Mood and anxiety disorders in systemic sclerosis patients

Emotional intelligence: a novel predictor of quality of life in patients with systemic sclerosis

Systemic sclerosis (SSc), a chronic systemic autoimmune disease, affects skin and internal organs compromising organ function and leading to significant morbidity and poor health-related quality of life (HrQoL). This cross-sectional study investigated whether HrQoL is influenced by trait emotional intelligence (TEI). Sixty patients with SSc (Female: 86.67%) completed the socio-demographic characteristics form, TEI Questionnaire Short-Form (TEIQue-SF), and Short-Form Health Survey (SF-36). Sixty healthy controls were also completed the TEIQue-SF. A series of multiple linear regression analyses with correlation matrix was used to analyze SF-36 domains as dependent variables with TEI domains (well-being, self-control, emotionality, sociability) as independent variables. The average age of participants was 57.3 ± 12.9 years with a mean disease duration of 7.7 ± 6.7 years. Patients differed from controls in the sociability domain of TEI. TEI global was found to affect the physical and mental component summaries (p < .001), and all 8 dimensions of the HrQoL (p < .001). Age, disease duration, and gastrointestinal manifestations were negatively associated with various components of SF-36. TEI was positively associated with all dimensions of HrQoL. Understanding the relationship between TEI and HrQoL dimensions is important for the support and empowerment of SSc patients, as well as the establishment and implementation of appropriate psychotherapeutic interventions.

The association of resilience and positive mental health in systemic sclerosis: A Scleroderma Patient-centered Intervention Network (SPIN) cohort cross-sectional study

OBJECTIVE

A previous study using Scleroderma Patient-centered Intervention Network (SPIN) Cohort data identified five classes of people with systemic sclerosis (also known as scleroderma) based on patient-reported somatic (fatigue, pain, sleep) and mental health (anxiety, depression) symptoms and compared indicators of disease severity between classes. Across four classes ("low", "normal", "high", "very high"), there were progressively worse somatic and mental health outcomes and greater disease severity. The fifth ("high/low") class, however, was characterized by high disease severity, fatigue, pain, and sleep but low mental health symptoms. We evaluated resilience across classes and compared resilience between classes.

METHODS

Cross-sectional study. SPIN Cohort participants completed the 10-item Connor-Davidson-Resilience Scale (CD-RISC) and PROMIS v2.0 domains between August 2022 and January 2023. We used latent profile modeling to identify five classes as in the previous study and multiple linear regression to compare resilience levels across classes, controlling for sociodemographic and disease variables.

RESULTS

Mean CD-RISC score (N = 1054 participants) was 27.7 (standard deviation = 7.3). Resilience decreased progressively across "low" to "normal" to "high" to "very high" classes (mean 4.7 points per step). Based on multiple regression, the "high/low" class exhibited higher resilience scores than the "high" class (6.0 points, 95% confidence interval [CI] 4.9 to 7.1 points; standardized mean difference = 0.83, 95% CI 0.67 to 0.98).

CONCLUSIONS

People with worse disease severity and patient-reported outcomes reported substantially lower resilience, except a class of people with high disease severity, fatigue, pain, and sleep disturbance but positive mental health and high resilience.

Perceived Cognitive Function in People With Systemic Sclerosis: Associations With Symptoms and Daily Life Functioning

OBJECTIVE

Perceived cognitive dysfunction is prevalent in patients with systemic sclerosis (SSc) but not well understood. This study aimed to examine potential factors associated with perceived cognitive function and to investigate the contributions of perceived cognitive function and symptoms to functional measures.

METHODS

A cross-sectional survey was conducted among patients with SSc (n = 106). Participants were mainly female (84%) and White (82%). Perceived cognitive function, symptoms, and functional measures were assessed with Patient-Reported Outcomes Measurement Information System (PROMIS) measures. A multivariable regression was conducted to identify factors associated with perceived cognition. Hierarchical linear regressions examined the unique contributions of perceived cognitive function and symptoms to social participation and physical function.

RESULTS

Fifty-nine (56%) patients with SSc perceived mild-to-severe cognitive dysfunction. Being on work disability and having more fatigue were both significantly associated with perceived cognitive dysfunction. When examining the contributions of cognition and other symptoms to functional measures, self-reported cognition became nonsignificant after fatigue and pain were entered into the regression model.

CONCLUSION

Being on work disability and having more fatigue were most highly associated with perceived cognitive dysfunction in patients with SSc. Unlike fatigue and pain, perceived cognitive function was not independently associated with functional measures. Nonetheless, future research should disentangle cognitive function and other symptoms, as well as their effects on daily activities, in SSc.

[Gastrointestinal tract involvement in systemic sclerosis]

Gastrointestinal tract involvement in systemic sclerosis concerns more than 90% of patients but is of heterogeneous clinical expression. It can involve the entire intestinal tract and be responsible for multifactorial malnutrition, which is frequent in this disease. It is a major source of deterioration in the quality of life and can even be life-threatening. Management is complex and multidisciplinary, ranging from simple hygienic and dietary measures, to specialized endoscopic or surgical interventional procedures, also including medical treatments, particularly proton pump inhibitors and prokinetics, with potential side effects. Ongoing research for new diagnostic and therapeutic tools promises to improve the management and prognosis of these patients.

Results from a living systematic review of the prevalence of mood and anxiety disorders and factors associated with symptoms in systemic sclerosis

We aimed to synthesize evidence on (1) the prevalence of mood and anxiety disorders and (2) factors associated with symptoms in systemic sclerosis (SSc). We searched MEDLINE, CINAHL, EMBASE, Cochrane CENTRAL, and PsycINFO via an ongoing living systematic review with automated monthly searches. We identified 6 eligible studies through March 1, 2023. Based on 3 studies (N = 93 to 345), current or 30-day major depressive disorder prevalence was 4% (95% confidence interval [CI] 2%, 6%) in a sample of Canadian outpatients (N = 345), 18% (95% CI 12%, 27%) in a study of Indian outpatients (N = 93), 10% (95% CI 4%, 21%) for French patient conference attendees (N = 51), and 29% (95% CI 18%, 42%) for French inpatients (N = 49). Current or 30-day prevalence of any anxiety disorder was 49% (95% CI 36%, 62%) for French conference attendees and 51% (95% CI 38%, 64%) for French inpatients; current or 30-day prevalence of generalized anxiety disorder was 3% for Indian outpatients (95% CI 1%, 9%; N = 93). In 3 studies (N = 114 to 376) that examined factors associated with depressive symptoms, higher education and being married or living as married were associated with lower symptoms and pulmonary involvement, breathing problems, and tender joint counts with higher symptoms; age and disease severity markers were not associated. Only 1 study (N = 114) assessed factors associated with anxiety symptoms and found no statistically significant associations. Limitations included heterogeneous populations and assessment methods, small samples, and substantial risk of bias concerns. Mood and anxiety disorder prevalence appear high in SSc, but estimates vary, and existing studies have important limitations. Future research should assess mood and anxiety prevalence and factors associated with symptoms using large representative samples and validated classification and assessment methods.Review registration: PROSPERO (CRD 42021251339).

Mental Health Care Use and Associated Factors in Systemic Sclerosis: A Scleroderma Patient-Centered Intervention Network Cohort Study

Objective

Systemic sclerosis (SSc) has significant psychosocial implications. We aimed to evaluate the proportion of participants in a large international SSc cohort who used mental health services in a 3‐month period and to evaluate demographic, psychological, and disease‐specific factors associated with use.

Methods

Baseline data of participants enrolled in the Scleroderma Patient‐Centered Intervention Network Cohort were analyzed. We determined the proportion that used mental health services and the source of services in the 3 months prior to enrollment. Multivariable logistic regression was used to identify variables associated with service use.

Results

Of the 2319 participants included in the analysis, 417 (18%) used mental health services in the 3 months prior to enrollment. General practitioners were the most common mental health service providers (59%), followed by psychologists (25%) and psychiatrists (19%). In multivariable analysis, mental health service use was independently associated with higher education (odds ratio [OR] 1.07, 95% confidence interval [CI] 1.03‐1.11), smoking (OR 1.06, 95% CI 1.02‐1.11), being retired (OR 0.60, 95% CI 0.38‐0.93), having limited SSc (OR 1.39, 95% CI 1.02‐1.89), and having higher anxiety symptom scores (OR 1.04, 95% CI 1.03‐1.06) and lower self‐efficacy scores (OR 0.90, 95% CI 0.83‐0.97). Variables not significantly associated included age, race, disease manifestations, depression symptom scores, and body image distress.

Conclusion

About 18% of participants in a large international cohort received mental health services in a 3‐month period, of whom the majority received these services from a general practitioner.

Affective and anxiety disorders in patients with different rare chronic diseases: a systematic review and meta-analysis

We aimed to identify the prevalence of affective and anxiety disorders across different rare disease and identify correlates of psychopathology. We performed a systematic review and meta-analysis. We systematically searched Medline, PSYNDEX, PsycINFO for observational studies examining clinically diagnosed affective and/or anxiety disorders in adults with rare chronic diseases. Two researchers reviewed titles and abstracts independently and, for eligible studies, independently extracted data. The prevalence rates were pooled using a random intercept logistic regression model. We published a review protocol (http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42018106614CRD42018106614). We identified and screened 34 402 records for eligibility and considered 39 studies in the qualitative and 37 studies in the quantitative analysis, including N = 5951 patients with 24 different rare diseases. Heterogeneity between studies was large. Prevalence rates ranged widely between studies, with pooled prevalence estimates of 13.1% (95% CI 9.6-17.7%; I2 = 87%, p < 0.001) for current and 39.3% (95% CI 31.7-47.4%; I2 = 84%, p < 0.001) for lifetime major depressive disorder, 21.2% (95% CI 15.4-28.6%; I2 = 90%, p < 0.001) for current and 46.1% (95% CI 35.8-56.8%; I2 = 90%, p < 0.001) for lifetime affective disorders, and 39.6% (95% CI 25.5-55.6%; I2 = 96%, p < 0.001) for current and 44.2% (95% CI 27.0-62.9%; I2 = 94%, p < 0.001) for lifetime anxiety disorders. Sensitivity analyses excluding studies of low quality revealed nearly the same results. We conducted the first systematic review examining affective and anxiety disorders in adults with different rare diseases and found high prevalence rates. Supporting patients in disease adjustment can be crucial for their overall health and well-being.

Effects of illness perceptions on health-related quality of life in patients with rheumatoid arthritis in China

Objectives

For patients with rheumatoid arthritis (RA) in China, little is known of how their illness perceptions affect their health-related quality of life (HRQoL). The present study investigated associations between specific illness perceptions due to RA and HRQoL features.

Methods

For 191 patients with RA, illness perceptions were measured using the Brief Illness Perceptions Questionnaire (BIPQ) comprising 8 domains. HRQoL was determined with the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). Multivariate linear regression analyses were performed.

Results

The overall BIPQ of patients with RA was 49.09 ± 11.06. The highest and lowest scores were for concern (9.15 ± 1.81) and personal control (4.30 ± 2.52), respectively. Multivariate stepwise regression analyses showed that the overall BIPQ was significantly negatively associated with each HRQoL feature, and HRQoL total score (β = − 0.343, P < 0.001, 95% CI − 7.080 to − 4.077). Positive associations between BIPQ features and HRQoL included personal control (β = 0.119, P = 0.004, 95% CI 2.857–14.194) and treatment control (β = 0.084, P = 0.029, 95% CI 0.640–12.391). Negative associations with HRQoL were identity (β = − 0.105, P = 0.034, 95% CI − 13.159 to − 0.430) and emotional response (β = − 0.207, P < 0.001, 95% CI − 18.334 to − 6.811).

Conclusions

Patients with RA in China perceive their illness in ways that affect their HRQoL. These results suggest that strategies that target these perceptions may improve the quality of life of these patients.

The PREdictor of MAlnutrition in Systemic Sclerosis (PREMASS) Score: A Combined Index to Predict 12 Months Onset of Malnutrition in Systemic Sclerosis

Objective: Malnutrition is a severe complication in Systemic Sclerosis (SSc) and it is associated with significant mortality. Notwithstanding, there is no defined screening or clinical pathway for patients, which is hampering effective management and limiting the opportunity for early intervention. Here we aim to identify a combined index predictive of malnutrition at 12 months using clinical data and specific serum adipokines. Methods: This was an international, multicentre observational study involving 159 SSc patients in two independent discovery (n = 98) and validation (n = 61) cohorts. Besides routine clinical and serum data at baseline and 12 months, Malnutrition Universal Screening Tool (MUST) score and serum concentration of leptin and adiponectin were measured for each participant at baseline. The endpoint of malnutrition was defined according to European Society of Clinical Nutrition and Metabolism (ESPEN) recommendation. Significant parameters from univariate analysis were tested in logistic regression analysis to identify the predictive index of malnutrition in the derivation cohort. Results: The onset of malnutrition at 12 months correlated with adiponectin, leptin and their ratio (A/L), MUST, clinical subset, disease duration, Scl70 and Forced Vital Capaciy (FVC). Logistic regression analysis defined the formula: -2.13 + (A/L*0.45) + (Scl70*0.28) as the best PREdictor of MAlnutrition in SSc (PREMASS) (AUC = 0.96; 95% CI 0.93, 0.99). PREMASS < -1.46 had a positive predictive value (PPV) > 62% and negative predictive value (NPV) > 97% for malnutrition at 12 months. Conclusion: PREMASS is a feasible index which has shown very good performance in two independent cohorts for predicting malnutrition at 12 months in SSc. The implementation of PREMASS could aid both in clinical management and clinical trial stratification/enrichment to target malnutrition in SSc.

Exploring the Evidence Implicating the Renin-Angiotensin System (RAS) in the Physiopathology of Mood Disorders

Mood disorders include Major Depressive Disorder (MDD), Bipolar Disorder (BD) and variations of both. Mood disorders has a public health significance with high comorbidity, suicidal mortality and economic burden on the health system. Research related to mood disorders has evolved over the years to relate it with systemic conditions. The Renin Angiotensin System (RAS) has been noticed to play major physiological roles beyond renal and cardiovascular systems. Recent studies have linked RAS not only with neuro-immunological processes, but also with psychiatric conditions like mood and anxiety disorders. In this comprehensive review, we integrated basic and clinical studies showing the associations between RAS and mood disorders. Animal studies on mood disorders models - either depression or mania - were focused on the reversal of behavioral and/or cognitive symptoms through the inhibition of RAS components like the Angiotensin- Converting Enzyme (ACE), Angiotensin II Type 1 receptor (AT1) or Mas receptors. ACE polymorphisms, namely insertion-deletion (I/D), were linked to mood disorders and suicidal behavior. Hypertension was associated with neurocognitive deficits in mood disorders, which reversed with RAS inhibition. Low levels of RAS components (renin activity or aldosterone) and mood symptoms improvement with ACE inhibitors or AT1 blockers were also observed in mood disorders. Overall, this review reiterates the strong and under-researched connection between RAS and mood disorders.

Positive Psychological Factors Are Associated With Better Spiritual Well-Being and Lower Distress in Individuals With Skin Diseases

In this study we examined whether aspects of positive functioning [reappraisal, sense of coherence (SOC), and positivity] were associated with spiritual well-being and psychological distress after controlling for negative functioning (skin-related symptoms, type of disease, and expressive suppression) in individuals with skin diseases. We also examined whether negative functioning aspects were linked to spiritual well-being and distress when controlling for aspects of positive functioning. The study used a cross-sectional design with a sample of 192 individuals with psoriasis and systemic sclerosis (SSc) (M age = 51.6 years, SD = 16.5). Two hierarchical multiple regressions were conducted to determine whether spiritual well-being and psychological distress were accounted for by skin-related symptoms, type of disease, emotion regulation strategies, SOC, and positivity. Positivity was the most important contributor to better spiritual well-being, followed by both the comprehensibility/manageability and meaningfulness SOC subscales, after controlling for the other variables. High skin-related symptoms and expressive suppression were associated with lower psychological distress, whereas high SOC and reappraisal correlated with higher psychological distress. The findings of this study pave the way for further research on how SOC and positivity may reduce the effects of both skin-related symptoms and emotion dysregulation and facilitate spiritual well-being of individuals with skin diseases. Interventions aimed to enhance inner resources of these individuals and help them to find a meaning in their experience of skin disease might reduce psychological distress and improve spiritual well-being. Our findings suggest that healthcare professionals should consider positive functioning aspects in future interventions for individuals with skin diseases.

Cosmetic treatment in patients with autoimmune connective tissue diseases: Best practices for patients with morphea/systemic sclerosis

Morphea and systemic sclerosis are inflammatory, sclerosing disorders. Morphea primarily affects the dermis and subcutaneous fat, while systemic sclerosis typically involves the skin and internal organs. Functional impairment and cosmetic disfigurement are common in both diseases. Treatment options to mitigate disease progression remain limited. Both functional impairment and cosmetic deficits negatively impact quality of life and psychological well-being in this patient population. While the number of cosmetic procedures performed in the United States continues to rise each year, limited data exist regarding best practices for correcting aesthetic deficits caused by autoimmune conditions. There is scarce information to guide safety decisions regarding laser parameters, soft tissue augmentation, treatment intervals, and the concurrent use of immune-modifying or immune-suppressing medications. Given the fears of disease reactivation and exacerbation from postprocedural inflammation along with limited data, it is difficult for clinicians to provide evidence-based cosmetic treatment with realistic expectations with regard to short- and long-term outcomes. In the first article in this continuing medical education series, we attempt to address this practice gap.

Malnutrition, associated clinical factors, and depression in systemic sclerosis: a cross-sectional study

INTRODUCTION

The aim of this study was to evaluate the associations between malnutrition and the clinical features of the disease and depression in patients with systemic sclerosis (SSc).

METHOD

Patients with SSc who were followed up in our clinic were enrolled in the study. Malnutrition risk was assessed using the Malnutrition Universal Screening Tool (MUST). Skin involvement was assessed using the modified Rodnan skin score (mRSS) and interincisal distance (ID) measurements were used to assess the maximal mouth opening capacity. The Beck Depression Inventory (BDI) was used for measuring the severity of depression.

RESULTS

Ninety-eight patients with SSc (84.7% women; mean age 52.67 ± 11.26 years) were included in the study. According to the MUST scores, 61.2%, 15.3%, and 23.5% of patients had low, medium, and high risk for malnutrition, respectively. The mRSS was significantly higher in the group with high malnutrition risk compared with low-risk group (p = 0.014). Malnutrition risk was associated with interstitial lung disease and bowel involvement (p = 0.044 and p = 0.021, respectively). Interincisal distance was lower in the group with high malnutrition risk compared with the low-risk group (p = 0.003). Malnutrition risk was higher in patients who had mild-to-severe depressive symptoms than in those without (p = 0.012). Interincisal distance and bowel involvement were the most relevant factors for malnutrition.

CONCLUSIONS

The risk of malnutrition is increased in patients with SSc. In our study, microstomia and bowel involvement were the most relevantly associated factors with malnutrition.

KEY POINTS

• The risk of malnutrition is increased in patients with systemic sclerosis (SSc). • Microstomia and bowel involvement are found to be the most important factors associated with malnutrition. • Depressive symptoms are seen frequently among patients with SSc, and depression seems to be one of the etiologic factors or the result of malnourishment in SSc. • Assessment of nutritional status and the presence of depression should be a part of routine clinical visits of patients with SSc.

Anxiety, Depression, and Obsessive-compulsive Disorder in a Recently Diagnosed Case of Systemic Sclerosis

Systemic sclerosis is an autoimmune condition that frequently affects women. It is a progressive, debilitating disease that has widespread manifestations, targeting different organs of the body with potentially fatal consequences due to lung and kidney involvement. Women with this disease mostly present with Raynaud’s phenomenon along with symptoms of gastro-esophageal reflux disease (GERD). Just like any chronic debilitating condition, patients with systemic sclerosis often suffer from mental health issues that can further worsen their condition, significantly affecting their quality of life. Further research regarding the effects and severity of the disease should be encouraged for a better understanding of the illness, its diagnosis, and treatment. We present a rare case of a 55-year-old woman who presented with complaints of a major depressive episode. She was diagnosed with systemic sclerosis last year and has a history of generalized anxiety disorder. She was prescribed Mirtazapine, an antidepressant. On her follow-up after one month, she started complaining of obsessive ruminations that were causing her significant distress. She was prescribed an add-on therapy with a selective serotonin reuptake inhibitor (SSRI) antidepressant with the emphasis being placed on cognitive behavioral therapy (CBT). She reported an improvement in her obsessive symptoms as well as depression after two months.

Shortening patient-reported outcome measures through optimal test assembly: application to the Social Appearance Anxiety Scale in the Scleroderma Patient-centered Intervention Network Cohort

OBJECTIVES

The Social Appearance Anxiety Scale (SAAS) is a 16-item measure that assesses social anxiety in situations where appearance is evaluated. The objective was to use optimal test assembly (OTA) methods to develop and validate a short-form SAAS based on objective and reproducible criteria.

DESIGN

This study was a cross-sectional analysis of baseline data from adults enrolled in the Scleroderma Patient-centered Intervention Network (SPIN) Cohort.

SETTING

Adults in the SPIN Cohort in the present study were enrolled at 28 centres in Canada, the USA and the UK.

PARTICIPANTS

The SAAS was administered to 926 adults with scleroderma.

PRIMARY AND SECONDARY MEASURES

The SAAS, Brief Fear of Negative Evaluation II (BFNE II), Brief Satisfaction with Appearance Scale (Brief-SWAP), Patient Health Questionnaire-8 (PHQ8) and Social Interaction Anxiety Scale-6 (SIAS-6) were collected, as well as demographic characteristics.

RESULTS

OTA methods identified a maximally informative shortened version for each possible form length between 1 and 15 items. The final shortened version was selected based on prespecified criteria for reliability, concurrent validity and statistically equivalent convergent validity with the BFNE II scale. A five-item short version was selected (SAAS-5). The SAAS-5 had a Cronbach's α of 0.95 and had high concurrent validity with the full-length form (r=0.97). The correlation of the SAAS-5 with the BFNE II was 0.66, which was statistically equivalent to that of the full-length form. Furthermore, the correlation of the SAAS-5 with the two subscales of the Brief-SWAP, and the SIAS-6, were statistically equivalent to that of the full-length form.

CONCLUSIONS

OTA was an efficient method for shortening the full-length SAAS to create the SAAS-5.

Prevalence, Risk Factors and Assessment of Depressive Symptoms in Patients With Systemic Sclerosis

Objectives

This study aims to evaluate the prevalence of depressive symptoms among systemic sclerosis (SSc) patients using the Major Depression Inventory (MDI), identify possible risk factors, and analyze the current standard of care to raise awareness and improve clinical care for SSc patients.

Patients and methods

The study included 94 SSc patients (12 males, 82 females; mean age 58.3±13.6 years; range, 28 to 83 years) who completed the MDI, Short Form 36 Health Survey, Scleroderma Health Assessment Questionnaire, Brief Fatigue Inventory and Physical Activity Questionnaire. Clinical parameters were assessed according to standardized procedures. Discharge letters were analyzed for evaluation of depressive symptoms.

Results

The prevalence of depressive symptoms was 22.3%. It correlated with female sex (p=0.047), underweight (p=0.002), fatigue (p<0.001), decreased quality of life (p<0.001) and less physical activity (p=0.048). The latter three were confirmed as independent risk factors in a multivariable regression analysis. The analysis of the current standard of care revealed no assessment of depressive symptoms in the majority of patients (89.4%), including 19 with depressive symptoms according to the MDI score.

Conclusion

This study confirms the high prevalence of depressive symptoms in SSc patients. There is an unmet need of regular assessment of mental health during SSc consultations. Fatigue, decreased quality of life and reduced physical activity were ascertained as independent risk factors, while special attention should also be paid to weight loss and underweight.

Cosmetic camouflage improves quality of life among patients with skin disfigurement: A systematic review

This study systematically reviewed the impact of cosmetic camouflage use on different psychosocial outcomes in patients with disfiguring skin disorders. Electronic databases and reference lists were searched in February 2018 for studies reporting the impact of cosmetic camouflage on different quality of life (QoL) outcomes. Eighteen studies met the inclusion criteria: six randomized controlled trials, two quasi-experimental studies, nine single group 'before and after' interventions, and one comparative study with single post-intervention measurement. Quality appraisal of included studies was undertaken using the Joanna Briggs critical appraisal tools. While the studies varied in design, those included in this review indicated significant improvement in QoL after the use of cosmetic camouflage. The mean reduction in Dermatological Life Quality Index scores ranged from 1.4 to 6.4 signifying improvement in QoL of participants after treatment with cosmetic camouflage. Cosmetic camouflage can be an effective therapy in improving QoL among patients with skin disfigurement.

Resilience in women with autoimmune rheumatic diseases

OBJECTIVE

To evaluate the relationship between resilience and clinical outcomes in patients with autoimmune rheumatic diseases.

METHODS

Focus groups, individual interviews, and chart reviews were done to collect data on 188 women with autoimmune rheumatic diseases, namely rheumatoid arthritis (n=51), systemic lupus erythematosus (n=70), systemic sclerosis (n=35), and Sjögren's syndrome (n=32). Demographic, clinical, and laboratory variables were assessed including disease activity by patient reported outcomes. Resilience was evaluated by using the Brief Resilience Scale. Bivariate, multiple linear regression, and classification and regression trees were used to analyse data.

RESULTS

Resilience was influenced by age, duration of disease, and socioeconomic status. Lower resilience scores were observed in younger patients (<48years) with systemic lupus erythematosus, rheumatoid arthritis, and systemic sclerosis who had low socioeconomic status, whereas older patients (>50years) had higher resilience scores regardless of socioeconomic status. There was no influence of disease activity on resilience. A particular behaviour was observed in systemic sclerosis in which patients with high socioeconomic status and regular physical activity had higher resilience scores.

CONCLUSION

Resilience in patients with autoimmune rheumatic diseases is a continuum process influenced by age and socioeconomic status. The ways in which these variables along with exercise influence resilience deserve further investigation.

The prevalence of depression in general hospital inpatients: a systematic review and meta-analysis of interview-based studies

BACKGROUND

Comorbid depression in the medically ill is clinically important. Admission to a general hospital offers an opportunity to identify and initiate treatment for depression. However, we first need to know how common depression is in general hospital inpatients. We aimed to address this question by systematically reviewing the relevant literature.

METHODS

We reviewed published prevalence studies in any language which had used diagnostic interviews of general hospital inpatients and met basic methodological quality criteria. We focussed on interview-based studies in order to estimate the proportion of patients with a diagnosis of depressive illness.

RESULTS

Of 158 relevant articles, 65 (41%) describing 60 separate studies met our inclusion criteria. The 31 studies that focussed on general medical and surgical inpatients reported prevalence estimates ranging from 5% to 34%. There was substantial, highly statistically significant, heterogeneity between studies which was not materially explained by the covariates we were able to consider. The average of the reported prevalences was 12% (95% CI 10-15), with a 95% prediction interval of 4-32%. The remaining 29 studies, of a variety of specific clinical populations, are described.

CONCLUSIONS

The available evidence suggests a likely prevalence high enough to make it worthwhile screening hospital inpatients for depression and initiating treatment where appropriate. Further, higher quality, research is needed to clarify the prevalence of depression in specific settings and to further explore the reasons for the observed heterogeneity in estimates.

Gastrointestinal Manifestations of Systemic Sclerosis

Systemic sclerosis (SSc) is a rare autoimmune disease characterized by fibroproliferative alterations of the microvasculature leading to fibrosis and loss of function of the skin and internal organs. Gastrointestinal manifestations of SSc are the most commonly encountered complications of the disease affecting nearly 90% of the SSc population. Among these complications, the esophagus and the anorectum are the most commonly affected. However, this devastating disorder does not spare any part of the gastrointestinal tract (GIT), and includes the oral cavity, esophagus, stomach, small and large bowels as well as the liver and pancreas. In this review, we present the current understanding of the pathophysiologic mechanisms of SSc including vasculopathy, endothelial to mesenchymal transformation as well as the autoimmune pathogenetic pathways. We also discuss the clinical presentation and diagnosis of each part of the GIT affected by SSc. Finally, we highlight the latest developments in the management of this disease, addressing the severe malnutrition that affects this vulnerable patient population and ways to assess and improve the nutritional status of the patients.

Prospective associations between illness perceptions and health outcomes in patients with systemic sclerosis and systemic lupus erythematosus: a cross-lagged analysis

Objective

Perceptions of patients with SLE and SSc are strongly associated with physical and psychological outcomes. This interplay is not yet fully understood. Therefore, the aim of this study was to explore the prospective associations between illness perceptions and depressive symptoms, anxiety, perceived health status and disease activity in SLE and SSc patients.

Methods

Patients with SLE and SSc from a single-centre university hospital participated in a longitudinal study spanning 1 year. At both time points, participants completed the revised Illness Perception Questionnaire; Hospital Anxiety and Depression Scale for measuring depressive symptoms and anxiety; The EuroQol five-dimensions with 5 response levels for perceived health status; and disease activity was recorded. The directionality of the associations was investigated using cross-lagged path analysis.

Results

A total of 128 SLE and 113 SSc patients with a mean (s.d.) age of 46.28 (14.97) and 60.17 (10.82) years, respectively, and mean (S.D.) disease duration of 13.90 (9.31) and 8.48 (9.14) years, respectively, participated. In SLE, more depressive symptoms, more anxiety and worse perceived health status predicted a relative decrease in illness coherence 1 year later. More severe perceived consequences predicted a relative decrease in perceived health status. The perception of a more chronic time course predicted an increase in depressive symptoms. In SSc, reporting more depressive symptoms and more anxiety predicted a relative decrease in illness coherence. A good perceived health status and less reporting of depressive symptoms predicted a relative decrease in perceived consequences.

Conclusion

Evidence was obtained for reciprocal pathways between health outcomes and illness perceptions, although the predominant direction of effects was found to be from health outcomes to illness perceptions.

Trial registration

ClinicalTrials.gov, http://clinicaltrials.gov, NCT02655640.

[Chronic stress and mental disorders in patients with systemic scleroderma: Results of an interdisciplinary study]

AIM

To analyze of the prevalence of stressful factors and mental disorders (MDs), as well as their clinical psychopathological and clinical psychological characteristics to improve the comprehensive diagnosis and treatment of systemic scleroderma (SSD).

SUBJECTS AND METHODS

Examinations were performed in 110 patients (predominantly women (n=97 (88.2%); mean age, 49.9±2.47 years) with a documented diagnosis of SSD (its mean duration, 7.25±0.42 years). 62 (56.4%) patients had limited SSD, 36 (32.7%) had diffuse SSD, and 12 (10.9%) had overlap syndrome. The disease was rapidly and slowly progressive in 33 (30%) and 77 (70%) patients, respectively. Oral glucocorticosteroids were used in 99 (90%) patients included in the study, cytotoxic drugs in 66 (60%), plaquenil in 33 (30%); 8 (7%) patients were treated with the biological agent rituximab. All the patients were examined by a psychologist and a psychiatrist. The psychopathological diagnosis of MD was made during a semistructured interview in accordance with the ICD-10 criteria. The Montgomery-Asberg depression and Hamilton anxiety rating scales were used to evaluate the severity of depression and anxiety, respectively. All patients underwent a clinical and psychological examination, including tests assessing memory, attention, and logical thinking, as well as projective techniques.

RESULTS

MDs were detected in 91 (83%) patients with SSD. There was a preponderance of depressive disorders in 74 (67.3%) patients: chronic (dysthymia in 33 (30%) patients)) and recurrent (recurrent depressive disorder in 34 (31%)) depressions. Cognitive impairment (CI) of varying severities was diagnosed in 100% of the patients. Schizotypal personality disorder was stated in 44 (40%) patients. 90% of patients were found to have chronic psychic traumas mainly as parental deprivation in childhood (in children less than 11 years of age). 76.7% of the SSD cases developed recurrent episodes of depression in the presence of long-term MD or had a history of the episodes. There was no relationship of MD to gender, age, duration of SSD and its individual clinical manifestations. The nature of SSD treatment did not affect the frequency and spectrum of MD.

CONCLUSION

MDs, predominantly chronic and recurrent depression, and CI are characteristic of most SSD patients. Multiple chronic stressful factors, both previous SSD and those over time, have commonly an impact on the mental health of patients with SSD.

Exploring Sources of Emotional Distress among People Living with Scleroderma: A Focus Group Study

Background

Systemic sclerosis, or scleroderma, is a chronic and rare connective tissue disease with negative physical and psychological implications. Sources of emotional distress and the impact they have on the lives of people with scleroderma are not well understood.

Objectives

To gain an in-depth understanding of the emotional experiences and sources of emotional distress for women and men living with scleroderma through focus group discussions.

Methods

Three semi-structured focus group discussions were conducted (two in English, one in French) with a total of 22 people with scleroderma recruited through the Scleroderma Society of Ontario in Hamilton, Ontario and a scleroderma clinic in Montreal, Canada. Interviews were recorded, transcribed, and then coded for emerging themes using thematic inductive analysis.

Results

Core themes representing sources of emotional distress were identified, including: (a) facing a new reality; (b) the daily struggle of living with scleroderma; (c) handling work, employment and general financial burden; (d) changing family roles; (e) social interactions; and (f) navigating the health care system. Collectively, these themes refer to the stressful journey of living with scleroderma including the obstacles faced and the emotional experiences beginning prior to receiving a diagnosis and continuing throughout the participants’ lives.

Conclusion

Scleroderma was portrayed as being an unpredictable and overwhelming disease, resulting in many individuals experiencing multiple sources of emotional distress. Interventions and supportive resources need to be developed to help individuals with scleroderma and people close to them manage and cope with the emotional aspects of the disease.

Gastrointestinal Manifestations, Malnutrition, and Role of Enteral and Parenteral Nutrition in Patients With Scleroderma

Scleroderma (systemic sclerosis) is an autoimmune disease that can affect multiple organ systems. Gastrointestinal (GI) involvement is the most common organ system involved in scleroderma. Complications of GI involvement including gastroesophageal reflux disease, small intestinal bacterial overgrowth, and chronic intestinal pseudoobstruction secondary to extensive fibrosis may lead to nutritional deficiencies in these patients. Here, we discuss pathophysiology, progression of GI manifestations, and malnutrition secondary to scleroderma, and the use of enteral and parenteral nutrition to reverse severe nutritional deficiencies. Increased mortality in patients with concurrent malnutrition in systemic sclerosis, as well as the refractory nature of this malnutrition to pharmacologic therapies compels clinicians to provide novel and more invasive interventions in reversing these nutritional deficiencies. Enteral and parenteral nutrition have important implications for patients who are severely malnourished or have compromised GI function as they are relatively safe and have substantial retrospective evidence of success. Increased awareness of these therapeutic options is important when treating scleroderma-associated malnutrition.

Psychosocial Aspects of Scleroderma

Patients with systemic sclerosis (SSc; also called scleroderma) have to cope with not only the physical impacts of the disease but also the emotional and social consequences of living with the condition. Because there is no cure for SSc, improving quality of life is a primary focus of treatment and an important clinical challenge. This article summarizes significant problems faced by patients with SSc, including depression, anxiety, fatigue, sleep disruption, pain, pruritus, body image dissatisfaction, and sexual dysfunction, and describes options to help patients cope with the consequences of the disease.

Health-related quality of life in patients with ankylosing spondylitis: a comprehensive review

Ankylosing spondylitis (AS) is a complex systemic rheumatological disease which often causes severe disability and impaired quality of life (QoL). We searched the PubMed/MEDLINE electronic database for available literature on QoL and its predictors in patients with AS. Recent evidence indicates that AS patients have poorer QoL compared to the general population, but similar to that of patients with other rheumatological disorders. Disease activity is one of the most powerful predictors of QoL, however latest advances in pharmacological treatment (namely, anti-TNF-α) along with physical exercise can minimize the effects of AS on QoL. Psychological distress symptoms contribute to impaired QoL both directly and indirectly by influencing disease activity. The impact of other psychosocial variables, however, is less studied and more prospective investigations are necessary, which could eventually lead to the development of psychosocial interventions that are personalized to this patient population.

Clinical, functional and health-related quality of life correlates of clinically significant symptoms of anxiety and depression in patients with systemic sclerosis: a cross-sectional survey

Objectives

To identify clinical, functional and health-related quality of life (HRQoL) correlates of clinically significant symptoms of anxiety and depression in patients with systemic sclerosis (SSc).

Methods

Three-hundred-and-eighty-one patients fulfilling the American College of Rheumatology and/or the Leroy and Medsger criteria for SSc were assessed for visceral involvement, disability and HRQoL (assessed by SF-36). Clinically significant symptoms of anxiety and depression were evaluated with the Hospital Anxiety Depression Scale (HAD) (defined cut-off≥8).

Results

9.2% the patients had limited SSc, 50.5% limited cutaneous SSc (lcSSc), and 40.3% diffuse cutaneous SSc (dcSSc). Overall, 40.4% and 58.8% of the patients had clinically significant symptoms of depression and anxiety, respectively. Compared to patients without clinically significant symptoms of depression, patients with clinically significant symptoms of depression had poorer health status, HRQoL mental and physical component, and greater global disability, hand disability and aesthetic impairment. Compared to patients without clinically significant symptoms of anxiety, patients with clinically significant symptoms of anxiety had poorer SF-36 mental and physical component scores. On multivariable analysis, excluding mental component score of SF-36, variables independently associated with clinically significant symptoms of depression and anxiety were global disability and physical component of SF-36, plus female gender for clinically significant symptoms of anxiety only. Remarkably, patients with and without clinically significant psychiatric symptoms were comparable for all disease-related clinical features assessed.

Conclusion

High levels of clinically significant symptoms of anxiety and depression are observed among SSc patients. Clinically significant psychiatric symptoms are rather associated with increased disability and altered HRQoL, than with disease-specific organ manifestations.

Evaluation of the temperament and character properties of patients with ankylosing spondylitis

PURPOSE

The aim of this study was to evaluate temperament and character of ankylosing spondylitis (AS) patients and to examine the association between these specific temperament and character properties and clinical variables.

PATIENTS AND METHODS

This study involved 73 AS patients. Temperament properties of patients were evaluated using Cloninger's Temperament and Character Inventory (TCI). Association between clinical variables and specific temperament features were evaluated using correlation and regression analyses.

RESULTS

Forty eight (65.8 %) of the study participants were men and the mean age was 42 ± 11.4 years. There was slight negative correlations between self directedness (S) and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) scores (p = 0.01, r = - 0.30), and between the Visual Analog Scale (VAS) and reward dependence (RD) scores (p = 0.03, r = - 0.26). Regression analysis showed that correlations between BASDAI and S, and between VAS and RD scores were statistically significant.

CONCLUSION

Our study showed that the dimensions temperament and character are related to disease activation, and disease course is more severe in patients who have low scores in these TCI dimensions. Therefore, we suggest that evaluating temperament and character properties of AS patients will help clinicians to predict treatment compliance and motivation of patients during disease course.

Negative affect in systemic sclerosis

Negative affect appears frequently in rheumatic diseases, but studies about their importance and prevalence in systemic sclerosis patients are scarce, and the results are inconclusive separately. We conducted a comprehensive search on April 2013 of PubMed, Medline, and PsycINFO databases to identify original research studies published. A total of 48 studies were included in this systematic review. We found negative emotions have very high levels in these patients, compared to both healthy population other chronic rheumatic patients assessed with the same instruments and cutoffs. Depression has been, of the three negative emotions that we approach to in this review, the most widely studied in systemic sclerosis, followed by anxiety. Despite the fact that anger is a common emotion in these diseases is poorly studied. Methodologic issues limited the ability to draw strong conclusions from studies of predictors. Disease-specific symptoms (swollen joints, gastrointestinal and respiratory symptoms and digital ulcers) and factors related to physical appearance were associated with negative emotions. Interdisciplinary care and biopsychosocial approach would have a great benefit in the clinical management of these patients.

In systemic sclerosis, anxiety and depression assessed by hospital anxiety depression scale are independently associated with disability and psychological factors

Background. Anxious and depressive symptoms are frequent in Systemic Sclerosis (SSc). Our objective is to assess their prevalence and association with district and global disability and psychological variables. Methods. 119 SSc patients were assessed by Hospital Anxiety Depression Scale (HADS). Clinical depression and anxiety were defined for HADS score cutoff ≥8. Patients were assessed for psychological symptoms (RSES, COPE-NIV), hand (HAMIS, CHFDS, fist closure, and hand opening) and face disability (MHISS, mouth opening), global disability, and fatigue (HAQ, FACIT). Results. Both depression and anxiety in SSc are 36%. Depressive patients with comorbid anxiety have higher HADS-D score than patients with depression only (P = 0.001). HADS-A and -D are positively correlated with global disability, hands and mouth disability, fatigue, self-esteem and avoidance coping strategy, and, only HADS-A, also with social support (P < 0.05). By multiple regression, HADS-D is independently associated with FACIT-F (P < 0.001), RSES (P < 0.001), and MHISS total score (P = 0.016), together explaining 50% of variance. HADS-A is independently associated with RSES (P = 0.006), COPE-NIV SA (P = 0.003), COPE-NIV SS (P = 0.008), FACIT-F (P = 0.022), and MHISS mouth opening (P = 0.029), explaining 41% of variance. Conclusions. In SSc depression and anxiety correlate to local and global disabilities and psychological characteristics. Depressive patients with comorbid anxiety have higher level of depressive symptoms.

Neurologic involvement in scleroderma: a systematic review

OBJECTIVES

To perform a systematic review of neurologic involvement in Systemic sclerosis (SSc) and Localized Scleroderma (LS), describing clinical features, neuroimaging, and treatment.

METHODS

We performed a literature search in PubMed using the following MeSH terms, scleroderma, systemic sclerosis, localized scleroderma, localized scleroderma "en coup de sabre", Parry-Romberg syndrome, cognitive impairment, memory, seizures, epilepsy, headache, depression, anxiety, mood disorders, Center for Epidemiologic Studies Depression (CES-D), SF-36, Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Patient Health Questionnaire-9 (PHQ-9), neuropsychiatric, psychosis, neurologic involvement, neuropathy, peripheral nerves, cranial nerves, carpal tunnel syndrome, ulnar entrapment, tarsal tunnel syndrome, mononeuropathy, polyneuropathy, radiculopathy, myelopathy, autonomic nervous system, nervous system, electroencephalography (EEG), electromyography (EMG), magnetic resonance imaging (MRI), and magnetic resonance angiography (MRA). Patients with other connective tissue disease knowingly responsible for nervous system involvement were excluded from the analyses.

RESULTS

A total of 182 case reports/studies addressing SSc and 50 referring to LS were identified. SSc patients totalized 9506, while data on 224 LS patients were available. In LS, seizures (41.58%) and headache (18.81%) predominated. Nonetheless, descriptions of varied cranial nerve involvement and hemiparesis were made. Central nervous system involvement in SSc was characterized by headache (23.73%), seizures (13.56%) and cognitive impairment (8.47%). Depression and anxiety were frequently observed (73.15% and 23.95%, respectively). Myopathy (51.8%), trigeminal neuropathy (16.52%), peripheral sensorimotor polyneuropathy (14.25%), and carpal tunnel syndrome (6.56%) were the most frequent peripheral nervous system involvement in SSc. Autonomic neuropathy involving cardiovascular and gastrointestinal systems was regularly described. Treatment of nervous system involvement, on the other hand, varied in a case-to-case basis. However, corticosteroids and cyclophosphamide were usually prescribed in severe cases.

CONCLUSIONS

Previously considered a rare event, nervous system involvement in scleroderma has been increasingly recognized. Seizures and headache are the most reported features in LS en coup de sabre, while peripheral and autonomic nervous systems involvement predominate in SSc. Moreover, recently, reports have frequently documented white matter lesions in asymptomatic SSc patients, suggesting smaller branches and perforating arteries involvement.

Utility of the Patient Health Questionnaire-9 to assess suicide risk in patients with systemic sclerosis

OBJECTIVE

Item 9 of the Patient Health Questionnaire-9 (PHQ-9), which inquires about both passive thoughts of death and active ideas of self-harm, has been used to assess suicide risk in arthritis. The objectives of this study were 1) to determine the proportion of systemic sclerosis (SSc; scleroderma) patients who responded "yes" to item 9 who endorsed active suicidal ideation in response to more direct questions during a structured clinical interview, and 2) to report whether the PHQ-8, which does not include item 9 from the PHQ-9, performs similarly to the PHQ-9.

METHODS

Patients were recruited from the Canadian Scleroderma Research Group Registry. The PHQ-9 and Composite International Diagnostic Interview (CIDI) depression module were administered during a phone interview. Scores on the PHQ-8 were calculated by removing item 9 from the PHQ-9. Item 9 responses were compared to suicidal ideation and intent in the last year based on the CIDI. Scores on the PHQ-8 and PHQ-9 were compared using Pearson's correlations.

RESULTS

There were 345 patients interviewed, of whom 31 (9.0%) endorsed item 9 of the PHQ-9. Of those, based on the CIDI, 14 (45.2%) had passive thoughts of suicide or death. Only 1 patient (3.2%) had thoughts about suicide in some detail at any point in the last 12 months. The correlation between PHQ-9 and PHQ-8 scores was 0.998.

CONCLUSION

Item 9 appears to identify many patients who do not report active suicidal ideation. The PHQ-8 may be a better option for assessment of depressive symptoms than the PHQ-9 in patients with SSc.

A systemic sclerosis and systemic lupus erythematosus pan-meta-GWAS reveals new shared susceptibility loci

Systemic sclerosis (SSc) and systemic lupus erythematosus (SLE) are two archetypal systemic autoimmune diseases which have been shown to share multiple genetic susceptibility loci. In order to gain insight into the genetic basis of these diseases, we performed a pan-meta-analysis of two genome-wide association studies (GWASs) together with a replication stage including additional SSc and SLE cohorts. This increased the sample size to a total of 21,109 (6835 cases and 14,274 controls). We selected for replication 19 SNPs from the GWAS data. We were able to validate KIAA0319L (P = 3.31 × 10(-11), OR = 1.49) as novel susceptibility loci for SSc and SLE. Furthermore, we also determined that the previously described SLE susceptibility loci PXK (P = 3.27 × 10(-11), OR = 1.20) and JAZF1 (P = 1.11 × 10(-8), OR = 1.13) are shared with SSc. Supporting these new discoveries, we observed that KIAA0319L was overexpressed in peripheral blood cells of SSc and SLE patients compared with healthy controls. With these, we add three (KIAA0319L, PXK and JAZF1) and one (KIAA0319L) new susceptibility loci for SSc and SLE, respectively, increasing significantly the knowledge of the genetic basis of autoimmunity.

The experience of emotional distress among women with scleroderma

Emotional distress is common among patients with chronic medical illnesses, but the nature of the distress is not well understood. Our objective was to understand patients' experiences of emotional distress by conducting in-depth interviews using the McGill Illness Narrative Interview with women affected by scleroderma (N = 16). We sought to determine how participants described their distress, what they believed caused it, and how they coped. We analyzed interview transcripts using thematic analysis. Many participants described distress associated with scleroderma, but the term depression was reserved for extraordinary, severe experiences. Instead, participants preferred more normal mood descriptors and often viewed their distress in keeping with the definition of "demoralization." Participants listed concrete symptoms and experiences that caused distress, and some added that stress could exacerbate scleroderma. Participants dealt with distress by not dwelling on their circumstances and working to maintain autonomy. Most preferred to not rely on psychologists and support groups.

Systemic sclerosis-dermatological aspects. Part 1: Pathogenesis, epidemiology, clinical findings

Systemic sclerosis is a chronic inflammatory multiorgan disease belonging to the group of collagen-vascular disorders. With a prevalence of 10/100,000 inhabitants it may be regarded a rather rare disease. Its etiology and pathogenesis have still not been elucidated in detail, especially with regard to the differential involvement of skin and the cause of the clinically heterogeneous disease courses. Various components of the vasculature, connective tissue as well as the immune system are involved in a yet unknown sequence and significance. Patients need to be cared for in an interdisciplinary fashion depending on the individual organ involvement. Apart from the skin, the heart, kidneys and lungs are mainly affected in addition to frequent gastrointestinal and musculoskeletal symptoms. Clinically two distinct subsets may be separated, acral (also termed limited) and diffuse scleroderma, which are characterized by anti-centromere and anti-Scl-70/topoisomerase-1 antibodies, respectively. Recent data demonstrate a poor prognosis even in limited disease when pulmonary arterial hypertension develops at an early stage. In diffuse disease sudden and rapid onset will result in a sclerosis of major internal organs and early death in many cases.

Malnutrition in systemic sclerosis

SSc is a chronic multi-system disease with wide-reaching consequences. Gastrointestinal features are present in over 90% of cases and these, together with other disease manifestations, may lead to nutritional decline. This produces substantial morbidity, including reliance on enteral support and even parenteral nutrition-dependent intestinal failure. These complications carry an associated mortality. Up to 18% of patients with SSc are reported to be at high risk of malnutrition [as assessed by Malnutrition Universal Screening Tool (MUST) criteria], with risk increasing with disease severity. Little is known about this decline, its rate of progression and how it affects the individual. Few case series report on nutritional interventions. Most current interventions are based on experience in other diseases. The development of specialist knowledge of SSc-related gastrointestinal disease management and nutritional screening and interventions is required. This paper reviews current knowledge relating to malnutrition and its management in SSc.

Psychiatric symptoms and quality of life in systemic sclerosis

INTRODUCTION

Systemic sclerosis (SSc) is a rare conjunctive tissue disorder characterized by fibrosis of the skin and internal organs, and vascular obliteration phenomena. Patients with SSc often experience elevated symptoms of psychological distress, determined by the disfiguration, the pain, the fatigue sensation, and the difficult in daily life occupations. The characteristics of the disease may influence the perceived quality of life (QoL) in people with SSc.

METHODS

This is a narrative review aiming to define the amount of impairment of Quality of Life in patients with Systemic Sclerosis and the component of this impairment due to depressive or other psychiatric symptoms. The search of the significant articles was carried out in PubMed for the key words "Psychiatric symptoms and Systemic Sclerosis"; "Quality of life and Systemic Sclerosis"; "Depressive Disorders and Systemic Sclerosis".

RESULTS

Psychiatric symptoms are frequents in patients with SSc, but pain, fatigue, disability, body changes don't appear to explain the high prevalence of psychiatric comorbidity in SSc. Many studies founded a significant impairment in SSc patients' QoL, and despite the undeniable correlation between physical symptoms and SSc patients' QoL, mental health was found significantly impaired.

DISCUSSION

The high rate of depression seems to strictly correlate with poor quality of life, and this finding needs more research to establish the cause of such a correlation. Patients' point of view regarding their health-related QoL could help physicians to enlarge the knowledge about physical and mental correlates of the disease, and to fit therapies as patient required. Particular attention must be given to provide the patient with correct information, in order to mitigate the anxious state on disease course, and to enhance coping skills of the patients.

Determinants of disability, quality of life and depression in dermatological patients with systemic scleroderma

BACKGROUND

Systemic scleroderma (SSc) is a rare disease and knowledge about the relationship between clinical signs, disability, quality of life and depressive symptoms is still limited. Although patients with SSc are frequently treated by dermatologists, the vast majority of published evidence is based on rheumatological samples.

OBJECTIVES

To identify determinants of disability, decreased quality of life, and depression in a sample of dermatological patients with SSc.

METHODS

This was a cross-sectional study on consecutive patients with SSc attending one specialist dermatological centre between April 2008 and November 2009. Validated questionnaires, the Health Assessment Questionnaire (HAQ), EuroQol (EQ-5D) and the Center for Epidemiologic Studies Depression scale (CES-D) were utilized to measure disability, quality of life and depressive symptoms. Additionally, disease characteristics (SSc subtype, skin thickness, organ involvement), subjective symptoms of SSc, treatment and socioeconomic characteristics were collected by trained investigators. Based on an a priori hypothesized causal model, multivariate logistic regression models were used to analyse determinants of disability, quality of life and depression in patients with SSc.

RESULTS

A total of 72 patients [59 female (82%), mean age 59years] were enrolled. According to the CES-D, 69% (48 out of 70) were screened positive for depression. Quality of life impairment and female sex and were independent risk factors for depressive symptoms. Disease-specific disability was the main determinant of quality of life impairment in SSc. Pain involvement of the musculoskeletal system and male sex were the main determinants of disability in our sample of patients with SSc.

CONCLUSIONS

The high psychosomatic morbidity in our sample of consecutive patients with SSc calls for the investigation of interdisciplinary models of care.