Psychiatric and psychosocial disorders in patients with systemic lupus erythematosus: a longitudinal study of active and inactive stages of the disease

Refractory Systemic Lupus Erythematosus: Identification and Pharmacological Management

Systemic lupus erythematosus (SLE) is characterized by an aberrant immune response, leading to an extremely heterogeneous clinical presentation, potentially affecting different systems and organs. Despite the fact that SLE mortality has greatly decreased since the introduction of steroids, some forms of refractory/severe SLE still have the potential to result in permanent organ damage as well as increased mortality and morbidity. Furthermore, SLE patients with multiple comorbidities may face a clinical conundrum and have a bad prognosis. An improved prognosis for severe refractory SLE depends on prompt and appropriate treatment. Due to the scarcity of solid data from a well-characterized group of patients with refractory/severe SLE coming from randomized controlled studies, this review aims to shed light on this with real-world evidence from clinical research performed at our Unit, the University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID) (Turin, Italy). In order to determine the key clinical and prognostic features, and therapeutic approaches for severe and/or refractory SLE, our experience will be described together with existing literature, primarily focused on dermatological, neuropsychiatric, and renal symptoms.

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

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

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.

Correlation between physical markers and psychiatric health in a Portuguese systemic lupus erythematosus cohort: The role of suffering in chronic autoimmune disease

BACKGROUND

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that affects a large number of people throughout the world. Anxiety, depression and fatigue are common symptoms of SLE that substantially contribute to decreased quality of life. This study investigates the interplay between physical and psychiatric manifestations of lupus. To this end, an SLE patient cohort was examined for correlations between clinical presentation, laboratory tests, and psychological indicators.

METHODS

Seventy-two lupus patients were evaluated for psychological status using a battery of instruments, including assessments for fatigue (CFS & FSS), depression (HADS), anxiety (HADS), overall health (SF-36 & PSQI) and intimate relationship satisfaction (RAS & CSI). Scores from these assessments were correlated with lupus clinical profiles and laboratory test values.

RESULTS

The prevalence of depression in the SLE patient cohort was 41.7%, as measured by the hospital depression and anxiety scale. The study identified that pain (p = 0.001), body mass index (p = 0.026), Chalder's fatigue scale (p < 0.001), fatigue severity scale (p < 0.001), and anxiety (p = 0.001) are all positively correlated with depression in SLE patients. Total complement (CH50) (p = 0.032), and SF-36 physical and mental characteristic assessments are negatively correlated with depression. Longitudinal analysis indicated that the disease related complaint alopecia (p = 0.008) and relationship assessment scale scores (p = 0.004) may also be correlated to depression in SLE patients. Multivariant scrutiny of the clinical and psychosocial characteristics identified the fatigue severity scale (p = 0.026), SF-36 physical function (p = 0.040), physical role function (0.030), and mental health (p = 0.002) as the best indicators directly correlated with depression for the SLE cohort.

CONCLUSION

These results reveal the influence of physical manifestations of lupus including fatigue, pain, body mass index and anxiety, as well as decreased physical and mental function, on depression. Fatigue is the strongest factor correlated with depression in SLE patients in the cohort. Both physical and social/psychological aspects likely contribute to the depression and anxiety in lupus.

Measurement properties of the brief resilient coping scale in patients with systemic lupus erythematosus using rasch analysis

Bacground

Resilience has been defined as the capacity or the ability to rebound from and positively adapt to significant stressors, despite experiences of significant adversity or trauma. To capture to what extent an individual copes with stress in a resilient fashion the Brief Resilient Coping Scale (BRCS) was developed. This tool was validated in people with chronic disease, such as rheumatoid arthritis using standard psychometric techniques of classical test theory, but not yet in patients with Systemic lupus erythematosus (SLE). The aim of this study was to explore the psychometric properties of the Brief Resilient Coping Scale in patients with SLE using Rasch analysis.

Method

This study used cross-sectional data. The BRCS was administered to 232 patients with systemic lupus erythematosus. The aspects analyzed were unidimensionality, local independence and differential item functioning (DIF) to construct an interpretative scale of scores with the Rasch model.

Results

Rating scale mode (RSM) showed that the four categories used in the items of the BRCS are properly ordered. The four items provided a good fit to the polytomous Rasch model. Moreover, the parameters were sufficiently separated to measure resilience in patients with SLE. BRCS is a unidimensional scale (eigenvalue = 1.843) of resilience and the items were locally independent. There was no DIF between males and females in the sample. Only marginally significant differences depending on the level of education were found. The BRCS showed adequate discriminant validity between groups of scores.

Conclusions

BRCS is a suitable scale for measuring resilience in patients with SLE. This scale might be useful for clinicians to obtain information concerning the degree of resilience that each patient has, allowing individuals with low resilience to be identified who need interventions aimed at developing coping skills.

Gender differences in systemic lupus erythematosus concerning anxiety, depression and quality of life

Several studies have demonstrated a high prevalence of depression and anxiety in patients with systemic lupus erythematosus (SLE); however, few data address gender differences regarding these manifestations. This study aimed to investigate gender differences in the prevalence of depressive and anxiety symptoms, and their effect on the quality of life (QOL) of male and female SLE patients. This study included 54 male SLE patients, 54 female SLE patients, 54 male controls and 54 female controls. Depressive symptoms were assessed using the Beck Depression Inventory (BDI), the Center for Epidemiologic Studies Depression Scale (CES-D) and the Hospital Anxiety and Depression Scale (HADS); the anxiety symptoms were examined using HADS. We used the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) to assess QOL. Depressive symptoms were found in 22.2% of BDI respondents, 24.1% of CES-D respondents and 13% of HADS-D respondents who were male SLE patients; while in the female SLE patient group, they were found in 38.9% of BDI respondents ( p = 0.063), 51.9% of CES-D respondents ( p = 0.653) and 31.5% of HADS-D respondents ( p = 0.003). Anxiety symptoms were found in 16.7% of the male SLE patients and 38.9% of the female SLE patients ( p = 0.024). Lower scores on the SF-36 (for QOL) were found in both male and female SLE patients with depression and anxiety symptoms. In conclusion, we observed significant gender differences regarding the prevalence of depressive and anxiety symptoms in patients with SLE, with significantly higher values in the female group. The presence of these symptoms appears to have a negative effect on the QOL of patients of both genders.

Pregnancy in patients with rheumatic diseases: psychological implication of a chronic disease and neuropsychological evaluation of the children

As a consequence of the general improvement in the diagnosis and management of rheumatic diseases, patients achieve a better quality of life, with the possibility of a normal family life including one or more pregnancies. It is important, therefore, to consider the psychological aspects of these mothers’ life and the influence of their chronic disease on their children is development. Several papers have reported the impact of systemic lupus erythematosus (SLE) on the quality of life. They found higher incidence of anxiety (from 15 to 45%) and depression (from 25 to 47%) compared to the general population. We have investigated the psychological influence of SLE on family planning, and we observed that it can interfere with physiological phenomena such as parenthood and the upbringing of children. The children of lupus mothers have a normal intelligence level for their age. What is emerging, however, is an increased incidence of learning disabilities compared to the general population. This observation suggests the importance of an early neuropsychological examination, in order to identify the children needing particular care. Therefore, psychological support seems to be an important help in the counseling of patients with rheumatic disease and in the future life of their children.

Anti-ribosomal P-protein and its role in psychiatric manifestations of systemic lupus erythematosus: myth or reality?

Systemic lupus erythematosus (SLE) is an autoimmune disease that may involve the central nervous system (CNS) resulting in neuropsychiatric manifestations. The associated psychiatric disorders include depression, psychosis, mood disorders, anxiety, cognitive dysfunction, and delirium/encephalopathy. Several autoantibodies may play a role in the pathogenesis of psychiatric complications of SLE, particularly antibodies against ribosomal P-proteins (anti-P) and possibly antibodies against endothelial cells (AECA). The reported prevalence of anti-P is highly variable in SLE patients and is dependent on different ethnic backgrounds, sensitivity and specificity of the assays employed for autoantibody detection, and the time at which sera were analysed in relation to the clinical event. Controversial data exist on the association of anti-P with psychiatric manifestations of SLE. These autoantibodies have been suggested to be specific markers of the psychiatric manifestations of SLE, particularly of the psychosis and depression, and the antibody level varied with the clinical activity of the disease. Some studies have confirmed the hypothesis of an association of anti-P antibodies with psychiatric manifestations of neuropsychiatric SLE (NPSLE) while others have disputed this relationship. This review summarizes the recent studies about relationship between anti-P antibodies and psychiatric manifestation of SLE.

Psychosocial research on systemic lupus erythematosus: a literature review

This article is the first to review published research on psychosocial factors and behavioral interventions related to systemic lupus erythematosus (SLE). The first section presents descriptive studies, followed by studies that investigate psychosocial factors as predictor and outcome variables. These studies demonstrate that the consideration of psychosocial factors is critical to understanding the disease experience of persons with SLE. Next, studies of behavioral interventions are presented, leading to the conclusion that randomized controlled trials are essential yet rare. The final section highlights limitations of the extant literature and suggests directions for future research and recommendations for clinicians.

Depressive symptoms are associated with tumor necrosis factor alpha in systemic lupus erythematosus

BACKGROUND

Tumor necrosis factor alpha (TNF-α) is deeply related to pathogenesis of neurodevelopmental disorders, especially depression. The aim of this study was to explore potential relationships between sera TNF-α levels and mood and anxiety disorders in systemic lupus erythematosus (SLE) patients.

METHODS

We included 153 consecutive SLE patients (women 148; median age 30; range 10-62) and 40 (women 37; mean age 28.5; range 12-59) age- and sex-matched healthy controls. Mood and anxiety disorders were determined through Beck Depression and Beck Anxiety Inventory. SLE patients were further assessed for clinical and laboratory SLE manifestations. TNF-α levels were measured by enzyme-linked immunosorbent assay using commercial kits.

RESULTS

Depressive symptoms were identified in 70 (45.7 %) SLE patients and in 10 (25 %) healthy controls (p < 0.001). Anxiety symptoms were identified in 93 (60.7 %) SLE patients and in 16 controls (40 %) (p < 0.001). Sera TNF-α levels were increased in SLE patients with depressive symptoms (p < 0.001) and with anxiety symptoms (p = 0.014). A direct correlation between the severity of depressive symptoms and sera TNF-α levels (r = 0.22; p = 0.003) was observed. TNF-α levels were significantly increased in patients with active disease (p = 0.012). In addition, we observed a correlation between sera TNF-α levels and disease activity (r = 0.28; p = 0.008). In the multivariate analysis, sera TNF-α levels were independently associated with depressive symptoms (t = 3.28; 95 % CI 1.08-2.2; p = 0.002).

CONCLUSIONS

Sera TNF-α levels are increased in SLE patients with mood and anxiety disorders. In SLE, sera TNF-α levels are independently associated with mood disorders. The etiology of mood disorders is still debated in SLE, but our findings suggest the presence of immunological basis for depression in SLE.

Psychological distress in corticosteroid-naive patients with systemic lupus erythematosus: A prospective cross-sectional study

OBJECTIVE

Psychological distress, such as depression and anxiety, has been intensively studied in patients with systemic lupus erythematosus (SLE). However, those studies have mostly included patients who were treated with corticosteroids, which might themselves induce mood disturbances. We investigated psychological distress in corticosteroid-naive patients with SLE who did not exhibit any overt neuropsychiatric manifestations.

METHODS

Forty-three SLE in-patients with no current or past abnormal neuropsychiatric history participated in the study. Patients and 30 healthy control subjects with similar demographic and personality characteristics were administered a comprehensive battery of psychological/neuropsychological tests. The Profile of Mood States (POMS) was used to assess depression and anxiety. Results of clinical, laboratory, and neurological tests were compared with regard to their presence.

RESULTS

Prevalence of depression was higher in patients (n = 11, 25.6%) than in controls (n = 2, 6.7%; p = 0.035), although prevalence of anxiety did not differ across groups (patients: 34.9%, n = 15; controls: 16.7%, n = 5; p = 0.147). Using multiple logistic regression analysis, we identified avoidance coping methods (OR, 1.3; 95% CI 1.030-1.644; p = 0.027) as an independent risk factor for depression.

CONCLUSION

Our results indicate that depression presents more frequently in corticosteroid-naive patients with early-stage, active SLE than in the normal population, but anxiety does not. Depression may be related to psychological reactions to suffering from the disease.

Symptoms of attention deficit hyperactivity disorder in patients with systemic lupus erythematosus

OBJECTIVES

Cognitive function and mood disturbance are common in patients with systemic lupus erythematosus (SLE). This study aims to examine whether SLE patients have more features of adult attention deficit hyperactivity disorder (ADHD) and their relation to anxiety and depressive symptoms.

METHODS

Symptoms and clinically significant items of the inattention and hyperactivity/impulsivity domains of ADHD were examined in Part A and Part B by the screening instrument of the ADHD Self-Reported Scale (ASRS), respectively. Anxiety and depressive symptoms were measured by HADS-A and HADS-D, respectively.

RESULTS

There were no differences in symptom scores of inattention and hyperactivity/impulsivity between inactive SLE patients (n = 117) and age- and sex-matched controls (n = 64). However, SLE patients had more clinically significant items in the inattention domain compared with controls (p = 0.006), particularly among those who had previous cerebral involvement (p = 0.004). Patients who had psychiatric diseases had more clinically significant items in the hyperactivity/impulsivity domain (p = 0.006). Possible ADHD was found in 7.7% of SLE and 6.3% of healthy individuals (p = 1.00) by the screening tool. Patients with higher inattention symptom scores were more likely to be unemployed but not for duration of education and smoking habit. Anxiety and depressive symptoms correlated with ADHD symptoms. HADS-A was an independent predictive factor for clinically significant symptoms of inattention (p < 0.001) and hyperactivity/impulsivity (p = 0.04) by logistic regression.

CONCLUSION

Inactive SLE patients, particularly those who had previous cerebral lupus, had more clinically significant symptoms of inattention but not hyperactivity/impulsivity reflecting underlying cognitive impairment. Anxiety and depressive symptoms were common confounders for ADHD-like symptoms.

Prevalence and severity of depression and anxiety in patients with systemic lupus erythematosus: An epidemiologic study in Iranian patients

OBJECTIVES

We aimed to evaluate the prevalence of depression and anxiety in patients with systemic lupus erythematosus (SLE) and explore their association with demographic and clinical features.

METHODS

In this cross-sectional study, 166 SLE patients in rheumatology center of Shariati hospital, Tehran University of Medical Sciences were enrolled. SLE disease activity index (SLEDAI) and Beck and Cattell inventories for evaluation of depression and anxiety were completed for each patient.

RESULTS

The mean age of patients was 33.1 ± 11.1 years and 92.2% of them were female. Two patients (1.2%) had only depression (without anxiety), while 36 patients (21.6%) had only anxiety (without depression). Meanwhile, 105 patients (63.3%) had mixed depression-anxiety and 23 patients (13.8%) did not have either depression or anxiety. Mean daily dose of prednisolone and number of administered drugs did not show significant difference between different subgroups of patients. In assessment of clinical and therapeutic items, no significant correlation between severity of depression (P = 0.65) and anxiety (P = 0.36) with daily dose of prednisolone in SLE patients was observed. There was no significant association between SLEDAI and severity of depression or anxiety. Occupational status had significant correlation with severity of depression and anxiety (P = 0.005).On the contrary, no significant correlation between number of administered drugs and severity of depression and anxiety was present.

CONCLUSION

This study indicated the high prevalence of depression and anxiety among SLE patients and reinforced the need of a comprehensive psychiatric work-up in SLE.

Depression and anxiety and their association with healthcare utilization in pediatric lupus and mixed connective tissue disease patients: a cross-sectional study

BACKGROUND

Depression and anxiety adversely affects outcomes in systemic lupus erythematosus (SLE) and healthcare utilization is high for pediatric SLE. We aimed to characterize the prevalence of depression and anxiety in pediatric SLE, and their association with healthcare utilization.

METHODS

We conducted a cross-sectional analysis of pediatric SLE and mixed connective tissue disease (MCTD) subjects and healthy controls aged 8 years and above. We used the Patient Health Questionnaire 9 (PHQ-9) and the Screen for Childhood Anxiety Related Disorders (SCARED) to identify depression, suicidal ideation and anxiety symptoms, respectively. We compared symptom prevalence in SLE/MCTD and healthy subjects using logistic regression. For SLE/MCTD subjects, we calculated the rate of annual outpatient visits [rheumatology/nephrology, primary care provider (PCP) and emergency department], hospitalizations and rheumatology/nephrology telephone consultations in the preceding year. We compared these outcomes in those with and without depression and anxiety using negative binomial regression.

RESULTS

We identified depression symptoms in 10 (20%) SLE/MCTD and 4 (8%) healthy subjects, representing a trend towards increased prevalence in unadjusted analysis (OR = 2.9, 95% CI 0.8-9.9, p = 0.09). Adjusted analysis did not show a significant difference; however, non-white race was a statistically significant independent risk factor for depression symptoms compared to white race (OR = 5.4, 95% CI 1.1-27.2, p = 0.04). We identified anxiety symptoms in 11 (22%) SLE/MCTD and 13 (26%) healthy subjects, which was not statistically different. Suicidal ideation was present in 7 (14%) SLE/MCTD and 2 (4%) healthy subjects, which was a statistically significant difference (OR = 5.4, 95% CI 1.02-28.3, p = 0.047). Of the 34% of SLE/MCTD subjects with any symptoms, only 24% had previous mental health care. Those with depression symptoms had a statistically significant lower rate of visits to the PCP (IRR = 0.38, 95% CI 0.19-0.76, p < 0.001). Anxiety symptoms were not associated with the healthcare utilization outcomes.

CONCLUSIONS

Depression and anxiety symptoms were prevalent, and suicidal ideation significantly more common in SLE/MCTD than in healthy subjects. Non-white race was an independent risk factor for depression. Despite prevalent symptoms, there were poor rates of prior mental health treatment, and less frequent PCP visits among those with depression symptoms. Further investigation of barriers to mental health care and interventional strategies for symptomatic youth with SLE/MCTD is needed.

Predictors of incident depression in systemic lupus erythematosus

OBJECTIVE

Findings from previous studies of predictors of depression among patients with systemic lupus erythematosus (SLE) have been inconsistent. The aim of our study was to identify risk factors that preceded incident depression based on a large, closely followed longitudinal cohort.

METHODS

Data regarding 1609 patients with SLE in the Hopkins Lupus Cohort who had no history of depression prior to cohort entry were analyzed. Demographic variables, SLE manifestations, laboratory tests, physician's global assessment, Safety of Estrogens in Lupus Erythematosus National Assessment-SLE Disease Activity Index (SELENA-SLEDAI), cumulative organ damage (Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index), and onset of depression were recorded at enrollment and each quarterly visit. Rates of incident depression were calculated overall, and in subgroups defined by demographic and clinical variables. Adjusted estimates of association were derived using pooled logistic regression.

RESULTS

The incidence of depression was 29.7 episodes per 1000 person-years. In the multivariable analysis, these variables remained as independent predictors of incident depression: recent SLE diagnosis, non-Asian ethnicity, disability, cutaneous activity, longitudinal myelitis, and current prednisone use of 20 mg/day or higher. Global disease activity (SELENA-SLEDAI) was not a significant predictor after controlling for prednisone use.

CONCLUSION

Depression in SLE is multifactorial. Higher-dose prednisone (≥ 20 mg daily) is 1 important independent risk factor. Global disease activity is not a risk factor, but cutaneous activity and certain types of neurologic activity (myelitis) are predictive of depression. The independent effect of prednisone provides clinicians with an additional incentive to avoid and reduce high-dose prednisone exposure in SLE.

Mood, anxiety and personality disorders in patients with systemic lupus erythematosus

OBJECTIVE

This study presents the current prevalence of mood, anxiety and personality disorders and factors associated with the existence of psychiatric disorders in patients with systemic lupus erythematosus (SLE).

METHODS

The study sample was comprised of 45 patients with SLE and 60 control subjects. Mood and anxiety disorders were ascertained by means of the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition/Clinical Version. Personality disorders were diagnosed with the Structured Clinical Interview for DSM, Revised Third Edition Personality Disorders. The disease activity was assessed with SLE Disease Activity Index.

RESULTS

Of the 45 patients, 21 (46.7%) had at least one mood or anxiety disorder, and 16 (35.6%) had at least one personality disorder. The most common Axis I and Axis II diagnoses in the patient group were major depression (22.2%) and obsessive-compulsive personality disorder (20.0%), respectively. Specifically, major depression, generalized anxiety disorder and obsessive-compulsive personality disorder were more prevalent in the SLE group compared to the control group. The existence of Axis I disorders was associated with a more severe disease activity of SLE.

CONCLUSION

Mood and anxiety disorders, particularly major depression and generalized anxiety disorder, are frequently observed in patients with SLE.

Effect of autoimmune diseases on cognitive function

The location of both autoimmune processes and other causes of brain inflammation is important in determining the impact of inflammation on brain function. This chapter focuses on autoimmune and infectious diseases leading to inflammatory brain disease resulting in cognitive defects with a special focus on systemic lupus erythematosus (SLE). Collectively called neuropsychiatric SLE (NPSLE), NPSLE occurs in 20-95% of pediatric patients with SLE (pSLE). The incidence of cognitive dysfunction is difficult to ascertain in pediatric patients as few studies have been performed. Using formal neurocognitive testing of unselected pediatric SLE patients, the rate of cognitive abnormalities was approximately 50% and impairment was associated with longer disease duration in one study. A second small study showed global depression on performance and academic scores while a larger study using a neuropsychiatric inventory showed a 55% rate of dysfunction. These diverging findings may result from the lack of a standardized cognitive assessment battery. The Childhood Arthritis and Rheumatology Research Alliance (CARRA) group of pediatric rheumatologists proposed a 2 hour 40 minutes battery for assessment of cognitive testing of SLE patients from age 9 to 18 years. Further assessments using this battery should provide a better neurocognitive profile of pSLE.

Perceived illness stigma is associated with depression in female patients with systemic lupus erythematosus

OBJECTIVES

1) To assess the prevalence of depression in a sample of female patients with systemic lupus erythematosus (SLE) 2) To evaluate the association between perceived illness stigma and depression in those patients.

METHODS

In a cross-sectional study, 80 female SLE patients were evaluated for the presence of depression and perceived illness stigma. Depression was diagnosed using the Structured Clinical Interview for DSM-IV Axis Ι disorders, clinical version (SCID-I-CV), the severity of the depressive symptoms was evaluated using the Hospital Anxiety and Depression Scale-Depression Subscale (HADS-D), and the stigma of illness was assessed using the Stigma Impact Scale (SIS).

RESULTS

The prevalence of depression among female SLE patients was 18.75% (15/80). The perceived illness stigma was higher among the depressed group than among the non-depressed group (SIS mean scores were 43.87±7.87 and 26.62±3.79 respectively P<.001), there was a significant positive correlation between SIS and HAD-D scores (r=0.73, P=.002), and there was a significant association between perceived illness stigma and diagnosis of depression (R(2)=0.53, P=.002, odds ratio=3.2), which increased the severity of depressive symptoms (R(2)=0.64, P<.001).

CONCLUSION

This study demonstrates a significant association between illness stigma and depression in female SLE patients which may be important in promoting optimal coping for these women .

Depression and systemic lupus erythematosus: a systematic review

Objective

Systemic lupus erythematosus (SLE) is a chronic, relapsing–remitting autoimmune disorder that involves multiple organ systems including the central nervous system. Among the items included in the nomenclature for neuropsychiatric SLE, mood disorders have been identified. The aim of this paper is to review the clinical and psychobiological relationship between depression and SLE.

Method

We performed a systematic search of MEDLINE, EMBASE, PsychINFO, using MeSH headings and keywords for ‘depression’ and ‘SLE’.

Results

Seventeen studies reported depressive disorders, with prevalence rates in the range 17–75%. Three studies reported the most frequent symptoms, which may be represented by fatigue, weakness, somatic disorders and sleep disorders. Suicide ideation was much higher than in the general population. Nine studies analysed the relationship to SLE disease activity. The results of the available literature are contradictory. Psychobiological hypotheses have been considered in 13 studies. Among the psychobiological hypotheses which might underline the plausibility of their relationship, ‘psychosocial factors’ were the most frequently reported.

Conclusions

Differences in assessment techniques appear to be the main explanation for the variability in findings and important methodological limitations are present in the available literature to definitively point to the prevalence of depression, type of depression and most prevalent symptoms. To date, the relationship between depression and SLE disease activity also appears controversial. Methodological limitations are present in the available literature and it would be necessary to develop evidence-based guidelines to improve the diagnosis of depression in SLE. Identification of SLE-specific biomarkers of depression also has high priority.

Psychosocial functioning of children with systemic lupus erythematosus

AIMS

Systemic lupus erythematosus (SLE) is a chronic illness in children. Involvement of multiple systems; the chronicity, as well as the treatment, has had great impact on children and their families. The objective of this study was to assess emotional and behavioural problems in childhood lupus during disease remission.

METHODS

Children with SLE and healthy controls, aged 8-15 years, were studied. Disease remission was confirmed by using the SLE Disease Activity Index (SLEDAI). The Children's Depression Inventory (CDI) and Multidimensional Anxiety Scale for Children (MASC) were rated by the children themselves. The Child Behaviour Checklist was completed by their parents.

RESULTS

The sample included 40 children with SLE and 40 controls. Their mean age was 12.9 ± 2.1 and 12.1 ± 1.8 years in the SLE and control groups, respectively. The average duration of the disease was 2.6 years. The SLEDAI in the SLE group ranged from 0-1, indicating inactive disease. The mean CDI scores were 8.9 and 10.9 in lupus children and controls, respectively. The mean MASC score was 44.7 in children with SLE and 48.4 in controls. The internalizing, externalizing and total behavioural scores were not significantly different in both groups (9.0 vs. 10.6; 6.6 vs. 8.1; 27.3 vs. 32.5). Only the social competence score was lower in children with SLE (P= 0.03).

CONCLUSIONS

SLE is a multi-system involvement disease with wide ranging effects on children's physical and psychosocial functioning. However, children with SLE, during inactive disease, were not found to be at increased risk of psychosocial dysfunctions.

[Neuropsychiatric systemic lupus erythematosus (1st part). Cases definitions and diagnosis and treatment of central nervous system and psychiatric manifestations of systemic lupus erythematosus]

Systemic lupus erythematosus (SLE) is an autoimmune disease, which primarily affects skin and joints. Peripheral neurologic syndrome and central nervous system (CNS) manifestations are common in lupus patients but are not always attributable to lupus itself. A classification, published in 1999 by the American College of Rheumatology (ACR) research committee, described 12 CNS syndromes and seven peripheral neurologic syndromes compatible with "neuropsychiatric systemic lupus erythematosus" (NPSLE). Despite this consensus, studies which have been published since 1999 have reported a prevalence of NPSLE varying from 20 to 97 %, which shows the diagnosis difficulty and the heterogeneity of neuropsychiatric manifestations in SLE. In order to understand the limits of this classification, we propose in this first part an exhaustive review of publications describing neuropsychiatric manifestations according to the ACR 1999 classification. We also detail case definitions, prevalence and risk factors, clinical characteristics and diagnosis of each lupus-related psychiatric and CNS manifestation.

Listening to lupus patients and families: fine tuning the assessment

Given the chronicity and uncertainty of lupus, patients and their family members will face physical, financial, social, and emotional challenges that can be overwhelming. This article records the experiences of three different families affected by lupus. Although these patients and families are very different, their perspectives identify common emotional challenges. Understanding these experiences from their perspectives can help facilitate an assessment that is highly attuned to the potential psychosocial impact of lupus on the patient and the family.

Locus of control and lupus: patients' beliefs, perspectives, and disease activity

Patients with lupus often experience a high degree of psychological symptoms such as anxiety, depression, and mood disorders that can influence their beliefs and perceptions of their illness. The purpose of the study was to examine how a patient's self-reported psychosocial needs (depression and anxiety) and beliefs about how much control they have over their health (health locus of control) influences their perception of disease chronicity and acuity. The study findings were based on a survey of 378 patients self-diagnosed with lupus.

Psychiatric disorders in patients with systemic lupus erythematosus: association of anxiety disorder with shorter disease duration

Physicians' awareness about neuropsychiatric syndromes in systemic lupus erythematosus (SLE) is not rarely limited to seizures and psychoses included in the American College of Rheumatology (ACR) classification. Involvement of the central nervous system (CNS) with its rich symptomatology still belongs to the faintly recognised and understood aspects of lupus. The objective was to investigate prevalence and clinical correlations of psychiatric disorders in SLE patients. Fifty-two SLE patients were included. Disease duration and current and cumulative corticosteroid doses were calculated. Disease activity was assessed with the Systemic Lupus Activity Measure (SLAM). All subjects were examined by a psychiatrist. Psychiatric disorders were classified according to ACR criteria for neuropsychiatric systemic lupus erythematosus (NPSLE). Mini-Mental State Examination (MMSE) and Clock Drawing Test (CDT) were used to screen for cognitive impairments. Mental disorders were diagnosed in 16 (30.77%), depressive disorder in 6 (11.54%), cognitive dysfunction in 5 (9.62%), anxiety disorder in 4 (7.69%) and psychosis in one patient (1.92%). SLE duration was shorter in patients diagnosed with anxiety disorder (P < 0.05), and cumulative dose of corticosteroids was lower in patients with anxiety disorder (P < 0.01). There was high positive correlation between SLE duration and cumulative dose of corticosteroids (r = 0.684, P < 0.001). Shorter SLE duration in patients with anxiety disorder seems to reflect its adaptative nature.

Damage accrual, cumulative glucocorticoid dose and depression predict anxiety in patients with systemic lupus erythematosus

The burden of anxiety in patients with systemic lupus erythematosus (SLE) compared to those with other inflammatory rheumatological conditions is unclear. We aimed to compare the frequency and level of anxiety between patients with SLE, rheumatoid arthritis (RA), and gout and healthy individuals and explore independent predictors for anxiety in SLE patients. Consecutive patients with SLE, RA and gout and healthy individuals who were age and sex matched with the SLE group were evaluated for anxiety using the Hospital Anxiety and Depression Scale (HADS). Sociodemographic and disease-related variables were compared between all groups. Predictors for anxiety were studied by regression models, with construction of a prediction model for the presence of anxiety in SLE patients by the receiver operating characteristic (ROC) analysis. Amongst 271 subjects studied, 60 had lupus, 50 had gout, 100 had RA and 61 were healthy controls. The frequency and level of anxiety were significantly higher in SLE patients than patients with gout, RA and healthy controls. SLE per se was independently associated with higher HADS-anxiety score after controlling for potential confounders. Logistic regression model showed that higher damage accrual, higher cumulative glucocorticoid dose, depression and fewer regular medications predicted anxiety in SLE patients, with an accuracy of 90% by the ROC analysis.

Neurodevelopment in the offspring of Japanese systemic lupus erythematosus patients

OBJECTIVE

To evaluate pregnancy outcome of systemic lupus erythematosus (SLE) and the neuropsychological outcomes in offspring of SLE mothers.

STUDY DESIGN

Pregnancy outcomes of SLE patients from 1989 to 2006 were determined and the neuropsychological development of the children born to SLE patients was examined suited for their age; Bayley Scales of Infant Development up to four years and Kauffmann Assessment Battery for Children from four years onwards.

RESULTS

Of the 233 deliveries, 58 (24.7%) were preterm, 72 (30.9%) were low-birth-weight, and 46 (19.7%) were IUGR. Twenty-six children enrolled in this study had normal intelligence. The mean MDI and PDI were 95.8+/-10.1 and 94.6+/-14.1, respectively. The mean scores for the Sequential Processing scale, Simultaneous Processing scale, and Mental Processing composite were 103.1+/-13.3, 104.2+/-10.2, and 104.2+/-12.2, respectively. In the children with anti-Ro/SS-A antibody-positive mothers, mean gestational age and birth weight were significantly lower (p<0.05), as a result, the mean score of Sequential Processing and Mental Processing were significantly lower than that of negative mothers. The presence of maternal antiphospholipid antibody was not related to gestational age, birth weight and any score on the intelligence tests, except for the rate of IUGR.

CONCLUSION

The rates of preterm delivery and IUGR were frequent in the SLE patients and careful monitoring and management of the disease during pregnancy are still necessary. We should examine the neurodevelopment of the children born from mothers with anti-Ro/SS-A antibody prospectively.

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

OBJECTIVE

To examine the lifetime prevalence of mood and anxiety disorders in patients with systemic lupus erythematosus (SLE). Demographic and disease-related variables were examined for association with lifetime major depressive disorder (MDD) and the presence of any mood or anxiety disorder.

METHODS

Three hundred twenty-six white women with SLE completed the Composite International Diagnostic Interview and the Systemic Lupus Activity Questionnaire, a self-report measure of SLE disease activity. The binomial test was used to compare the prevalence of psychiatric diagnoses in patients with SLE with a population sample of white women.

RESULTS

Sixty-five percent of the participants received a lifetime mood or anxiety diagnosis. MDD (47%), specific phobia (24%), panic disorder (16%), obsessive-compulsive disorder (9%), and bipolar I disorder (6%) were more common among patients with SLE than among other white women (P = 0.00009 for specific phobia; for all other values P = 0.00001). Although most patients with histories of mood disorders reported their psychiatric symptoms to a medical provider, a substantial number of patients with anxiety disorders did not. Self-reported disease activity was associated with a lifetime history of MDD (P = 0.001) and presence of a mood or anxiety disorder (P = 0.001), after controlling for demographic and clinical characteristics.

CONCLUSION

Several mood and anxiety disorders were more common in women with SLE compared with the general population, and disease activity may contribute to this higher risk. Brief self-report questionnaires may help providers identify patients with these conditions, particularly when patients are reluctant to disclose their symptoms.

Psychiatric manifestations in systemic lupus erythematosus

Psychiatric abnormalities are common in systemic lupus erythematosus (SLE) with a prevalence of 17% to 75%, reflecting different methods of patient selection and assessment, the different professional orientation of clinicians, and lack of an accepted consensus for diagnosing active neuropsychiatric lupus (NPSLE). The psychiatric syndromes included in the ACR Neuropsychiatric Lupus Nomenclature Committee criteria are cognitive dysfunction, acute confusional state (delirium), anxiety disorder, mood disorder, and psychosis. In SLE patients, identification of psychiatric phenomena and the generation of a differential diagnosis are crucial. Possible mechanisms include vascular injury and pathogenic antibodies. Treatment strategies are based on small case studies. The purpose of this review is to discuss clinical manifestations, pathogenesis and the present therapeutic options in psychiatric lupus.

The relationship between anxiety disorders and physical disorders in the U.S. National Comorbidity Survey

Although depression has clearly been shown to be associated with physical disorders, few studies have examined whether anxiety disorders are independently associated with medical conditions after adjusting for comorbid mental disorders. We examined the relationship between anxiety disorders and a wide range of physical disorders in a nationally representative sample. Data came from the National Comorbidity Survey (N=5,877, range=age 15-54 years, response rate=82.4%). The Composite International Diagnostic Interview [Kessler et al., 1998] was used to make DSM-III-R [American Psychiatric Association, 1987] mental disorder diagnoses. Physical disorders were assessed based on a list of several conditions shown to respondents. All analyses utilized multiple logistic regression to examine the relationship between past-year anxiety disorder diagnosis and past-year chronic physical disorder. Anxiety disorders were positively associated with physical disorders even after adjusting for mood disorders, substance-use disorders, and sociodemographics. Among respondents with one or more physical disorders, a comorbid anxiety disorder diagnosis was associated with an increased likelihood of disability even after adjusting for severity of pain, comorbid mood, and substance use disorders. Among specific anxiety disorders, posttraumatic stress disorder, panic attacks, and agoraphobia were more likely to be associated with specific physical disorders than generalized anxiety disorder, social phobia, or simple phobia. There is a strong and unique association between anxiety disorders and physical disorders. Clinically, the presence of an anxiety disorder among patients with physical disorders may confer a greater level of disability.

Major life stress, coping styles, and social support in relation to psychological distress in patients with systemic lupus erythematosus

The objective of this study was to examine psychological processes in systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) patients in relation to measures of life stress, coping styles, social support and cognitive ability. Fifty-two SLE patients without overt neuropsychiatric symptoms, 29 RA patients and 27 healthy controls completed measures of depression, mood, disease activity, perceived health, stressful life events, coping, and social support. Variables entered into the multiple regression analysis following principal component analysis were: group, major difficult event, major life threatening event, disengaging coping, emotional coping, social support, and cognitive impairment. Depressive symptoms were associated with SLE group status (P < 0.001), major life-threatening events (P < 0.01), disengage coping (P < 0.001) and emotional coping (P < 0.05). SLE group status (P < 0.05), disengage coping (P < 0.05) and emotional coping (P < 0.05) were associated with current distressed mood. SLE patients without overt, major neuropsychiatric symptoms had greater psychological distress compared to RA and control subjects. Increased depressive symptoms and distressed mood state in SLE patients were related to use of disengaging and emotional coping styles. These findings are limited to SLE patients with no overt neuropsychiatric illness and low disease activity, suggesting the need for future studies with a greater variety of SLE patients. Interventions aimed at improving active coping and minimizing emotional response to stress may lower psychological distress in SLE patients with mild disease.

Autoantibody profile in systemic lupus erythematosus with psychiatric manifestations: a role for anti-endothelial-cell antibodies

This study was performed to determine the correlation between psychiatric manifestations and several autoantibodies that might participate in the pathogenesis of psychiatric disorders in the course of systemic lupus erythematosus (SLE). Fifty-one unselected outpatients with SLE were enrolled. Psychiatric evaluation was performed according to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition. The prevalence of antibodies against endothelial cells (AECA), cardiolipin, β2 glycoprotein I, Ro, Ro52, La, glial fibrillary acidic protein, ribosomal P protein, dsDNA, and nucleosomes was assessed by experimental and commercial enzyme-linked immunosorbent assays. According to the cutoff value, AECA were present in 11 of 17 (64.7%) SLE patients with psychosis and mood disorders and in 10 of 34 (29.4%) patients without psychiatric manifestations other than anxiety (P = 0.03). Moreover, the AECA binding index was significantly higher in the first group (P = 0.03). Conversely, no significant correlation was found between the presence of the other autoantibodies studied and psychiatric involvement. The results of this study suggest a relationship between AECA and psychosis and mood disorders in SLE, supporting the hypothesis of a biological origin of these disturbances.

Cognitive dysfunction in neuropsychiatric systemic lupus erythematosus

Neuropsychiatric syndromes associated with systemic lupus erythematosus are common, but diverse in etiology and presentation. Cognitive dysfunction is prevalent among these syndromes, but exhibit a significant degree of heterogeneity both within and between patient variability. Earlier studies of SLE-associated cognitive dysfunction addressed its identification and description. Common associations were repeatedly acknowledged, including concomitant or past neuropsychiatric disease, use of corticosteroids, disease activity, emotional disturbance, and antiphospholipid antibodies. The past several years have focused more on elucidating the relative strengths of various risk associations, patterns of cognitive abnormalities, both cross-sectionally and longitudinally (, clinical course), and novel means to identify cognitive impairment, both functionally and biologically.

[Clinical and serological characteristics of systemic lupus erythematosus: 128 cases]

OBJECTIVE

To analyse the clinical and serological characteristics of systemic lupus erythematosus (SLE) in the center of Tunisia.

METHODS

We studied 128 patients with SLE aged one to 73 years. Antinuclear antibodies (ANA) were detected by an immunofluorescence method. Anti-double-stranded DNA (anti-dsDNA) antibodies, anti-extractable nuclear antigen antibodies (anti-Sm, anti-SS-A, anti-SS-B and anti-RNP) and anti-cardiolipin (aCL of IgG, IgA and IgM isotypes) antibodies were detected by ELISA.

RESULTS

Malar rash (71%) and anemia (71%) were the most common clinical manifestations. Arthritis was seen in 62.5%. Severe kidney damage was observed in 39%. Pericarditis and pleuritis were observed in only 23%. Neurological manifestations (16%) were uncommon. Clinical manifestations of anti-phospholipid syndrome (SAPL) were observed in 15%. ANA were detected in 100%, anti-dsDNA in 76%, anti-Sm in 55.5%, anti-SS-A in 64%, anti-SS-B in 33.6%, anti-RNP in 49%. aCL of IgG, IgA and IgM isotypes were detected in 63.5%, 49% and 40.6% of the patients respectively. The only significant positive clinical associations were those of arthritis with anti-dsDNA antibodies (p = 0.022) and malar rash with anti-SS-A antibodies (p = 0.002).

CONCLUSIONS

This study suggests that tunisians with SLE present, in general, a mild form of disease predominantly manifested by cutaneous, musculoskeletal and hematologic involvement but low prevalence of major organ damage.