients after the diagnosis of breast cancer compared with a matched cohort.

METHODS

From January 2000 to December 2005, 26,629 newly diagnosed breast cancer patients were enrolled by the Taiwan National Health Insurance program database. The control cohort was selected randomly from 1,000,000 National Health Insurance beneficiaries from a population of 21,400,826 enrolled throughout Taiwan. Each patient was matched with one subject without breast cancer by age, sex, and presence of comorbidities with the same diagnosis index date. The diagnosis of mood disorders was defined by compatible International Classification of Diseases, 9th revision, clinical modification codes plus the prescription of antidepressants for at least 30 days.

RESULTS

The overall incidence rate ratio of mood disorders was 1.33 (95% CI 1.28-1.39, p < 0.001) in the breast cancer cohort compared with the matched cohort. The incidence rate ratios for specific mood disorders were 2.06 for bipolar disorder (95% CI 1.37-3.15 p = 0.0003), 1.94 for major depressive disorder (95% CI 1.76-2.13 p < 0.001), and 1.22 for anxiety (95% CI 1.16-1.27 p < 0.001). Independent risk factors for developing mood disorders included breast cancer, as well as age, hypertension, chronic obstructive pulmonary disease, autoimmune disease, ischemic heart disease, and cerebrovascular disease.

CONCLUSIONS

Breast cancer is a prominent risk factor for mood disorders, including major depressive disorder, anxiety, and bipolar disorder. The impact is most potent in the first year after diagnosis. Psychological support is a critical issue in these patients.

Perceived illness stigma is associated with depression in female patients with systemic lupus erythematosus

OBJECTIVES

1) To assess the prevalence of depression in a sample of female patients with systemic lupus erythematosus (SLE) 2) To evaluate the association between perceived illness stigma and depression in those patients.

METHODS

In a cross-sectional study, 80 female SLE patients were evaluated for the presence of depression and perceived illness stigma. Depression was diagnosed using the Structured Clinical Interview for DSM-IV Axis Ι disorders, clinical version (SCID-I-CV), the severity of the depressive symptoms was evaluated using the Hospital Anxiety and Depression Scale-Depression Subscale (HADS-D), and the stigma of illness was assessed using the Stigma Impact Scale (SIS).

RESULTS

The prevalence of depression among female SLE patients was 18.75% (15/80). The perceived illness stigma was higher among the depressed group than among the non-depressed group (SIS mean scores were 43.87±7.87 and 26.62±3.79 respectively P<.001), there was a significant positive correlation between SIS and HAD-D scores (r=0.73, P=.002), and there was a significant association between perceived illness stigma and diagnosis of depression (R(2)=0.53, P=.002, odds ratio=3.2), which increased the severity of depressive symptoms (R(2)=0.64, P<.001).

CONCLUSION

This study demonstrates a significant association between illness stigma and depression in female SLE patients which may be important in promoting optimal coping for these women .

Prevalence and predictors of depression in patients with systemic lupus erythematosus: a cross-sectional study

OBJECTIVE

The purpose of this study was to estimate the prevalence and examine the predictors of depression in patients with systemic lupus erythematosus (SLE).

METHODS

This cross-sectional study was conducted in the rheumatology clinic of a university hospital. All SLE patients that met the revised American College of Rheumatology (ACR) classification were included in the study. Sociodemographic data and medications were recorded. Disease activity for SLE was assessed with the Mexican-SLE Disease Activity Index (Mex-SLEDAI). All subjects were screened for anxiety and depression by using the Hamilton Anxiety Rating Scale (HAM-A) and the 17-item version of the Hamilton Depression Rating Scale (HAM-D17). Multiple linear regression analyses were used to determine predictors of depressive disorder.

RESULTS

A total of 62 SLE (61 females and 1 male) patients participated in the study. Based on HAM-D17 and HAM-A, rates of depression and anxiety in SLE patients were 45.2% and 37.1%, respectively. The multiple linear regression analysis revealed that HAM-A score and younger age were significant predictors of depression in SLE patients.

CONCLUSION

The findings suggest that depression and anxiety are common in SLE patients. In addition, higher levels of anxiety and a younger age may increase the risk of depression. Because of the small sample size, further studies should be conducted to confirm these results.

[Neuropsychiatric systemic lupus erythematosus (1st part). Cases definitions and diagnosis and treatment of central nervous system and psychiatric manifestations of systemic lupus erythematosus]

Systemic lupus erythematosus (SLE) is an autoimmune disease, which primarily affects skin and joints. Peripheral neurologic syndrome and central nervous system (CNS) manifestations are common in lupus patients but are not always attributable to lupus itself. A classification, published in 1999 by the American College of Rheumatology (ACR) research committee, described 12 CNS syndromes and seven peripheral neurologic syndromes compatible with "neuropsychiatric systemic lupus erythematosus" (NPSLE). Despite this consensus, studies which have been published since 1999 have reported a prevalence of NPSLE varying from 20 to 97 %, which shows the diagnosis difficulty and the heterogeneity of neuropsychiatric manifestations in SLE. In order to understand the limits of this classification, we propose in this first part an exhaustive review of publications describing neuropsychiatric manifestations according to the ACR 1999 classification. We also detail case definitions, prevalence and risk factors, clinical characteristics and diagnosis of each lupus-related psychiatric and CNS manifestation.

Locus of control and lupus: patients' beliefs, perspectives, and disease activity

Patients with lupus often experience a high degree of psychological symptoms such as anxiety, depression, and mood disorders that can influence their beliefs and perceptions of their illness. The purpose of the study was to examine how a patient's self-reported psychosocial needs (depression and anxiety) and beliefs about how much control they have over their health (health locus of control) influences their perception of disease chronicity and acuity. The study findings were based on a survey of 378 patients self-diagnosed with lupus.

Association between depression and vascular disease in systemic lupus erythematosus

OBJECTIVE

Systemic lupus erythematosus (SLE) is a chronic inflammatory autoimmune disease with increased prevalence of cardiovascular disease (CVD) and depression. Although depression may contribute to CVD risk in population-based studies, its influence on cardiovascular morbidity in SLE has not been evaluated. We evaluated the association between depression and vascular disease in SLE.

METHODS

A cross-sectional study was conducted from 2002-2005 in 161 women with SLE and without CVD. The primary outcome measure was a composite vascular disease marker consisting of the presence of coronary artery calcium and/or carotid artery plaque.

RESULTS

In total, 101 women met criteria for vascular disease. In unadjusted analyses, several traditional cardiovascular risk factors, inflammatory markers, adiposity, SLE disease-related factors, and depression were associated with vascular disease. In the final multivariable model, the psychological variable depression was associated with nearly 4-fold higher odds for vascular disease (OR 3.85, 95% CI 1.37, 10.87) when adjusted for other risk factors of age, lower education level, hypertensive status, waist-hip ratio, and C-reactive protein.

CONCLUSION

In SLE, depression is independently associated with vascular disease, along with physical factors.

Association of depression and urolithiasis

OBJECTIVES

To study the hypothesis that patients with urolithiasis would have a higher prevalence of depression compared to the general population. Urolithiasis is associated with frequent recurrences. Patients with urolithiasis may develop a chronic condition associated with poor quality of life and depression. The frequency and severity of stones episodes would relate to depression.

METHODS

In an institutional review board-approved study; we prospectively recruited 115 patients who were evaluated for urolithiasis. Patients completed an Emory stone questionnaire covering demographics and a validated CES-D depression questionnaire. Depression scores were compared with U.S. norms. Demographics and clinical variables were analyzed.

RESULTS

On the CES-D depression questionnaire 30.4% of patients scored ≥ 16, a "significant level of physiological distress." The U.S. lifetime prevalence of depression was 16.5%. Determinants of depression included the following: family history of urolithiasis (OR = 3.49, CI = 1.51; 8.07), stone episode within the last 12 months (OR = 2.77, CI = 1.18; 6.53), and >1 emergency room visits for stone disease (OR = 2.61, CI = 1.14; 5.99). Patients with Charlson comorbidity indexes of ≤ 1 were more likely to be depressed than those scoring >1 (OR 2.89, CI = 1.20; 6.95). There were no significant associations with age at first stone, number of lifetime stones, number of surgeries, number of workdays missed, and need for dietary modifications or medications for stone prevention.

CONCLUSIONS

The prevalence of depression in our patient cohort with urolithiasis was substantially greater than societal norms. Multiple stone-related factors were associated with significant psychological distress. Appreciation of this issue may allow better patient care.

Revisão da literatura sobre a eficácia da intervenção psicológica no tratamento do lúpus eritematoso sistêmico

Manifestações neuropsiquiátricas são comuns no lúpus eritematoso sistêmico (LES), especialmente depressão, ansiedade e psicose. O estresse psicológico e o uso de corticóide têm sido responsabilizados pelas manifestações psicopatológicas. Objetivou-se realizar revisão de literatura sobre a eficácia da intervenção psicológica no tratamento do LES, utilizando-se pesquisas em bases de dados, através dos descritores "psychotherapy" and "lupus", incluindo-se os ensaios clínicos randomizados e os estudos prospectivos. Foram encontrados seis artigos, sendo quatro ensaios clínicos randomizados e dois estudos prospectivos. Cinco artigos encontraram evidências de acentuada melhora nos pacientes que tinham acompanhamento psicológico e apenas um não encontrou tal evidência. Concluiu-se que a intervenção psicológica pode ser uma ferramenta importante no tratamento do LES.

The relationship between alexithymia and psychological factors in systemic lupus erythematosus

BACKGROUND

Alexithymia has been described as an important dimension in several medical diseases. Systemic lupus erythematosus (SLE) is a chronic condition characterized by unpredictable clinical manifestations. Our aim is to reveal which factors (psychological factors and quality of life dimensions) are associated with alexithymia in SLE patients.

METHODS

Fifty-three sequential SLE patients (ACR criteria) and 41 asthma patients were studied by means of validated scales for alexithymia (Toronto Alexithymia Scale), psychopathology (Brief Symptom Inventory, Hospital Anxiety and Depression Scale), personality dimensions (NEO-FFI), and quality of life (Short Form-36 Health Survey). Systemic lupus erythematosus patient's clinical and laboratorial evaluation was performed by indicators of activity (Systemic Lupus Erythematosus Disease Activity Index) of accumulated damage (Systemic Lupus International Collaborating Clinics/ACR Damage Index), length of disease, and therapy.

RESULTS

An association between alexithymia and psychopathological symptoms, and personality and quality of life dimensions was found. By means of multiple regression analysis, openness and depression were the 2 predictors for alexithymia in SLE patients. We found a high prevalence rate of alexithymia in SLE patients; however, when controlling for depression symptoms (Hospital Anxiety and Depression Scale-Depression, <7), we found a lower percentage of alexithymic traits than that of the total sample of SLE.

CONCLUSION

Alexithymia was associated with psychological distress and with quality of life impairment. Understanding the role of psychological factors in SLE patients may contribute to a more comprehensive perspective of the disease, its impact on patient's daily routine, and how patients adapt emotionally to a chronic disease.

Using the Center for Epidemiologic Studies Depression Scale to screen for depression in systemic lupus erythematosus

OBJECTIVE

Identifying persons with systemic lupus erythematosus (SLE) at risk for depression would facilitate the identification and treatment of an important comorbidity conferring additional risk for poor outcomes. The purpose of this study was to determine the utility of a brief screening measure, the Center for Epidemiologic Studies Depression Scale (CES-D), in detecting mood disorders in persons with SLE.

METHODS

This cross-sectional study examined 150 persons with SLE. Screening cut points were empirically derived using threshold selection methods, and receiver operating characteristic curves were estimated. The empirically derived cut points of the CES-D were used as the screening measures and were compared to other commonly used CES-D cut points in addition to other commonly used methods to screen for depression. Diagnoses of major depressive disorder or other mood disorders were determined using a "gold standard" structured clinical interview.

RESULTS

Of the 150 persons with SLE, 26% of subjects met criteria for any mood disorder and 17% met criteria for major depressive disorder. Optimal threshold estimations suggested a CES-D cut score of 24 and above, which yielded adequate sensitivity and specificity in detecting major depressive disorder (88% and 93%, respectively) and correctly classified 92% of participants. To detect the presence of any mood disorder, a cut score of 20 and above was suggested, yielding sensitivity and specificity of 87% and correctly classifying 87%.

CONCLUSION

These results suggest the CES-D may be a useful screening measure to identify patients at risk for depression.

Cardiovascular and disease-related predictors of depression in systemic lupus erythematosus

OBJECTIVE

Depression and cardiovascular disease are common and debilitating comorbidities associated with systemic lupus erythematosus (SLE). In this study, history of cardiovascular events, cardiovascular risk factors, and SLE disease-related factors were evaluated as longitudinal predictors of depression in a large cohort of patients with SLE.

METHODS

Data were derived from 663 adult participants in the 2004-2008 Lupus Outcomes Study, who were followed for up to 5 annual interviews. Multivariate logistic regression analyses using generalized estimating equations were used to determine predictors of the development of increased depressive symptom severity over a 12-month period (Center for Epidemiologic Studies Depression Scale [CES-D] score of 23 or greater), yielding 2,224 paired observations. Predictors included sociodemographics, traditional cardiovascular risk factors (reported presence of heart disease, history of stroke or myocardial infarction, hypertension, hypercholesterolemia, diabetes mellitus, obesity, smoking status, and family history), and SLE-specific risk factors (glucocorticoid use, renal involvement, disease duration, and disease activity).

RESULTS

The annual incidence of depression was 12% in this cohort. Multivariate predictors of new-onset depression included younger age (ages 20-39 years: odds ratio [OR] 2.3, 95% confidence interval [95% CI] 1.3-3.9; ages 40-59 years: OR 1.8, 95% CI 1.1-2.7), Hispanic/Latino ethnicity (OR 1.8, 95% CI 1.2-2.8), having some college education (OR 1.8, 95% CI 1.1-3.0), baseline CES-D score (OR per point 1.1, 95% CI 1.1-1.2), presence of diabetes mellitus (OR 1.8, 95% CI 1.1-2.8), and baseline SLE disease activity (OR 1.2, 95% CI 1.1-1.4).

CONCLUSION

These results suggest that, in addition to known sociodemographic factors, the presence of diabetes mellitus and SLE disease activity may play a role in the development of depression in SLE.

Multimodal neurophysiological and psychometric evaluation among patients with systemic lupus erythematosus

OBJECTIVE

To determine some of the neuropsychiatric manifestations of systemic lupus erythematosus (SLE) by applying multimodal neurophysiological and psychometric studies.

PATIENTS AND METHODS

Twenty-six SLE patients were evaluated for neurological and psychiatric disorders and compared with 26 healthy controls matched for age, sex, education, and social class. The severity of SLE disease was assessed. Each subject was subjected to the following examinations: laboratory, neurophysiology, magnetic resonance imaging of the brain, transcranial duplex, Modified Mini-mental State Examination, Cognitive Assessment Scale Inventory, Hamilton Depression Scale, and Hamilton Anxiety Scale.

RESULTS

The mean age of subjects was 25.9 ± 8.9 years. The most prevalent neurological manifestations were (in order of frequency) anxiety in 17 cases (65.4%), depression in 15 cases (57.7%), headache in 10 cases (38.5%), peripheral neuropathy in 7 cases (26.9%), seizures in 6 cases (23.1%), psychosis in 5 cases (19.2%), dementia in 4 cases (15.4%), radiculopathy in 4 cases (15.4%), myositis in 3 cases (11.5%), and stroke in 2 cases (7.7%). There was a significant affection in amplitude of the ulnar nerve, cognitive function impairment, and electroencephalography changes. There was a significant increased mean velocity and decreased Pulsatility Index of the most studied intracranial vessels in the patients.

CONCLUSION

The use of multimodal neurophysiological, transcranial duplex, and psychometric scales increases the sensitivity for detecting nervous system involvement.

[Neurological and psychiatric manifestations of systemic lupus erythematosus and antiphospholipid syndrome]

Neurological or psychiatric symptoms are present in 60% of the cases with systemic lupus erythematosus. Direct lesions of nervous system are associated with the presence of antibodies, vasculitis, thrombosis and impairments mediated by cytokines. Damages caused by injuries of other organs or those due to therapy are known as indirect causes. In the complex pathogenesis the primary cause is neuronal dysfunction mediated by autoantibodies, vasculopathia and coagulopathia. Until now, more than 20 antibodies have been identified in association with damages of the nervous system. These antibodies may impair neurons or astrocytes and may promote thrombotic processes in vessels of the brain. Activation of endothelial cells and disturbance of blood-brain barrier are also pathogenic factors. In patients with systemic lupus erythematosus the most frequent psychiatric manifestations are organic psychosyndrome, particularly deterioration of cognitive functions, and depression, while the most common neurological syndromes are epilepsy and ischemic stroke. In the pathogenesis of antiphospholipid syndrome β2-glycoprotein I plays the most important role; binding to its antibody the complex may interact with cells and modify haemostatic actions. The most frequent neurological manifestations of antiphospholipid syndrome are headache and ischemic stroke.

Prevalence of depression and depressive symptoms in patients with systemic lupus erythematosus: Iranian experience

Psychiatric disorders including depression represent clinical manifestation of systemic lupus erythematosus (SLE). Recognition of depression in SLE patients is of utmost importance since it is treatable and can be of fatal consequences if unrecognized. This study was conducted to determine the prevalence of depression and depressive symptoms in SLE patients in terms of age, gender, disease duration and severity, and duration of steroid treatment in SLE patients. Eighty-five SLE patients (77 women, 8 men) with verified SLE diagnosis completed Beck's depression inventory, a self-reported measure of depression. Clinical data on disease and treatment were obtained from patient files. In total, 60% of patients achieved scores indicating depression. The most common depressive symptoms in participants were fatigue and weakness (88.2%), irritability (82.3%), sadness (77.6%), and somatic preoccupation (76.4%), while the least common symptoms were weight loss (34.1%), low level of energy (28.2%), and suicide ideation (10.5%). There was a significant difference between the disease activity and the severity of depression (P = 0.0001). Our findings show higher prevalence of depression in our sample in comparison with previous studies, suggesting that the prevalence of depression varies across different populations. Severity of depression increases with more severe disease course.

Epidemiologic, socioeconomic and psychosocial aspects in lupus erythematosus

Epidemiologic, socioeconomic, and psychosocial factors play an important role in health care and handling of patients with the various clinical forms of lupus erythematosus (LE). Patients with LE are mostly young women; adolescents and some ethnic groups are especially prone to a severe course of disease. The unpredictable and fluctuating flares of disease, the need for longterm treatment, and the side effects and damage caused by the disease itself severely reduce quality of life. Problems arise, involving family members, adherence to medical advice and therapy, communication and self management. Socioeconomically, patients are often unable to take regular employment and to pay for health insurance. Stress factors that arise have a negative impact on the course of disease, increasing both fatigue and the basic burden of illness. Healthcare professionals must pay careful attention to all these items, as they attempt to treat flares, minimize drug side effects, provide pain relief, arrange communication and exercise programs along with behavioral and psychosocial interventions in multidisciplinary cooperation, and also involve and support family members.

Common mental disorders and psychological distress in systemic lupus erythematosus are not associated with disease activity

Psychiatric diagnosis in patients with systemic lupus erythematosus (SLE) is controversial: variations have been reported in frequency, diagnostic assays, associations with disease activity, autoantibodies, and contributing social factors. Eighty-three consecutive non-selected Chilean patients with SLE were evaluated for: (i) 26 common mental disorders according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), using the Mini-International Neuropsychiatric Interview (MINI-plus); (ii) psychological suffering measured by Hospital Anxiety and Depression Scale (HADS); (iii) ACR 1999 neuropsychiatric (NP)SLE criteria; (iv) SLE disease activity (SLEDAI-2K); (v) cumulative damage (SLICC/ACR); and (vi) anti-ribosomal P antibodies by enzyme-linked immunoassay and immunoblot. Psychiatric diagnoses occurred in 44.6% of patients; the most frequent (21.7%) was major depressive episode (MDE). No association with lupus activity was observed in patients with a DSM-IV diagnosis or MDE or psychological suffering. ACR 1999 NPSLE criteria were present in 42.2% of patients, the majority corresponding to mood (28.9%) or anxiety disorders (15.6%). Suicidal risk was present in 9.6% of patients. Anti-ribosomal P antibodies (13.3%) were not associated with DSM-IV diagnosis. Severe psychiatric disorders in SLE are common and not associated with disease activity.

Depression predicts self-reported disease activity in systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is an autoimmune disease that can significantly impact both physiological and psychological functioning. In order to examine the relationship between psychological functioning and disease activity in SLE, we administered instruments that collected sociodemographic information and measured indices of disease activity and psychosocial functioning from 125 adult Hispanic and White patients with SLE. Patients were recruited from four healthcare settings in the greater Southern California area. Both cross-sectional and longitudinal relationships between depression and disease activity were evaluated. Cross-sectional findings revealed that depression and ethnicity were independently correlated with self-reported disease activity. Longitudinally, depression alone predicted self-reported disease activity. These data suggest that depression may play a significant role in the health status of SLE patients and serve as an important target for clinical intervention.

Psychological correlates of adherence to self-care, disease activity and functioning in persons with systemic lupus erythematosus

The aim of the study was to assess the effects of Sense of Coherence (SOC), emotional distress and treatment adherence on disease activity and functioning level of persons with systemic lupus erythematosus (SLE). One hundred persons with SLE, aged 18–60, participated in the study. They responded to the SOC scale, hospital anxiety and depression scale (emotional distress) and to questionnaires about adherence to treatment, level of functioning and disease activity. The results show a moderate level of disease activity and everyday functioning, as well as moderate levels of emotional distress. Income, emotional distress and adherence significantly predicted the levels of functioning ( p < 0.001), while income and emotional distress significantly predicted the levels of disease activity only ( p < 0.001). SOC was significantly associated with higher level of functioning ( p < 0.001) and lower disease activity ( p < 0.01), while emotional distress, but not treatment adherence, highly mediated these relationships. The results emphasize the associations of emotional distress and SOC with severity of the symptoms and level of functioning, and the associations between SOC and adherence to treatment. Further confirmation of the results with larger samples and longitudinal designs are warranted.

Depression and cognitive impairment in newly diagnosed systemic lupus erythematosus

OBJECTIVE

Cognitive impairment is present in 80% of patients with systemic lupus erythematosus (SLE) 10 years after diagnosis. The natural history of cognitive dysfunction in newly diagnosed SLE is unknown. We examined the association of depression and cognitive performance in newly diagnosed SLE.

METHODS

A multicenter cohort of 111 patients newly diagnosed (within 9 months) with SLE underwent cognitive function testing using an automated battery [Automated Neuropsychological Assessment Metrics (ANAM)] with 9 subtests. Depression was measured using the Calgary Depression Scale (CDS).

RESULTS

The patient cohort was 97.3% female, 55.9% white, 15.3% African American, 20.7% Hispanic, mean age 37.8 years, mean education 15.2 years. CDS score ranged from 0 to 18 (mean 5.0 ± 4.6). CDS score did not differ by age, sex, ethnicity, or prednisone dose. Higher Krupp Fatigue Severity Scale scores and presence of fibromyalgia were significantly associated with higher CDS score (p < 0.001; p = 0.006, respectively). Depressed patients, defined by a CDS score > 6, had significantly poorer performance on 5 ANAM throughput measures: code substitution (p = 0.03), continuous performance (p = 0.02), matching-to-sample (p = 0.04), simple reaction time (p = 0.02), and the Sternberg memory test (p = 0.04). Adjusting for age, sex, ethnicity, education, and prednisone dose, a higher CDS score remained significantly associated with poorer performance on 3 measures, but the association was slightly attenuated for code substitution and matching-to-sample. Depression was not associated with mathematical or spatial processing.

CONCLUSION

Depression, a modifiable risk factor, is associated with significantly poorer function in several cognitive domains in patients newly diagnosed with SLE. Treatment of depression when the CDS score is greater than 6 may improve cognitive functioning and should be further studied.

Subclinical cerebrovascular cognitive function, and mood changes in patients with systemic lupus erythematosus

OBJECTIVE

To estimate the prevalence of neuropsychiatric disorders, cerebral atherosclerosis in patients with systemic lupus erythematosus (SLE) and explore the relation between transcranial duplex findings of different intracranial vessels with neuropsychiatric affect, and Systemic lupus erythematosus disease activity index (SLEDAI).

METHODS

Twenty-six consecutive SLE patients were evaluated for neurological and psychiatric disorders. Another 26 subjects matched with respect to age, sex, education, and socioeconomic status formed the control group. SLE disease activity was assessed by the SLEDAI. For each participant, a complete medical history was obtained and clinical, laboratory, and neurophysiological examinations, magnetic resonance imaging of the brain, transcranial duplex for intracranial vessels, and psychometric evaluations were performed. For the psychometric evaluation, we used the Modified Mini-mental State Examination and Cognitive Assessment Scale Inventory to assess cognitive function, and Hamilton Depression Rating Scale and Hamilton Anxiety Scale to assess symptoms of depression and anxiety.

RESULTS

Anxiety in 65.4% is the most prevalent manifestation followed by depression in 57.7%, headache in 38.5%, peripheral neuropathy in 26.9%, seizures in 23.1%, psychosis in 19.2%, radiculopathy and dementia in 15.4% for each, myositis in 11.5%, and stroke in 7.7%. There was a significant increased mean velocity and decreased pulsatility index of most studied intracranial vessels in both patient groups than in the control group. There was significant negative correlation between SLEDAI and transcranial Doppler findings in the pulsatility index of medial circumflex artery and procoagulant activity.

CONCLUSION

Neurological disorders, cognitive impairment, depression, anxiety, psychosis and cerebrovascular changes detected by transcranial Doppler ultrasound are common in SLE.

Reduced adult neurogenesis and altered emotional behaviors in autoimmune-prone B-cell activating factor transgenic mice

BACKGROUND

It has been postulated that brain inflammatory processes associated with autoimmune diseases may be causative factors in emotional disorders. Accordingly, we examined emotional behaviors in autoimmune-prone cytokine B-cell-activating factor (BAFF) transgenic mice, a model of systemic lupus erythematosus, rheumatoid arthritis, and Sjögren's syndrome.

METHODS

Male BAFF transgenic mice were examined on a series of standard laboratory assays of emotionality. Mice were also tested for brain inflammation, stress-induced c-Fos expression, hippocampal progenitor cell proliferation, and hippocampal neurogenesis-dependent and neurogenesis-independent long-term potentiation (LTP).

RESULTS

Our study revealed that older BAFF transgenic mice exhibit an anxiety-like phenotype associated with brain inflammation. Furthermore, anxious mice display an abnormal neuronal activation within the limbic system in response to mild anxiogenic stimuli. Proliferation of newly formed neurons in the subgranular zone of adult hippocampus was significantly decreased in anxious BAFF transgenic mice that also showed impaired neurogenesis-dependent and neurogenesis-independent dentate gyrus LTP.

CONCLUSIONS

Our results suggest that anxiety associated with autoimmune diseases such as systemic lupus erythematosus, rheumatoid arthritis, and Sjögren's syndrome can be linked to brain inflammation, impaired neurogenesis, and hippocampal plasticity. BAFF transgenic mice can be used in future studies to test compounds of therapeutic value for the treatment of mood disorders associated with autoimmune diseases.

The prevalence and associations of sleep disturbances in patients with systemic lupus erythematosus

The aim of this study was to analyze sleep complaints in patients with systemic lupus erythematosus (SLE) and to determine its prevalence and associations. Fifty outpatients with SLE and an equal number of age- and sex-matched controls were included in the study. Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI) in both cases and controls. Depressed mood, functional disability and pain severity were assessed in patients using standardized questionnaires. Disease severity, cumulative damage and presence of fibromyalgia were determined by clinical examination. Bivariate associations between sleep quality and disease-related variables as well as demographic variables were calculated. A series of hierarchical regression analyses were computed to determine the independent determinant of sleep quality. PSQI scores were significantly higher in patients with SLE. Prevalence of sleep disturbance was 62%. Functional disability, disease activity and depressed mood correlated positively with sleep disturbances. 36% of the patients satisfied ACR criteria for fibromyalgia. In multiple regression analyses disease activity was found to be an independent determinant of sleep quality. The prevalence of poor sleep quality in patients with SLE was higher than it is generally perceived to be. Functional disability, disease activity and depressed mood contributed significantly to sleep disturbances in SLE.

Association between depression and coronary artery calcification in women with systemic lupus erythematosus

OBJECTIVES

To determine the associations between depression, cardiovascular risk factors and coronary artery calcification (CAC) in women with SLE and controls.

METHODS

CAC was measured using electron-beam CT (EBCT). Traditional, inflammatory and lupus-related risk factors as well as depressive symptoms (Center for Epidemiologic Studies Depression Scale-CES-D) were measured at a single study visit in 161 women with SLE and 161 age- and race frequency-matched female healthy controls.

RESULTS

Women with SLE reported more depressive symptoms than controls, with 27% of SLE and 15% of controls having CES-D scores suggestive of clinical depression. SLE women were more likely to have CAC, as well as more severe CAC compared with controls. Among the SLE women, depression was associated with greater than 2-fold odds of having any CAC [odds ratio (OR) 2.48; 95% CI 1.05, 5.87; P = 0.04], independent of traditional risk factors (age, hypertension and triglycerides) and inflammatory markers. However, when BMI was included among the covariates, the association between depression and CAC was attenuated, indicating the potential mediating role of BMI. Depression was not a risk factor for CAC in controls.

CONCLUSIONS

In women with SLE, depression was associated with CAC. This association was mediated by BMI. Depression and adiposity may add to the inflammatory burden of SLE, thus contributing to cardiovascular disease risk.

Systemic lupus erythematosus with neuropsychiatric manifestation incurs high disease costs: a cost-of-illness study in Hong Kong

OBJECTIVE

To determine the direct and indirect costs of SLE in Hong Kong, and to ascertain the relationship between neuropsychiatric SLE (NPSLE) and disease costs.

METHODS

A retrospective, cross-sectional, non-randomized cost-of-illness study was performed in a tertiary rheumatology specialty centre in Hong Kong. Participants completed questionnaires on sociodemographics, employment status and out-of-pocket expenses. Healthcare resources consumption was recorded by chart review. The occurrence of NPSLE since onset of SLE was determined using the 1999 ACR nomenclature and standard definitions. Mann-Whitney U-test was used to compare disease costs between patients with and without NPSLE. Multiple linear regression was used to determine the predictors of the costs.

RESULTS

Three hundred and six Chinese patients were recruited, with a mean age of 41 years and mean disease duration of 9.6 years. A total of 108 NPSLE events were recorded by 83 patients. The most common manifestations were seizure and cardiovascular disease. The mean annual total costs were USD 13,307 per patient. The direct costs dominated the total costs, and the costs of inpatient care contributed 52% of the direct costs. Patients with NPSLE incurred significantly higher direct and indirect costs compared with those without NPSLE. The number of NPSLE events was an independent explanatory variable associated with both direct and indirect costs.

CONCLUSION

The economic impact of SLE in Hong Kong is considerable and patients with NPSLE incur higher disease costs compared with those without NPSLE. Improvement in prevention of end-organ damage, especially neuropsychiatric manifestation, may reduce costs of SLE patients.

IL-10 modulates depressive-like behavior

The role of pro-inflammatory cytokines in psychiatric disorders has been the focus of great research attention in recent years. Paradoxically, the same is not true for anti-inflammatory cytokines. In the present study, we assessed the behavioral profile of animals with altered expression of the anti-inflammatory cytokine IL-10. We performed a battery of tests to assess anxiety, depressive-like and cognitive behaviors in mice overexpressing IL-10 (PMT10) and IL-10(-/-) animals; in the later mice we also tested the behavioral effect of IL-10 administration. In the forced-swimming test, IL-10(-/-) females displayed increased depressive-like behavior; importantly, this phenotype was reverted by the injection of IL-10. Moreover, mice overexpressing IL-10 presented a decreased depressive-like behavior. Despite the presence of a similar trend, male animals did not reach significant differences in depressive-like behavior. Assessment in the open-field showed that the absence of IL-10 decreased the percentage of time spent in the center of the arena in both male and female mice, while male animals overexpressing IL-10 revealed an opposite behavior. For both sexes, imbalance in IL-10 levels did not affect spatial reference memory. In conclusion, variations in IL-10 expression are associated with an altered depressive-like behavior, but do not influence cognitive performance. Interestingly, IL-10 imbalance produced more profound behavioral changes in females than in male animals. This is in accordance with clinical data demonstrating an increased susceptibility of women to mood disorders, suggesting an interplay between anti-inflammatory cytokines and sexual steroids.

Prevalence of depressive and anxiety disorders in systemic lupus erythematosus and their association with anti-ribosomal P antibodies

OBJECTIVE

To estimate the prevalence of psychiatric disorders in patients with systemic lupus erythematosus (SLE) and explore their association with anti-ribosomal P (anti-P) antibodies.

METHODS

Seventy-one consecutive female SLE patients without neurological manifestations were evaluated for psychiatric disorders using the Structured Clinical Interview for DSM-IV (SCID). Anti-P antibodies were measured by enzyme-linked immunosorbent assay (ELISA)/immunoblot analysis.

RESULTS

The mean age of subjects was 34.8 years (SD: 10.1 years), and the mean duration of SLE was 9.8 years (SD: 6.5 years). The 30-day prevalences of psychiatric disorders were: mood disorders 26.8%, anxiety disorders 46.5%, adjustment disorders 8.4%, alcohol abuse 1.4%, and somatoform disorder 1.4%. The lifetime prevalences of psychiatric disorders were: mood disorders 69%, anxiety disorders 52.1%, alcohol abuse 1.4%, and somatoform disorder 1.4%. Subjects with and without psychiatric manifestations did not differ regarding SLE clinical and laboratorial parameters including presence or absence of anti-P antibodies (23.1% vs. 20%, respectively, p=1.0), disease activity, as measured by the Systemic Lupus Erythematosus Disease activity Index (4.08+/-5.7 vs. 4.95+/-6.3 respectively, p=0.60) and cumulated damage, as measured by the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (0.7+/-2.3 vs. 0.3+/-0.7 respectively, p=0.33).

CONCLUSIONS

Mood and anxiety disorders are the most frequently observed psychiatric disorders in female SLE patients without concomitant neurological manifestations. These mild/moderate forms of psychiatric disorders are not associated with anti-P antibodies in SLE patients. Our findings reinforce the importance of systematic psychiatric evaluation for these patients in order to provide adequate and comprehensive care.

Psychiatric manifestations in systemic lupus erythematosus

Psychiatric abnormalities are common in systemic lupus erythematosus (SLE) with a prevalence of 17% to 75%, reflecting different methods of patient selection and assessment, the different professional orientation of clinicians, and lack of an accepted consensus for diagnosing active neuropsychiatric lupus (NPSLE). The psychiatric syndromes included in the ACR Neuropsychiatric Lupus Nomenclature Committee criteria are cognitive dysfunction, acute confusional state (delirium), anxiety disorder, mood disorder, and psychosis. In SLE patients, identification of psychiatric phenomena and the generation of a differential diagnosis are crucial. Possible mechanisms include vascular injury and pathogenic antibodies. Treatment strategies are based on small case studies. The purpose of this review is to discuss clinical manifestations, pathogenesis and the present therapeutic options in psychiatric lupus.