Mental disorders in systemic lupus erythematosus: a cohort study

Psychosis as a manifestation in systemic lupus erythematosus: treatment and long-term results. Number of cases

We present a case series of 5 patients with psychosis associated with SLE according to the ACR 1999 criteria. It presented as an initial clinical manifestation, clinically they had visual and auditory hallucinations, all the patients were women, average age 25 years, the accompanying manifestations were mostly mucocutaneous, articular and renal. Two patients presented antiphospholipid syndromes. The remission induction treatment was based on pulses of steroids and cyclophosphamide with a complete response in 4/5 patients, maintenance was left with mycophenolic acid and azathioprine.

Possible roles of neuropeptide/transmitter and autoantibody modulation in emotional problems and aggression

The theoretical foundations of understanding psychiatric disorders are undergoing changes. Explaining behaviour and neuroendocrine cell communication leaning towards immunology represents a different approach compared to previous models for understanding complex central nervous system processes. One such approach is the study of immunoglobulins or autoantibodies, and their effect on peptide hormones in the neuro-endocrine system. In the present review, we provide an overview of the literature on neuropeptide/transmitter and autoantibody modulation in psychiatric disorders featuring emotional problems and aggression, including associated illness behaviour. Finally, we discuss the role of psycho-immunology as a growing field in the understanding of psychiatric disorders, and that modulation and regulation by IgG autoAbs represent a relatively new subcategory in psycho-immunology, where studies are currently being conducted.

Anxiety and Depression and Associated Risk Factors among Outpatients with Systemic Lupus Erythematosus: Eastern Province, Saudi Arabia

BACKGROUND

Although mood disorders are prevalent among systemic lupus erythematosus (SLE) patients, they are usually underrecognized. This study aimed to estimate the prevalence of anxiety and depression among Saudi SLE patients.

METHODS

This cross-sectional study was conducted among SLE patients from July 2022 to June 2023 in the Eastern Province of Saudi Arabia. A self-reported questionnaire was used to collect the data through validated tools including the Hamilton Anxiety Rating Scale-A and the Beck Depression Inventory score.

RESULTS

There were 133 females (91.7%) and 12 males (8.3%) included in this study. Based on the HAM-A score, 45.5% of participants had an anxiety disorder, and according to the BDI score, 46.2% had a depression disorder. Anxiety and depression were significantly associated with a longer duration of SLE, unemployment status, smoking, and the presence of comorbidities. Moreover, the present study found a significant association between depression and male gender.

CONCLUSION

This study found that Saudi SLE patients have a high prevalence of both anxiety and depression. Therefore, SLE patients should be screened for neuropsychiatric disorders during routine follow-ups and managed as early as possible.

Unveiling the Link Between Antiphospholipid Antibodies and Cognitive Dysfunction in the Almenara Lupus Cohort

OBJECTIVE

Cognitive dysfunction is a prevalent manifestation of systemic lupus erythematosus (SLE). There is evidence for the role of antiphospholipid (aPL) antibodies on its etiopathogenesis. Our objective was to identify the association between aPL antibodies and cognitive dysfunction in SLE patients.

METHODS

This cross-sectional study included 135 patients evaluated from March 2015 to October 2017 at one center. Cognitive deficit was measured using the NEUROPSI test. Disease activity and damage were ascertained using the SLEDAI-2K (SLE Disease Activity Index 2000) and the SDI (Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index), respectively; aPL antibodies were measured by enzyme-linked immunosorbent assay. The association between cognitive dysfunction and aPL antibodies was evaluated using univariable and multivariable linear regression models adjusted for age, sex, education, socioeconomic status, disease duration, SLEDAI-2K, SDI, mean current dose of prednisone, time of exposure to glucocorticoids, and drug use (immunosuppressants, hydroxychloroquine, aspirin, and warfarin).

RESULTS

One hundred thirty-one patients (97.1%) were women; their mean (SD) age was 46.6 (12.5) years; 59 patients (43.7%) had positivity for at least 1 aPL antibody. IgM anticardiolipin (aCL) was positive in 24.5%, IgG in 13.5%, IgM aβ2GP1 in 16.8%, IgG anti-β2 glycoprotein in 24.6%, and the lupus anticoagulant in 5.3%. Ninety patients (66.7%) had some cognitive dysfunction. In the univariable analysis, a significant correlation between the NEUROPSI score and IgM aCL antibodies was found (B = -20.87 [SE, 3.2]; p < 0.001), which remained significant in the multivariable model (B = -13.89 [SE, 3.14]; p < 0.001).

CONCLUSIONS

IgM aCL antibodies are associated with cognitive dysfunction in patients with SLE. Larger and longitudinal studies are needed to assess the impact of these findings.

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.

Undiagnosed Depression and Its Effects on Patients With Systemic Lupus Erythematosus

Introduction Different organs and organ systems are affected by a well-known chronic immune disorder called systemic lupus erythematosus (SLE). Besides the physical harm caused by this disorder, it affects the mental health of patients in a greater ratio by causing depression and anxiety. The objective of this study is to assess the prevalence of undiagnosed depression and its effects on patients with systemic lupus erythematosus. Material and methods This prospective cross-sectional study was carried out in the Rheumatology outpatient department of Fatima Memorial Hospital (FMH), Lahore, from November 2022 to February 2023. All study subjects had been given a prior diagnosis of SLE based on the 2012 Systemic Lupus International Collaborating Clinics (SLICC) criteria. Three sections comprised the survey form: section I asked questions about socio-demographic information (gender and age); section II assessed the degree of mental illness activity; and section III assessed the degree of SLE disease activity. The nine-item PHQ-9 (Patient Health Questionnaire 9) scale, which is used to diagnose severe depressive disorder, was utilized to measure depression. To compare categorical variables, we applied Fisher's exact tests and chi-square; for continuous variables, we utilized the student's t-test. The statistical analysis was conducted using SPSS software for Windows Version 21.0 (IBM Corp., Armonk, NY, USA), with a significance threshold of p-value <0.05. Results Mild, moderate, and severe depression were present in 20%, 37.5%, and 37.5% of the patients, respectively. Pearson correlation of disease severity was strongly positive with depression (R2=0.634, p=0.01). The correlation was statistically significant. Conclusion Our research indicates that depression is a real problem for SLE patients. There is a positive correlation between the activity of the disease and the intensity of depression.

Antipsychotics reduces mortality in patients with neuropsychiatric systemic lupus erythematosus: a retrospective study of psychiatric consultation cases

Objective

This study aimed to identify the presence of psychiatric comorbidities as well as investigate the relationship between psychiatric interventions for mental symptoms and mortality in patients with systemic lupus erythematosus (SLE).

Method

We retrospectively evaluated the records of 160 inpatients with SLE who required psychiatric consultation for further therapeutic intervention from 2013 to 2020 in a tertiary general hospital. We collected clinical data, including diagnoses, medications, and mortality rate. We compared clinical characteristics among the diagnosis groups and correlations between variables.

Results

A total of 138 (86.3%) patients met the diagnostic criteria for at least one mental disorder, with the most common being delirium (54.4%). The average Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K) score significantly differed among the diagnosis groups (p = 0.003). The mortality rate among patients with delirium was significantly higher than that in the other patient groups (x2 = 12.967, p = 0.024). SLEDAI-2K score was not significantly correlated with mortality (r = 0.123, p = 0.087). Antipsychotics use was associated with mortality (odds ratio 0.053, p = 0.021).

Conclusion

Antipsychotic use may decrease death risk for patients with NPSLE. Early psychiatric consultation is necessary for patients with SLE who have developed or have suspected psychiatric symptoms in order to establish a comprehensive intervention plan.

Anorexia Nervosa in Juvenile Systemic Lupus Erythematosus (SLE): A Causality Dilemma

Juvenile-onset systemic lupus erythematosus (jSLE) is an autoimmune disorder with multifaceted clinical findings in different organ systems. Neuropsychiatric manifestations affect more than half of SLE patients, and there is increasing evidence that anorexia nervosa (AN), a feeding and eating disorder (FED) characterized by significantly reduced energy intake, is among them. Herein, a review of the literature on the potential association between jSLE and AN was performed. Reported clinical cases were identified, and putative pathophysiological mechanisms were sought that could potentially explain the observed relationship between these two pathological entities. Four reports of isolated cases and a case series including seven patients were identified. In this limited patient pool, the diagnosis of AN preceded that of SLE in the majority of cases, whereas in all cases both entities were diagnosed within a time span of two years. Many explanations for the observed relationships have been proposed. AN has been associated with the stress of chronic disease diagnosis; on the other hand, the chronic inflammation associated with AN may contribute to the development/appearance of SLE. Adverse childhood experiences, concentrations of leptin, shared autoantibodies, and genetic traits appear to be important factors in this well-established interplay. In essence, it seems important to increase clinician awareness of the concomitant development of AN and SLE and invite further research on the subject.

A cross-sectional study on the association of anxiety and depression with the disease activity of systemic lupus erythematosus

BACKGROUND

Systemic Lupus Erythematosus (SLE) is an autoimmune disease that affects multiple systems and increases the risk of mental disorders such as depression and anxiety. We conducted an observational, single-center, cross-sectional study to investigate the relationship between depression, anxiety, and SLE disease activity.

METHODS

The Patient Health Questionnaire 9 (PHQ-9) was used to assess depression, and the 7-item Generalized Anxiety Disorders Scale was used to assess anxiety (GAD-7). Using the chi-square/exact Fisher's tests, socio-demographic data, clinical and other characteristics of SLE patients were compared between depression or anxiety and non-depression/non-anxiety groups. To identify optimal levels of Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) for predicting depression or anxiety, receiver-operator curves (ROC) were drawn.

RESULTS

Among the 325 patients involved in this study, patients with depression or anxiety had significantly higher SLE activity (p < 0.001), and more frequent musculoskeletal (p < 0.05) and neuropsychiatric symptoms (p < 0.05). Depression and anxiety are more common in the moderate-severe active group than in the inactive-mild active group (depression: OR 3.350, 95%CI 2.015, 5.570, p < 0.001; anxiety: OR 4.085, 95%CI 2.493, 6.692, p < 0.001). The optimal SLEDAI cutoff value of 8.5 predicted depression with a sensitivity of 50.5% and a specificity of 78.4% (AUC 0.660, p < 0.001) and anxiety with a sensitivity of 54.2% and a specificity of 78.4% (AUC 0.684, p < 0.001).

CONCLUSION

SLE disease activity is positively associated with the severity of depression and anxiety. Those patients whose SLEDAI scores are greater than 8.5 are more likely to suffer from mental disorders which require additional attention to them.

Persistence of Depression and Anxiety despite Short-Term Disease Activity Improvement in Patients with Systemic Lupus Erythematosus: A Single-Centre, Prospective Study

Mental disorders such as anxiety and depression are prevalent in systemic lupus erythematosus (SLE) patients, yet their association with the underlying disease activity remains uncertain and has been mostly evaluated at a cross-sectional level. To examine longitudinal trends in anxiety, depression, and lupus activity, a prospective observational study was performed on 40 adult SLE outpatients with active disease (SLE Disease Activity Index [SLEDAI]-2K ≥ 3 [excluding serology]) who received standard-of-care. Anxiety and depression were determined at baseline and 6 months by the Hospital Anxiety and Depression Scale. Treatment adherence was assessed with the Morisky Medication Adherence Scale-4. Increased anxiety (median [interquartile range] HADS-A: 11.0 [7.8]) and depression (HADS-D: 8.0 [4.8]) were found at inclusion, which remained stable and non-improving during follow-up (difference: 0.0 [4.8] and −0.5 [4.0], respectively) despite reduced SLEDAI-2K by 2.0 (4.0) (p < 0.001). Among possible baseline predictors, paid employment—but not disease activity—correlated with reduced HADS-A and HADS-D with corresponding standardized beta-coefficients of −0.35 (p = 0.017) and −0.27 (p = 0.093). Higher anxiety and depression correlated with lower treatment adherence (p = 0.041 and p = 0.088, respectively). These results indicate a high-mental disease burden in active SLE that persists despite disease control and emphasize the need to consider socioeconomic factors as part of comprehensive patient assessment.

Hospitalisation for systemic lupus erythematosus associates with an increased risk of mortality in Australian patients from 1980 to 2014: a longitudinal, population-level, data linkage, cohort study

Objective

Mortality rates for patients with SLE have not been reported in Australia. This study determined the association between a hospitalisation for SLE with mortality.

Methods

Population-level cohort study of patients with SLE (n=2112; 25 710 person-years) and general population comparators (controls) (n=21, 120; 280 637 person-years) identified from hospital records contained within the WA Rheumatic Disease Epidemiological Registry from 1980 to 2013. SLE was identified by ICD-9-CM: 695.4, 710.0, ICD-10-AM: L93.0, M32.0. Controls were nearest matched (10:1) for age, sex, Aboriginality and temporality. Using longitudinal linked health data, we assessed the association between a hospitalisation for SLE mortality and mortality with univariate and multivariate Cox proportional hazards and competing risks regression models.

Results

At timezero, patients with SLE were similar in age (43.96 years), with higher representation of females (85.1% vs 83.4%, p=0.038), Aboriginal Australians (7.8% vs 6.0%) and smokers (20.5% vs 13.2%). Before study entry, patients with SLE (mean lookback 9 years) had higher comorbidity accrual (Charlson Comorbidity Index ≥1 item (42.0% vs 20.5%)), especially cardiovascular disease (CVD) (44.7% vs 21.0%) and nephritis (16.4% vs 0.5%), all p<0.001. During follow-up (mean 12.5 years), 548 (26.0%) patients with SLE and 2450 (11.6%) comparators died. A hospitalisation for SLE increased the unadjusted (HR 2.42, 95% CI 2.20 to 2.65) and multivariate-adjusted risk of mortality (aHR 2.03, 95% CI 1.84 to 2.23), which reduced from 1980 to 1999 (aHR 1.42) to 2000–2014 (aHR 1.27). Females (aHR 2.11), Aboriginal Australians (aHR 3.32), socioeconomically disadvantaged (aHR 2.49), and those <40 years old (aHR 7.46) were most vulnerable. At death, patients with SLE had a higher burden of infection (aHR 4.38), CVD (aHR 2.09) and renal disease (aHR 3.43), all p<0.001.

Conclusions

A hospitalisation for SLE associated with an increased risk of mortality over the 1980–2014 period compared with the general population. The risk was especially high in younger (<40 years old), socioeconomically disadvantaged and Aboriginal Australians.

Inflamed brain: Targeting immune changes and inflammation for treatment of depression

Although there are a number of clinically effective treatments for depression, many patients exhibit treatment resistance. Recent clinical and preclinical studies reveal that peripheral and brain immune changes and inflammation are involved in the pathophysiology of depression. This 'Inflamed Brain' research provides critical clues for understanding of disease pathophysiology and many candidate molecules that are potentially useful for identifying novel drug targets for the treatment of depression. In this review, we will present clinical evidence on the role of inflammation in the pathophysiology of depression. We will also summarize current clinical trials which test drugs targeting inflammation for the treatment of patients with depression. Furthermore, we will briefly provide preclinical evidence demonstrating altered immune system function and inflammation in stress-induced animal models and will discuss the future potential of inflammation-related drug targets. Collectively, inflammatory signatures identified in clinical and preclinical studies may allow us to stratify depressive patients based on biotypes, contributing to the development of novel mechanism-based interventions that target specific patient populations.

Neuroinflammation: An Integrating Overview of Reactive-Neuroimmune Cell Interactions in Health and Disease

The concept of central nervous system (CNS) inflammation has evolved over the last decades. Neuroinflammation is the response of reactive CNS components to altered homeostasis, regardless of the cause to be endogenous or exogenous. Neurological diseases, whether traumatic, neoplastic, ischemic, metabolic, toxic, infectious, autoimmune, developmental, or degenerative, involve direct and indirect immune-related neuroinflammation. Brain infiltrates of the innate and adaptive immune system cells appear in response to an infective or otherwise noxious agent and produce inflammatory mediators. Mediators of inflammation include local and recruited cells and signals. Processes derived from extrinsic and intrinsic CNS diseases also elicit the CNS inflammatory response. A deeper understanding of immune-related inflammation in health and disease is necessary to find potential therapeutic targets for preventing or reducing CNS damage. This review is aimed at discussing the innate and adaptive immune system functions and their roles in regulating brain cell responses in disease and homeostasis maintenance.

Acute psychosis as the presenting manifestation of lupus

Neuropsychiatric manifestations like cognitive dysfunction, peripheral neuropathy, stroke headache, seizures in systemic lupus erythematosus (SLE) are quite common. However, psychosis as the sole presenting manifestation of SLE is rarely encountered clinically. If lupus is not kept as differential among patients with acute psychosis, delay in diagnosis and subsequent mismanagement are likely to happen. Here, we present a case of a young female presenting with acute psychosis as the predominant symptom and was further evaluated and diagnosed as a case of SLE. The patient was managed with immunosuppressive agents and carried an excellent outcome.

High Comorbidity Burden in Patients with SLE: Data from the Community-Based Lupus Registry of Crete

Comorbidities and multimorbidity, often complicating the disease course of patients with chronic inflammatory rheumatic diseases, may be influenced by disease-intrinsic and extrinsic determinants including regional and social factors. We analyzed the frequency and co-segregation of self-reported comorbid diseases in a community-based Mediterranean registry of patients (n = 399) with systemic lupus erythematosus (SLE). Predictors for multimorbidity were identified by multivariable logistic regression, strongly-associated pairs of comorbidities by the Cramer's V-statistic, and comorbidities clusters by hierarchical agglomerative clustering. Among the most prevalent comorbidities were thyroid (45.6%) and metabolic disorders (hypertension: 24.6%, dyslipidemia: 33.3%, obesity: 35.3%), followed by osteoporosis (22.3%), cardiovascular (20.8%), and allergic (20.6%) disorders. Mental comorbidities were also common, particularly depression (26.7%) and generalized anxiety disorder (10.7%). Notably, 51.0% of patients had ≥3 physical and 33.1% had ≥2 mental comorbidities, with a large fraction (n = 86) displaying multimorbidity from both domains. Sociodemographic (education level, marital status) and clinical (disease severity, neurological involvement) were independently associated with physical or mental comorbidity. Patients were grouped into five distinct clusters of variably prevalent comorbid diseases from different organs and domains, which correlated with SLE severity patterns. Conclusively, our results suggest a high multimorbidity burden in patients with SLE at the community, advocating for integrated care to optimize outcomes.

Case Report: Psychopathological Syndromes in the Course of Lupus Erythematosus and the Co-occurrence of Lupus Erythematous With Mental Disorders

Background: Systemic lupus erythematosus (SLE) is an autoimmune disease that leads to a chronic inflammatory process in tissues and organs. The neuropsychiatric systemic lupus erythematosus (NPSLE) is a set of neuropsychiatric symptoms that derive from the central and peripheral nervous system and are observed in the course of SLE. Case Report and Final Diagnostic and Therapeutic Results: A diagnostic and therapeutic process in a patient with the signs and symptoms of SLE and bipolar disorder (BD) has been described. Bipolar disorder has been diagnosed as a primary disorder while SLE as a comorbid disease. Discussion: Common immunological mechanisms in BD and SLE are the reason for difficulties in diagnosing BD with co-occurring SLE. It should be determined whether BD is a primary disorder or a secondary component of a clinical picture of SLE (NPSLE) or whether mood and/or psychotic disorders are the result of steroid therapy in the course of SLE (steroid-induced mood and psychotic disorders, SIMPD). Conclusion and the Patient's Perspective: The presented case report is a unique description of a patient with a primary diagnosis of BD with comorbid SLE.