The inter-correlation between and co-existence of depression and anxiety may engender inconsistency in addressing the relationship between the severity of depression and disease activity of systemic lupus erythematosus (SLE). We aimed at identifying whether lupus disease activity is independently associated with depression and anxiety in lupus patients.
Methods
Adult lupus patients were assessed for the severity of depressive and anxiety symptoms and lupus disease activity by using the Hospital Anxiety and Depression Scale (HADS) and the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI), respectively. Age- and gender-matched healthy controls (HCs) were recruited for comparison. Prevalence and severity of depressive and anxiety symptoms were compared between lupus patients and HCs. Independent relationships between the severity of anxiety (HADS-Anxiety) and depressive (HADS-Depression) symptoms, and SLEDAI were studied with regression models.
Results
In total, 110 lupus patients and 110 HCs were studied. Lupus patients had significantly higher HADS scores than HCs (10.82 ± 6.5 vs 7.34 ± 4.9, p < 0.001). Significantly more lupus patients had anxiety (40.9 vs 21.8%, p = 0.002) and depressive symptoms (15.5 vs 6.4%, p = 0.025) than HCs. Multiple linear regression analyses revealed that SLEDAI (β = 0.160, p = 0.016), calcineurin inhibitor non-use (β = –1.929, p = 0.041) and past cyclophosphamide non-use (β = –1.603, p = 0.039) independently predicted HADS-Anxiety amongst lupus patients even after adjusting for HADS-Depression. Conversely, SLEDAI (β = 0.014, p = 0.834) lost its significant univariate correlation with HADS-Depression after controlling for HADS-Anxiety and other covariates.
Conclusion
Anxiety is more common in lupus patients than in HCs, and its severity is independently associated with more active SLE regardless of the presence or absence of concomitant depression.
BachenEAChesneyMACriswellLA. Prevalence of mood and anxiety disorders in women with systemic lupus erythematosus. Arthritis Rheum2009; 61: 822–829.
3.
LangoschJRandSGhoshB. A clinical electrophysiological study of emotional lability in patients with systemic lupus erythematosus. J Neuropsychiatry Clin Neurosci2008; 20: 201–209.
4.
BerlitP. Neuropsychiatric disease in collagen vascular diseases and vasculitis. J Neurol2007; 254(Suppl 2): II87–II89.
5.
AinialaHLoukkolaJPeltolaJKorpelaMHietaharjuA. The prevalence of neuropsychiatric syndromes in systemic lupus erythematosus. Neurology2001; 57: 496–500.
6.
UguzFKucukACicekEKayhanFTuncR. Mood, anxiety and personality disorders in patients with systemic lupus erythematosus. Compr Psychiatry2013; 54: 341–345.
7.
CavacoSMartins da SilvaASantosE. Are cognitive and olfactory dysfunctions in neuropsychiatric lupus erythematosus dependent on anxiety or depression?J Rheumatol2012; 39: 770–776.
8.
SchmedingASchneiderM. Fatigue, health-related quality of life and other patient-reported outcomes in systemic lupus erythematosus. Best Pract Res Clin Rheumatol2013; 27: 363–375.
9.
LauCSMakA. The socioeconomic burden of SLE. Nat Rev Rheumatol2009; 5: 400–404.
10.
KasitanonNAchsavalertsakUManeetonB. Associated factors and psychotherapy on sleep disturbances in systemic lupus erythematosus. Lupus2013; 22: 1353–1360.
11.
ShenBFengGTangW. The quality of life in Chinese patients with systemic lupus erythematosus is associated with disease activity and psychiatric disorders: A path analysis. Clin Exp Rheumatol2014; 32: 101–107.
12.
TamLSWongAMokVC. The relationship between neuropsychiatric, clinical, and laboratory variables and quality of life of Chinese patients with systemic lupus erythematosus. J Rheumatol2008; 35: 1038–1045.
13.
StollTKauerYBüchiSKlaghoferRSenskyTVilligerPM. Prediction of depression in systemic lupus erythematosus patients using SF-36 Mental Health scores. Rheumatology (Oxford)2001; 40: 695–698.
14.
TenchCMMcCurdieIWhitePDD’CruzDP. The prevalence and associations of fatigue in systemic lupus erythematosus. Rheumatology (Oxford)2000; 39: 1249–1254.
15.
DönmezSPamukÖNÜmitEGTopMŞ. Autoimmune rheumatic disease associated symptoms in fibromyalgia patients and their influence on anxiety, depression and somatisation: A comparative study. Clin Exp Rheumatol2012; 30(6 Suppl 74): 65–69.
16.
Torrente-SegarraVCarbonell-AbellóJCastro-OreiroSManresa DomínguezJM. Association between fibromyalgia and psychiatric disorders in systemic lupus erythematosus. Clin Exp Rheumatol2010; 28(6 Suppl 63): S22–S26.
17.
García MoralesMCallejas RubioJIPeralta-RamírezMI. Impaired sexual function in women with systemic lupus erythematosus: A cross-sectional study. Lupus2013; 22: 987–995.
18.
DoriaARinaldiSErmaniM. Health-related quality of life in Italian patients with systemic lupus erythematosus. II. Role of clinical, immunological and psychological determinants. Rheumatology (Oxford)2004; 43: 1580–1586.
19.
MokCCChanKLCheungEFYipPS. Suicidal ideation in patients with systemic lupus erythematosus: Incidence and risk factors. Rheumatology (Oxford)2014; 53: 714–721.
20.
MakATangCSChanMFCheakAAHoRC. Damage accrual, cumulative glucocorticoid dose and depression predict anxiety in patients with systemic lupus erythematosus. Clin Rheumatol2011; 30: 795–803.
21.
WaldheimEElkanACPetterssonS. Health-related quality of life, fatigue and mood in patients with SLE and high levels of pain compared to controls and patients with low levels of pain. Lupus2013; 22: 1118–1127.
22.
FriedmanAWTewiMBAhnC. Systemic lupus erythematosus in three ethnic groups: XV. Prevalence and correlates of fibromyalgia. Lupus2003; 12: 274–279.
23.
NeryFGBorbaEFHatchJPSoaresJCBonfáENetoFL. Major depressive disorder and disease activity in systemic lupus erythematosus. Compr Psychiatry2007; 48: 14–19.
24.
WalkerSESmarrKLParkerJCWeidensaulDNNelsonWMcMurrayRW. Mood states and disease activity in patients with systemic lupus erythematosus treated with bromocriptine. Lupus2000; 9: 527–533.
25.
NeryFGBorbaEFVianaVS. Prevalence of depressive and anxiety disorders in systemic lupus erythematosus and their association with anti-ribosomal P antibodies. Prog Neuropsychopharmacol Biol Psychiatry2008; 32: 695–700.
26.
ShortallEIsenbergDNewmanSP. Factors associated with mood and mood disorders in SLE. Lupus1995; 4: 272–279.
27.
JarpaEBabulMCalderónJ. Common mental disorders and psychological distress in systemic lupus erythematosus are not associated with disease activity. Lupus2011; 20: 58–66.
28.
LimLRonMAOrmerodIE. Psychiatric and neurological manifestations in systemic lupus erythematosus. Q J Med1988; 66: 27–38.
29.
KheirandishMFaeziSTParagomiP. Prevalence and severity of depression and anxiety in patients with systemic lupus erythematosus: An epidemiologic study in Iranian patients. Mod Rheumatol2015; 25: 405–409.
30.
PalaginiLMoscaMTaniCGemignaniAMauriMBombardieriS. Depression and systemic lupus erythematosus: A systematic review. Lupus2013; 22: 409–416.
31.
WehryAMMcNamaraRKAdlerCM. Neurostructural impact of co-occurring anxiety in pediatric patients with major depressive disorder: A voxel-based morphometry study. J Affect Disord2014; 171: 54–59.
32.
HochbergMC. Updating the American College of Rheumatology revised criteria for the classification of systemic lupus erythematosus. Arthritis Rheum1997; 40: 1725–1725.
33.
HärterMWollSWunschABengelJReuterK. Screening for mental disorders in cancer, cardiovascular and musculoskeletal diseases. Comparison of HADS and GHQ-12. Soc Psychiatry Psychiatr Epidemiol2006; 41: 56–62.
34.
LamCLPanPCChanAWChanSYMunroC. Can the Hospital Anxiety and Depression (HAD) Scale be used on Chinese elderly in general practice?Fam Pract1995; 12: 149–154.
35.
GladmanDDGoldsmithCHUrowitzMB. Crosscultural validation and reliability of 3 disease activity indices in systemic lupus erythematosus. J Rheumatol1992; 19: 608–611.
36.
GladmanDGinzlerEGoldsmithC. The development and initial validation of the Systemic Lupus International Collaborating Clinics/American College of Rheumatology damage index for systemic lupus erythematosus. Arthritis Rheum1996; 39: 363–369.
37.
FieldA. Regression. In: Discovering statistics using SPSS, 3rd ed. London: SAGE, 2005, pp. 197–263.
38.
KarolDECriscione-SchreiberLGLinMClowseME. Depressive symptoms and associated factors in systemic lupus erythematosus. Psychosomatics2013; 54: 443–450.
39.
AldarHLapaATBelliniB. Prevalence and clinical significance of anti-ribosomal P antibody in childhood-onset systemic lupus erythematosus. Lupus2012; 21: 1225–1231.
40.
Abdel-NasserAMGhalebRMMahmoudJAKhairyWMahmoudRM. Association of anti-ribosomal P protein antibodies with neuropsychiatric and other manifestations of systemic lupus erythematosus. Clin Rheumatol2008; 27: 1377–1385.
41.
ContiFAlessandriCBompaneD. Autoantibody profile in systemic lupus erythematosus with psychiatric manifestations: A role for anti-endothelial-cell antibodies. Arthritis Res Ther2004; 6: R366–R372.
MakATangCSHoRC. Serum tumour necrosis factor-alpha is associated with poor health-related quality of life and depressive symptoms in patients with systemic lupus erythematosus. Lupus2013; 22: 254–261.
44.
ManeetonBManeetonNLouthrenooW. Prevalence and predictors of depression in patients with systemic lupus erythematosus: A cross-sectional study. Neuropsychiatr Dis Treat2013; 9: 799–804.
45.
MokCCLauCSWongRW. Neuropsychiatric manifestations and their clinical associations in southern Chinese patients with systemic lupus erythematosus. J Rheumatol2001; 28: 766–771.
46.
HollowayLHumphreyLHeronL. Patient-reported outcome measures for systemic lupus erythematosus clinical trials: A review of content validity, face validity and psychometric performance. Health Qual Life Outcomes2014; 12: 116–116.
47.
TugluCKaraSHCaliyurtOVardarEAbayE. Increased serum tumor necrosis factor-alpha levels and treatment response in major depressive disorder. Psychopharmacology (Berl)2003; 170: 429–433.
48.
WaheedAHameedKKhanAMSyedJAMirzaAI. The burden of anxiety and depression among patients with chronic rheumatologic disorders at a tertiary care hospital clinic in Karachi, Pakistan. J Pak Med Assoc2006; 56: 243–247.
