Q J Med 1999; 92: 283-286
© 1999 Association of Physicians
Psychiatric morbidity in patients with systemic lupus erythematosus
From the Department of Psychiatry, Fairfield Hospital, Hutchen, 1 General Adult Psychiatry, Addenbrooke's and Fulbourn Hospital, Cambridge, UK, and 2 King Edward VII Memorial Hospital, Mumbai, India
Received 28 January 1999 and in revised form 12 March 1999
Dr A.C. Wagle, Drug, Alcohol and Tranquilizer Services, The Mill House, 351 Mill Road, Cambridge CB1 3DF. e-mail: ajaywagle{at}msn.com
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We investigated psychiatric morbidity in patients with systemic lupus erythematosus, in a hospital-based study. Thirty patients (23 consecutive out-patients and seven unselected in-patients) were prospectively assessed by a multidisciplinary team for the presence of psychiatric disorders and disease activity. Psychiatric assessment was done with structured interviews. Demographic information was recorded in a structured proforma; all the patients completed the Presumptive Stressful Life Event Scale. A close relative was interviewed in every case. Patients who had psychiatric disorders were compared with the rest with respect to demographic variables, lupus disease activity, use of steroids, and stressful life events. We found a 50% prevalence of psychiatric disorders. The patients with psychiatric disorders were similar to those who had no psychopathology with respect to age, sex, duration of illness, lupus activity and the use of steroids. However, they had experienced more stressful life events in the last year.
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Introduction |
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Systemic lupus erythematosus (SLE) is a complex multi-system disease in which tissues and cells are damaged by deposition of pathogenic antibodies and immune complexes. Psychiatric abnormalities are common accompaniments of SLE. More than hundred years ago, Kaposi1 reported that mental changes could accompany this autoimmune disease. The prevalence of psychiatric symptoms shows great variability, ranging from 17%2 to 75%.3 Such a wide range reflects different methods of patient selection and assessment,4,5 different professional orientation of researchers,4,5 and lack of acceptable criteria for diagnosing `active lupus'.6,7 Controversy also exists concerning the factors responsible for psychiatric manifestations in these patients, which have been variously attributed to pathophysiology of the disease,7 iatrogenic effects of corticosteroids8 and psychosocial stressors related to chronic disease.9 Indeed, it has been suggested that psychosocial variables may have more aetiological relevance for psychiatric symptoms than the disease process. Although studies from India have suggested that overall pattern of SLE is similar to that seen in the West,10 psychiatric morbidity in Indian patients suffering from SLE has not been systematically studied. The few studies which have looked at this issue in migrant populations from Indian subcontinent,11 and in Indian men12 suffer from several methodological flaws. For example, psychiatric diagnostic systems were not specified, assessment methods were not clearly defined, diagnoses were not made by qualified professionals, and the studies were retrospective, using archival data, and did not look specifically at psychiatric manifestations. Although these studies have mentioned `neuropsychiatric features' in SLE, they have either not been defined10,11 or defined in crude terms, such as presence of seizures and psychoses.12 Therefore it is of interest to investigate the prevalence of psychiatric disorders and their correlation to other disease parameters in Indian patients, especially as although not very common, SLE is probably more prevalent in this population than in White patients.13 We therefore studied psychiatric morbidity in patients of SLE and its correlation with some of the disease parameters such as disease activity, duration of disease and use of corticosteroids. We also looked at the association between stressful life events and psychiatric morbidity.
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Methods |
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This study was done at the King Edward VII Memorial Hospital, one of four municipal general hospitals in Mumbai, India, with a capacity of 1500 beds. It mainly caters to working-class residents of the city, but also treats patients from surrounding rural areas and from other parts of the country, mainly north India. Mumbai is the capital of the state Maharashtra, where the language spoken is Marathi. Hindi is India's national language and is spoken extensively in north India.
This was a prospective study in which 30 patients who fulfilled the Revised Criteria of the American Association for SLE14 were studied. Of these, 23 were consecutive presentations to the out-patient clinic run by the rheumatology department; the remaining seven were unselected in-patients admitted to either nephrology, medicine or dermatology wards. The study was done over a period of 1 year (November 1994 to December 1995).
The psychiatric evaluation was based on a structured interview with the patient, the Structured Clinical Interview for Diagnostic and Statistical Manual, Third Edition, Revised (DSM-III R) (SCID),15 using a close relative as an additional informant in all cases, as well as clinical psychiatric evaluation, and a review of all obtainable case notes. Informed consent was given for the psychiatric interview. SCID is a clinician-rated instrument, based on the DSM criteria. For the purpose of the study, the SCID was also translated and back-translated to Hindi and Marathi versions. This is an acceptable way of using the SCID and has previously been used in an Indian population.16 Of the 30 patients, 25 spoke Marathi, while the rest spoke Hindi. The psychiatrist using the SCID and performing clinical psychiatric examination was familiar with the DSM-III R from his clinical training and practice, and at the time of conducting the interview was unaware of the disease activity or medication status.
The activity of the disease was measured clinically using the British Isles Lupus Assessment Group (BILAG) index (version 3). This is a computerized index for measuring clinical disease activity in SLE. It assigns a separate alphabetical score to each organ- based system, and the patients are classified into four categories: A, active disease; B, mild, reversible; C, stable; and D, previous involvement. Validity and reliability of the BILAG index has been shown.17 The BILAG index was applied by a rheumatologist, who was unaware of the results of the psychiatric assessment. All the patients were administered the presumptive stressful life event scale (PSLES).18 Where patients had difficulties, help was sought from the relatives. The PSLES is a 51-item instrument, which measures stressful life events on two time scales; (a) lifetime and (b) the past year. It is standardized for an Indian population, and uses stressful life-events relevant to Indian culture (for example: conflict over dowry, lack of son, conflicts in the extended family, going on a pilgrimage, prophecy of astrologers, damage to crops, etc.). Norms have been established for each event covered in the scale. The scale items are divided into three categories: desirable/undesirable, personal/impersonal, and ambiguous. The scale is easy to use and can be administered to both literate and illiterate subjects. Information was obtained from patients' medical notes about age, sex, marital status, duration of the illness; and use of concurrent medication, especially steroids. This information was recorded in a structured proforma.
Patients were divided into two groups according to the presence or absence of psychiatric disorder. Age and duration of illness were analysed using t-test for independent samples. The variances of the two groups were compared on these two variables using Levene's test for equality of variance. The two groups were compared on the remaining variables (gender, disease activity, use of steroids and stressful life events) using Fisher's exact test. The patients who had psychiatric manifestations were subdivided into those who had major psychopathology, and those who had minor psychopathology. The former were compared with the rest (combined minor and non-psychiatric group) with respect to disease activity, using Fisher's exact test.
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Results |
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Of the 30 patients interviewed, 15 (50%) had psychiatric morbidity (group A), whereas the remainder (50%) demonstrated no psychopathology (group B). Of the 15 patients with psychiatric disorders, 11 showed major psychopathology, i.e. a major depressive disorder (n=7) or an organic mental syndrome (n=4). All the patients diagnosed as having organic mental syndrome were in-patients and were experiencing delirium. Four patients showed minor psychopathology in the form of dysthymia and adjustment disorder. Interestingly, none of the patients displayed psychosis (Table 1
). The descriptive statistics for the two groups regarding age, duration of illness and gender are summarized in Table 2. The two groups did not differ significantly on these parameters. Overall, females (n=25) outnumbered males (n=5) by a ratio of 5 : 1. Although more patients from group A (73%) than from group B (60%) had active lupus (defined as BILAG `A' in any system), this difference failed to reach statistical significance (Fisher's exact test: p=0.139, two-tailed). Similarly, although more patients from group A (n=5) had CNS-active lupus than patients from group B (n=3), the difference was again not statistically significant (Fisher's exact test: p=0.682, two-tailed). CNS activity was determined from the neurological section of the BILAG index, excluding psychiatric symptoms and peripheral nervous system involvement from the checklist. When patients with major psychopathology were compared with the rest with regards to lupus activity, there was a positive association between major psychopathology and lupus activity, which just failed to reach statistical significance (Fisher's exact test: p=0.057, two-tailed). There was no significant difference between the two groups with respect to use of steriods. However, significantly more patients from group A (66%) had more than two stressful life events in the past one year compared with patients from group B (20%), (Fisher's exact test: p=0.025, two-tailed).
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Discussion |
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This was a prospective study. Although the patient sample was drawn from one centre, care was taken to include in-patients as well as out-patients in the study. Although females outnumbered males in a proportion of 5 : 1, this was somewhat less than the even higher proportions (9 : 1) reported in Western countries. Studies in Asian populations have reported higher proportion of males.11 Our study found an overall psychiatric morbidity of 50%. Similar high findings have been reported in studies in Western populations.19,20 We are confident that the high percentage in our study was not a result of professional bias, as the diagnoses were made according to standardized, reliable and valid instrument (the SCID) based on an established diagnostic system (DSM—III R). Also, previous reviews5 have found no significant differences between `psychiatric' and `non-psychiatric' groups. Depressive spectrum disorders were the commonest (36.67%) in our sample, with major depression accounting for 23.34% of the patients; followed by delirium (13%). This finding is in accordance with those of others.20 Interestingly, our sample did not have a single case of functional psychosis—depressed or schizophreniform. The four patients (13%) who were delirious experienced visual and transient auditory hallucinations, and in that sense could have been said to be suffering from an `organic psychosis'. Pande et al.12 found the prevalence of `psychosis' to be 25% in women and 7% in men, in their North Indian study, however they did not comment on the nature of the psychosis. It has been suggested that psychiatric disorders which occur 2 or more years before other established criteria of SLE should be considered as independent of illness.21 Using this criterion, premorbid psychiatric disorder was present in only one patient (6.6%) from our sample, a finding similar to others in literature.7,22 None of the patients had a family history of psychiatric illness or suicide. Our study did not find any correlation between psychiatric disorders and systemic disease activity. Similar findings have been reported in some9,22 but not all20 recent studies. However, there was a positive association between major psychopathology and disease activity which just failed to reach the statistical significance. This could have been due to the relatively small sample size. It has to be said however that the division of psychiatric disorders between `major' and `minor' was done on an ad hoc basis by the authors. The DSM itself does not differentiate between `major' and `minor' psychiatric disorders. There was no correlation between psychiatric symptoms and treatment with steroids, a finding similar to that of Hay et al.9 This was probably due to the fact that the dose range of prednisolone (4–20 mg) was much less than the dose levels (40 mg/day) which are thought to be associated with increased risk of psychiatric manifestations.8 A significantly greater number of patients from group A had experienced more than two stressful life events in the last one year, compared with patients from group B. Similar findings have been reported in the literature.9,22 Two stressful events was chosen as a pivotal point, as it has been estimated that the mean number of life events experienced in a year by an average Indian is approximately two.17 The principal limitations of this study were the absence of a comparison group and the relatively small number of patients. Therefore it is difficult to comment on the nature of the exact association between stressors and psychiatric symptomatology; although absence of correlation between CNS-lupus activity and psychiatric disorder would tend to suggest that the relationship was guided more by the maladjustment frequently found in chronic illnesses. It is important to bear in mind that depression has a known relation to adverse life events.23
In summary, our study found a high prevalence (50%) of psychiatric disorders in our patient sample. Patients who had psychiatric disorders were similar to those who had no psychopathology, with respect to age, sex, duration of illness, lupus activity and use of steroids. However they had experienced more stressful life events in the last year.
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Acknowledgments |
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We thank Dr (Mrs) P.M. Pai, the Dean of KEM Hospital and Seth G.S. Medical College, for giving us her permission to carry out this study; the Departments of Medicine and Rheumatology for providing us with patients; Dr Suvira Ahuja for administering the BILAG Index; and Drs Suvarna Bhole, Manisha Pawar and K. Hanumantha for helping with the Marathi and Hindi translations of the SCID.
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References |
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1. Kaposi MK. Nene beitrage zur kenntnis des lupus erythematosus. Arch Derm Syph 1872; 4:36–78.
2. Buchbinder R, Hall S, Littlejohn GO, Ryan FPJ. Neuropsychiatric manifestations of systemic lupus erythematosus. Aust N Z J Med 1988; 18:679–84.[Web of Science][Medline]
3. Johnson RT, Richardson EP. The neurologic manifestations of systemic lupus erythematosus. Medicine 1968; 47:337–69.[Medline]
4.
Gurland BJ, Ganz VF, Fleiss JL, Zubin J. The study of psychiatric symptoms of systemic lupus erythematosus. Psychosom Med 1972; 34:199–206.
5.
Wekking EM. Psychiatric symptoms in systemic lupus erythematosus; an update. Psychosom Med 1993; 55:219–28.
6.
Gibson T, Myers AR. Nervous involvement in systemic lupus erythematosus. Ann Rheum Dis 1976; 35:398–406.
7. Feniglass EJ, Arnett FC, Dorsch CA, Zizic TM, Stevens MB. Neuropsychiatric manifestations of systemic lupus erythematosus: Diagnosis, clinical spectrum and relationship to other features of the disease. Medicine 1976; 55:323–39.[Medline]
8. Lewis DA, Smith RE. Steroid induced psychiatric syndromes: A report of 14 cases and a review of literature. J Affect Disord 1983; 5:319–32.[Web of Science][Medline]
9. Hay EM, Black D, Huddy A, Creed F, Tomenson B, Bernstein Holt PJ. Psychiatric disorder and cognitive impairment in systemic lupus erythematosus. Arthritis Rheum 1992; 35:411–16.[Web of Science][Medline]
10. Malaviya AN, Misra R, Banerjee S, Kumar A, Tiwari SC, Bhuyan UN, Malhotra KK, Gulreja JS. Systemic lupus erythematosus in North India Asians. A prospective analysis of clinical and immunological features. Rheumatol Int 1986; 6:97–101.[Web of Science][Medline]
11.
Samanta A, Feehally J, Roy S, Nichol FE, Sheldon PJ, Walls J. High prevalence of systemic disease and mortality in Asian subjects with systemic lupus erythematosus. Ann Rheum Dis 1991; 50:490–2.
12.
Pande I, Malaviya AN, Sekharan NG, Kailash S, Uppal SS, Kumar A. SLE in Indian men: analysis of the clinical and laboratory features with a review of literature. Lupus 1994; 3:181–6.
13.
Feehally J, Burden AC, Mayberry JF, Probert CSJ, Roshan M, Samanta AK, Woods SKL. Disease variations in Asians in Leicester.Q J Med 1993; 86:263–9.
14. Tan EM, Cohen AS, Fries JF, Masi AT, McShane DJ, Rothfield NF, Schaller JG, Talal N, Winchester RJ. The 1982 revised criteria for the classification of systemic lupus erythematosus. Arthritis Rheum 1982; 25:1271–7.[Web of Science][Medline]
15. Spitzer RL, Williams JB, Gibbon M, et al. Structured clinical interview for DSM—III R 1988—Non-patient version. New York, Biometric Research Department, New York State Psychiatric Institute, 1988.
16.
Weiss MG, Doongaji DR, Siddartha S, Wypij D, Pathare S, Bhatawdekar M, Bhave A, Sheth A, Fernandes R. The Explanatory Model Interview Catalogue (EMIC): contribution to cross-cultural research methods from a study of leprosy and mental health. Br J Psych 1992; 160:819–30.
17.
Hay EM, Bacon PA, Gordon C, Isenberg DA, Maddison P, Snaith ML, Symmons DPM, Viner N, Zoma A. The BILAG Index: a reliable and valid instrument for measuring clinical disease activity in systemic lupus erythematosus.Q J Med 1993; 86:447–58.
18. Singh G, Kaur D, Kaur H. Presumptive Stressful Life Events Scale: a new stressful life events scale for use in India. Ind J Psych 1984; 26:107–14.
19.
Ganz VF, Gurland BJ, Edwards DW, Fisher B. The study of the psychiatric symptoms of systemic lupus erythematosus. Psychosom Med 1972; 34:207–20.
20. Miguel ES, Rodrigues Pereira RM, De Braganca Pereira CA, Baer L, Gomes RE, Ferreira LC, Hirsch R, De Barros NG, De Navarro JM, Gentil V. Psychiatric manifestations of systemic lupus erythematosus: clinical features, symptoms, and signs of central nervous system activity in 43 patients. Medicine 1994; 73:224–32.[Medline]
21. Perry SW. Psychiatric aspects of SLE. In Lahita RG, ed. SLE. New York, Wiley and Sons, 1987; 821–46.
22.
Lim L, Ron MA, Ormerod IEC, David J, Miller DH, Logsdail SJ, Walport MJ, Harding AE. Psychiatric and neurological manifestations in systemic lupus erythematosus.Q J Med 1988; 66:27–38.
23. Paykel ES. Contribution of life events to causation of psychiatric illness. Psychol Med 1978; 8:245–53.[Web of Science][Medline]
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