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

The interferon-rich skin environment regulates Langerhans cell ADAM17 to promote photosensitivity in lupus

The autoimmune disease lupus erythematosus (lupus) is characterized by photosensitivity, where even ambient ultraviolet radiation (UVR) exposure can lead to development of inflammatory skin lesions. We have previously shown that Langerhans cells (LCs) limit keratinocyte apoptosis and photosensitivity via a disintegrin and metalloprotease 17 (ADAM17)-mediated release of epidermal growth factor receptor (EGFR) ligands and that LC ADAM17 sheddase activity is reduced in lupus. Here, we sought to understand how the lupus skin environment contributes to LC ADAM17 dysfunction and, in the process, differentiate between effects on LC ADAM17 sheddase function, LC ADAM17 expression, and LC numbers. We show through transcriptomic analysis a shared IFN-rich environment in non-lesional skin across human lupus and three murine models: MRL/lpr, B6.Sle1yaa, and imiquimod (IMQ) mice. IFN-I inhibits LC ADAM17 sheddase activity in murine and human LCs, and IFNAR blockade in lupus model mice restores LC ADAM17 sheddase activity, all without consistent effects on LC ADAM17 protein expression or LC numbers. Anti-IFNAR-mediated LC ADAM17 sheddase function restoration is associated with reduced photosensitive responses that are dependent on EGFR signaling and LC ADAM17. Reactive oxygen species (ROS) is a known mediator of ADAM17 activity; we show that UVR-induced LC ROS production is reduced in lupus model mice, restored by anti-IFNAR, and is cytoplasmic in origin. Our findings suggest that IFN-I promotes photosensitivity at least in part by inhibiting UVR-induced LC ADAM17 sheddase function and raise the possibility that anifrolumab ameliorates lupus skin disease in part by restoring this function. This work provides insight into IFN-I-mediated disease mechanisms, LC regulation, and a potential mechanism of action for anifrolumab in lupus.

Obsessive-Compulsive Disorder as an Epiphenomenon of Comorbid Bipolar Disorder? An Updated Systematic Review

BACKGROUND

Bipolar disorder (BD) and obsessive-compulsive disorder (OCD) comorbidity is an emerging condition in psychiatry, with relevant nosological, clinical, and therapeutic implications.

METHODS

We updated our previous systematic review on epidemiology and standard diagnostic validators (including phenomenology, course of illness, heredity, biological markers, and treatment response) of BD-OCD. Relevant papers published until (and including) 15 October 2023 were identified by searching the electronic databases MEDLINE, Embase, PsychINFO, and Cochrane Library, according to the PRISMA statement (PROSPERO registration number, CRD42021267685).

RESULTS

We identified 38 new articles, which added to the previous 64 and raised the total to 102. The lifetime comorbidity prevalence ranged from 0.26 to 27.8% for BD and from 0.3 to 53.3% for OCD. The onset of the two disorders appears to be often overlapping, although the appearance of the primary disorder may influence the outcome. Compared to a single diagnosis, BD-OCD exhibited a distinct pattern of OC symptoms typically following an episodic course, occurring in up to 75% of cases (vs. 3%). Notably, these OC symptoms tended to worsen during depressive episodes (78%) and improve during manic or hypomanic episodes (64%). Similarly, a BD course appears to be chronic in individuals with BD-OCD in comparison to patients without. Additionally, individuals with BD-OCD comorbidity experienced more depressive episodes (mean of 8.9 ± 4.2) compared to those without comorbidity (mean of 4.1 ± 2.7).

CONCLUSIONS

We found a greater likelihood of antidepressant-induced manic/hypomanic episodes (60% vs. 4.1%), and mood stabilizers with antipsychotic add-ons emerging as a preferred treatment. In line with our previous work, BD-OCD comorbidity encompasses a condition of greater nosological and clinical complexity than individual disorders.

Psychiatric manifestations of systemic lupus erythematosus: A brief review with two case-reports

Neuropsychiatric systemic lupus erythematosus is a severe neurological and psychiatric manifestation following systemic lupus erythematosus. Neuropsychiatric systemic lupus erythematosus is a global concern with limited data on its impact on quality of life in Africa. Furthermore, there is a lack of published research on neuropsychiatric systemic lupus erythematosus in Ethiopia. In this article, we present two case reports of Ethiopian patients with systemic lupus erythematosus and neuropsychiatric systemic lupus erythematosus, highlighting the challenges of diagnosing neuropsychiatric systemic lupus erythematosus worldwide. Although the patients were treated with alternative pharmacological agents based on available medications, interdisciplinary collaboration between psychologists, psychiatrists, neurologists, and internists is necessary to decrease the burden of systemic lupus erythematosus patients with neuropsychiatric manifestations. Overall, symptomatic therapy for neuropsychiatric systemic lupus erythematosus in developing countries is a good approach until future evidence-based pharmacotherapy is developed.

Development and psychometric properties of the Reproductive Health Assessment in Systemic Lupus Erythematosus: Mixed-Methods study

OBJECTIVES

Systemic lupus erythematosus (SLE) with a high morbidity rate (7% in general and 325/100.000 in reproductive period) was known as "the mother of autoimmune diseases." But healthcare providers hadn't reliable scales to measure the effectiveness of interventions to improve reproductive health. Women with systemic lupus erythematosus (SLE) express concern about a significant gap in their reproductive and sexual health during medical care due to the lack of a specific scale to measure this concept. This study developed psychometrically specific scale to evaluate this concept in Iranian women.

METHODS

The study utilized a sequential-exploratory mixed-methods design, wherein the concept of reproductive health was clarified during the qualitative phase using conventional content analysis (inductive-deductive) to create a pool of RHASLE (Reproductive Health Assessment in SLE) items. During the psychometric process, the face, content, and construct validities of the RHASLE were checked with 650 individuals (320 using exploratory factor analysis [EFA] and 330 using confirmatory factor analysis [CFA]) through interviews and completion of the questionnaire. Convergent and divergent validities were then checked, and the reliability was assessed through stability and internal consistency. Finally, the measurement error, responsiveness, and interpretability of the scale were evaluated and confirmed.

RESULTS

The study's findings revealed that the RHASLE consisted of 5 factors (33 items): physical-psychological disorder (13 items), relaxing feeling (6 items), spirituality (3 items), high-risk pregnancies (5 items), and sexual satisfaction (6 items). These factors explained a total of 99.97% of the variance in the concept of reproductive health. Confirmatory factor analysis confirmed the good model fit, and its validity and reliability were deemed acceptable.

CONCLUSION

The RHASLE consisted of 27 items with high internal consistency, stability, responsiveness, and interpretability. That was able to get approval of Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) checklist. Based on the results, RHASLE is a valid and reliable multidimensional scale that encompasses various aspects of reproductive health (physical, sexual, psychological, social, and spiritual).

Roles of microglia in adult hippocampal neurogenesis in depression and their therapeutics

Adult hippocampal neurogenesis generates functional neurons from neural progenitor cells in the hippocampal dentate gyrus (DG) to complement and repair neurons and neural circuits, thus benefiting the treatment of depression. Increasing evidence has shown that aberrant microglial activity can disrupt the appropriate formation and development of functional properties of neurogenesis, which will play a crucial role in the occurrence and development of depression. However, the mechanisms of the crosstalk between microglia and adult hippocampal neurogenesis in depression are not yet fully understood. Therefore, in this review, we first introduce recent discoveries regarding the roles of microglia and adult hippocampal neurogenesis in the etiology of depression. Then, we systematically discuss the possible mechanisms of how microglia regulate adult hippocampal neurogenesis in depression according to recent studies, which involve toll-like receptors, microglial polarization, fractalkine-C-X3-C motif chemokine receptor 1, hypothalamic-pituitary-adrenal axis, cytokines, brain-derived neurotrophic factor, and the microbiota-gut-brain axis, etc. In addition, we summarize the promising drugs that could improve the adult hippocampal neurogenesis by regulating the microglia. These findings will help us understand the complicated pathological mechanisms of depression and shed light on the development of new treatment strategies for this disease.

Peer Support in Rheumatic Diseases: A Narrative Literature Review

Rheumatic diseases are a group of chronic conditions that are associated with significant morbidity, impaired physical function, psychosocial stress, and cost to the healthcare system. Peer support interventions have been shown to have a positive impact on health outcomes in several chronic conditions, but no review has specifically assessed the impact of peer support on rheumatic conditions. The aim of this narrative literature review was to understand how peer support has been applied in the field of rheumatology, with a specific focus on the impact of observational and randomized studies of direct peer support interventions on various outcome measures across rheumatic conditions. We also examined studies exploring patient attitudes and preferences toward peer support. The majority of studies included focused on peer support in rheumatoid arthritis and systemic lupus erythematosus. Generally, patients across the spectrum of rheumatic disease perceive peer support as a useful tool. Peer support interventions, while highly variable, were generally associated with positive impacts on health-related quality of life metrics (both perceived and measured), although these differences were not always statistically significant. Important limitations include variability in study design, selection bias among study participants, and short follow-up periods across most peer support interventions.

Transcranial direct current stimulation for bipolar depression: systematic reviews of clinical evidence and biological underpinnings

Despite multiple available treatments for bipolar depression (BD), many patients face sub-optimal responses. Transcranial direct current stimulation (tDCS) has been advocated in the management of different conditions, including BD, especially in treatment-resistant cases. The optimal dose and timing of tDCS, the mutual influence with other concurrently administered interventions, long-term efficacy, overall safety, and biological underpinnings nonetheless deserve additional assessment. The present study appraised the existing clinical evidence about tDCS for bipolar depression, delving into the putative biological underpinnings with a special emphasis on cellular and molecular levels, with the ultimate goal of providing a translational perspective on the matter. Two separate systematic reviews across the PubMed database since inception up to August 8^th 2022 were performed, with fourteen clinical and nineteen neurobiological eligible studies. The included clinical studies encompass 207 bipolar depression patients overall and consistently document the efficacy of tDCS, with a reduction in depression scores after treatment ranging from 18% to 92%. The RCT with the largest sample clearly showed a significant superiority of active stimulation over sham. Mild-to-moderate and transient adverse effects are attributed to tDCS across these studies. The review of neurobiological literature indicates that several molecular mechanisms may account for the antidepressant effect of tDCS in BD patients, including the action on calcium homeostasis in glial cells, the enhancement of LTP, the regulation of neurotrophic factors and inflammatory mediators, and the modulation of the expression of plasticity-related genes. To the best of our knowledge, this is the first study on the matter to concurrently provide a synthesis of the clinical evidence and an in-depth appraisal of the putative biological underpinnings, providing consistent support for the efficacy, safety, and tolerability of tDCS.

Another side of lupus: A case report of lupus presenting with cutaneous vasculitis

Systemic lupus erythematosus (SLE) is a systemic autoimmune complex disease that affects any organ, characterized by immune complex formation and autoantibody production. Lupus vasculitis begins at a young age. These patients generally have a longer disease duration. Ninety percent of cases in lupus-associated vasculitis present with cutaneous vasculitis. Disease activity, severity, organ involvement, response to treatment and drug toxicity determine the frequency of outpatient control in lupus. Depression and anxiety are observed more frequently in SLE than in the normal population. Our case, it is an example of the patient's disruption of controls due to psychological trauma and that lupus can cause serious cutaneous vasculitis. In addition, psychiatric evaluation of lupus cases from the time of diagnosis may have a positive effect on the prognosis.

White matter integrity and pro-inflammatory cytokines as predictors of antidepressant response in MDD

Major depressive disorder (MDD) is a multifactorial, serious and heterogeneous mental disorder that can lead to chronic recurrent symptoms, treatment resistance and suicidal behavior. MDD often involves immune dysregulation with high peripheral levels of inflammatory cytokines that might have an influence on the clinical course and treatment response. Moreover, patients with MDD show brain volume changes as well as white matter (WM) alterations that are already existing in the early stage of illness. Mounting evidence suggests that both neuroimaging markers, such as WM integrity and blood markers, such as inflammatory cytokines might serve as predictors of treatment response in MDD. However, the relationship between peripheral inflammation, WM structure and antidepressant response is not yet clearly understood. The aim of the present review is to elucidate the association between inflammation and WM integrity and its impact on the pathophysiology and progression of MDD as well as the role of possible novel biomarkers of treatment response to improve MDD prevention and treatment strategies.

Trajectories of depressive symptoms in systemic lupus erythematosus over time

OBJECTIVES

The objectives of this study were to determine the trajectories of depressive symptoms in patients with SLE and to identify baseline characteristics that are associated with a patient's trajectory of depression.

METHODS

Data from the Lupus Outcomes Study at the University of California, San Francisco were analysed. Depressive symptomatology was assessed in years two through seven using the Center for Epidemiologic Studies Depression Scale (CES-D), with higher scores representing more severe depressive symptoms. Group-based trajectory modelling was used to determine latent classes of CES-D scores over time. Ordinal logistic regression analyses were performed to identify baseline characteristics associated with worse classes of depressive symptoms.

RESULTS

CES-D scores for 763 individuals with SLE over 6 years were mapped into four distinct classes. Class 1 (36%) and class 2 (32%) comprised the largest proportion of the cohort and were defined by the lowest and low CES-D scores (no depression), respectively. Class 3 (22%) and class 4 (10%) had high and the highest scores (depression), respectively. Greater age [odds ratio (OR): 0.97, 95% CI: 0.96, 0.99] and higher education level (OR: 0.79, 95% CI: 0.70, 0.89) at baseline were associated with lower odds of membership in worse classes of depressive symptoms. Conversely, lower income (OR: 1.73, 95% CI: 1.03, 2.92), worse SF-36 physical functioning scores (OR: 1.12, 95% CI: 1.12, 1.13) and worse SF-36 bodily pain scores (OR: 1.58, 95% CI: 1.55, 1.61) were positively associated with membership in worse classes of depressive symptoms.

CONCLUSION

Four classes of depressive symptoms were identified in patients with SLE. Understanding the trajectories of depressive symptoms and the associated risk factors can aid in the management of these symptoms in individuals living with SLE.

Mendelian randomization study on the causal effects of systemic lupus erythematosus on major depressive disorder

The vast majority of epidemiological studies suggested a link between systemic lupus erythematosus (SLE) and major depressive disorder (MDD). However, the causality for SLE on the risk of MDD remained unknown due to confounding factors or reverse causality. Herein, we investigated the causality between SLE and MDD in those of European ancestry by a Mendelian randomization (MR) approach. Summary genetic data of cases with SLE/MDD were derived from independent largest public genome-wide association study. Forty-six single nucleotide polymorphisms associated with SLE were used as instrumental variables. The main causal inference was carried out using the MRE-IVW method. Additional, reverse-direction MR and multivariable MR analyses were further performed. Result indicated that SLE was causally associated with a lower risk of MDD (using the MRE-IVW method, odds ratio [OR] = 0.983, 95% confidence interval [CI] = 0.974-0.991, p = 1.18 × 10^-4). Complementary analysis found no heterogeneity or horizontal pleiotropy. Multivariate MR analysis yielded consistent results (OR =  0.981; 95% CI = 0.969-0.993; p = 2.75 × 10^-3). Reverse-direction MR analysis suggested non-causal relationship of MDD on the risk of SLE (using the IVW method, OR = 0.846, 95% CI = 0.345-2.072; p = 0.714). Thus, this is the first study providing evidence of potential causal links between SLE and MDD and further related research is needed.

Response to the coronavirus disease 2019 pandemic of dental hygienists in South Korea-Part II: Fear and anxiety

OBJECTIVES

The purpose of this cross-sectional study was to evaluate the mental fear and anxiety about coronavirus disease 2019 (COVID-19) among Korean clinical dental hygienists and to investigate factors influencing the anxiety felt after the outbreak of COVID-19.

METHODS

A questionnaire on mental fear (Fear-C) and anxiety for COVID-19 was conducted among 500 clinical dental hygienists in South Korea. Fear-C was identified with eight questions. The General Anxiety Disorder-7 (GAD-7) questionnaire was scored for the pre-COVID-19 situation (GAD_Before ) and the current situation going through the pandemic (GAD_After ). The scores for the responses to the questionnaire were 0 points for strong negative and 3 points for strong positive. Higher scores indicate higher levels of fear and anxiety. All data were analysed using IBM SPSS Statistics, and the statistical significance was set at α = 0.05.

RESULTS

The average Fear-C was 16.11 ± 3.89 out of 24.00. There were significant differences in Fear-C when the type of work organization and symptoms related to COVID-19 (Sx-C) differed. Significant differences were confirmed in GAD_Before according to age range, systemic diseases, and Sx-C (p < 0.05). There was no difference in GAD_After for all general characteristics, except Sx-C (p > 0.05). In the regression model of GAD_After , Sx-C (β = 0.526), Fear-C (β = 0.358), and GAD_Before (β = 0.515) were positively related to GAD_After (p < 0.001), respectively.

CONCLUSIONS

Most dental hygienists complained of Fear-C. GAD_After was significantly higher than GAD_Before . The factor that had the greatest impact on GAD_After was Sx-C.

Associations of a family history of lupus with the risks of lupus and major psychiatric disorders in first-degree relatives

BACKGROUND

Genetic factors link psychiatric disorders, particularly major depressive disorder (MDD), bipolar disorder, and obsessive-compulsive disorder (OCD), with systemic lupus erythematosus (SLE). Additionally, maternal SLE is a risk factor for long-term developmental problems, particularly learning disabilities, attention disorders, autism spectrum disorder (ASD) and speech disorders, in children.

AIM

We aimed to determine whether first-degree relatives (FDRs) of patients with SLE have increased risks of SLE and major psychiatric disorders.

DESIGN AND METHODS

Using the Taiwan National Health Insurance Research Database, we recruited 40 462 FDRs of patients with SLE as well as 161 848 matched controls. The risks of major psychiatric disorders, including schizophrenia, bipolar disorder, OCD, MDD, ASD and attention-deficit/hyperactivity disorder (ADHD), were assessed.

RESULTS

The FDRs of patients with SLE had higher risks of SLE (reported as the adjusted relative risk and 95% confidence interval: 14.54; 12.19-17.34), MDD (1.23; 1.12-1.34), ADHD (1.60; 1.55-1.65), OCD (1.41; 1.14-1.74) and bipolar disorder (1.18; 1.01-1.38) compared with controls. Specifically, male FDRs of patients with SLE had higher risks of SLE and bipolar disorder, whereas female FDRs of patients with SLE had higher risks of MDD and OCD. Differences in the familial relationship (i.e. parents, children, siblings and twins) were consistently associated with higher risks of these disorders compared with controls.

CONCLUSIONS

The FDRs of patients with SLE had higher risks of SLE, MDD, ADHD, OCD and bipolar disorder than the controls.

Neuroimmune mechanisms in fear and panic pathophysiology

Panic disorder (PD) is unique among anxiety disorders in that the emotional symptoms (e.g., fear and anxiety) associated with panic are strongly linked to body sensations indicative of threats to physiological homeostasis. For example, panic attacks often present with feelings of suffocation that evoke hyperventilation, breathlessness, or air hunger. Due to the somatic underpinnings of PD, a major focus has been placed on interoceptive signaling and it is recognized that dysfunctional body-to-brain communication pathways promote the initiation and maintenance of PD symptomatology. While body-to-brain signaling can occur via several pathways, immune and humoral pathways play an important role in communicating bodily physiological state to the brain. Accumulating evidence suggests that neuroimmune mediators play a role in fear and panic-associated disorders, although this has not been systematically investigated. Currently, our understanding of the role of immune mechanisms in the etiology and maintenance of PD remains limited. In the current review, we attempt to summarize findings that support a role of immune dysregulation in PD symptomology. We compile evidence from human studies and panic-relevant rodent paradigms that indicate a role of systemic and brain immune signaling in the regulation of fear and panic-relevant behavior and physiology. Specifically, we discuss how immune signaling can contribute to maladaptive body-to-brain communication and conditioned fear that are relevant to spontaneous and conditioned symptoms of PD and identify putative avenues warranting future investigation.

Gut microbiome and fecal metabolic alteration in systemic lupus erythematosus patients with depression

Background

Mental health disorders in systemic lupus erythematosus (SLE) are gradually getting recognized; however, less is known regarding the actual structure and compositional alterations in gut microbiome and metabolism and the mechanisms of how they affect depression development in SLE patients.

Methods

Twenty-one SLE patients with depression (SLE-d), 17 SLE patients without depression (SLE-nd), and 32 healthy controls (HC) were included in this study. Fecal samples were collected for 16S rRNA gene sequencing and ultra-high-performance liquid chromatography-quadrupole time-of-flight mass spectrometry (UHPLC-QTOF-MS) based metabolomics.

Results

The structure of gut microbiome in the SLE-d group changed compared with that in the other two groups. The microbiome composition of SLE-d group showed decreased species richness indices, characterized by low ACE and Chao1 indices, a decrease in the ratio of phylum Firmicutes to Bacteroidetes, genus Faecalibacterium and Roseburia. A downregulation of the metabolite fexofenadine involved in bile secretion was positively correlated with the genus Faecalibacterium, Subdoligranulum and Agathobacter. Compared with the SLE-nd group, the SLE-d group had elevated serum levels of IL-2 and IL-6 and decreased BDNF. Interestingly, abundance of the genus Faecalibacterium and Roseburia was negatively correlated with IL-6, abundance of the genus Roseburia was negatively correlated with IL-2, and abundance of the genus Bacteroides was positively correlated with IL-2.

Conclusion

This study identified specific fecal microbes and their metabolites that may participate in the development of SLE-d. Our findings provide a new perspective for improving depression in SLE patients by regulating the gut-brain axis.

Severe psychiatric disorders and general medical comorbidities: inflammation-related mechanisms and therapeutic opportunities

Individuals with severe psychiatric disorders, such as mood disorders and schizophrenia, are at increased risk of developing other medical conditions, especially cardiovascular and metabolic diseases. These medical conditions are underdiagnosed and undertreated in these patients contributing to their increased morbidity and mortality. The basis for this increased comorbidity is not well understood, possibly reflecting shared risks factors (e.g. lifestyle risk factors), shared biological mechanisms and/or reciprocal interactions. Among overlapping pathophysiological mechanisms, inflammation and related factors, such as dysbiosis and insulin resistance, stand out. Besides underlying the association between psychiatric disorders and cardiometabolic diseases, these mechanisms provide several potential therapeutic targets.

Development of a nomogram prediction model for depression in patients with systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is an inflammatory autoimmune disease with depression as one of its most common symptoms. The aim of this study is to establish a nomogram prediction model to assess the occurrence of depression in patients with SLE. Based on the Hospital Anxiety and Depression Scale cutoff of 8, 341 patients with SLE, recruited between June 2017 and December 2019, were divided into depressive and non-depressive groups. Data on socio-demographic characteristics, medical history, sociopsychological factors, and other risk factors were collected. Between-group differences in clinical characteristics were assessed with depression as the dependent variable and the variables selected by logistic multiple regression as predictors. The model was established using R language. Marital status, education, social support, coping, and anxiety predicted depression (p < 0.05). The nomogram prediction model showed that the risk rate was from 0.01 to 0.80, and the receiver operating characteristic curve analysis showed that the area under the curve was 0.891 (p < 0.001). The calibration curve can intuitively show that the probability of depression predicted by the nomogram model is consistent with the actual comparison. The designed nomogram provides a highly predictive assessment of depression in patients with SLE, facilitating more comprehensive depression evaluation in usual clinical care.

Depression in systemic lupus erythematosus: Modifiable or inheritable? a two-sample mendelian randomization study

Observational studies have found increased incidence of depression, the leading cause of disability worldwide, in patients with systemic lupus erythematosus (SLE). However, it is not clear whether the association was genetically inheritable or caused by modifiable risk factors, such as socioeconomic factors. We investigated the causal relationship between genetically predicted SLE and depression by two-sample Mendelian randomization analysis. Single nucleotide polymorphisms (SNPs) associated with SLE were selected as instrumental variables (IVs) from a genome-wide association study (GWAS) of 14,267 European-ancestry participants. A large GWAS of depression (180,866 European-ancestry participants) and another GWAS of major depressive disorder (MDD) (173,005 European-ancestry participants) were selected as outcomes. Then we estimated the effects of IVs on the odds of depression or MDD by using the inverse-variance weighted (IVW) meta-analysis method (random-effects), which had a power of 90% to detect 4% increase of depression in SLE. Interestingly, genetically predicted SLE decreased the odds of depression [odds ratio (OR): 0.995; 95% CI: 0.990–0.999; p = 0.025] and MDD [odds ratio (OR): 0.985; 95% CI: 0.975–0.996; p = 0.009], indicating increased depression in SLE was not due to inheritable risk factors.

Intermittent and Persistent Type 2 lupus: patient perspectives on two distinct patterns of Type 2 SLE symptoms

OBJECTIVE

We have developed a new conceptual model to characterise the signs and symptoms of SLE: the Type 1 and 2 SLE Model. Within the original model, Type 1 SLE consists of inflammatory manifestations like arthritis, nephritis and rashes; Type 2 SLE includes symptoms of fatigue, myalgia, mood disturbance and cognitive dysfunction. Through in-depth interviews, we explored how the Type 1 and 2 SLE Model fits within the lived experience of patients with SLE, with a focus on the connection between Type 1 and Type 2 SLE symptoms.

METHODS

Semistructured in-depth interviews were conducted among adult participants meeting 1997 American College of Rheumatology or Systemic Lupus International Collaborating Clinics criteria for SLE. Participants were purposefully selected for age, race, sex and nephritis history. All interviews were audio-recorded and transcribed. Data were analysed through episode profile and thematic analysis.

RESULTS

Through interviews with 42 patients with SLE, two patterns of Type 2 SLE emerged: Intermittent (n=18) and Persistent (n=24). Participants with Intermittent Type 2 SLE described feeling generally well when Type 1 is inactive; these participants were younger and had more internal SLE manifestations. Participants with Persistent Type 2 described always experiencing Type 2 symptoms despite inactive Type 1, although the severity may fluctuate. Participants with Persistent Type 2 SLE experienced traditional lupus symptoms of joint pain, hair loss and rash, but less often had severe organ system involvement.

CONCLUSIONS

By listening to the stories of our patients, we found two underlying patterns of Type 2 SLE: Intermittent Type 2 symptoms that resolve in synchrony with Type 1 inflammatory symptoms, and Persistent Type 2 symptoms that continue despite remission of Type 1 symptoms.

Physical Inactivity and Incident Depression in a Multiracial, Multiethnic Systemic Lupus Erythematosus Cohort

OBJECTIVE

Physical activity is known to improve depressive symptoms. The present study was undertaken to examine physical inactivity as a predictor of incident depression in systemic lupus erythematosus (SLE).

METHODS

Data derive from the California Lupus Epidemiology Study (CLUES), a longitudinal cohort with confirmed SLE diagnoses. Physical inactivity was assessed from a single item, "I rarely or never do any physical activities," and depressive symptoms by the 8-item Patient Health Questionnaire (PHQ-8). Analysis included those not depressed at baseline (PHQ-8 score <10) who completed an in-person baseline assessment and at least 1 follow-up visit (n = 225). Incident depression was defined as a PHQ-8 score of ≥10 at follow-up. Cox proportional hazards regression modeled incident depression over 2 years as a function of baseline physical inactivity, controlling for age, sex, race, income, comorbidities, disease activity, and disease damage.

RESULTS

At baseline, the mean ± SD age of the participants was 45 ± 15 years, 88% were female, and 70% identified as non-White. Mean PHQ scores for those without depression at baseline did not differ by activity status, but those who were inactive at baseline were significantly more likely to develop depression over the next 2 years (hazard ratio [HR] 2.89 [95% confidence interval (95% CI) 1.46-5.71]). After adjusting for covariates, the association remained strong, including a >3-fold increased risk of incident depression among the sedentary group (HR 3.88 [95% CI 1.67-9.03]).

CONCLUSION

In this diverse SLE cohort, a simple question about physical inactivity was highly predictive of incident depression over the subsequent 2 years. Results suggest an urgent need for approaches to reduce sedentary behavior in this high-risk population.

High risk of depression, anxiety, and an unfavorable complex comorbidity profile is associated with SLE: a nationwide patient-level study

Objectives

The aim of this national population-based, retrospective database study is to compare the comorbidity profiles of systemic lupus erythematosus (SLE) patients and general population controls matched for age, gender, and region and assess the risk of depression or anxiety when controlled for age, gender and adjusted for the Charlson Comorbidity Index (CCI).

Methods

Claims data of 1051 patients diagnosed with SLE (full population between January 01, 2011, and December 31, 2014) from the Hungarian National Health Insurance Fund have been analyzed against matched controls (1:5 ratio) with a follow-up of 30 months. The first record of SLE diagnosis was considered the diagnosis date. The odds ratio (OR) and 99.9% confidence interval (CI) of having depression or anxiety among patients with SLE vs. controls have been assessed using logistic regression models.

Results

SLE patients report more comorbidities than the matched general population both in pre- and post-index periods (mean CCI 1.79 vs. 1.15 and 2.78 vs. 1.22 [both p<0.001], respectively). Both SLE patients and controls diagnosed with depression or anxiety had significantly higher CCI than those without comorbid depression or anxiety (p<0.001). However, SLE patients had a twofold higher risk of depression or anxiety than matched controls when controlled for age, gender, and adjusted for CCI.

Conclusion

Our analysis indicates the enormity of comorbidity burden in SLE, especially that of anxiety and depression. The size and complexity of the comorbidity burden emphasizes the importance of early diagnosis and intervention with comprehensive modalities incorporating attention to comorbidities in SLE patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13075-022-02799-6.

Low-Dose Aspirin Augments the Anti-Inflammatory Effects of Low-Dose Lithium in Lipopolysaccharide-Treated Rats

Mounting evidence suggests that immune-system dysfunction and inflammation play a role in the pathophysiology and treatment of mood-disorders in general and of bipolar disorder in particular. The current study examined the effects of chronic low-dose aspirin and low-dose lithium (Li) treatment on plasma and brain interleukin-6 and tumor necrosis factor-α production in lipopolysaccharide (LPS)-treated rats. Rats were fed regular or Li-containing food (0.1%) for six weeks. Low-dose aspirin (1 mg/kg) was administered alone or together with Li. On days 21 and 42 rats were injected with 1 mg/kg LPS or saline. Two h later body temperature was measured and rats were sacrificed. Blood samples, the frontal-cortex, hippocampus, and the hypothalamus were extracted. To assess the therapeutic potential of the combined treatment, rats were administered the same Li + aspirin protocol without LPS. We found that the chronic combined treatment attenuated LPS-induced hypothermia and significantly reduced plasma and brain cytokine level elevation, implicating the potential neuroinflammatory diminution purportedly present among the mentally ill. The combined treatment also significantly decreased immobility time and increased struggling time in the forced swim test, suggestive of an antidepressant-like effect. This preclinical evidence provides a potential approach for treating inflammation-related mental illness.

Self-Reported Anxiety and Depression in a Monocentric Cohort of Patients With Systemic Lupus Erythematosus: Analysis of Prevalence, Main Determinants, and Impact on Quality of Life

Aims of the study

To analyze the prevalence of self-reported anxiety and depression in a monocentric cohort of patients with Systemic Lupus Erythematosus (SLE); to study the main determinants and the impact on quality of life (QoL).

Methods

A cross-sectional observational study including adult outpatients with SLE. Demographic and clinical data were analyzed: indices of disease activity (SELENA-SLEDAI); damage (SLICC-DI); comorbidities and concomitant therapies. The definitions for remission (DORIS) and “Lupus Low Disease Activity State” (LLDAS) were applied. At enrollment, each patient completed the following questionnaires: SF-36, FACIT-Fatigue, Lupus Impact Tracker (LIT), Systemic Lupus Activity Questionnaire (SLAQ), and the Hospital Anxiety and Depression Scale (HADS) in order to self-assess anxiety and depression symptoms. The Student t-test and Chi² tests were conducted for univariate analysis. The Spearman test was used for linear correlation between continuous data. Multivariate analysis was performed by multiple linear and logistic regression.

Results

One hundred fifty-four consecutive patients with SLE were enrolled, the majority female and Caucasian with a mean age = 43.3 ± 13.7 years. 79.9% were in LLDAS or remission. 36.4% had a SDI > 1. 13.7% of patients had concomitant fibromyalgia. 37.4% had symptoms indicating anxiety and 25% of depression according to the HADS questionnaire. In the multivariate analysis, patients with active disease were significantly more anxious and depressed (p < 0.01) compared to patients in LLDAS or remission. Fibromyalgia and older age were independently associated with anxiety and depression, respectively (p < 0.05). Active skin involvement was significantly linked to depression (p < 0.05). Higher scores on the HADS questionnaire (higher levels of anxiety and depression) were found to be significantly linked to patients’ perception of higher disease activity and worse quality of life, irrespective of disease activity, age and fibromyalgia.

Conclusion

Symptoms of anxiety and depression are frequent in SLE patients, including outpatients with mild/moderate disease. Such symptoms have a significant negative impact on QoL and perception of disease activity, regardless of other factors. Moreover, disease activity, advanced age and fibromyalgia appear to be significantly linked to mood disorders. Assessing symptoms of the anxious-depressive spectrum in patients with SLE could lead to improvement in patients’ perception of health status and quality of life.

Anxiety Symptoms Among Patients With Systemic Lupus Erythematosus Persist Over Time and Are Independent of SLE Disease Activity

Objective

The objectives of this study are to identify patterns of anxiety symptomology over time among patients with systemic lupus erythematosus (SLE) and to assess the longitudinal relationship between SLE disease activity and anxiety symptomology.

Methods

Longitudinal data from 139 patients with American College of Rheumatology or Systemic Lupus International Collborating Clinic (SLICC)‐classified SLE were analyzed. Anxiety symptomology was assessed using the Patient‐Reported Outcomes Measurement Information System (PROMIS) Emotional Distress: Anxiety Short Form 8a. SLE disease activity was measured using the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI)‐2000 (S2K) and S2K Responder Index 50 (S2K RI‐50). Group‐based trajectory modeling (GBTM) identified longitudinal trajectories of anxiety symptomology. The relationship between disease activity and anxiety over time was assessed using multilevel linear regressions.

Results

The mean patient age was 40.2 years (standard deviation [SD], 12.7); 90.6% were female, and 56.1% were of Black race. All patients had at least three PROMIS anxiety scores over an average of 30.9 months (SD, 13.0). GBTM identified four trajectories of anxiety symptomology, labeled as the following: low (LA), average (AA), moderate (MA), and high anxiety (HA). Black patients were 2.47 (95% confidence interval: 1.19‐5.12) times as likely as White patients to be classified into the MA or HA groups compared with the LA or AA groups. On multivariable analysis, active SLE disease was not significantly associated with anxiety over time (P = 0.19).

Conclusion

Anxiety trajectories remained stable over time, and racial differences in anxiety severity were observed. SLE disease activity was not longitudinally associated with anxiety after controlling for depression and other factors. Further understanding of the factors that contribute to the persistence of anxiety among individuals with SLE is necessary.

Determination of the Risk Factors Contributing to the Development of Neuropsychiatric Lupus in a Systemic Lupus Erythematosus Cohort

Background

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease with a complex, varied clinical presentation that is both more common and has poor outcomes in women of color. SLE outcomes also seem to be influenced by socioeconomic factors. Neuropsychiatric lupus (NPL) is a common manifestation of SLE that is difficult to diagnose and treat and has poor clinical outcomes. There is no clear relationship between NPL and SLE-related autoantibodies, and this contributes to the difficulty in diagnosing NPL. As a result, NPL is a significant contributor to morbidity and mortality in patients with SLE.

Objective

The purpose of this study was to examine the relationship between serological and socioeconomic factors in the development of NPL in our patient cohort and determine the risk factors for the development of NPL.

Methods

This was an SLE single-center, retrospective chart review study that was performed at a university-based tertiary referral center. Patients aged 18 and older who meet the American College of Rheumatology (ACR) 1997 criteria and were seen between June 1st, 2015, and June 1st, 2019, were included in this study. Overall, 629 patients with SLE were identified, and 263 patients were included. Demographic and serological data were collected. Supplemental socioeconomic information for each zip code in Southwest Virginia was obtained from the United States Government Census website. Continuous variables were analyzed using the T-test or Mann-Whitney U test. Categorical variables were analyzed using chi-square tests or Fisher’s exact tests. Statistical analysis was performed using SAS9.4, and p-value < 0.05 was considered statistically significant.

Results

We reviewed a number of risk factors including age, sex, race, and median household income (MHI), noting no statistical relationship between these factors and the diagnosis of NPL. We did find that the presence of antiphospholipid antibodies (aPL) was significantly associated with a diagnosis of NPL and that complement 4 (C4) levels trended toward statistical significance.

Conclusion

In our cohort of patients, there was no relationship between age, sex, race, and median household income, and the diagnosis of NPL. There was a statistically significant relationship between aPL and the diagnosis of NPL. Other SLE-related antibodies showed no statistical relationship with the diagnosis of NPL. Although not statistically significant, there was a trend toward significance between complement 4 (C4) levels and the diagnosis of NPL.

Association of clinical characteristics, disease activity and health-related quality of life in SLE patients with major depressive disorder

OBJECTIVE

To determine the contributing factors associated with major depressive disorder (MDD) in SLE patients and examine the association between disease-specific health-related quality of life [lupus quality of life (LupusQoL)] domains and MDD.

METHODS

Depression was assessed by the patient health questionnaire (PHQ)-9, and scores ≥10 indicate MDD. Demographic data, LupusQoL domains, clinical and other features of the SLE patients were described and compared between MDD (PHQ-9 ≥10) and non-MDD (PHQ-9 <10) groups using χ2 tests for categorical variables and Wilcoxon rank sum tests for non-normal continuous variables. The risk of MDD was evaluated for the patient and physician-reported features individually using log-binomial models to estimate relative risks and 95% confidence limits.

RESULTS

Eighty-eight patients with SLE met eligibility criteria, with a mean (range) age of 48.6 (19-80), mostly female (80%) and with a mean disease duration of 13.2 years. Compared with the non-MDD group, patients with MDD (n = 32, 36%) were more likely to have the following SLE manifestations: mucocutaneous, vascular, ocular, pulmonary and musculoskeletal involvement. Self-rated health described as poor/fair was markedly associated with MDD (P < 0.001, relative risk = 0.48). Based on relative risks, higher pain visual analogue score, and patient and physician global assessment scores were also linked to MDD. The LupusQoL domain scores were notably lower in the MDD patients, with a statistically significant reduction in all LupusQoL domains.

CONCLUSION

Predictors of MDD in SLE patients include higher scores in pain and global assessment, poor or fair self-reported health, and specific organ involvement. These findings may help clinicians to recognize and manage MDD promptly.

Safety and Efficacy of Combined Low-Dose Lithium and Low-Dose Aspirin: A Pharmacological and Behavioral Proof-of-Concept Study in Rats

Despite established efficacy in bipolar disorder patients, lithium (Li) therapy has serious side effects, particularly chronic kidney disease. We examined the safety and behavioral effects of combined chronic low-dose aspirin plus low-dose Li in rats to explore the toxicity and therapeutic potential of this treatment. Rats were fed regular or Li-containing food (0.1% [low-dose, LLD-Li] or 0.2% [standard-dose, STD-Li]) for six weeks. Low-dose aspirin (1 mg/kg) was administered alone or together with Li. Renal function and gastric mucosal integrity were assessed. The effects of the combination treatment were evaluated in depression-like and anxiety-like behavioral models. Co-treatment with aspirin did not alter plasma Li levels. Chronic STD-Li treatment resulted in significant polyuria and polydipsia, elevated blood levels of creatinine and cystatin C, and increased levels of kidney nephrin and podocin—all suggestive of impaired renal function. Aspirin co-treatment significantly damped STD-Li-induced impairments in kidney parameters. There were no gastric ulcers or blood loss in any treatment group. Combined aspirin and LLD-Li resulted in a significant increase in sucrose consumption, and in the time spent in the open arms of an elevated plus-maze compared with the LLD-Li only group, suggestive of antidepressant-like and anxiolytic-like effects, respectively. Thus, we demonstrate that low-dose aspirin mitigated the typical renal side effects of STD-Li dose and enhanced the beneficial behavioral effects of LLD-Li therapy without aggravating its toxicity.

Bipolar Patients and Bullous Pemphigoid after Risperidone Long-Acting Injectable: A Case Report and a Review of the Literature

Neuropsychiatric disorders are found to be associated with bullous pemphigoid (BP), an autoimmune subepidermal blistering disease. Antipsychotics have emerged as possible inducing factors of BP. However, large sample studies concerning BP associated with antipsychotics, as well as with specific mental disorders, are still lacking. Our review retrieved a few clinical studies and case reports on the topic, producing controversial results. We report for the first time a bipolar patient case presenting BP following five-month therapy with risperidone long-acting injectable (LAI). We hypothesize that the dermatological event is associated with the medication administered. The issue emerged during psychiatric consultation and was confirmed by histological examination, direct and indirect immunofluorescence studies, plus positive plasma and cutaneous BP180 and BP230 IgG. Neurodegeneration or neuroinflammation might represent a primary process leading to a cross-reactive immune response between neural and cutaneous antigens and contributing to self-tolerance failure. Furthermore, the time sequence of the shared biological mechanisms leading to clinical manifestations of the neuropsychiatric disorder and BP remains undefined. BP comorbid with bipolar disorder might occasionally represent a serious health risk and affect patients' physical and psychosocial quality of life. Thus, clinicians treating psychiatric patients should consider BP as a possible adverse effect of psychotropic medications.

Neuropsychiatric involvement in systemic lupus erythematosus: A case series

Patients with systemic lupus erythematous that suffers from one or more of several neuropsychiatric symptoms represent a subcategory termed "neuropsychiatric systemic lupus erythematosus" (NPSLE). Different environmental factors, such as infection, stress, and ischemia, mediated by inflammatory cytokines, may damage the blood-brain barrier, further contributing to neuropsychiatric symptoms. Antiribosomal-P antibodies are specifically related to psychosis in NPSLE. Three patients of systemic lupus erythematosus who developed features of psychosis are presented and the condition is briefly discussed.

[Importance of cognitive disorders in internal medicine: Pathophysiology, diagnosis, management. The example of systemic lupus erythematosus]

Systemic diseases, which are in France mainly monitored in internal medicine, affect multiple organs or tissues. While cutaneous or articular manifestations are the most common, neurological involvement is often associated with severity. Diagnosis of peripheral (e.g, neuropathies) or central (e.g, myelitis) nervous disorders is quite easy through clinical examination and dedicated complementary tests. However, neuropsychological manifestations that affect cognition, including memory, attention, executive functions or reasoning, are difficult to diagnose, sometimes trivialized by practitioners. Their causes are often numerous and interrelated. Nevertheless, these cognitive manifestations are closely related to patients' quality of life, affecting their social life, family dynamics and professional integration but also the treatment adherence. The purpose of this review, focused on the example of systemic lupus erythematosus, is to raise awareness of cognitive dysfunction in systemic diseases including their management from diagnosis to treatments. The final aim is to go further into setting up research groups and care programs for patients with cognitive impairment followed in internal medicine.

Cellular and Extracellular White Matter Abnormalities in Obsessive-Compulsive Disorder: A Diffusion Magnetic Resonance Imaging Study

BACKGROUND

While previous studies have implicated white matter (WM) as a core pathology of obsessive-compulsive disorder (OCD), the underlying neurobiological processes remain elusive. This study used free-water (FW) imaging derived from diffusion magnetic resonance imaging to identify cellular and extracellular WM abnormalities in patients with OCD compared with control subjects. Next, we investigated the association between diffusion measures and clinical variables in patients.

METHODS

We collected diffusion-weighted magnetic resonance imaging and clinical data from 83 patients with OCD (56 women/27 men, age 37.7 ± 10.6 years) and 52 control subjects (27 women/25 men, age 32.8 ± 11.5 years). Fractional anisotropy (FA), FA of cellular tissue, and extracellular FW maps were extracted and compared between patients and control subjects using tract-based spatial statistics and voxelwise comparison in FSL Randomise. Next, we correlated these WM measures with clinical variables (age of onset and symptom severity) and compared them between patients with and without comorbidities and patients with and without psychiatric medication.

RESULTS

Patients with OCD demonstrated lower FA (43.4% of the WM skeleton), lower FA of cellular tissue (31% of the WM skeleton), and higher FW (22.5% of the WM skeleton) compared with control subjects. We did not observe significant correlations between diffusion measures and clinical variables. Comorbidities and medication status did not influence diffusion measures.

CONCLUSIONS

Our findings of widespread FA, FA of cellular tissue, and FW abnormalities suggest that OCD is associated with microstructural cellular and extracellular abnormalities beyond the corticostriatothalamocortical circuits. Future multimodal longitudinal studies are needed to understand better the influence of essential clinical variables across the illness trajectory.

Structural Changes on MRI Demonstrate Specific Cerebellar Involvement in SLE Patients-A VBM Study

The purpose of this study is to investigate possible differences in brain structure, as measured by T1-weighted MRI, between patients with systemic lupus erythematosus (SLE) and healthy controls (HC), and whether any observed differences were in turn more severe in SLE patients with neuropsychiatric manifestations (NPSLE) than those without (non-NPSLE). Structural T1-weighted MRI was performed on 69 female SLE patients (mean age = 35.8 years, range = 18–51 years) and 24 age-matched female HC (mean age = 36.8 years, range = 23–52 years) in conjunction with neuropsychological assessment using the CNS Vital Signs test battery. T1-weighted images were preprocessed and analyzed by FSL-VBM. The results show that SLE patients had lower grey matter probability values than the control group in the VIIIa of the cerebellum bilaterally, a region that has previously been implied in sensorimotor processing in human and non-human primates. No structural differences for this region were found between NPSLE and non-NPSLE patients. VBM values from the VIIIa region showed a weak positive correlation with the psychomotor speed domain from CNS Vital Signs (p = 0.05, r = 0.21), which is in line with its presumed role as a sensorimotor processing area.

Medication adherence is influenced by resilience in patients with systemic lupus erythematosus

OBJECTIVE

Evidence on the relationship between resilience and medication adherence in systemic lupus erythematosus (SLE) patients is lacking. We aimed to examine the impact of resilience on medication adherence in SLE patients.

METHOD

In a cross-sectional analysis SLE outpatients were assessed for resilience (Connor-Davison Resilience Scale, CD-RISC), depressive symptoms (CES-D) and medication adherence (Compliance Questionnaire for Rheumatology [CQR]). The disease activity index (mexSLEDAI) and damage (SLICC Damage Index) were administered. Factors independently associated with adherence were identified using multivariate logistic regression.

RESULTS

Of the 157 patients, 152 (96.8%) were female with a median age of 45.9 (IQR: 39.0-55.5) years and disease duration of 14 (IQR: 10.0-19.0) years. Medication adherence (CQR ≥80%) and depressive symptoms were found in 74.5% and 43.9% of patients, respectively. Adherent patients had a lower CES-D score and a higher CD-RISC score. In the multivariate analysis adjusting for demographic and clinical confounders, resilience and older age protected against non-adherence (OR 0.96, [95% CI 0.94-0.99] and OR 0.96 [95% CI 0.93-0.98], respectively).

CONCLUSION

In SLE patients, resilience and older age, which possibly associated with better medication adherence, may protect against non-adherence.

Psychopathology in paediatric systemic lupus erythematosus

INTRODUCTION

Although systemic lupus erythematosus (SLE) is more common in adults, when it is diagnosed before the age of 16, it has a worse prognosis. Depressive and anxious symptoms are common in this population but few studies have examined anxiety or its relationship with manifestations of the disease or type of treatment received.

OBJECTIVE

To determine the frequency of anxious and depressive symptoms in children and adolescents with SLE, as well as their relationship with disease activity and the immunosuppressive treatment used.

METHODS

A cross-sectional study in which paediatric patients with SLE from 9 to 17 years of age from a paediatric referral centre in the city of Bogota were included. Each patient was interviewed and immunosuppressive treatment, time to diagnosis and disease activity were recorded. The frequency of depressive and anxious symptoms and quality of life were measured with validated questionnaires. The relationship between anxious or depressive symptoms and disease activity and immunosuppressive treatment was sought.

RESULTS

40 patients with a mean age of 14±2 years were interviewed. 52% of cases had active disease. 60% presented scores indicating anxiety and one patient a score suggesting depression. 37% reported suicidal thoughts following the diagnosis of SLE. No relationship was found between disease activity and psychiatric manifestations. Of the different drugs used, only prednisone was associated with higher anxiety symptom scores (p=0.002).

CONCLUSIONS

Anxiety was more prevalent than depression in patients with paediatric SLE. This disorder and the use of corticosteroids were factors of vulnerability to manifest psychopathology. Lupus activity is not related to psychiatric symptoms. SLE has a significant impact on the quality of life of patients.

Investigational and Experimental Drugs to Treat Obsessive-Compulsive Disorder

Treatment-resistance is a frequent condition for obsessive-compulsive disorder (OCD). Over the past decades, a lot of effort has been made to address this issue, and several augmentation strategies of serotonergic drugs have been investigated. Antidopaminergic drugs are considered the first choice as augmentation strategy for treatment-resistant OCD patients, but they seem to work only for a subset of patients, and none of them have been officially approved for OCD. Recently, the role of glutamate and inflammation in OCD pathophysiology clearly emerged, and this has led to several investigations on glutamatergic and anti-inflammatory agents. Results seem promising but still inconclusive. Probiotic interventions (considered to modulate the immune systems and the brain activity) are gaining attention in several psychiatric fields but are still at their early stages in the OCD field. Research on new treatment approaches for OCD is moving forward, and more than one hundred interventional trials are ongoing around the world. While the vast majority of these trials involve neuromodulation and psychotherapeutic approaches, only a small proportion (around 20%) involve the investigation of new pharmacological approaches (tolcapone, nabilone, psilocybin, troriluzole, nitrous oxide, rituximab, naproxen, and immunoglobulins). Here, we provide a comprehensive review of investigational and experimental drugs to treat OCD.

Inflammation, Obsessive-Compulsive Disorder, and Related Disorders

Initial reports supporting the possibility of inflammation in the brain in obsessive-compulsive disorder (OCD) evolved from the models of Sydenham's Chorea, and Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus (PANDAS), which implicated excessive autoimmune responses following exposure to group A B-hemolytic streptococcal infections. Subsequently, this model was expanded to Pediatric Autoimmune Neuropsychiatric Syndrome (PANS) which applied the same concept but included other infections. A critical shortcoming of this model was that it was attributable to a small minority of OCD cases. The relationship between inflammation and OCD was more broadly demonstrated through translocator protein (TSPO) positron emission tomography imaging, a method that detects gliosis, an important component of brain inflammation, in neuropsychiatric diseases, including morphological activation and proliferation of microglia and to some extent astroglia. This method identified greater TSPO binding in the cortico-striatal-thalamo-cortical circuit in OCD, providing a direct brain measure of an important component of inflammation. To identify OCD cases with prominent elevations in TSPO binding in clinical research settings with lower cost peripheral markers, a promising approach is to apply blood serum biomarkers of inflammatory molecules produced by activated microglia and astroglia (gliosis). Such measures may aid stratification in future clinical trials. Several inflammatory-modifying interventions, including celecoxib, minocycline, and n-acetylcysteine, have been tested as treatments in randomized double-blind placebo controlled clinical trials and there is a tendency toward positive results, although these medications are not optimized for brain penetration and sample sizes for most trials were small. Future clinical trials of medications that target gliosis in OCD should apply larger sample sizes, ideally incorporating stratification approaches to enrich samples for the presence of gliosis.

Neuroinflammation in psychiatric disorders: PET imaging and promising new targets

Neuroinflammation is a multifaceted physiological and pathophysiological response of the brain to injury and disease. Given imaging findings of 18 kDa translocator protein (TSPO) and the development of radioligands for other inflammatory targets, PET imaging of neuroinflammation is at a particularly promising stage. This Review critically evaluates PET imaging results of inflammation in psychiatric disorders, including major depressive disorder, schizophrenia and psychosis disorders, substance use, and obsessive-compulsive disorder. We also consider promising new targets that can be measured in the brain, such as monoamine oxidase B, cyclooxygenase-1 and cyclooxygenase-2, colony stimulating factor 1 receptor, and the purinergic P2X7 receptor. Thus far, the most compelling TSPO imaging results have arguably been found in major depressive disorder, for which consistent increases have been observed, and in schizophrenia and psychosis, for which patients show reduced TSPO levels. This pattern highlights the importance of validating brain biomarkers of neuroinflammation for each condition separately before moving on to patient stratification and treatment monitoring trials.

Association between depression and anxiety with skin and musculoskeletal clinical phenotypes in systemic lupus erythematosus

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.

Clinical Team Perspectives on the Psychosocial Aspects of Transition to Adult Care for Patients With Childhood-Onset Systemic Lupus Erythematosus

OBJECTIVE

The transition from pediatric to adult care for youth with childhood-onset systemic lupus erythematosus (SLE) is a vulnerable period. Adverse outcomes during this transition include gaps in care, unscheduled health care utilization, loss of insurance, and high disease activity. The objective of this study was to examine the clinical care teams' perspective on the psychosocial factors associated with transition outcomes, which are poorly understood in this population.

METHODS

We conducted in-depth interviews with clinical care team members who interact with childhood-onset SLE patients during transfer from pediatric to adult rheumatology. A semistructured interview guide was used to prompt participants' perspectives about the psychosocial factors associated with the transition process for patients with childhood-onset SLE. Audio recordings were transcribed and analyzed using the constant comparative method. We stopped conducting interviews once thematic saturation was achieved.

RESULTS

Thirteen in-depth interviews were conducted. Participants included pediatric rheumatologists (n = 4), adult rheumatologists from both academic and private practice settings (n = 4), nurses (n = 2), a nurse practitioner, a social worker, and a psychologist. We identified several themes deemed by clinical care teams as important during the transition, including the impact of the family, patient resilience and coping mechanisms, the role of mental health and emotional support, and the need for education, peer support, and social connectedness.

CONCLUSION

We identified several psychosocial themes that clinical team members believe impact the transition of patients with childhood-onset SLE into adult care. The role of parental modeling, youth resilience, mental health and emotional care, improved childhood-onset SLE education, and structured peer support and social connectedness are highlighted, which may be amenable to interventions.

Relationships Between Adverse Childhood Experiences and Health Status in Systemic Lupus Erythematosus

OBJECTIVE

Adverse childhood experiences (ACEs) are associated with poor adult health and immune dysregulation. The impact of ACEs on patients with autoimmune disease is unknown. The present study was undertaken to compare the prevalence of ACEs in patients with systemic lupus erythematosus (SLE) to a population-based survey estimate and to investigate relationships between ACEs and SLE outcomes.

METHODS

Data derived from the California Lupus Epidemiology Study (CLUES), a sample of adult patients with SLE. Participants completed a 10-item ACE questionnaire covering 3 domains (abuse, neglect, household challenges). We estimated ACE prevalence in 269 CLUES participants compared to geographically matched respondents from the 2015 California Behavioral Risk Factor Surveillance System (BRFSS), which was standardized to CLUES participant characteristics (age, sex, race/ethnicity). We examined associations of patient-reported and physician-assessed health status measures with overall ACE levels and domains using multivariable linear regression, controlling for sociodemographics, nephritis, and juvenile-onset SLE.

RESULTS

Although specific domains varied, overall ACE levels were similar for CLUES and BRFSS respondents. Among SLE patients, 63.2% had ≥1 ACE, and 19.3% had ≥4. ACEs were more prevalent in those who were older, women, Latino or African American, and without college degrees, but not in those with lupus nephritis. In adjusted models, higher ACE levels and ACE domains were associated with worse patient-reported SLE activity, depression, and health status but were not significantly associated with physician-assessed SLE activity, damage, or severity.

CONCLUSION

Given the association between ACE levels and important patient-reported outcomes in SLE, our study reinforces the need for prevention of ACEs in childhood and for clinical interventions to promote resilience among adults who have experienced ACEs.

The association between systemic lupus erythematosus and bipolar disorder – a big data analysis

Background:

Systemic lupus erythematosus (SLE) is a chronic, autoimmune disease that has a wide variety of physical manifestations, including neuropsychiatric features. Bipolar disorder (BD) is a chronic, episodic illness, that may present as depression or as mania. The objective of this study was to investigate the association between SLE and BD using big data analysis methods.

Methods:

Patients with SLE were compared with age- and sex-matched controls regarding the prevalence of BD in a cross-sectional study. Chi-square and t-tests were used for univariate analysis and a logistic regression model was used for multivariate analysis, adjusting for confounders. The study was performed utilizing the chronic disease registry of Clalit Health Services medical database.

Results:

The study included 5018 SLE patients and 25,090 matched controls. BD was found in a higher prevalence among SLE patients compared to controls (0.62% vs. 0.26%, respectively, P < 0.001). BD patients had a greater prevalence of smokers compared to non-BD patients (62.5% vs 23.5%, respectively, P < 0.001). In a multivariate analysis, smoking and SLE were both found to be significantly associated with BD.

Conclusions:

SLE was found to be independently associated with BD. These findings may imply that an autoimmune process affecting the central nervous system among SLE patients facilitates the expression of concomitant BD.

Psychological distress and quality of life are improved in autoimmune patients through Tandem-Psychotherapy, combining individual hypnosis and eye movement desensitization and reprocessing (EMDR) treatment for trauma, followed by supportive-expressive group therapy

OBJECTIVE

Autoimmune diseases are associated with psychological distress, resulting in greatly impaired quality of life. Tandem-Psychotherapy comprises trauma-focused psychotherapy with hypnosis and eye movement desensitization and reprocessing (EMDR), followed by supportive-expressive group therapy. The objective was to evaluate whether Tandem-Psychotherapy could reduce psychological distress and improve quality of life.

METHODS

In a case-control study, 45 patients were divided into two groups: 24 patients in the therapy group (TG) and 21 in the control group (CG). The autoimmune diagnoses were undifferentiated connective tissue disease (9 patients in TG and 12 in CG), Behçet's syndrome (4/TG, 5/CG), mixed connective tissue disease (3/TG, 1/CG), and other diagnoses (8/TG and 3/CG). At start of treatment point, the patients were evaluated with SCL-90-R for distress and psychological symptoms, Life Stressor Checklist-Revised for relevant trauma, and SF-36 for quality of life. SF36 and SCL-90 were repeated at the end of treatment and at 6-month follow-up.

RESULTS

Relevant trauma was found in 24/24 TG patients and in 17/21 CG. Eighteen out of twenty-four TG patients exhibited psychiatric comorbidity with 18/21 in the CG. At start of treatment, all patients exhibited high level of distress (GSI > 0.5) and high Depression and Anxiety scores in SCL-90-R. At end of therapy, the TG exhibited greatly improved GSI (p < 0.001), Depression (p < 0.001), and Anxiety (p < 0.001) compared with the GC; SF-36 scores were also much better in the TG, with significant differences ranging from p = 0.002 to p = 0.0004 at end of therapy. These results persisted at the 6-month follow-up.

CONCLUSIONS

Tandem-Psychotherapy is effective for improving psychological symptoms and quality of life in autoimmune patients with high levels of distress and relevant psychiatric comorbidity.Key Points• Psychological distress is very high in autoimmune patients, often for previous traumatic experiences.• Psychological support must be both trauma-focused and aimed to improve social functioning.• Quality of life is very much improved by reducing psychological distress.• Tandem-Psychotherapy is feasible because it is contained within a relatively limited time, also for patients with history of trauma.

Major depressive disorders accompanying autoimmune diseases - Response to treatment

MDDs (major depressive disorders) belong to the most frequently diagnosed mental diseases and affect approximately 350 million people all over the world. A growing body of evidence suggests that inflammatory processes may play a significant role in the pathophysiology and progression of the disease. The comorbidity of MDDs with many other medical conditions, for example autoimmune diseases (ADs) caused by inflammation, has been observed on numerous occasions. In both cases, increased levels of pro-inflammatory cytokines, chemokines and other inflammatory agents are observed. Furthermore, higher rates of inflammatory markers are associated with a poorer response to antidepressant treatment. Additionally, the presence of any AD is associated with higher prevalence of depression and may reduce the chance of effective therapy. Interestingly, the administration of several anti-inflammatory agents used in AD treatment is positively correlated with a reduction of depressive symptoms. In conclusion, the factors contributing to the coexistence of depression as well as affecting antidepressant treatment effectiveness may lead to an alteration of the cytokine profiles in many autoimmune diseases.

Immune-Related Comorbidities in Childhood-Onset Obsessive Compulsive Disorder: Lifetime Prevalence in the Obsessive Compulsive Disorder Collaborative Genetics Association Study

Objective: To evaluate the lifetime prevalence of infectious, inflammatory, and autoimmune disorders in a multisite study of probands with childhood-onset obsessive compulsive disorder (OCD) and their first-degree relatives. Methods: Medical questionnaires were completed by 1401 probands and 1045 first-degree relatives in the OCD Collaborative Genetics Association Study. Lifetime prevalence of immune-related diseases was compared with the highest available population estimate and reported as a point estimate with 95% adjusted Wald interval. Worst-episode OCD severity and symptom dimensions were assessed with the Yale-Brown Obsessive Compulsive Scale (YBOCS) and Symptom Checklist (YBOCS-CL). Results: Probands reported higher-than-expected prevalence of scarlet fever (4.0 [3.1-5.2]% vs. 1.0%-2.0%, z = 1.491, p < 0.001, n = 1389), encephalitis or meningitis (1.4 [0.9-2.1]% vs. 0.1%-0.4%, z = 5.913, p < 0.001, n = 1393), rheumatoid arthritis (1.1 [0.6-2.0]% vs. 0.2%-0.4%, z = 3.416, p < 0.001, n = 949) and rheumatic fever (0.6 [0.3-1.2]% vs. 0.1%-0.2%, z = 3.338, p < 0.001, n = 1390), but not systemic lupus erythematosus, diabetes, asthma, multiple sclerosis, psoriasis, or inflammatory bowel disease. First-degree relatives reported similarly elevated rates of scarlet fever, rheumatic fever, and encephalitis or meningitis independent of OCD status. There was no association between worst-episode severity and immune-related comorbidities, although probands reporting frequent ear or throat infections had increased severity of cleaning-/contamination-related symptoms (mean factor score 2.5 ± 0.9 vs. 2.3 ± 1.0, t = 3.183, p = 0.002, n = 822). Conclusion: These data suggest high rates of streptococcal-related and other immune-mediated diseases in patients with childhood-onset OCD and are consistent with epidemiological studies in adults noting familial clustering. Limitations include potential reporting bias and absence of a control group, underscoring the need for further prospective studies characterizing medical and psychiatric disease clusters and their interactions in children. Such studies may ultimately improve our understanding of OCD pathogenesis and aid in the development of adjunctive immune-modulating therapeutic strategies.

Depressive Symptoms Are Associated With Low Treatment Adherence in African American Individuals With Systemic Lupus Erythematosus

OBJECTIVE

African American (AA) people with systemic lupus erythematosus (SLE) are at high morbidity and mortality risk, and they often require multiple medications. Low medication adherence is a highly prevalent, multidimensional problem associated with poor outcomes in people with SLE. Depression, a predictor of low adherence in people with chronic conditions, has been described in over 35% of AAs with SLE. We hypothesized that depressive symptoms would be increasingly associated with low adherence in this population.

METHODS

Research subjects predominantly belong to the Georgians Organized Against Lupus cohort, a population-based cohort of predominantly AA individuals with SLE in the Atlanta metropolitan area. Medication adherence and severity of depressive symptoms were measured using validated self-reported tools: the 8-item Morisky Medication Adherence Scale and the 9-item Patient Health Questionnaire, respectively. We used univariate and multivariate logistic regression to examine the odds ratios of low medication adherence across individuals with increasing severity of depressive symptoms.

RESULTS

Among 632 AA SLE participants, 336 (54%) reported low medication adherence and 217 (34.6%) reported "moderate" or "severe" depressive symptoms. In univariate logistic regression, significant risk factors for low adherence were depressive symptoms, low self-efficacy, poor satisfaction with care, female sex, younger age, hurried patient-physician communication, poorer shared decision-making, less compassionate physician communication style, poor/fair health, and higher disease activity score. In multivariate regression, younger age, female sex, and more severe depressive symptoms were associated with low medication adherence.

CONCLUSIONS

This is the first study to examine factors associated with low medication adherence among a population-based cohort of AA individuals with SLE. Depression was a strong correlate of low medication adherence. Mental health interventions aiming to address and treat depression may increase medication adherence.

The Assessment of Anxiety and Depression and its Associated Factors in SLE

BACKGROUND

Depression and anxiety are common neuropsychiatric complaints in patients with Systemic Lupus Erythematosus (SLE). While numerous studies have been performed to investigate the prevalence, impact, and associated factors of depression and anxiety, current literature presents mixed results. In particular, the prevalence of anxiety and depression varies substantially between studies due to methodological limitations, and heterogeneity in defining anxiety and depression, patient selection, and metrics used. Moreover, there is a lack of studies evaluating the validity, reliability, and interpretability of commonly used screening tools for depression and anxiety in SLE patients.

RESULT AND CONCLUSION

Further investigations should aim to reach a consensus surrounding the role of controversial associated factors in depression and anxiety of SLE patients, while also focusing on the identification of novel factors that have not yet been highlighted in the literature.

Associations between resilience and sociodemographic factors and depressive symptoms in women with systemic lupus erythematosus

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.

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

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