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.

Barriers, Facilitators, and Preferences for Mental Health Services Among Patients With Systemic Lupus Erythematosus: A Qualitative Study

OBJECTIVE

Although patients with systemic lupus erythematosus (SLE) experience high levels of depression and anxiety disorders, evidence concerning patient perceptions of facilitators and barriers to effective uptake of mental health services (eg, referral to therapists and psychiatrists, psychoeducational interventions, or support groups) is limited.

METHODS

We conducted semistructured qualitative interviews with 15 adults with SLE to explore patient experiences and perceptions of mental health services to identify facilitators and barriers to accessing mental health care among patients with SLE. Qualitative interviews were conducted via telephone and audio recorded for transcription and directed content analysis using NVivo software by two coders.

RESULTS

The median age of the 15 participants was 48 years, 87% were female, 33% identified as Black or African American, and 33% identified as Hispanic or Latino. Qualitative themes were organized into three domains: barriers, facilitators, and preferences for mental health services. Barriers to the use of mental health services include mental health stigma, sociodemographic factors, lack of autonomy, and time commitment. Facilitators to the use of mental health services included strong relationships with their rheumatologists and mental health care clinician experience with patients with SLE. Preferences for mental health services included education-based formats, mental health providers who work with patients with SLE, peer group formats, demographically and disease-matched psychological resources, and an emphasis on non-disease-related activities.

CONCLUSION

In the setting of persistent unmet psychosocial needs of patients living with SLE, data from this qualitative study will inform the development and refinement of mental health interventions that bolster psychological wellbeing in the SLE population.

The communication GAP between patients and clinicians and the importance of patient reported outcomes in Systemic Lupus Erythematosus

Systemic Lupus Erythematosus (SLE) imposes a great burden on the lives of patients. Patients' and physicians' concerns about the disease diverge considerably. Physicians focus on controlling disease activity to prevent damage accrual, while patients focus on symptoms that impact on Health-Related Quality of Life (HRQoL). We explored the physicians' and patients' perspective and the potential role of Patient Reported Outcomes (PROs). Physicians are aware of the theoretical usefulness of PROs to collect information deriving from the patients' perspective. However, they often do not know how to interpret and use these questionnaires in a real shared therapeutic strategy. For the patients, it's important to be seen as a whole person with a true consideration of how they feel and function. Strategies to help bridge the communication gap could include: better use of time during visits, preparing for the consultation, a more understandable lay language used by the doctor, a dedicated nurse.

Association between depression and pain, functional disability, disease activity and health-related quality of life in patients with systemic lupus erythematosus: a meta-analysis

OBJECTIVE

The aim of this study was to explore the effect of depression on pain, disease activity, functional disability and health-related quality of life measured by Visual Analogue Scale, Systemic Lupus Erythematosus Disease Activity Index, Health Assessment Questionnaire and Short Form-36 in patients with systemic lupus erythematosus.

DESIGN

Meta-analysis.

DATA SOURCES

The PubMed, EMBASE, Cochrane Library and Web of Science were searched for obtaining available studies from inception to 7 March 2023.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies evaluating the impact of depression on pain, disease activity, functional disability and quality of life were included.

DATA EXTRACTION AND SYNTHESIS

Two authors independently screened publications and extracted data according to set inclusion and exclusion criteria. Statistical analyses were conducted with RevMan V.5.3.0. Data were pooled using a fixed-effects or random-effects model according to heterogeneity.

RESULTS

A total of 13 identified studies met the inclusion criteria, reporting on a total of 1911 patients with systemic lupus erythematosus. The Visual Analogue Scale score was significantly higher in patients with depression than those without depression (standardised mean difference (SMD)=0.84 (95% CI 0.27 to 1.42), p=0.004). The Health Assessment Questionnaire score was significantly higher in patients with depression than those without depression (SMD=1.05 (95% CI 0.14 to 1.95), p<0.05). The Systemic Lupus Erythematosus Disease Activity Index score was significantly higher in patients with depression than those without depression (SMD=0.46 (95% CI 0.27 to 0.64), p<0.00001). Scores in most Short Form-36 dimensions (physical function, role physical function, emotional role function, vitality, mental health, social function, general health, physical component scale, mental component scale) were lower in patients with depression than those without depression.

CONCLUSION

This meta-analysis showed that depression was associated with increased in pain, functional disability and disease activity, and decline in health-related quality of life in patients with systemic lupus erythematosus. Awareness of the importance of the relationship between depression in systemic lupus erythematosus patients and pain, functional disability and the quality of life might assist rheumatology physicians and nurses in assessing and preventing these symptoms.

PROSPERO REGISTRATION NUMBER

CRD42021265694.

A randomized controlled trial of an intervention promoting physical activity and healthy eating recommendations in systemic lupus erythematosus: the protocol study "Living Well with Lupus"

There is a paucity of studies assessing multidisciplinary interventions focused on tackling physical inactivity/sedentary behavior and poor dietary habits in SLE. The Living well with Lupus (LWWL) is a randomized controlled trial to investigate whether a six-month lifestyle change intervention will improve cardiometabolic risk factors (primary outcome) among systemic lupus erythematosus (SLE) patients with low disease activity (SLEDAI score ≤ 4) and with high cardiovascular risk. As secondary goals, we will evaluate: (1) the intervention's safety, efficacy, and feasibility in promoting lifestyle changes, and (2) the effects of the intervention on secondary outcomes (i.e., clinical parameters, functional capacity, fatigue, psychological aspects, sleep quality and health-related quality of life). Patients will be randomly allocated to either a control (i.e., standard care) or a lifestyle intervention group using a simple randomization (1:1 ratio, blocks of 20). Mixed Model analyses will be conducted for comparing groups following an intention-to-treat approach. A per protocol analysis will also be conducted. This study has the potential to generate new, clinically relevant data able to refine the multidisciplinary management of SLE patients. Protocol version number: NCT04431167 (first version).

Complex relationships between inflammatory manifestations/type 1 and type 2 symptoms in systemic lupus erythematosus: A narrative literature review

OBJECTIVE

Recent studies have highlighted that systemic lupus erythematosus (SLE) is characterized by different types of symptoms: type 1 symptoms related to inflammation and disease activity and type 2 symptoms such as fatigue, anxiety-depression, and pain. Our aim was to investigate the relation between type 1 and type 2 symptoms, and their impact on health-related quality of life (HRQoL) in SLE.

METHODS

A literature review was conducted about disease activity/type1 and type 2 symptoms. Articles in English published after 2000 were located on Medline via Pubmed. The articles chosen evaluated at least one type 2 symptom or HRQoL using a validated scale in adult patients.

RESULTS

Overall, 182 articles were analyzed and 115 were retained including 21 randomized, controlled trials and corresponding to 36 831 patients. We found that in SLE, inflammatory activity/type 1 symptoms were mostly uncorrelated with type 2 symptoms and/or HRQoL. Several studies even showing an inverse relationship. No or weak correlation was observed in 85, 3% (92, 6%), 76, 7% (74, 4%) and 37, 5% (73, 1%) of studies (patients) for fatigue, anxiety-depression, and pain, respectively. For HRQoL, no or weak correlation was observed in 77, 5% of studies (88% of patients).

CONCLUSION

Type 2 symptoms are poorly correlated with inflammatory activity/type 1 symptoms in SLE. Possible explanations and implications for clinical care and therapeutic evaluation are discussed.

Omega-3 fatty acids: Current insights into mechanisms of action in systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is one of the autoimmune diseases characterized by the lack of self-tolerance and the formation of immune complexes and nuclear autoantigens resulting in inflammation in multiple organs. Nowadays, the major aim of SLE therapy is the control of disease activity. However, the biological heterogeneity between patients and the absence of safe and specific targeted treatments complicate the lupus management. Therefore, the potential prophylactic effects of natural therapy considering the potential side effects of classical pharmacology, also the role of diet therapy in decreasing co-morbidities and improving quality of life in SLE patients could be a promising approach to SLE disease. Omega-3 polyunsaturated fatty acids (omega-3 PUFAs) are one of the agents that are considered for their preventive and therapeutic properties in disease activity of SLE and the related complications. The intake of omega-3 PUFAs likely has a direct relationship with improvements in inflammatory, cardiovascular, depressive, and neuromotor symptoms of the patients. The current review summarizes clinical and preclinical studies with comprehensive insights into the mechanisms of action of omega-3 fatty acids (omega-3 FAs) in Systemic Lupus Erythematosus to provide an update on the negative and positive aspects of the intake of omega-3 FAs in SLE patients.

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 and Anxiety Symptoms Are Associated with Mean Platelet Volume in Autoimmune Disorders

Platelets are increasingly considered a bridge between mental and immunological disorders. However, data relating to platelet parameters in patients with autoimmune disorders are limited. The aim of the present study was to investigate, for the first time, the association of platelet parameters with the symptoms of affective disorders in patients with autoimmune conditions. In this cross-sectional study, we measured the complete blood count (CBC), the Generalized Anxiety Disorder Scale for anxiety (GAD-7), and the Beck Depression Inventory for depression (BDI) in 121 patients with autoimmune disorders. Mean platelet volume (MPV) was positively correlated with both anxiety and depression. Platelet distribution width (PDW) was negatively correlated with anxiety and depression. Before adjustment for covariates, logistic regression analysis revealed a significant association of MPV with depression and anxiety. After adjustment for covariates, only depression was associated with MPV. The area under the ROC curve of MPV for GAD-7 determined anxiety and BDI determined depression was 0.63. Our study showed that among the CBC hematological parameters, the MPV might be a useful biomarker of depression and anxiety in patients with autoimmune disorders. Further investigations of platelet parameters in controlled prospective studies are warranted to confirm our preliminary results.

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.

Depression-, Pain-, and Health-Related Quality of Life in Patients with Systemic Lupus Erythematosus

Objectives. A significant number of patients with systemic lupus erythematosus (SLE) have depression, and many are untreated. We aim to assess the frequency of moderate to severe depression (MSD) in a multiethnic group of SLE patients with different sociodemographic backgrounds, identify modifiable factors associated with depression, and determine the impact of depression, disease activity, damage, cognitive function, and pain severity on health-related quality of life (HRQoL). Methods. Ninety-nine patients with SLE were evaluated in a cross-sectional study. Sociodemographic data, Beck Depression Inventory (BDI II), SLE disease activity index (SLEDAI-2K), SLICC Damage Index (SLICC-DI), pain severity (10 cm visual analogue scale), cognitive function (Automated Neuropsychologic Assessment Metrics (ANAM)), and the physical (PCS) and mental (MCS) component scores of the Short Form Health Survey (SF-36) were recorded. Bivariate analysis identified potential associations of relevant variables with BDI II and SF-36. Regression analysis determined independent correlates with MSD, PCS, and MCS. Results. Over 50% of subjects (50.5%) were African-American, 37.1% had a family income of ≤$20,000, and 31.3% had MSD. In the bivariate analysis, family income, SLEDAI-2K, cognitive function, and pain severity were associated with MSD. Using binary logistic regression, SLEDAI-2K and pain severity remained independently correlated with MSD ( $p=0.004$ ). In the multiple linear regression analysis, pain severity was the only independent correlate of PCS ( $p<0.0001$ ), while cognitive function and BDI II were the main factors associated with MCS ( $p=0.020$ and $p<0.0001$ , respectively). Conclusion. Pain severity and disease activity are associated with MSD in our unique population, are potentially modifiable, and deserve further attention in the clinic. Depression and pain significantly affect HRQoL and should be aggressively managed.

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.

Evaluation of depression and general health assessment among systemic lupus erythematosus patients in relation to disease activity and damage

Background

Systemic lupus erythematosus (SLE) is a chronic autoimmune illness defined by involvement of several systems and a variety of clinical symptoms among them the neuropsychiatric manifestations. The purpose of the study was to evaluate the presence of depression and to assess overall health in individuals with SLE, as well as their relation to SLE disease activity and damage. Sixty adult SLE patients were enrolled, along with sixty age and sex-matched controls. For the presence of major depression, all patients were examined using the Beck Depression Inventory (BDI-II) and the General Health Questionnaire (GHQ-12) for mental distress. Antinuclear antibody, anti-ds DNA, complements 3 and 4, and anti-ribosomal P antibody were performed for SLE patients. The SLEDAI-2 K and SLEDDI were assessed.

Results

The 60 patients were 52 (86.7%) females and 8 (13.3%) men, with a mean age of 32.5 ± 11.5 years and disease duration of 3.57 ± 3.55 years. Patients with depression accounted for 43 (71.6%) of the total, whereas controls accounted for just 14 (23.3%). Patients with substantial depression had significantly higher SLEDAI-2 K, SLEDDI, and illness duration than those without major depression (p = 0.047, p = 0.043, and p = 0.033, respectively). The patients’ mean GHQ-12 score was 17 ± 5.96, whereas the control group's was 10.0 ± 67.30, with a p value of 0.002. SLEDAI-2 K, SLEDDI, and depression score had a substantial positive association (p = 0.001, p = 0.042), while BDI-II and GHQ-12 had a significant positive correlation (p 0.001).

Conclusions

Depression and psychological distress were both common in SLE patients. Depression severity was linked to illness duration, activity, and damage.

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.

Prevalence and biopsychosocial factors associated with depressive symptoms among patients living with systemic lupus erythematosus in clinical settings in urban Thailand

BACKGROUND

Depressive symptoms are globally recognized as a significant mental health problem in patients with chronic disease, particularly those with systemic lupus erythematosus (SLE). The purpose of this study was to estimate the prevalence and examine biopsychosocial factors of depressive symptoms among patients with SLE.

METHODS

This cross-sectional study was conducted among 185 participants diagnosed with SLE and received treatment for at least 3 months, aged 18-59 years attending the outpatient clinic of a university hospital, Bangkok, Thailand. Depressive symptoms were measured by the Thai version of the Patient Health Questionnaire-9. We assessed Demographic data, the Systemic Lupus Erythematosus Activity Index, the Systemic Lupus International Collaborating Clinics Damage Index, Numeric Rating Scale, Fatigue Severity Scale, Body Image Scale, and the ENRICHD Social Support Instrument. Data were collected from March to May 2021. Multivariable logistic regression was used to analyze the data.

RESULTS

The proportion of the participants with depressive symptoms was 43.2%, which 8.1% of those patients presented moderate to severe depressive symptoms. In a multivariable logistic regression model, SLE patients with depressive symptoms were more likely to be severe pain (aOR = 12.11, 95% CI: 1.35, 108.46), fatigue (aOR = 2.36, 95%CI: 1.08, 5.14), taking prednisolone ≥15 mg daily (aOR = 5.75, 95%CI: 1.76, 18.80), low satisfied of body image (aOR = 12.49, 95%CI: 2.23, 69.80), and low social support (aOR = 17.96, 95% CI: 1.86, 173.77). Disease flare, organ damage, and family income sufficiency did not significantly increase the risk of depressive symptoms in patients with SLE.

CONCLUSIONS

The findings highlight depressive symptoms in patients with SLE. Therefore, the health professional should be concerned about the perception of body image, level of social support, fatigue, and pain while treating patients with SLE. Public health screening programs to identify depressive symptoms in patients with SLE are needed. In addition, a high dose of prednisolone should be considered if required, along with monitoring.

Functional Visual Loss in a Young Patient With Systemic Lupus Erythematosus

We describe a rare case of a patient with systemic lupus erythematosus (SLE) with functional visual loss (FVL). A 30-year-old female had blindness in the left eye due to multiple episodes of optic neuritis with underlying SLE. She presented with blurred vision in the right eye after an upper respiratory tract infection. The visual acuity in the right eye was 6/24, while the left eye had no light perception. The right eye optic nerve function tests were within normal limits. There was a positive relative afferent pupillary defect in the left eye. Fundoscopy showed left optic atrophy, while the right fundus was normal. The patient was treated according to a diagnosis of right retrobulbar optic neuritis. However, despite a course of intravenous methylprednisolone, her right visual acuity deteriorated to light perception. A magnetic resonance imaging (MRI) scan of the brain and orbit was normal. The visual evoked potential (VEP) in the right eye was also normal. The patient was suspected of having FVL and was referred to a psychiatrist. She was diagnosed with major depressive disorder after a full psychiatric assessment.

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.

Mindfulness-Based Stress Reduction for Systemic Lupus Erythematosus: A Mixed-Methods Pilot Randomized Controlled Trial of an Adapted Protocol

BACKGROUND

The psychological effects of systemic lupus erythematosus (SLE) are tremendous. This pilot mixed-methods randomized controlled trial aimed to evaluate the effects of a mindfulness-based stress reduction (MBSR) adapted protocol on psychological distress among SLE patients.

METHODS

26 SLE patients were randomly assigned to MBSR group therapy (n = 15) or a waitlist (WL) group (n = 11). An adapted MBSR protocol for SLE was employed. Three measurements were conducted: pre-intervention, post-intervention and 6-months follow up. A sub-sample (n = 12) also underwent qualitative interviews to assess their subjective experience of MBSR.

RESULTS

Compared to the WL, the MBSR group showed greater improvements in quality of life, psychological inflexibility in pain and SLE-related shame. Analysis among MBSR participants showed additional improvements in SLE symptoms and illness perception. Improvements in psychological inflexibility in pain and SLE-related shame remained stable over six months, and depression levels declined steadily from pre-treatment to follow-up. Qualitative analysis showed improvements in mindfulness components (e.g., less impulsivity, higher acceptance), as well as reduced stress following MBSR.

CONCLUSIONS

These results reveal the significant therapeutic potential of MBSR for SLE patients. With its emphasis on acceptance of negative physical and emotional states, mindfulness practice is a promising treatment option for SLE, which needs to be further applied and studied.

[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.

Biomarkers of Post-COVID Depression

The COVID-19 pandemic is spreading around the world and 187 million people have already been affected. One of its after-effects is post-COVID depression, which, according to the latest data, affects up to 40% of people who have had SARS-CoV-2 infection. A very important issue for the mental health of the general population is to look for the causes of this complication and its biomarkers. This will help in faster diagnosis and effective treatment of the affected patients. In our work, we focused on the search for major depressive disorder (MDD) biomarkers, which are also present in COVID-19 patients and may influence the development of post-COVID depression. For this purpose, we searched PubMed, Scopus and Google Scholar scientific literature databases using keywords such as 'COVID-19', 'SARS-CoV-2', 'depression', 'post-COVID', 'biomarkers' and others. Among the biomarkers found, the most important that were frequently described are increased levels of interleukin 6 (IL-6), soluble interleukin 6 receptor (sIL-6R), interleukin 1 β (IL-1β), tumor necrosis factor α (TNF-α), interferon gamma (IFN-γ), interleukin 10 (IL-10), interleukin 2 (IL-2), soluble interleukin 2 receptor (sIL-2R), C-reactive protein (CRP), Monocyte Chemoattractant Protein-1 (MCP-1), serum amyloid a (SAA1) and metabolites of the kynurenine pathway, as well as decreased brain derived neurotrophic factor (BDNF) and tryptophan (TRP). The biomarkers identified by us indicate the etiopathogenesis of post-COVID depression analogous to the leading inflammatory hypothesis of MDD.

Fatigue in Systemic Lupus Erythematosus: An Update on Its Impact, Determinants and Therapeutic Management

Fatigue is a complex and multifactorial phenomenon which is often neglected by clinicians. The aim of this review was to analyze the impact, determinants and management of fatigue in patients with Systemic Lupus Erythematosus (SLE). Fatigue is one of the most prevalent symptoms in SLE, reported by 67% to 90% of patients. It is also described as the most bothersome symptom, considering that it may impair key aspects of health-related quality of life, while also leading to employment disability. It is a multifactorial phenomenon involving psychological factors, pain, lifestyle factors such as reduced physical activity, whereas the contribution of disease activity remains controversial. The management of fatigue in patients with SLE should rely upon a person-centered approach, with targeted interventions. Some pharmacological treatments used to control disease activity have demonstrated beneficial effects upon fatigue and non-pharmacological therapies such as psychological interventions, pain reduction and lifestyle changes, and each of these should be incorporated into fatigue management in SLE.

Short-term exposures to atmospheric evergreen, deciduous, grass, and ragweed aeroallergens and the risk of suicide in Ohio, 2007-2015: Exploring disparities by age, gender, and education level

BACKGROUND

Seasonal trends in suicide mortality are observed worldwide, potentially aligning with the seasonal release of aeroallergens. However, only a handful of studies have examined whether aeroallergens increase the risk of suicide, with inconclusive results thus far. The goal of this study was to use a time-stratified case-crossover design to test associations of speciated aeroallergens (evergreen, deciduous, grass, and ragweed) with suicide deaths in Ohio, USA (2007-2015).

METHODS

Residential addresses for 12,646 persons who died by suicide were linked with environmental data at the 4-25 km grid scale including atmospheric aeroallergen concentrations, maximum temperature, sunlight, particulate matter <2.5 μm, and ozone. A case-crossover design was used to examine same-day and 7-day cumulative lag effects on suicide. Analyses were stratified by age group, gender, and educational level.

RESULTS

In general, associations were null between aeroallergens and suicide. Stratified analyses revealed a relationship between grass pollen and same-day suicide for women (OR = 3.84; 95% CI = 1.44, 10.22) and those with a high school degree or less (OR = 2.03; 95% CI = 1.18, 3.49).

CONCLUSIONS

While aeroallergens were generally not significantly related to suicide in this sample, these findings provide suggestive evidence for an acute relationship of grass pollen with suicide for women and those with lower education levels. Further research is warranted to determine whether susceptibility to speciated aeroallergens may be driven by underlying biological mechanisms or variation in exposure levels.

Pathways linking census tract typologies with subjective neighborhood disorder and depressive symptoms in the Black Women's Experiences Living with Lupus (BeWELL) Study

Depression is a common comorbidity among Black women with systemic lupus erythematosus (SLE), an understudied autoimmune disease characterized by major racial and gender inequities. Research is needed that examines how area-level factors influence risk of depression in this population. Latent profile analysis revealed four neighborhood typologies among metropolitan Atlanta, Georgia census tracts that participants (n=438) in the Black Women's Experiences Living with Lupus (BeWELL) Study were living in: Integrated/High-SES, Moderately Segregated/Mid-SES, Highly Segregated/Mid-SES, and Highly Segregated/Low-SES. Structural equation models indicated that highly segregated census tracts were associated with the greatest levels of depression via increased subjective assessments of neighborhood disorder. Policies that invest in segregated areas and address physical and social aspects of the environment that contribute to neighborhood disorder may promote mental health among Black women with SLE.

Impact of depression on quality of life in systemic lupus erythematosus patients

Background

Depression is common in systemic lupus erythematosus (SLE) and is an unmeasured risk factor, yet its symptoms can be neglected in standard disease evaluations. The purpose of this study was to assess the frequency and the impact of depression on quality of life in SLE patients. We recruited 32 patients with SLE and 15 healthy control volunteers in the study. The following investigations were undertaken in each patient: clinical and rheumatologic assessment, SLE Disease Activity Index-2k (SLEDAI-2k), Beck Depression Inventory (BDI), Short-Form Health Survey (SF-36) questionnaire, and routine laboratory tests.

Results

There was a high percentage of depression (46.9%) in the SLE patients. Regarding quality of life (SF-36), there were significant affection of the physical and mental composite summary domains (PCS and MCS) scores in lupus patients compared with controls (P < 0.000 for both) with the same significant in depressed compared with non-depressed patients. SF-36 subscales (physical function, limit emotional, emotional wellbeing, and social function) were significantly affected in depressed lupus patients compared with non-depressed patients. There was a significant negative correlation between the score of MCS domain of SF-36 with BDI (P < 0.000) while positive correlation between SLEDAI score with depression score. In contrast, there were no significant correlations between MCS or PCS with age, duration of illness, or SLEDAI-2K.

Conclusions

Depression is common in SLE patients and had a negative impact on quality of life particularly on MCS domain and positive correlation with disease severity score.

Trial registration

This study was registered on clinical trial with registration number: NCT03165682 https://clinicaltrials.gov/ct2/show/NCT03165682 on 24 May 2017.

Impact of sustained remission on quality of life among women with rheumatoid arthritis and systemic lupus erythematosus: a prospective observational study

Background

Health-related quality of life (HRQOL) as a patient reported outcome plays important roles in the life of patients with RA (rheumatoid arthritis) and SLE (Systemic lupus erythematosus) as well as their families. Evaluating the impact of sustained remission on HRQOL is important and could be of potential help in daily practice. Thus, we aimed to assess and compare prospectively the impact of sustained remission on HRQOL in Saudi RA and SLE female cohorts.

Results

Sixty-two female patients with active RA and 34 female patients with active SLE fulfilled the inclusion-, entry- and follow-up criteria. At baseline, the SLE patients had significantly better SF-36 scores than the RA patients. In both groups, significant correlations were found between disease activity and physical (PCS) and mental (MCS) components summary of the SF-36 (all p’s ≤ 0.001). In sustained remission, both SLE and RA patients showed significant improvements of the SF-36 scores (p < 0.001) compared to baseline. RA patients in sustained remission had a significantly better general health, bodily pain and physical functioning, and total PCS scores (p < 0.001) than those with SLE.

Conclusions

Both SLE and RA patients in sustained remission showed strongly improved HRQOL. In sustained remission, RA patients had comparable or better HRQOL than SLE patients.

Fatigue in patients with systemic lupus erythematosus and neuropsychiatric symptoms is associated with anxiety and depression rather than inflammatory disease activity

INTRODUCTION

We aimed to investigate risk factors for fatigue in patients with systemic lupus erythematosus (SLE) and neuropsychiatric symptoms in order to identify potential interventional strategies.

METHODS

Patients visiting the neuropsychiatric SLE (NPSLE) clinic of the Leiden University Medical Center between 2007-2019 were included. In a multidisciplinary consensus meeting, SLE patients were classified as having neuropsychiatric symptoms of inflammatory origin (inflammatory phenotype) or other origin (non-inflammatory phenotype). Fatigue was assessed with the SF-36 vitality domain (VT) since 2007 and the multidimensional fatigue inventory (MFI) and visual analogue scale (VAS) since 2011. Patients with a score on the SF-36 VT ≥1 standard deviation (SD) away from the mean of age-related controls of the general population were classified as fatigued; patients ≥2 SD away were classified as extremely fatigued. Disease activity was measured using the SLE disease activity index-2000. The influence of the presence of an inflammatory phenotype, disease activity and symptoms of depression and anxiety as measured by the hospital anxiety and depression scale (HADS) was analyzed using multiple regression analyses corrected for age, sex and education.

RESULTS

348 out of 371 eligible patients filled in questionnaires and were included in this study . The majority was female (87%) and the mean age was 43 ± 14 years. 72 patients (21%) had neuropsychiatric symptoms of an inflammatory origin. Fatigue was present in 78% of all patients and extreme fatigue was present in 50% of patients with an inflammatory phenotype vs 46% in the non-inflammatory phenotype. Fatigue was similar in patients with an inflammatory phenotype compared to patients with a non-inflammatory phenotype on the SF-36 VT (β: 0.8 (95% CI -4.8; 6.1) and there was less fatigue in patients with an inflammatory phenotype on the MFI and VAS (β: -3.7 (95% CI: -6.9; -0.5) and β: -1.0 (95% CI -1.6; -0.3)). There was no association between disease activity and fatigue, but symptoms of anxiety and depression (HADS) associated strongly with all fatigue measurements.

CONCLUSION

This study suggests that intervention strategies to target fatigue in (NP)SLE patients may need to focus on symptoms of anxiety and depression rather than immunosuppressive treatment.

Mortality and adverse events of special interest with intravenous belimumab for adults with active, autoantibody-positive systemic lupus erythematosus (BASE): a multicentre, double-blind, randomised, placebo-controlled, phase 4 trial

BACKGROUND

Belimumab is approved for the treatment of active systemic lupus erythematosus (SLE). Although clinical trials showed a favourable benefit-risk profile, numerical differences in the incidence of mortality and adverse events of special interest (AESIs) have been reported. We assessed the frequency of these events in patients with SLE receiving belimumab or placebo plus standard therapy.

METHODS

BASE was a double-blind, randomised, placebo-controlled, phase 4 trial done in 33 countries. Adults with active SLE were randomly assigned (1:1) to receive intravenous belimumab (10 mg/kg) or placebo, plus standard therapy, for 48 weeks. The primary endpoints were incidences of all-cause mortality and AESIs during the on-treatment period (first-to-last study drug dose + 28 days). Safety analyses were done in the as-treated population (patients grouped by actual treatment received >50% of the time). This study was registered with ClinicalTrials.gov (NCT01705977).

FINDINGS

Between Nov 27, 2012, and July 28, 2017, we randomly assigned 4018 patients. The as-treated population included 2002 patients in the belimumab group versus 2001 in the placebo group. Ten (0·50%) patients in the belimumab group died versus eight (0·40%) in the placebo group (difference 0·10%, 95% CI -0·31 to 0·51). Incidences were similar in the belimumab and placebo groups for serious infections (75 [3·75%] of 2002 vs 82 [4·10%] of 2001; difference -0·35%, 95% CI -1·55 to 0·85), opportunistic infections and other infections of interest (36 [1·80%] vs 50 [2·50%]; -0·70%, -1·60 to 0·20), non-melanoma skin cancers (4 [0·20%] vs 3 [0·15%]; 0·05%, -0·21 to 0·31) and other malignancies (5 [0·25%] vs 5 [0·25%]; 0·00%, -0·31 to 0·31). A higher proportion of patients in the belimumab group than in the placebo group had infusion and hypersensitivity reactions (8 [0·40%] vs 2 [0·10%]; 0·30%, -0·01 to 0·61), serious depression (7 [0·35%] vs 1 [0·05%]; 0·30%, 0·02 to 0·58), treatment-emergent suicidality (28 [1·42%] of 1972 patients vs 23 [1·16%] of 1986; 0·26%, -0·44 to 0·96), and sponsor-adjudicated serious suicide or self-injury (15 [0·75%] of 1972 patients vs 5 [0·25%] of 1986; post hoc difference 0·50%, 0·06 to 0·94).

INTERPRETATION

In line with previously published data, incidences of all-cause mortality and AESIs were similar in patients given belimumab and placebo, except for serious infusion or hypersensitivity reactions, serious depression, treatment-emergent suicidality, and sponsor-adjudicated serious suicide or self-injury events.

FUNDING

GSK.

Major Depression and Adverse Patient-Reported Outcomes in Systemic Lupus Erythematosus: Results From a Prospective Longitudinal Cohort

OBJECTIVE

Health-related quality of life (HRQoL) is reduced in systemic lupus erythematosus (SLE), partly driven by comorbid depression. Among patients with SLE, the association between major depression and HRQoL, measured using the NIH's Patient-Reported Outcomes Measurement Information System (PROMIS), is not well characterized. The objective was to determine an association between major depression and HRQoL as measured by PROMIS.

METHODS

Cross-sectional data were obtained from the California Lupus Epidemiology Study, a cohort of adults in the San Francisco Bay Area with SLE. We studied the association between major depression (score ≥10 on the Patient Health Questionnaire 8 depression scale) and T scores (scaled to population mean ± SD of 50 ± 10) on 12 PROMIS domains representing physical, mental, and social health. Mean T scores in depressed and nondepressed individuals were compared using multiple linear regression models adjusting for age, sex, race/ethnicity, disease activity, damage, body mass index, and household income.

RESULTS

Mean age of the 326 participants was 45 years; ~89% were women, 29% White, 23% Hispanic, 10% African American, and 36% Asian. One-fourth met the criteria for major depression. In multivariable analyses, major depression was independently associated with worse T scores on all 12 PROMIS domains (P < 0.001); compared with those without major depression, depressed individuals scored >10 points (1 SD) worse on fatigue, sleep impairment, negative psychosocial impact of illness, satisfaction in discretionary social activities, and satisfaction in social roles.

CONCLUSION

In individuals with SLE, major depression is associated with markedly worse PROMIS scores in physical, mental, and social domains. Diagnosing and treating depression may help improve HRQoL in individuals with SLE.

Investigation of early and lifetime clinical features and comorbidities for the risk of developing treatment-resistant depression in a 13-year nationwide cohort study

BACKGROUND

To investigate the risk of treatment-resistant depression (TRD) in patients with depression by examining their clinical features, early prescription patterns, and early and lifetime comorbidities.

METHODS

In total, 31,422 depressive inpatients were followed-up from diagnostic onset for more than 10-years. Patients were diagnosed with TRD if their antidepressant treatment regimen was altered ≥two times or if they were admitted after at least two different antidepressant treatments. Multiple Cox regression model were used to determine whether physical and psychiatric comorbidities, psychosis, and prescription patterns increased the risk of TRD by controlling for relevant demographic covariates. Survival analyses were performed for important TRD-associated clinical variables.

RESULTS

Females with depression (21.24%) were more likely to suffer from TRD than males (14.02%). Early anxiety disorders were more commonly observed in the TRD group than in the non-TRD group (81.48 vs. 58.96%, p < 0.0001). Lifetime anxiety disorders had the highest population attributable fraction (42.87%). Seventy percent of patients with multiple psychiatric comorbidities developed TRD during follow-up. Cox regression analysis further identified that functional gastrointestinal disorders significantly increased TRD risk (aHR = 1.19). Higher doses of antidepressants and benzodiazepines and Z drugs in the early course of major depressive disorder increased TRD risk (p < 0.0001).

CONCLUSION

Our findings indicate the need to monitor early comorbidities and polypharmacy patterns in patients with depression associated with elevated TRD risk.

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.

Dietary Omega Polyunsaturated Fatty Acid Intake and Patient-Reported Outcomes in Systemic Lupus Erythematosus: The Michigan Lupus Epidemiology and Surveillance Program

OBJECTIVE

To examine associations between dietary intake of omega-3 (n-3; generally antiinflammatory) and omega-6 (n-6; generally proinflammatory) fatty acids and patient-reported outcomes in systemic lupus erythematosus (SLE).

METHODS

This study was based on the population-based Michigan Lupus Epidemiology and Surveillance cohort. Estimates of n-3 and n-6 intake were derived from Diet History Questionnaire II items (past year with portion size version). Patient-reported outcomes included self-reported lupus activity (Systemic Lupus Activity Questionnaire [SLAQ]). Multivariable regression, adjusted for age, sex, race, and body mass index, was used to assess associations between absolute intake of n-3 and n-6, as well as the n-6:n-3 ratio, and patient-reported outcomes.

RESULTS

Among 456 SLE cases, 425 (93.2%) were female, 207 (45.4%) were African American, and the mean ± SD age was 52.9 ± 12.3 years. Controlling for potential confounders, the average SLAQ score was significantly higher by 0.3 points (95% confidence interval [95% CI] 0.1, 0.6; P = 0.013) with each unit increase of the n-6:n-3 ratio. Both lupus activity and Patient-Reported Outcomes Measurement Information System (PROMIS) sleep disturbance scores were lower with each 1-gram/1,000 kcal increase of n-3 fatty acids (SLAQ regression coefficient β = -0.8 [95% CI -1.6, 0.0]; P = 0.055; PROMIS sleep β = -1.1 [95% CI -2.0, -0.2]; P = 0.017). Higher n-3 intakes were nonsignificantly associated with lower levels of depressive symptoms and comorbid fibromyalgia, and with higher quality of life, whereas results for the n6:n3 ratio trended in the opposite direction.

CONCLUSION

This population-based study suggests that higher dietary intake of n-3 fatty acids and lower n-6:n-3 ratios are favorably associated with patient-reported outcomes in SLE, particularly self-reported lupus activity and sleep quality.

Centrally Acting Angiotensin-Converting Enzyme Inhibitor Suppresses Type I Interferon Responses and Decreases Inflammation in the Periphery and the CNS in Lupus-Prone Mice

Systemic lupus erythematosus (SLE) is an autoimmune disease characterized by multi-organ damage. Neuropsychiatric lupus (NPSLE) is one of the most common manifestations of human SLE, often causing depression. Interferon-α (IFNα) is a central mediator in disease pathogenesis. Administration of IFNα to patients with chronic viral infections or cancers causes depressive symptoms. Angiotensin-converting enzyme (ACE) is part of the kallikrein-kinin/renin-angiotensin (KKS/RAS) system that regulates many physiological processes, including inflammation, and brain functions. It is known that ACE degrades bradykinin (BK) into inactive peptides. We have previously shown in an in vitro model of mouse bone-marrow-derived dendritic cells (BMDC) and human peripheral blood mononuclear cells that captopril (a centrally acting ACE inhibitor-ACEi) suppressed Type I IFN responsive gene (IRG) expression. In this report, we used the MRL/lpr lupus-prone mouse model, an established model to study NPSLE, to determine the in vivo effects of captopril on Type I IFN and associated immune responses in the periphery and brain and effects on behavior. Administering captopril to MRL/lpr mice decreased expression of IRGs in brain, spleen and kidney, decreased circulating and tissue IFNα levels, decreased microglial activation (IBA-1 expression) and reduced depressive-like behavior. Serotonin levels that are decreased in depression were increased by captopril treatment. Captopril also reduced autoantibody levels in plasma and immune complex deposition in kidney and brain. Thus, ACEi's may have potential for therapeutic use for systemic and NPSLE.

Update on lupus epidemiology: advancing health disparities research through the study of minority populations

The current review focuses on recent population-based studies that have examined the burden of lupus, disease outcomes, and gaps in quality of care, with an emphasis in research addressing health disparities.

Depression in the medically ill

BACKGROUND

Depressive disorders are significantly more common in the medically ill compared to the general population. Depression is associated with worsening of physical symptoms, greater healthcare utilization and poorer treatment adherence. The present paper provides a critical review on the assessment and management of depression in the medically ill.

METHODS

Relevant articles pertaining to depression in the medically ill were identified, reviewed and synthesized qualitatively. A systematic review was not performed due to the large breadth of this topic, making a meaningful summary of all published and unpublished studies not feasible. Notable studies were reviewed and synthesized by a diverse set of experts to provide a balanced summary.

RESULTS

Depression is frequently under-recognized in medical settings. Differential diagnoses include delirium, personality disorders and depressive disorders secondary to substances, medications or another medical condition. Depressive symptoms in the context of an adjustment disorder should be initially managed by supportive psychological approaches. Once a mild to moderate major depressive episode is identified, a stepped care approach should be implemented, starting with general psychoeducation, psychosocial interventions and ongoing monitoring. For moderate to severe symptoms, or mild symptoms that are not responding to low-intensity interventions, the use of antidepressants or higher intensity psychotherapeutic interventions should be considered. Psychotherapeutic interventions have demonstrated benefits with small to moderate effect sizes. Antidepressant medications have also demonstrated benefits with moderate effect sizes; however, special caution is needed in evaluating side effects, drug-drug interactions as well as dose adjustments due to impairment in hepatic metabolism and/or renal clearance. Novel interventions for the treatment of depression and other illness-related psychological symptoms (e.g. death anxiety, loss of dignity) are under investigation.

LIMITATIONS

Non-systematic review of the literature.

CONCLUSION

Replicated evidence has demonstrated a bidirectional interaction between depression and medical illness. Screening and stepped care using pharmacological and non-pharmacological interventions is merited.

Quality of life in patients with systemic lupus erythematosus: the mediator role of psychological morbidity and disease activity

Patients with systemic lupus erythematosus (SLE) experience chronic symptoms that negatively impact their quality of life (QoL). This study analyzed the variables that contributed to QoL in patients with SLE, including the mediating role of psychological morbidity and disease activity. This study used a transversal design and included 104 women with SLE. Participants answered several instruments assessing fatigue, psychological morbidity (depression and anxiety), body image, disease activity, and quality of life. The results showed that disease activity, fatigue severity, psychological morbidity and body image were associated with all domains of QoL. Additionally, psychological morbidity and disease activity mediated the relationship between body image and psychological morbidity. Also, disease activity mediated the relationship between body image and fatigue severity. According to the results, intervention in patients with SLE should focus on patients' psychological morbidity, particularly in the active phase of the disease. Body image, fatigue severity and psychological morbidity should be monitored in patients with SLE in order to promote QoL.

PTPN22 Gene Polymorphisms in Pediatric Systemic Lupus Erythematosus

Objective: Pediatric systemic lupus erythematosus (PSLE) is a heterogeneous autoimmune disorder of unknown origin. PTPN22 gene polymorphisms have been associated with SLE in different populations. We investigated the associations of the rs2476601, rs1217414, rs33996649, rs1276457, and rs1310182 SNPs in the PTPN22 gene with PSLE. Materials and methods: 55 PSLE patients and 93 healthy controls were recruited. SNPs were genotyped by the real-time PCR allelic discrimination method. Results: We found that the PTPN22 polymorphisms rs1310182 A allele (p = 0.01, OR = 1.92 95% CI = 1.16-3.18), and rs1310182 AA genotype with (p < 0.001) and rs12760457 TT (p = 0.046) were associated with PSLE. No significant associations were found between other SNPs and PSLE. Conclusions: The PTPN22 rs1310182 A allele and rs1310182 AA genotype were associated with PSLE and may be a possible genetic marker for susceptibility to PSLE. However, further investigation would be required to elucidate the mechanistic role of this association.

Effect of Mental Health Problems on the Quality of Life in Children with Lupus Nephritis

INTRODUCTION

Mental health problems, such as anxiety, depression, and ineffective family coping, in children with lupus nephritis (LN) can increase the severity and affect the management of the disease, thus affecting the quality of life (QoL) of patients.

OBJECTIVE

Analyzing the association between levels of depression, anxiety, coping, disease activity on the QoL of pediatric patients with LN.

PATIENTS AND METHODS

There were 62 pediatric LN participants (16 participants in the induction phase and 46 participants in the maintenance phase). Participants were measured for anxiety, depression, coping, disease activity (systemic lupus erythematosus disease activity index/SLEDAI), and QoL. The measurement results were compared between induction and maintenance groups. Analysis of the association between anxiety, depression, coping, and disease activity with the QoL of children with LN used a multiple logistic regression test with p <0.05.

RESULTS

The measurement results obtained anxiety (induction = 69.06±3.92 and maintenance = 45.24±10.33; p <0.001), depression (induction = 69.88±3.34 and maintenance = 42.20±9.12; p <0.001), coping (induction = 99.88±12.93 and maintenance = 115.67±7.34; p <0.001), SLEDAI (induction = 15.81±12.58 and maintenance = 0.43±1.26; p <0.001), and QoL (induction = 49.92±12.44 and maintenance = 88.15±8.06; p <0.001).. Anxiety level in the induction group (p = 0.043) and maintenance group (p <0.001; p = 0.032; p = 0.008; p = 0.009). Depression level in the induction group (p = 0.031) and maintenance group (p = 0.024; p = 0.042; p = 0.003). SLEDAI score in the maintenance group (p = 0.003; p = 0.003). Coping in induction group (p = 0.016; p = 0.016) and maintenance group (p = 0.005).

CONCLUSION

Mental health disorders reduce the QoL of LN children, and the level of QoL in induction phase is lower than maintenance phase.

Depressive and anxiety symptom prevalence in childhood-onset systemic lupus erythematosus: A systematic review

BACKGROUND

Depressive and anxiety symptoms are common in children and youth and may impact outcomes for individuals with childhood-onset systemic lupus erythematosus. Research into the prevalence of depressive and anxiety symptoms and childhood-onset systemic lupus erythematosus comorbidity has reported conflicting results.

OBJECTIVE

To synthesize current knowledge regarding the prevalence of depressive and anxiety symptoms in childhood-onset systemic lupus erythematosus.

METHODS

Studies were identified through a comprehensive search of MEDLINE, EMBASE, PsychINFO, LILACS and Web of Science (from database inception to July 2018) using MESH headings and keywords for 'lupus erythematosus', and 'depression' or 'anxiety'. Included studies measured depressive and/or anxiety symptoms prospectively among children and youth aged 8 to 21 years with a diagnosis of childhood-onset systemic lupus erythematosus. Neuropsychiatric systemic lupus erythematosus was included. Studies without use of validated screening tools for major depressive disorder or anxiety disorders were excluded, as were studies where diagnosis was by retrospective analysis of patient charts. Data were extracted by two independent coders and where discrepancies occurred, agreement was reached by consensus.

RESULTS

In total, 70 studies met the criteria for full text review and of these, 14 were included in the final analysis. The majority (70%) of studies were of cross-sectional design, with sample sizes ranging from 20 to 100 (mean = 48) participants. The mean age of participants was 15.9 years and participants were predominantly female. Prevalence rates for depressive symptoms ranged from 6.7% to 59%. Anxiety symptom prevalence was 34% to 37%. All studies employed self-report instruments to assess depressive and anxiety symptoms; none of the studies utilized a semi-structured diagnostic interview to make psychiatric diagnoses. Significant heterogeneity precluded meta-analysis of the data.

CONCLUSIONS

Depressive and anxiety symptoms may be common comorbidities of childhood-onset systemic lupus erythematosus; however, current research is limited by a paucity of studies, small sample sizes and an inability to confirm psychiatric diagnoses. Future research addressing these limitations is needed.

Kinesiophobia and related factors in systemic lupus erythematosus patients

Background/aim

This study was designed to investigate the relationship between kinesiophobia and the level of physical activity, depression, disease activity, fatigue, pain, and quality of life in female patients with systemic lupus erythematosus (SLE).

Materials and methods

Seventy volunteer female patients were included in the study. Kinesiophobia, physical activity level, disease activity, fatigue, depression, pain, and quality of life were assessed using the Tampa Scale for Kinesiophobia (TSK), International Physical Activity Questionnaire- Short Form (IPAQ), Systemic Lupus Erythematosus Disease Activity Index (SLEDAI), Fatigue Severity Scale (FSS), Beck Depression Inventory (BDI), McGill Pain Questionnaire- Short Form (MPQ-SF) and Nottingham Health Profile (NHP), respectively.

Results

Two-thirds of the patients in the study had a high degree of kinesiophobia. Although there was a significant correlation between kinesiophobia and depression and some subscales of quality of life (sleep, social isolation, emotional reactions) (P < 0.05), no significant correlation with other parameters was found.

Conclusion

As a result of this study, the majority of SLE patients included in the study were identified as having high levels of kinesiophobia. Patients’ fear and avoidance reaction from movement can be influenced by psychosocial factors. Treatments focusing on kinesiophobia of SLE patients could be beneficial in increasing the success of rehabilitation.

Mental disorders in systemic lupus erythematosus: a cohort study

Currently, the evaluation of mental disorders in patients with Systemic lupus erythematosus (SLE) is essential in the management of the illness because of their impact in morbimortality. The main purpose of this study was to determine the prevalence of mental disorders in a group of patients with SLE in a tertiary referral hospital in Quito-Ecuador. The main diffuse central nervous system psychiatric syndromes in SLE (psychosis, anxiety and mood disorders) and cognitive dysfunction were evaluated with the MINI International Neuropsychiatric Interview and the Montreal scale, respectively. This was a descriptive, cross-sectional study which included patients 15 years and older diagnosed with SLE in a tertiary referral hospital in Quito, Ecuador. 85 patients diagnosed with SLE attending the internal medicine outpatient clinic during October 2017-May 2018 were included. A bivariate analysis of possible associations between these mental disorders with corticosteroid use, antiphospholipid syndrome (APS), and quality of life was also studied. Eighty-five patients, with an average age of 34.12 ± 11.5 years were included, of which 94% were females. 71% of participants (60 patients) had at least one mental disorder evaluated in this study. The most frequent was cognitive impairment (n = 43, 51%) followed by anxiety disorders (n = 35, 41%), mood disorders (n = 34, 40%) and psychosis (n = 1; 1%). 38% presented mild cognitive impairment and 13% had moderate cognitive impairment. Memory and visuospatial/executive function were the most affected domains in the cognitive assessment. 38% of participants were previously diagnosed with antiphospholipid syndrome, of which 78% had a mental disorder (OR = 1.83, p = 0.2). Most patients (n = 84; 99%) were treated with corticosteroids, of these, 59 patients presented a mental disorder (OR = 0.9, p = 0.8). Associations with APS or corticosteroid use were not statistically significant. However, the multivariate regression suggests an association between presence of mental disease and quality of life. There were statistically significant alterations in anxiety/depression and pain. There is a high prevalence of neuropsychiatric syndromes in this cohort of patients. Almost ¾ of our cohort had at least one mental disorder, the most common was cognitive impairment.

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.

Body image mediates the impact of pain on depressive symptoms in patients with systemic lupus erythematosus

Objective

Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease with treatment manifestations that can cause changes in appearance, including skin rashes, alopecia, vitiligo, and scars. SLE has been shown to adversely impact body image outcomes, and previous research has identified that greater disease activity is associated with worse body image outcomes which, in turn, are associated with greater depressive symptoms. For patients with SLE who also experience significant pain, poor body image outcomes may further compromise wellbeing and lead to greater depressive symptoms. The role of pain in body image has not been explored in SLE. Thus, the present study examined whether body image (specifically, body image-related quality of life) serves as a mediator of the relationship between pain and depressive symptoms among patients with SLE.

Methods

Multiple mediation analysis was used to examine the hypothesis that body image-related quality of life mediates the relationship between pain and depressive symptoms in a sample of patients with SLE ( N = 135) from an urban region in Los Angeles, California.

Results

The sample was predominately female (92.6%) with a mean disease duration of approximately 17 years. Approximately one-quarter of the sample had elevated depressive symptoms. Body image-related quality of life was a significant mediator in the relationship between pain and depressive symptoms. The model accounted for 51% of the total variance in depressive symptoms ( R2 = 0.51).

Conclusion

This cross-sectional study suggested that body image-related quality of life may mediate the effects of pain on depressive symptoms among patients with SLE.

The impact of SLE on health-related quality of life assessed with SF-36: a systemic review and meta-analysis

OBJECTIVE

To evaluate the impact of systemic lupus erythematosus (SLE) on health-related quality of life (HRQoL) assessed with SF-36 and explore factors associated with HRQoL in SLE patients.

METHODS

A random-effect meta-analysis was performed to calculate extracted data. Sensitivity and subgroup analyses were performed to distinguish sources of heterogeneity.

RESULTS

A total of 36 articles were finally included in this meta-analysis, including 6510 patients. The pooled mean scores of SF-36 physical component summary and mental component summary were 46.10 (95% confidence interval (CI): 43.09-49.10) and 50.37 (95% CI: 47.78-52.87), respectively. Spearman's correlation analysis found that mean age, proportion of female participants, and publication decades were negatively associated with some of the SF-36 domains. Sample size and SLEDAI were positively associated with some of the SF-36 domains. Patients with SLE have lower HRQoL in comparison to the general population.

CONCLUSIONS

SLE has a significant impact on HRQoL, which proves that the necessity of improving HRQoL in SLE patients cannot be ignored. Measuring HRQoL should be considered as an indispensable part of the overall evaluation of health conditions of SLE patients.

The clinically crucial predictors of depression in women with systemic autoimmune diseases

The researchers' aim of this study was to identify and quantify the useful, clinically crucial predictors of depression in Taiwanese women with systemic autoimmune diseases (SADs). We used a cross-sectional method. A total of 241 Taiwanese women with SADs between 21 and 85 years of age participated in the study. Analysis revealed that the strongest predictors of depression in participants were: perceived stress, fatigue, mental health, physical health, chronic-disease-related comorbidities, self-perceived SAD severity, and social support. The model used in the present study explained 70.9% of the variance in the depression.

Cytokine secretion and the risk of depression development in patients with connective tissue diseases

Research in the past two decades has revolutionized our understanding of depressive illnesses. Proinflammatory cytokines have become a point of interest in the interconnecting areas of neuropsychiatric and autoimmune diseases. The cytokine hypothesis of depression suggests that pro-inflammatory cytokines play a primary role in the mediation of the pathophysiological characteristics of major depression, in which an inflammatory process may be induced by external and internal stressors, such as psychological and inflammatory diseases, respectively. The higher prevalence of depression, particularly in patients with chronic autoimmune connective tissue disorders (CTD), suggests that depression may present a dysfunctional adaptation of cytokine-induced sickness, which could manifest in times of an exacerbated activation of the innate immune system. Inflammation is thought to contribute to the development of clinical depression through its ability to induce sickness behaviors corresponding to the neurovegetative features of depression, through the dysregulation of the hypothalamic-pituitary-adrenal axis, alterations in neurotransmitter synthesis and reuptake, and through its involvement in the neuroprogression pathways. This review explores the complex interrelationships in which inflammatory responses alter neuroendocrine and neuropsychological regulation contributing to depressive symptoms in CTD. The prevalence and characteristics of depression, and its correlation to the levels of inflammatory cytokines and disease activity among different CTD will be reviewed.

Chronic Cutaneous Lupus Erythematosus: Depression Burden and Associated Factors

OBJECTIVES

Depression may occur in up to 30% of individuals with cutaneous lupus erythematosus (CLE), many of whom may also have systemic manifestations. Chronic cutaneous lupus erythematosus (CCLE) conditions are less likely to present systemic involvement than acute and subacute conditions but more often cause permanent scarring and dyspigmentation. However, little is known about depression in those who have CCLE confined to the skin (primary CCLE). As African Americans are at high risk for primary CCLE and depression, we aimed to investigate the prevalence of and explore the risk factors for depression in a population-based cohort of predominantly Black patients with primary CCLE.

METHODS

This was a cross-sectional analysis of a cohort of individuals with a documented diagnosis of primary CCLE, established in metropolitan Atlanta, GA, USA. Participants were recruited from the Centers for Disease Control and Prevention (CDC) population-based Georgia Lupus Registry, multicenter dermatology clinics, community practices, and self-referrals. The Patient-Reported Outcomes Measurement Information System (PROMIS) was used to measure the primary outcome: depressive symptoms. Stand-alone questions were used to assess sociodemographics and healthcare utilization. Emotional, informational, and instrumental support were measured with PROMIS short forms, interpersonal processes of care with the IPC-29 survey, and skin-related quality of life with the Skindex-29+ tool.

RESULTS

Of 106 patients, 92 (86.8%) were female, 91 (85.8%) were Black, 45 (42.9%) were unemployed or disabled, and 28 (26.4%) reported moderate to severe depressive symptoms. Depression severity was lower in patients who were aged ≥ 60 years, were married, or had graduated from college. Univariate analysis showed that being employed (odds ratio [OR] 0.24; 95% confidence interval [CI] 0.10-0.61), insured (OR 0.23; 95% CI 0.09-0.60), reporting higher instrumental, informational, and emotional support (OR 0.75; 95% CI 0.60-0.94; OR 0.62; 95% CI 0.49-0.78; and OR 0.48; 95% CI 0.35-0.65, respectively), visiting a primary care physician in the last year (OR 0.16; 95% CI 0.04-0.61) and reporting better physician-patient interactions (OR 0.56; 95% CI 0.37-0.87) were negatively associated with depression. Patient's perception of staff disrespect (OR 2.30; 95% CI 1.19-4.47) and worse skin-related quality of life (OR 1.04; 95% CI 1.02-1.06) rendered higher risk. In multivariate analysis, only perception of staff disrespect (OR 2.35; 95% CI 1.06-5.17) and lower emotional support (OR 0.48; 95% CI 0.35-0.66) remained associated with depression.

CONCLUSION

Over one-quarter of a predominantly Black population-based cohort of individuals with primary CCLE reported moderate to severe depression, a rate three to five times higher than described previously in the general population from the same metropolitan Atlanta area. Our findings suggest that, while patient's perception of discrimination in the healthcare setting may play a role as a determinant of depression, social support may be protective. In addition to routine mental health screening and depression treatment, interventions directed at providing emotional support and improving office staff interpersonal interactions may contribute to reduce the risk of depression in patients with CCLE.

Non-pharmacologic therapies for systemic lupus erythematosus

BACKGROUND

Non-pharmacologic therapies have been deemed as potentially beneficial for patients with systemic lupus erythematosus. We conducted an updated review to determine the effects of these therapies to inform practice.

METHODS

A literature search was performed using PubMed (MEDLINE), EMBASE, Cochrane, PsychINFO, the Cumulative Index to Nursing and Allied Health Literature, Web of Science, and Google Scholar from inception until August 2018. We included randomized controlled trials of non-pharmacologic therapies in systemic lupus erythematosus patients with sample size ≥10. Systemic lupus erythematosus was defined by 1982 or 1997 American College of Rheumatology criteria. Studies were synthesized separately by patient-reported outcomes and disease activity. Due to the heterogeneity of interventions and comparisons, a meta-analysis was not performed.

RESULTS

A total of 15 randomized controlled trials involving 846 participants met the inclusion criteria. Of the 15 trials, eight used exercise interventions, six used psychological interventions (one group psychotherapy, three cognitive behavioral therapies, one psychoeducation, one mindfulness-based cognitive therapy) and one used electro-acupuncture. Five of 15 studies utilized control groups consisting of usual medical care. Other studies included control interventions of relaxation, attention placebo, symptom monitoring support, education, minimal needling, isotonic and resistance exercise. Compared with the control conditions, non-pharmacological interventions were associated with a significant improvement in fatigue in three out of six studies. Three out of eight studies reported improved anxiety and depression, and one study reported improved pain after interventions. Seven out of 11 studies reported improvement in overall quality of life in at least one domain of the Short-Form Health Survey. Of note, no studies demonstrated an improvement in disease activity after 5-52 weeks of non-pharmacological therapies.

CONCLUSION

This review showed promising results for physical exercise and psychological interventions as adjuncts to traditional medical therapy for improvement in fatigue, depression, pain and quality of life for systemic lupus erythematosus. Further high-quality randomized controlled trials with longer follow-up periods are warranted.