Quantifying the Association Between Anxiety and Depressive Features and High Disease Activity Scores in SLE

Anxiety and depression are two of the most common conditions encountered by budding physicians, regardless of their primary specialty. Within rheumatoid arthritis, these conditions can adversely affect the patient’s experience at several points. Access to health care and treatment may be limited, resulting in delayed diagnosis, poor adherence to treatment, and consequent poor disease management with associated negative sequelae. The clinical symptoms of anxiety and depression may overlap with features of active rheumatic disease, exacerbating the symptom burden experienced by patients.1 Within the paradigm of systemic lupus erythematosus (SLE), fatigue symptoms become more pronounced and may be exacerbated with a concurrent diagnosis of depression.2 In addition, characteristics of undertreated depression and anxiety were significant confounders when evaluating outcome measures such as Visual Analogue Scales (VAS), Short Form 36, FACIT-Fatigue, and other patient-reported outcome scores. may become.3

A recent Chinese single-center, observational, cross-sectional study evaluated the impact of SLE disease activity on the prevalence of anxiety or depressive features.Four The study enrolled 325 patients aged 18 years and older with SLE as defined by the 2012 Systemic Lupus International Collaborative Clinic (SLICC) criteria. The main exclusion criteria were previous diagnosis of anxiety/depression or other psychiatric illness, major organ pathology, and history of substance abuse. Depressive characteristics were assessed using the Patient Health Questionnaire-9 (PHQ-9) and anxiety characteristics using his 7-item Generalized Anxiety Disorder Scale (GAD-7). SLE disease activity was assessed using the SLE Disease Activity Index (SLEDAI).

Of the 325 patients enrolled in the study, 61.5% had a PHQ-9 score consistent with severe depression and 54.4% had a GAD-7 score consistent with severe anxiety. Patients with significant depressive/anxiety features had significantly higher her SLEDAI scores (p = 0.001) and significantly higher rates of musculoskeletal and neuropsychiatric involvement than their counterparts. This is consistent with previous studies that showed that musculoskeletal features were an important factor in her patient experience with SLE.Five

The main confounders were almost identical between the anxiety/depression and non-anxiety/depression groups, except for household income. Those with lower household income, defined as having a household income greater than 50,000 RMB (RMB), had higher rates of depression than those with higher income (p = 0.005).

The authors used receiver operating characteristic (ROC) curve analysis to assess the utility of SLEDAI as a predictor of depression or anxiety in patients with SLE. An optimal cutoff of SLEDAI >8.5 showed 50.5% sensitivity and 78.4% specificity in predicting depression (AUC 0.660, p < 0.001). This cutoff had a sensitivity of 54.2% and a specificity of 78.4% in predicting significant anxiety (AUC 0.684, p < 0.001).

This study has some limitations. The authors identify the lack of longitudinal data as an important factor. Lack of ethnic diversity within the cohort is another important consideration. As with most SLE studies, the selected disease activity scores have some additional limitations. The SLEDAI scores features based on the presence or absence of features such as arthritis, rashes, and oral ulcers. Therefore, a patient with severe rash over 50% of her body surface area would score the same as a patient with mild cheek rash. Moreover, patients with 2 synovial joints score the same as those with 12 synovial joints, despite very different clinical presentations. Therefore, using an alternative measure such as the British Isles Lupus Assessment Group (BILAG-2004) score may be more accurate in describing a patient’s individual symptom burden.6 While it is understandable to exclude people with pre-existing diagnoses of anxiety/depression in this study, given the widespread prevalence of these diagnoses, the generalization of these findings in rheumatology clinics It may limit your possibilities.

This study provides welcome data on the underestimated and often underaddressed function of long-term SLE management. However, this paper provides welcome quantitative evidence for this fact. Holistic care of SLE is important, and the mental health sequelae of high disease activity should be addressed in a manner similar to musculoskeletal or mucocutaneous features.


1. Arnaud L, Mertz P, Amoura Z, Voll RE, Schwarting A, Maurier F, et al. Association of fatigue patterns with disease activity and clinical manifestations in systemic lupus erythematosus.Rheumatology [Internet]June 18, 2021 [cited 2021 Jul 7];60(6):2672–7. Available from https://pubmed.ncbi.nlm.nih.gov/33175957/

2. Figueiredo-Braga M, Cornaby C, Cortez A, Bernardes M, Terroso G, Figueiredo M, et al. Depression and anxiety in systemic lupus erythematosus: crosstalk between immunological, clinical, and psychosocial factors. Medicine (Baltimore) [Internet]July 1, 2018 [cited 2023 Jan 17];97(28). Available at: /pmc/articles/PMC6076116/

3. Meacock R, Dale N, Harrison MJ.The humane and economic burden of systemic lupus erythematosus: a systematic review. [Internet]. roll. 31, Pharmacoeconomics.Springer; 2013 [cited 2021 Jul 2].p. 49–61. Available from https://link.springer.com/article/10.1007/s40273-012-0007-4

4. Liao J, Kang J, Li F, Li Q, Wang J, Tang Q, et al. A cross-sectional study of the association between anxiety and depression and systemic lupus erythematosus disease activity. BMC Psychiatry [Internet]December 1, 2022 [cited 2022 Oct 6];22(1):591. Available at https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-022-04236-z

5. Chaigne B, Chizzolini C, Perneger T, Trendelenburg M, Huynh-Do U, Dayer E, et al. Impact of disease activity on health-related quality of life in systemic lupus erythematosus – a cross-sectional analysis of the Swiss Systemic Lupus Erythematosus Cohort Study (SSCS). BMC immunity [Internet]March 28, 2017 [cited 2022 Mar 18];18(1). Available from https://pubmed.ncbi.nlm.nih.gov/28351341/

6. Carter LM, Gordon C, Yee CS, Bruce I, Isenberg D, Skeoch S, et al. Easy-BILAG: A new tool to easily record his SLE disease activity using the BILAG-2004 index. Rheumatology (Oxford) [Internet]October 6, 2022 [cited 2023 Jan 17];61(10):4006. Available at: /pmc/articles/PMC9536795/

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