Systemic lupus erythematosus (SLE) is a chronic, relapsing autoimmune disorder that is most prevalent in women and involves multiple organ systems (1). Due to the potentially debilitating nature of the disease and relatively early onset for many women, SLE can pose multiple challenges and disrupt life goals throughout adulthood. Previous studies have found higher levels of psychiatric disturbance in patients with SLE, particularly depression or distress (2–10). The reported prevalence of depressive symptomatology in SLE varies widely across studies, from 17 to 71% (11). This variation is likely due to divergent criteria used to define distress or psychiatric disturbance, differences in sample characteristics, the assessment tools used, and small sample sizes. Some studies, but not all, have found that greater disease activity, SLE severity or longer disease duration increases vulnerability for clinical depression in SLE (4–12).

Although most research has focused on depressed mood or clinical unipolar depression in SLE, others suggest that symptoms of anxiety may be equally important in this population. In an Icelandic study of 62 SLE patients, diagnoses of agoraphobia with and without panic, specific phobia and social phobia were more prevalent in SLE patients than the general population (13). Segui et al. (6) reported that among 20 female SLE patients, 40% met criteria for a psychiatric disorder, with generalized anxiety disorder and panic disorder being the most common diagnoses. Higher levels of social introversion (10) and obsessive-compulsive disorder have also been reported in patients with SLE (14), compared to healthy controls or population rates. Because population prevalence rates of some anxiety and depressive disorders are low, employing larger sample sizes to examine rates of these disorders in SLE is advantageous (15).

In the United States, epidemiological studies indicate that comorbidity of psychiatric disorders is common, with more than half of all lifetime disorders occurring in 14% of the population who have a history of three or more comorbid disorders and only 21% of lifetime disorders occurring in respondents with a history of just one disorder (15). These findings suggest that while a history of psychiatric disorders is common (affecting nearly 50%), the major burden of such disorders is concentrated in a highly comorbid group (15). No studies to date have examined the comorbidity of psychiatric disorders among patients with SLE.

In addition to high rates of psychiatric comorbidity, U.S. studies also find an underutilization of professional services for emotional problems (15–16). Fewer than 40% of respondents with any lifetime psychiatric disorder receive professional treatment (15). Physicians provide the most care for psychiatric problems in the U.S. and primary care physicians are responsible for almost all referrals to mental health specialists (17–18). Because rheumatology patients may visit their rheumatologists as often or more often than primary care providers (19), rheumatologists can also play an important role in identifying and facilitating the treatment of psychiatric problems. Recently, Sleath et al. (20) found that only 19% of depressed patients with rheumatoid arthritis discussed depression with their rheumatologists during medical visits, and that patients initiated the discussion each time.

The purpose of this study is to investigate lifetime prevalence rates of anxiety and depressive disorders in patients with SLE. It extends previous work by simultaneously assessing multiple lifetime anxiety and mood disorders in a large sample of SLE patients, using a reliable and validated structured clinical interview, and diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV, 21). In addition, we determine rates of comorbidity for lifetime disorders and the prevalence of symptom reporting to medical providers in the sample. Finally, demographic and clinical characteristics of SLE, including duration of disease, recent self-reported disease activity, history of renal involvement (as an indicator of SLE severity), and current prednisone use are examined as potential correlates of lifetime major depression and presence of a psychiatric disorder.

https://onlinelibrary.wiley.com/doi/pdf/10.1002/art.24519

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

Activation of the immune system during various medical conditions produces neural, neuroendocrine, and behavioral effects. The psychological and physiological effects of immune activation resemble many characteristics of depression. The essential features of depression are depressed mood and loss of interest or pleasure in all, or almost all activities (anhedonia). Several associated symptoms are also present, including, appetite disturbance, change in body weight, sleep disturbance, psychomotor disturbance, fatigue, loss of energy, and difficulty in thinking or concentrating (DSM-IV, 1994). Depression is also characterized by specific alterations in the functioning of neurochemical and neuroendocrine systems, including monoaminergic systems and the hypothalamic-pituitary-adrenal (HPA) axis (Brown, Steinberg, & van Praag, 1994; Holsboer, 1995). Most of these psychological and neuroendocrine symptoms appear both in humans and animals during diseases that involve immune activation. Based on these findings, and on several additional lines of evidence that will be presented below, we have recently argued that immune activation is involved in the etiology and symptomatology of depression associated with various medical conditions (Yirmiya, 1997).

/pdf/cytokines-depression-due-to-a-general-medical-condition-and-1rw0hiu0qi.pdf

Cytokines, "depression due to a general medical condition," and antidepressant drugs.

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

Depression and systemic lupus erythematosus: a systematic review

Objectives. To establish the central nervous system (CNS) manifestations of systemic lupus erythematosus (SLE) as described in the literature and to compare the results with two previously published classifications. Methods. Using PUBMED, a systematic search was performed for publications from 1980 onwards on CNS syndromes of patients with SLE. A distinction was made between CNS syndromes induced by SLE and the CNS autoimmune diseases associated with SLE. Criteria were defined for inclusion of CNS syndromes or diseases as SLE-induced or SLE-associated. Results. The literature search yielded names of 30 syndromes and two diseases, but only 16 syndromes and one disease fulfilled the set of predefined criteria. Two syndromes—depression and anxiety—were predominantly psychological in origin in most patients; other syndromes were biological. Discussion. Strengths and weaknesses of two classifications of CNS syndromes are evaluated. The older of the two is long and has not been accepted fully. Brevity is an advantage of the American College of Rheumatology (ACR) nomenclature system. A disadvantage of this system is the concealment of differences in health risks by the pooling of items. Furthermore, the items of the system do not all belong to the same dimension: one is pathological and the others are clinical. To remedy these drawbacks, we suggest the rephrasing and subdivision of items and that the predominantly psychopathological syndromes should be dealt with separately in epidemiological studies. Conclusions. SLE may induce 16 different clinical syndromes of the CNS and is occasionally associated with one other CNS autoimmune disease. A modification of the ACR nomenclature system is proposed.

/pdf/the-central-nervous-system-in-systemic-lupus-erythematosus-1etffbwd28.pdf

The central nervous system in systemic lupus erythematosus. Part 1. Clinical syndromes: a literature investigation

Lupus nephritis in childhood usually presents after the age of 10 years, and presentation under 5 years is very rare. More males (F:M ratio 4.5:1) are affected than in adult-onset cases, but the ratio is the same in prepubertal and pubertal children. The incidence of clinically evident renal disease is greater at onset than in adults (82%), the usual presentation being with proteinuria, 50% having a nephrotic syndrome. Half the children show World Health Organisation class IV nephritis in renal biopsies. Neuropsychiatric lupus is present at onset in 30%, may complicate 50% at some point and remains a major problem. Prognosis has improved greatly over the past 30 years, at least in part the result of immunosuppressive treatment. Treatment of the initial phase may be guided by the severity of the renal biopsy appearances, more aggressive treatment including cytotoxic agents, i.v. methylprednisolone and perhaps plasma exchange, although the value of exchange is not established. Controversy persists as to the most effective cytotoxic treatment in the acute phase, both oral and i.v. cyclophosphamide and azathioprine being used in different units. In the chronic maintenance phase it seems established both clinically and histologically that addition of a cytotoxic agent improves outcome, but again the drug and route of administration are contentious. Azathioprine has the advantage of being safe for pregnancy and not gonadotoxic, whilst i.v. cyclophosphamide has been demonstrated to improve results over prednisolone alone in controlled trials and has advantages in non-compliant patients. No trial comparing the two regimes has been carried out, and one is needed. Today children much less commonly go into renal failure, and the main causes of actual death (15% of patients over 10 years) are now infections and extra-renal manifestations of lupus, principally neurological. Morbidity of the disease and the treatment remain a major problem, especially when treatment exacerbates complications of the disease itself, such as infections, osteonecrosis, thrombosis, vascular disease and possibly neoplasia.

Lupus nephritis in childhood and adolescence.

SUMMARY

The frequency and type of psychiatric disease were investigated in 40 patients suffering from systemic lupus erythematosus (SLE) and 27 control subjects with rheumatoid arthritis or inflammatory bowel disease. The psychiatric morbidity at the time of interview was the same in the two groups, but the patients with SLE had experienced more episodes of psychiatric illness in the past, and psychotic symptoms occurred only in this group.

Half of the patients with SLE had previous or current evidence of neurological involvement; an association was found between neurological disease and psychotic symptoms in SLE, while anxiety and affective disturbances appeared to be closely related to environmental factors in both patients with SLE and controls. There was no correlation between psychiatric and neurological disease and clinical or laboratory indices of disease activity. Magnetic resonance imaging of the brain was performed in 15 patients with SLE. Abnormalities were more often present in those with neurological disease; no such correlation was found with psychiatric illness.

Psychiatric and neurological manifestations in systemic lupus erythematosus.

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Psychiatric and neurological manifestations in systemic lupus erythematosus.