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Wu X, Zhang K, Xing Y, Zhou W, Shao Y, Li G, Rui Q. Dysregulated thyroid hormones correlate with anxiety and depression risk in patients with autoimmune disease. J Clin Lab Anal 2020; 35:e23573. [PMID: 33210405 PMCID: PMC7843266 DOI: 10.1002/jcla.23573] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 07/29/2020] [Accepted: 08/23/2020] [Indexed: 12/12/2022] Open
Abstract
Background Autoimmune disease (AID) patients always present with increased risk of psychiatric disorders, and thyroid function or thyroid hormone may play a critical role in the development of anxiety and depression. Thus, this study aimed to assess the free triiodothyronine (FT3), free tetraiodothyronine (FT4), thyroid‐stimulating hormone (TSH) levels, and their correlations with anxiety/depression in patients with AID. Methods Ninety‐eight AID patients and 100 health controls (HCs) were recruited. Serum samples were obtained from all the participants to detect FT3, FT4, and TSH levels. Anxiety and depression were determined using the HADS assessment. Results HADS‐Anxiety score, anxiety subject percentage, HADS‐Depression score, and depression subject proportion were elevated in AID patients compared with HCs. FT3 and FT4 were downregulated while TSH was upregulated in AID patients compared with HCs. In AID patients, FT3 and FT4 negatively correlated with HADS‐Anxiety score, and they were downregulated in patients with anxiety compared to patients without anxiety. Meanwhile, FT3 and FT4 were negatively associated while TSH level positively associated with HADS‐Depression score. Besides, FT3 and FT4 reduced, but TSH level was of no difference in patients with depression compared to patients without depression. Additionally, increased FT4 independently correlated with both reduced anxiety risk and depression risk. Conclusions FT3, FT4, and TSH are dysregulated, and FT4 has the potential to serve as an independent biomarker related to anxiety as well as depression in AID patients. These findings may provide some information on the values of thyroid hormones in facilitating the management of AID patients with anxiety/depression.
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Affiliation(s)
- Xiaorong Wu
- Department of Rheumatology, Gaochun Branch, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Kaikai Zhang
- Department of Rheumatology, Gaochun Branch, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Yulong Xing
- Department of Rheumatology, Gaochun Branch, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Wei Zhou
- Department of Rheumatology, Gaochun Branch, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Yanqiu Shao
- Department of Rheumatology, Gaochun Branch, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Guizheng Li
- Department of Rheumatology, Gaochun Branch, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Qing Rui
- Department of Rheumatology, Gaochun Branch, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
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Eldeiry D, Zandy M, Tayer-Shifman OE, Kwan A, Marzouk S, Su J, Bingham K, Touma Z. Association between depression and anxiety with skin and musculoskeletal clinical phenotypes in systemic lupus erythematosus. Rheumatology (Oxford) 2020; 59:3211-3220. [DOI: 10.1093/rheumatology/keaa098] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023] Open
Abstract
Abstract
Objectives
To study the clinical phenotypes, determined based on cumulative disease activity manifestations, and sociodemographic factors associated with depression and anxiety in SLE.
Methods
Patients attending a single centre were assessed for depression and anxiety. SLE clinical phenotypes were based on the organ systems of cumulative 10-year SLE Disease Activity Index 2000 (SLEDAI-2K), prior to visit. Multivariable logistic regression analyses for depression, anxiety, and coexisting anxiety and depression were performed to study associated SLE clinical phenotypes and other factors.
Results
Among 341 patients, the prevalence of anxiety and depression was 34% and 27%, respectively, while 21% had coexisting anxiety and depression. Patients with skin involvement had significantly higher likelihood of anxiety compared with patients with no skin involvement [adjusted odds ratio (aOR) = 1.8; 95% CI: 1.1, 3.0]. Patients with skin involvement also had higher likelihood of having coexisting anxiety and depression (aOR = 2.0, 95% CI: 1.2, 3.9). Patients with musculoskeletal (MSK) (aOR = 1.9; 95% CI: 1.1, 3.5) and skin system (aOR = 1.8; 95% CI: 1.04, 3.2) involvement had higher likelihood of depression compared with patients without skin or musculoskeletal involvement. Employment status and fibromyalgia at the time of the visit, and inception status were significantly associated with anxiety, depression, and coexisting anxiety and depression, respectively.
Conclusion
SLE clinical phenotypes, specifically skin or MSK systems, along with fibromyalgia, employment and shorter disease duration were associated with anxiety or depression. Routine patient screening, especially among patients with shorter disease duration, for these associations may facilitate the diagnosis of these mental health disorders, and allow for more timely diagnosis.
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Affiliation(s)
- David Eldeiry
- Department of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
- Department of Medicine, Division of Rheumatology, University of Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital
| | - Moe Zandy
- Department of Medicine, Division of Rheumatology, University of Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital
| | - Oshrat E Tayer-Shifman
- Department of Medicine, Division of Rheumatology, University of Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital
| | - Andrew Kwan
- Department of Medicine, Division of Rheumatology, University of Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital
| | | | - Jiandong Su
- Department of Medicine, Division of Rheumatology, University of Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital
| | - Kathleen Bingham
- Centre for Mental Health, Psychiatry Department, University Health Network, Toronto General Hospital
| | - Zahi Touma
- Department of Medicine, Division of Rheumatology, University of Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital
- Institute of Health Policy, University of Toronto, Toronto, Ontario, Canada
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Manzano BR, da Silva Santos PS, Bariquelo MH, Merlini NRG, Honório HM, Rubira CMF. A case-control study of oral diseases and quality of life in individuals with rheumatoid arthritis and systemic lupus erythematosus. Clin Oral Investig 2020; 25:2081-2092. [PMID: 32803443 DOI: 10.1007/s00784-020-03518-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 08/10/2020] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To evaluate the impact of oral alterations on the quality of life (QoL) of individuals with rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). METHODS A case-control study in 32 individuals with RA, 28 with SLE, and 29 in the control group (CG). The questionnaire SF-36 (Medical Outcomes Study Short-Form 36) was used to evaluate the health-related quality of life (HRQoL), and OHIP-14 (Oral Health Impact Profile-14) was used to evaluate the oral health-related quality of life (OHRQoL). The severity of xerostomia was evaluated by the Xerostomia Inventory (XI). In the clinical examination, decayed (D-T), missing(M-T), and filled teeth (F-T) (DMF-T), periodontal status, plaque index (PI), gingival index (GI), unstimulated whole salivary flow rate (UWSFR), and stimulated whole salivary flow rate (SWSFR) were also assessed. Data were analyzed by Student's t tests, chi-square test, Kruskal-Wallis test, ANOVA, Pearson's correlation, and Spearman's correlation. RESULTS Individuals with RA had a higher caries index (D-T/p = 0.004) and more frequent periodontal disease (PI/p = 0.017). In the SLE group, there was a significant lower salivary flow (SFR/p = 0.016, SFMS/p = 0.004) and severe xerostomia (p = 0.002). The impact of ORHQoL in individuals with RA occurred due to oral candidiasis, halitosis, and xerostomia, compromising the HRQoL. Overall, OHRQoL and HRQoL were more compromised in individuals with SLE, with xerostomia being the main oral problem. CONCLUSION Individuals with RA and SLE present oral diseases with negative impact on their QoL. CLINICAL RELEVANCE This study shows the main oral manifestations in rheumatic autoimmune diseases, with mainly xerostomia compromising the quality of life.
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Affiliation(s)
- Brena Rodrigues Manzano
- Department of Surgery, Stomatology, Pathology and Radiology, Bauru School of Dentistry, University of São Paulo, Alameda Dr Octávio Pinheiro Brisolla, 9-75, Bauru, 17012-901, Brazil.
| | - Paulo Sérgio da Silva Santos
- Department of Surgery, Stomatology, Pathology and Radiology, Bauru School of Dentistry, University of São Paulo, Alameda Dr Octávio Pinheiro Brisolla, 9-75, Bauru, 17012-901, Brazil
| | - Matheus Henrique Bariquelo
- Hospital for Rehabilitation of Craniofacial Anomalies, University of São Paulo (HRAC/USP), Silvio Marchione, 3-20, Bauru, 17012-900, Brazil
| | | | - Heitor Marques Honório
- Department of Pediatric Dentistry, Orthodontics and Public Health, Bauru School of Dentistry, University of São Paulo, Alameda Dr Octávio Pinheiro Brisolla, 9-75, Bauru, 17012-901, Brazil
| | - Cássia Maria Fischer Rubira
- Department of Surgery, Stomatology, Pathology and Radiology, Bauru School of Dentistry, University of São Paulo, Alameda Dr Octávio Pinheiro Brisolla, 9-75, Bauru, 17012-901, Brazil
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Wu L, Shi PL, Tao SS, Tao JH, Wu GC. Decreased sleep quality in patients with systemic lupus erythematosus: a meta-analysis. Clin Rheumatol 2020; 40:913-922. [PMID: 32748069 DOI: 10.1007/s10067-020-05300-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 07/13/2020] [Accepted: 07/17/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To obtain a reliable estimation on the sleep quality in patients with systemic lupus erythematosus (SLE) and identify the main sleep problems, a meta-analysis was performed. METHODS Up to March 21, 2020, PubMed, EMBASE, and Cochrane Library were searched; quality evaluation were conducted with Newcastle-Ottawa Scale; statistical analyses were performed by stata14.0 software; results were expressed by weighted mean difference or standardized mean difference (WMD/SMD) and 95% confidence interval (CI). RESULTS Eighteen case-control studies were included in meta-analysis, 1086 SLE patients and 2866 controls were collected. The score of sleep quality in the case group was higher than that in the control group (SMD = 1.03, 95% CI: 0.80-1.27), and so was the Pittsburgh Sleep Quality Index (PSQI) (WMD = 3.45, 95% CI: 2.49-4.42). The first three complaints of sleep problems in PSQI were daytime dysfunction (WMD = 0.64, 95% CI: 0.36-0.92), subjective sleep quality (WMD = 0.62, 95% CI: 0.40-0.84), and habitual sleep efficiency (WMD = 0.54, 95% CI: 0.37-0.72). Subgroup analyses showed that the score of sleep quality in SLE patients were higher than controls among different regions, races, and disease duration. The sleep quality score of SLE patients with fibromyalgia (FM) was higher than that in general control, but no significant difference as compared with SLE patients without FM. CONCLUSIONS Our meta-analysis indicates that the sleep quality of SLE patients is worse than that of the general population; thus, more attention should be paid to the sleep status among this disease. Key Points •The sleep quality of SLE patients is worse than that of the general population. •Region, race, and disease duration are correlated with sleep quality in SLE patients.
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Affiliation(s)
- Li Wu
- School of Nursing, Anhui Medical University, Hefei, 230032, Anhui, China
| | - Pei-Li Shi
- School of Nursing, Anhui Medical University, Hefei, 230032, Anhui, China
| | - Sha-Sha Tao
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, Anhui, China.,Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, 81 Meishan Road, Hefei, 230032, Anhui, China
| | - Jin-Hui Tao
- Department of Rheumatology & Immunology, Anhui Provincial Hospital, Hefei, Anhui, China
| | - Guo-Cui Wu
- School of Nursing, Anhui Medical University, Hefei, 230032, Anhui, China.
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Liu RT, Rowan-Nash AD, Sheehan AE, Walsh RFL, Sanzari CM, Korry BJ, Belenky P. Reductions in anti-inflammatory gut bacteria are associated with depression in a sample of young adults. Brain Behav Immun 2020; 88:308-324. [PMID: 32229219 PMCID: PMC7415740 DOI: 10.1016/j.bbi.2020.03.026] [Citation(s) in RCA: 129] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 03/07/2020] [Accepted: 03/25/2020] [Indexed: 12/15/2022] Open
Abstract
We assessed the gut microbiota of 90 American young adults, comparing 43 participants with major depressive disorder (MDD) and 47 healthy controls, and found that the MDD subjects had significantly different gut microbiota compared to the healthy controls at multiple taxonomic levels. At the phylum level, participants with MDD had lower levels of Firmicutes and higher levels of Bacteroidetes, with similar trends in the at the class (Clostridia and Bacteroidia) and order (Clostridiales and Bacteroidales) levels. At the genus level, the MDD group had lower levels of Faecalibacterium and other related members of the family Ruminococcaceae, which was also reduced relative to healthy controls. Additionally, the class Gammaproteobacteria and genus Flavonifractor were enriched in participants with MDD. Accordingly, predicted functional differences between the two groups include a reduced abundance of short-chain fatty acid production pathways in the MDD group. We also demonstrated that the magnitude of taxonomic changes was associated with the severity of depressive symptoms in many cases, and that most changes were present regardless of whether depressed participants were taking psychotropic medications. Overall, our results support a link between MDD and lower levels of anti-inflammatory, butyrate-producing bacteria, and may support a connection between the gut microbiota and the chronic, low-grade inflammation often observed in MDD patients.
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Affiliation(s)
- Richard T Liu
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA.
| | - Aislinn D Rowan-Nash
- Department of Molecular Microbiology and Immunology, Brown University, Providence, RI, USA
| | - Ana E Sheehan
- Department of Psychological and Brain Sciences, University of Delaware, Newark, DE, USA
| | - Rachel F L Walsh
- Department of Psychology, Temple University, Philadelphia, PA, USA
| | - Christina M Sanzari
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA
| | - Benjamin J Korry
- Department of Molecular Microbiology and Immunology, Brown University, Providence, RI, USA
| | - Peter Belenky
- Department of Molecular Microbiology and Immunology, Brown University, Providence, RI, USA
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Bearne LM, Bieles J, Georgopoulou S, Andrews J, Tully A, Stolarchuk-Prowting K, Williamson T, Suarez BS, Nel L, D'Cruz D, Lempp H. Fatigue in adults with primary antiphospholipid syndrome: findings from a mixed-methods study. Lupus 2020; 29:924-933. [PMID: 32501170 PMCID: PMC7543013 DOI: 10.1177/0961203320928421] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Objective This study aimed to explore the experience and impact of fatigue in adults with primary antiphospholipid syndrome (pAPS). Methods This sequential, explanatory mixed-methods study enrolled adults with a six-month or more history of pAPS. Consenting participants completed the Functional Assessment of Chronic Illness Therapy–Fatigue subscale (FS), Multi-Dimensional Perceived Social Support Scale, Patient Health Questionnaire (PHQ9), Pittsburgh Sleep Quality Index (PSQI), International Physical Activity Questionnaire (IPAQMETS). Relationships between FS and other variables were explored with multiple linear regression. Interviews were conducted with a subgroup of participants, and the data were analysed thematically. Results A total of 103 participants were recruited (Mage = 50.3 years; standard deviation = 10.1 years; 18 males). Of these, 62% reported severe fatigue. Greater fatigue was associated with lower mood, physical inactivity, poorer sleep quality and lower perceived social support. The best-fit model explained 56% of the variance in FS (adjusted R2 = 0.560, F(3, 74) = 33.65, p > 0.001) and included PHQ9 and IPAQMETS as significant predictors, and PSQI as a non-significant predictor. Twenty participants completed interviews. Three key themes were identified: characteristics of fatigue, impact on life and coping strategies. Conclusion Fatigue was a common symptom of pAPS and challenging to manage. Other factors, particularly mood and physical activity, influenced fatigue. Evidence-based self-management interventions are needed.
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Affiliation(s)
- Lindsay M Bearne
- Department of Population Health Sciences, King's College London, London, UK
| | - Julie Bieles
- Department of Population Health Sciences, King's College London, London, UK
| | - Sofia Georgopoulou
- Centre for Rheumatic Diseases, Department of Inflammation Biology, King's College London, London, UK
| | - Josie Andrews
- Department of Population Health Sciences, King's College London, London, UK
| | - Amy Tully
- Department of Population Health Sciences, King's College London, London, UK
| | | | - Tom Williamson
- Department of Population Health Sciences, King's College London, London, UK
| | - Beatriz Santana Suarez
- Centre for Rheumatic Diseases, Department of Inflammation Biology, King's College London, London, UK
| | - Louise Nel
- Guys and St Thomas Hospitals NHS Foundation Trust, London, UK
| | - David D'Cruz
- Guys and St Thomas Hospitals NHS Foundation Trust, London, UK.,Department of Inflammation Biology, King's College London, London, UK
| | - Heidi Lempp
- Centre for Rheumatic Diseases, Department of Inflammation Biology, King's College London, London, UK
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Predictive factors of quality of life among systemic lupus erythematosus patients in Thailand: a web-based cross-sectional study. Qual Life Res 2020; 29:2415-2423. [PMID: 32270369 DOI: 10.1007/s11136-020-02494-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE This study aimed to assess mental health status (depression, anxiety, and stress) and explore factors associated with the disease-specific quality of life among Systemic Lupus Erythematosus (SLE) patients in Thailand. METHODS This cross-sectional study used an online convenience sampling of 650 SLE patients who were registered members of the Thailand SLE Club. The study survey comprised of demographic information, health history, Depression, Anxiety, Stress Scale (DASS), and Lupus Quality of Life Scale (LupusQoL). RESULTS The survey response rate was 61.2%. Out of 344 respondents, most were female (96.9%). The scores were suggestive of the presence of mild depression and stress, but moderate anxiety. The higher depression, anxiety, and stress levels were associated with lower education and income (r = - .14 to - .29, p < .01) and higher number of SLE symptoms (r = .17 to .33, p < .05). Better quality of life was significantly related to lower number of symptoms, lower levels of stress/anxiety/depression, higher education, and better income. Also, the longer the patients were kept out of the hospital (last hospitalization), the better their quality of life. By using hierarchical multiple regression, four predictors of the quality of life were identified; the number of symptoms, stress, anxiety, and depression. These predictors combined explained 51% of the variance, F(5,108) = 24.34, p < .001, adjusted R2 = .51. CONCLUSIONS To improve the quality of life, SLE patients should focus on self-management of their symptoms. Health care providers should include SLE self-care health education in the plan of care. They also should use multidisciplinary approach in order to provide holistic treatment, including psychological care.
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58
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Resende R, Fernandes T, Pereira AC, De Pascale J, Marques AP, Oliveira P, Morais S, Santos V, Madeira N, Pereira CF, Moreira PI. Mitochondria, endoplasmic reticulum and innate immune dysfunction in mood disorders: Do Mitochondria-Associated Membranes (MAMs) play a role? Biochim Biophys Acta Mol Basis Dis 2020; 1866:165752. [PMID: 32119897 DOI: 10.1016/j.bbadis.2020.165752] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 02/25/2020] [Accepted: 02/26/2020] [Indexed: 02/07/2023]
Abstract
Mood disorders like major depression and bipolar disorder (BD) are among the most prevalent forms of mental illness. Current knowledge of the neurobiology and pathophysiology of these disorders is still modest and clear biological markers are still missing. Thus, a better understanding of the underlying pathophysiological mechanisms to identify potential therapeutic targets is a prerequisite for the design of new drugs as well as to develop biomarkers that help in a more accurate and earlier diagnosis. Multiple pieces of evidence including genetic and neuro-imaging studies suggest that mood disorders are associated with abnormalities in endoplasmic-reticulum (ER)-related stress responses, mitochondrial function and calcium signalling. Furthermore, deregulation of the innate immune response has been described in patients diagnosed with mood disorders, including depression and BD. These disease-related events are associated with functions localized to a subdomain of the ER, known as Mitochondria-Associated Membranes (MAMs), which are lipid rafts-like domains that connect mitochondria and ER, both physically and biochemically. This review will outline the current understanding of the role of mitochondria and ER dysfunction under pathological brain conditions, particularly in major depressive disorder (MDD) and BD, that support the hypothesis that MAMs can act in these mood disorders as the link connecting ER-related stress response and mitochondrial impairment, as well as a mechanisms behind sterile inflammation arising from deregulation of innate immune responses. The role of MAMs in the pathophysiology of these pathologies and its potential relevance as a potential therapeutic target will be discussed.
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Affiliation(s)
- R Resende
- Center for Neuroscience and Cellular Biology (CNC), University of Coimbra, Portugal; Institute for Interdisciplinary Research (IIIUC), University of Coimbra, Portugal.
| | - T Fernandes
- Center for Neuroscience and Cellular Biology (CNC), University of Coimbra, Portugal
| | - A C Pereira
- Center for Neuroscience and Cellular Biology (CNC), University of Coimbra, Portugal
| | - J De Pascale
- Center for Neuroscience and Cellular Biology (CNC), University of Coimbra, Portugal
| | - A P Marques
- Center for Neuroscience and Cellular Biology (CNC), University of Coimbra, Portugal; Institute for Interdisciplinary Research (IIIUC), University of Coimbra, Portugal
| | - P Oliveira
- Department of Psychiatry, Centro Hospitalar e Universitário de Coimbra (CHUC), Portugal; Institute of Psychological Medicine, Faculty of Medicine, University of Coimbra, Portugal
| | - S Morais
- Department of Psychiatry, Centro Hospitalar e Universitário de Coimbra (CHUC), Portugal; Institute of Psychological Medicine, Faculty of Medicine, University of Coimbra, Portugal
| | - V Santos
- Department of Psychiatry, Centro Hospitalar e Universitário de Coimbra (CHUC), Portugal; Institute of Psychological Medicine, Faculty of Medicine, University of Coimbra, Portugal
| | - N Madeira
- Department of Psychiatry, Centro Hospitalar e Universitário de Coimbra (CHUC), Portugal; Institute of Psychological Medicine, Faculty of Medicine, University of Coimbra, Portugal
| | - C F Pereira
- Center for Neuroscience and Cellular Biology (CNC), University of Coimbra, Portugal; Institute of Biochemistry, Faculty of Medicine, University of Coimbra, Portugal
| | - P I Moreira
- Center for Neuroscience and Cellular Biology (CNC), University of Coimbra, Portugal; Institute of Physiology, Faculty of Medicine, University of Coimbra, Portugal
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Laskoski PB, Serralta FB, Barros AJS, Teche SP, Hauck S, Eizirik CL. From Soma To Psyche: An Outcome Evaluation Of Psychodynamic Psychotherapy In A Patient With Somatic Symptoms And Chronic Diseases. BRITISH JOURNAL OF PSYCHOTHERAPY 2020. [DOI: 10.1111/bjp.12523] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Ding J, Su S, You T, Xia T, Lin X, Chen Z, Zhang L. Serum interleukin-6 level is correlated with the disease activity of systemic lupus erythematosus: a meta-analysis. Clinics (Sao Paulo) 2020; 75:e1801. [PMID: 33084768 PMCID: PMC7536892 DOI: 10.6061/clinics/2020/e1801] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 06/08/2020] [Indexed: 02/06/2023] Open
Abstract
Interleukin-6 (IL-6) plays a crucial role in systemic autoimmunity and pathologic inflammation. Numerous studies have explored serum IL-6 levels in systemic lupus erythematosus (SLE) and their correlation with disease activity. Here, we performed a meta-analysis to quantitatively assess the correlation between the serum IL-6 levels and SLE activity. The PubMed and EMBASE databases were thoroughly searched for relevant studies up to September 2019. Standardized mean differences (SMDs) with 95% confidence intervals (95% CIs) were used to describe the differences between serum IL-6 levels in SLE patients and healthy controls and between those in active SLE patients and inactive SLE patients. The correlation between the serum IL-6 levels and disease activity was evaluated using Fisher's z values. A total of 24 studies involving 1817 SLE patients and 874 healthy controls were included in this meta-analysis. Serum IL-6 levels were significantly higher in SLE patients than in the healthy controls (pooled SMD: 2.12, 95% CI: 1.21-3.03, Active SLE patients had higher serum IL-6 levels than inactive SLE patients (pooled SMD: 2.12, 95% CI: 1.21-3.03). Furthermore, the pooled Fisher's z values (pooled Fisher's z=0.36, 95% CI: 0.26-0.46, p<0.01) showed that there was a positive correlation between the serum IL-6 levels and SLE activity. This study suggested that serum IL-6 levels were higher in patients with SLE than in healthy controls, and they were positively correlated with disease activity when Systemic Lupus Erythematosus Disease Activity Index>4 was defined as active SLE. More homogeneous studies with large sample sizes are warranted to confirm our findings due to several limitations in our meta-analysis.
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Affiliation(s)
- Jianwen Ding
- Department of Kidney Disease, Lanzhou University Second Hospital, Lanzhou 730030, China
- *Corresponding authors. E-mail: / / E-mail:
| | - Shujun Su
- Department of Gynecology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- *Corresponding authors. E-mail: / / E-mail:
| | - Tao You
- Department of Endocrinology and Rheumatology, Affiliated Southeast Hospital of Xiamen University/909th Hospital of People's Liberation Army, 269 Zhanghua Middle Road, Zhangzhou, 363000, Fujian Province, China
- *Corresponding authors. E-mail: / / E-mail:
| | - Tingting Xia
- Center for Reproductive Medicine, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou city, Guangdong Province, China
| | - Xiaoying Lin
- Department of Endocrinology and Rheumatology, Affiliated Southeast Hospital of Xiamen University/909th Hospital of People's Liberation Army, 269 Zhanghua Middle Road, Zhangzhou, 363000, Fujian Province, China
| | - Zhaocong Chen
- Department of Rehabilitation Medicine, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong 510630, China
- *Corresponding authors. E-mail: / / E-mail:
| | - Liqun Zhang
- Department of Endocrinology and Rheumatology, Affiliated Southeast Hospital of Xiamen University/909th Hospital of People's Liberation Army, 269 Zhanghua Middle Road, Zhangzhou, 363000, Fujian Province, China
- *Corresponding authors. E-mail: / / E-mail:
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Brailovski E, Vinet E, Pineau CA, Lee J, Lukusa L, Kalache F, Grenier LP, DaCosta D, Bernatsky S. Marital status and age of systemic lupus erythematous diagnosis: the potential for differences related to sex and gender. Lupus Sci Med 2019; 6:e000325. [PMID: 31448125 PMCID: PMC6687032 DOI: 10.1136/lupus-2019-000325] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 07/12/2019] [Accepted: 07/15/2019] [Indexed: 11/24/2022]
Abstract
Objectives Chronic rheumatic diseases can challenge social and family relationships. We compared marital status in patients with systemic lupus erythematous (SLE) with their general population counterparts, stratified by sex and age of SLE onset. Methods We performed a cross-sectional analysis of a cohort of 382 patients with SLE at our centre (349 females, 33 males). We determined how many were married or living common-law at the time of last study visit. Patients were then divided into: SLE diagnosis before 18, between 18 and 30, between 31 and 44 and after 45 years of age. We then compared marital status among male and female patients with SLE, to Quebec age-specific marital statistics. Results Of 382 patients with SLE, 202 (52.9%) were married or living common-law, which was 9% lower than general population rates (95% CI 2% to 16%). One-third of women with paediatric-onset SLE were married or living common-law, which was 28% lower than their general population counterparts (95% CI 6% to 46%). Half of women diagnosed between age 18 and 30 were married or living common law, which was 14% less than general population rates (95% CI 4% to 25%). We could not establish significant differences for women diagnosed after age 30, or for males, versus their general population counterparts. Conclusions Women diagnosed with SLE before age 30 were less likely to be married/living common-law, versus general population rates. This was not apparent for those diagnosed later in life. We did not clearly establish this effect in males, possibly due to power issues (vs a true effect of sex/gender). Additional studies (eg, focus groups) could elucidate reasons for our findings.
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Affiliation(s)
| | - Evelyne Vinet
- McGill University, Departmemt of Medicine, Montreal, Quebec, Canada.,McGill University Health Centre, Division of Rheumatology, Montreal, Quebec, Canada
| | - Christian A Pineau
- McGill University, Departmemt of Medicine, Montreal, Quebec, Canada.,McGill University Health Centre, Division of Rheumatology, Montreal, Quebec, Canada
| | - Jennifer Lee
- McGill University Health Centre, Division of Rheumatology, Montreal, Quebec, Canada
| | - Luck Lukusa
- McGill University Health Centre, Division of Rheumatology, Montreal, Quebec, Canada
| | - Fares Kalache
- McGill University Health Centre, Division of Rheumatology, Montreal, Quebec, Canada
| | - Louis-Pierre Grenier
- McGill University Health Centre, Division of Rheumatology, Montreal, Quebec, Canada
| | - Deborah DaCosta
- McGill University, Departmemt of Medicine, Montreal, Quebec, Canada.,McGill University Health Centre, Division of Rheumatology, Montreal, Quebec, Canada
| | - Sasha Bernatsky
- McGill University, Departmemt of Medicine, Montreal, Quebec, Canada.,McGill University Health Centre, Division of Rheumatology, Montreal, Quebec, Canada
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García-Carrasco M, Mendoza-Pinto C, León-Vázquez J, Méndez-Martínez S, Munguía-Realpozo P, Etchegaray-Morales I, Montiel-Jarquín Á, de Lara LGV, Alonso-García NE, Gándara-Ramírez JL, López-Colombo A. Associations between resilience and sociodemographic factors and depressive symptoms in women with systemic lupus erythematosus. J Psychosom Res 2019; 122:39-42. [PMID: 31126410 DOI: 10.1016/j.jpsychores.2019.05.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 05/07/2019] [Accepted: 05/08/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To compare resilience in women with SLE and healthy women and determine whether sociodemographic factors and depressive symptoms were associated with resilience in patients with SLE. METHODS This was a cross-sectional study. Participants were 123 women with SLE according to the ACR criteria and 132 age-matched healthy women (median = 45 (IQR = 34-54) years). Scales administered were: SLEDAI-2 K for disease activity, Graffar method, SLICC damage index, Center for Epidemiologic Studies Depression Scale, and the Spanish version of the Resilience Scale of Wagnild and Young. The statistical analysis was made using the Student t, Mann Whitney, Chi-square, and Spearman's Rho tests and multivariate analysis with a generalized linear model (GLM). Statistical significance was set as p < .05. RESULTS There were no differences in resilience scores between women with SLE and healthy women (median = 80, IQR = 75-87 vs. median = 80, IQR = 74-86.75, p = .38), although patients with SLE had higher self-efficacy scores (median = 47 IQR = 43-50 vs. median = 45, IQR = 42-48, p = .002) and depressive symptoms (median = 10, IQR = 5-18 vs. median = 8, IQR = 5-18, p = .01). The overall resilience score correlated with depressive symptoms (r = -0.537, p < .01). The GLM showed no association between sociodemographic factors and resilience in patients with SLE. CONCLUSIONS Resilience did not differ between women with SLE and healthy women. In patients with SLE, depressive symptoms may influence resilience and its domains, but sociodemographic factors do not. PUBLIC HEALTH SIGNIFICANCE STATEMENT The results suggest that resilience was similar between females with systemic lupus erythematosus (SLE) and age-matched healthy women. Depressive symptoms correlated negatively with resilience in patients with SLE. Sociodemographic factors were not associated with resilience in patients with SLE.
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Affiliation(s)
- Mario García-Carrasco
- Systemic Autoimmune Diseases Research Unit, UMAE Manuel Ávila Camacho-CIBIOR Instituto Mexicano del Seguro Social, Puebla, Mexico; Department of Rheumatology, Benemérita Universidad Autónoma de Puebla, Puebla, Mexico
| | - Claudia Mendoza-Pinto
- Systemic Autoimmune Diseases Research Unit, UMAE Manuel Ávila Camacho-CIBIOR Instituto Mexicano del Seguro Social, Puebla, Mexico; Department of Rheumatology, Benemérita Universidad Autónoma de Puebla, Puebla, Mexico.
| | - Julia León-Vázquez
- Systemic Autoimmune Diseases Research Unit, UMAE Manuel Ávila Camacho-CIBIOR Instituto Mexicano del Seguro Social, Puebla, Mexico
| | - Socorro Méndez-Martínez
- Systemic Autoimmune Diseases Research Unit, UMAE Manuel Ávila Camacho-CIBIOR Instituto Mexicano del Seguro Social, Puebla, Mexico
| | - Pamela Munguía-Realpozo
- Systemic Autoimmune Diseases Research Unit, UMAE Manuel Ávila Camacho-CIBIOR Instituto Mexicano del Seguro Social, Puebla, Mexico
| | - Ivet Etchegaray-Morales
- Physiotherapy Program, Medical School, Benemérita Universidad Autónoma de Puebla, Puebla, Mexico
| | - Álvaro Montiel-Jarquín
- Division of Health Research UMAE Manuel Ávila Camacho, Instituto Mexicano del Seguro Social Puebla, Puebla, Mexico
| | | | | | | | - Aurelio López-Colombo
- Puebla Research Coordination, High-Specialty Medical Unit, Specialty Hospital of Puebla, Instituto Mexicano del Seguro Social, Puebla, Mexico
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63
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Khan WA, Zaman GS, Alouffi S, Khan MWA. Depression and its related parameters increased the production of autoantibodies against 16α-hydroxyestrone-albumin complex in systemic lupus erythematosus. Int Immunopharmacol 2019; 71:215-223. [DOI: 10.1016/j.intimp.2019.03.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 03/02/2019] [Accepted: 03/20/2019] [Indexed: 12/16/2022]
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Hsu CL, Tsai SJ, Shen CC, Lu T, Hung YM, Hu LY. Risk of benign paroxysmal positional vertigo in patients with depressive disorders: a nationwide population-based cohort study. BMJ Open 2019; 9:e026936. [PMID: 30928959 PMCID: PMC6475146 DOI: 10.1136/bmjopen-2018-026936] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE The association between depression and benign paroxysmal positional vertigo (BPPV) remains debated. This study aimed to investigate the risk of BPPV in patients with depressive disorders. DESIGN Longitudinal nationwide cohort study. SETTING National health insurance research database in Taiwan. PARTICIPANTS We enrolled 10 297 patients diagnosed with depressive disorders between 2000 and 2009 and compared them to 41 188 selected control patients who had never been diagnosed with depressive disorders (at a 1:4 ratio matched by age, sex and index date) in relation to the risk of developing BPPV. METHODS The follow-up period was defined as the time from the initial diagnosis of depressive disorders to the date of BPPV, censoring or 31 December 2009. Cox proportional hazard regression analysis was used to investigate the risk of BPPV by sex, age and comorbidities, with HRs and 95% CIs. RESULTS During the 9-year follow-up period, 44 (0.59 per 1000 person-years) patients with depressive disorders and 99 (0.33 per 1000 person-years) control patients were diagnosed with BPPV. The incidence rate ratio of BPPV among both cohorts calculating from events of BPPV per 1000 person-years of observation time was 1.79 (95% CI 1.23 to 2.58, p=0.002). Following adjustments for age, sex and comorbidities, patients with depressive disorders were 1.55 times more likely to develop BPPV (95% CI 1.08 to 2.23, p=0.019) as compared with control patients. In addition, hyperthyroidism (HR=3.75, 95% CI 1.67-8.42, p=0.001) and systemic lupus erythematosus (SLE) (HR=3.47, 95% CI 1.07 to 11.22, p=0.038) were potential risk factors for developing BPPV in patients with depressive disorders. CONCLUSIONS Patients with depressive disorders may have an increased risk of developing BPPV, especially those who have hyperthyroidism and SLE.
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Affiliation(s)
- Chiao-Lin Hsu
- Department of Health Management Center, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Department of Nursing, Meiho University, Pingtung, Taiwan
- Department of Medical Education and Research and Research Center of Medical Informatics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Center for Geriatrics and Gerontology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Shih-Jen Tsai
- Top Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan
- Division of Psychiatry, Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Cheng-Che Shen
- Division of Psychiatry, Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Psychiatry, Taichung Veterans General Hospital Chiayi Branch, Chiayi, Taiwan
| | - Ti Lu
- Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Yao-Min Hung
- Department of Emergency Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Li-Yu Hu
- Center for Geriatrics and Gerontology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Top Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan
- Division of Psychiatry, Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Social Work, Soochow University, Taipei, Taiwan
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Bazsó A, Szappanos Á, Rásonyi R, Nagy E, Farkas A, Várnai B, Patócs A, Kiss E, Poór G. Polymorphisms of human glucocorticoid receptor gene in systemic lupus erythematosus: a single-centre result. Clin Rheumatol 2019; 38:1979-1984. [PMID: 30850964 DOI: 10.1007/s10067-019-04478-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 02/06/2019] [Accepted: 02/11/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND SLE is a systemic autoimmune disorder with multiple organ manifestations. Despite of the innovations glucocorticoids (GC) have still remained the first-line therapy in SLE. Besides HSD11B enzymes, intracellular glucocorticoid receptors (GR) affect tissue-specific cortisol effect and the consequent signalisation pathway. SNPs of the glucocorticoid receptor gene (NR3C1) modulate individual sensitivity to glucocorticoids. Our aim was to determine the allele frequency of the three, clinically most important SNPs in a SLE patient population in comparison to healthy volunteers and to find association with particular manifestations of SLE. METHODS We analysed results of 104 SLE patients compared to 160 healthy subjects. All patients were genotyped for the functional GR polymorphisms BclI, N363S, and A3669G. The GR gene polymorphisms were determined using allele-specific PCR and Taqman allelic discrimination assays. RESULTS The BclI allele frequency was lower in the SLE group compared to the healthy control group. The central nervous system and especially psychiatric symptoms developed more frequently in the BclI carriers compared to none carriers. The prevalence of theA3669G polymorphism was the same in both groups, but showed a negative association with the psychiatric symptoms. CONCLUSION The increased and decreased sensitivity associated with GR BclI and A3669G polymorphisms could have a pathogenic significance in SLE especial with the central nervous system and psychiatric symptoms. Improving our knowledge on the importance of GR polymorphisms may reveal their pathophysiologic and therapeutic consequences.
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Affiliation(s)
- Anna Bazsó
- National Rheumatology and Physiotherapy Institute, Frankel Leo út 38-40,, Budapest, 1023, Hungary.
| | - Ágnes Szappanos
- National Rheumatology and Physiotherapy Institute, Frankel Leo út 38-40,, Budapest, 1023, Hungary
- HAS-SE Lendulet Hereditary Endocrine Tumours Research Group, Budapest, Hungary
| | - Rita Rásonyi
- National Rheumatology and Physiotherapy Institute, Frankel Leo út 38-40,, Budapest, 1023, Hungary
| | - Eszter Nagy
- National Rheumatology and Physiotherapy Institute, Frankel Leo út 38-40,, Budapest, 1023, Hungary
| | - Abigél Farkas
- 2nd Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Blanka Várnai
- 2nd Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Attila Patócs
- HAS-SE Lendulet Hereditary Endocrine Tumours Research Group, Budapest, Hungary
- Department of Laboratory Medicine, Semmelweis University, Budapest, Hungary
| | - Emese Kiss
- National Rheumatology and Physiotherapy Institute, Frankel Leo út 38-40,, Budapest, 1023, Hungary
- 3rd Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Gyula Poór
- National Rheumatology and Physiotherapy Institute, Frankel Leo út 38-40,, Budapest, 1023, Hungary
- 3rd Department of Medicine, Semmelweis University, Budapest, Hungary
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Jordan J, Thompson NJ, Dunlop-Thomas C, Lim SS, Drenkard C. Relationships among organ damage, social support, and depression in African American women with systemic lupus erythematosus. Lupus 2019; 28:253-260. [PMID: 30482093 PMCID: PMC6415670 DOI: 10.1177/0961203318815573] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- J Jordan
- 1 Rollins School of Public Health, Atlanta, GA, United States
| | - N J Thompson
- 1 Rollins School of Public Health, Atlanta, GA, United States
| | - C Dunlop-Thomas
- 2 School of Medicine, Emory University, Atlanta, GA, United States
| | - S Sam Lim
- 2 School of Medicine, Emory University, Atlanta, GA, United States
| | - C Drenkard
- 2 School of Medicine, Emory University, Atlanta, GA, United States
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Yoon S, Kang DH, Choi TY. Psychiatric Symptoms in Systemic Lupus Erythematosus: Diagnosis and Treatment. JOURNAL OF RHEUMATIC DISEASES 2019. [DOI: 10.4078/jrd.2019.26.2.93] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Seoyoung Yoon
- Department of Psychiatry, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Dae Hun Kang
- Department of Psychiatry, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Tae Young Choi
- Department of Psychiatry, Catholic University of Daegu School of Medicine, Daegu, Korea
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68
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Tisseverasinghe A, Peschken C, Hitchon C. Anxiety and Mood Disorders in Systemic Lupus Erythematosus: Current Insights and Future Directions. Curr Rheumatol Rep 2018; 20:85. [DOI: 10.1007/s11926-018-0797-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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