The prevalence of psychological problems is frequent in systemic lupus erythematosus (SLE) patients and appears to be increasing. The current study investigated the relationship among disease parameters, quality of life, and the psychological status in Chinese patients with SLE. A self-report survey design was administered to 170 SLE patients and 210 healthy individuals using the Self-Rating Anxiety Scale, the Self-Rating Depression Scale, and the Short Form 36 health survey (SF-36). Our results showed that 20.3% SLE patients had anxiety, and 32.9% had depression, which were significantly higher than the control group (7.1%, 14.3%, resp.). And there were significant correlations among socioeconomic status (SES), disease activity, and anxiety/depression in SLE patients. Meanwhile, SF-36 analysis results revealed that VT, PF, and RP scales were the most powerful predictors of anxiety of SLE patients, and SLEDAI, VT, PF, SF, and RE domains were significantly accounted for anxiety. In summary, there were significant relationships among disease parameters, quality of life, and anxiety/depression in Chinese SLE patients. Therefore, it is necessary to have psychiatric and psychological evaluations and formulate an integrated approach for managing mental health in Chinese lupus patients, especially those who have high disease activity, low SES, and poor quality of life.
Systemic lupus erythematosus (SLE) is a chronic inflammatory autoimmune disease that may affect multiple organ systems, including the central nervous system (CNS) [
Even though SLE presents accompany with a wide variety of treatable psychiatric symptoms, such as depression and anxiety, they rarely seek and receive adequate treatment [
The pathogenesis of psychiatric symptoms in lupus is still not well understood, but in which genetic and environmental factors may play a pivotal role. Depression and anxiety may also be present as a reaction to a serious recurring, painful illness, which is associated with visible symptoms such as insomnia, fatigue, and limited functioning [
There are several studies focus on psychological problems in China lupus patients. A study from Hong Kong has found that anxiety disorder was present in 22% SLE patients, and 18.2% had depression [
Thus, the aim of this study was to examine the relationship among disease parameters, quality of life, and the psychological status in Chinese patients with SLE. Moreover, we wished to ascertain the possible risks of anxiety and depression.
SLE patients were recruited from Affiliated Hospital of Nantong University between January 2010 and July 2011. A total of 170 SLE patients and 210 healthy individuals were consecutively invited to participate in a single-center cross-sectional study. Healthy individuals were used as the control group. All patients fulfilled the 1997 American College of Rheumatology (ACR) revised criteria for the classification of SLE. Patients were excluded based on the following: (1) they did not complete questionnaire; (2) they had comorbidities (e.g., serious infections or cardiac, respiratory, gastrointestinal, neurological, or endocrine diseases) that could influence SLE activity. Control subjects were excluded if they exhibited current or history of other systemic diseases or psychiatric disorders. This study was approved by the Ethics Committee of Affiliated Hospital of Nantong University, and written informed consent was obtained from all participants.
The Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) was used to measure disease activity [
SAS was used to evaluate the level of anxiety-related symptoms during the week prior to the survey. This self-administered test has 20 questions, with 15 items reflecting increasing anxiety levels and 5 questions reflecting decreasing anxiety levels. Each question was scored on a scale from 1 to 4 (rarely, sometimes, frequently, and always). The scores ranged between 20 and 80: scores greater than 70 suggest severe anxious symptoms, scores between 60 and 69 indicate moderate to marked anxiety, scores between 50 and 59 suggest minimal to mild anxiety, and scores less than 50 indicate no anxious symptoms.
SDS is a 20-item questionnaire designed to assess mood symptoms over the past week (e.g., “I feel downhearted, blue and sad”). Each item is scored on a Likert scale ranging from 1 to 4; scores greater than 70 suggest severe depressive symptoms, scores between 60 and 69 indicate moderate to marked depression, scores between 50 and 59 suggest minimal to mild depression, and scores less than 50 indicate no depressive symptoms.
The patient’s general health status was measured using the Short Form- (SF-) 36 questionnaire, which measured eight multi-item dimensions: physical functioning (PF, 10 items); role limitations due to physical problems (RP, four items); role limitations due to emotional problems (RE, three items); social functioning (SF, two items); mental health (MH, five items); energy/vitality (VT, four items); body pain (BP, two items); and general health perception (GH, five items). For each dimension, item scores were coded, summed, and transformed on a scale from 0 (worst possible health state measured by the questionnaire) to 100 (best possible health state).
The data were expressed as means ± SDs for continuous variables and as frequencies (%) for categorical variables. The Statistical Package for SPSS 18.0 was used for all data management and analyses. Descriptive analyses were performed to investigate the participants’ characteristics. Student’s
12 SLE patients and 14 healthy individuals did not complete the questionnaire, resulting in the enrollment of 158 SLE patients (14 males and 144 females) and 196 healthy individuals (20 males and 176 females) in the current study. Table
Demographic, psychological, and disease characteristics in SLE patients and controls.
Variables | SLE patients |
Control subjects |
|
---|---|---|---|
Female gendera | 144 (91.2) | 176 (89.8) | 0.76 |
Age, yearsb | 32.9 ± 10.2 | 35.0 ± 11.4 | 0.20 |
SAS (≥50)a | 32 (20.3) | 14 (7.1) | <0.01 |
SDS (≥53)a | 52 (32.9) | 28 (14.3) | 0.003 |
SLEDAI | 11.8 ± 9.5 | ||
Marital statusb | |||
Single | 32 (20.3) | 56 (18.6) | 0.20 |
Married | 126 (79.7) | 140 (71.4) | |
Educationb | |||
<9 years | 86 (54.4) | 96 (49.0) | 0.47 |
≥9 years | 72 (45.6) | 100 (51.0) | |
Work statusb | |||
Working | 30 (19.0) | 44 (22.5) | 0.57 |
Unemployed | 128 (81.0) | 152 (77.5) | |
Income/personb | |||
≤2000 yuan | 100 (63.3) | 118 (60.2) | 0.68 |
>2000 yuan | 58 (36.7) | 78 (39.8) | |
Menstrual historyb | |||
Normal | 96 (66.7) | 102 (58.0) | 0.26 |
Abnormal | 48 (33.3) | 74 (42.0) |
SAS: revised Self-Rating Anxiety Scale; SDS: revised Self-Rating Depression Scale; SLEDAI: Systemic Lupus Erythematosus Disease Activity Index.
Correlations between psychological scores, disease parameters, and quality of life in SLE patients.
Variables | SAS | SDS | ||
---|---|---|---|---|
|
|
|
| |
Domains of SF-36 | ||||
PCS | −0.53 | <0.0001 | −0.53 | <0.0001 |
MCS | −0.68 | <0.0001 | −0.73 | <0.0001 |
PF | −0.49 | <0.0001 | −0.54 | <0.0001 |
RP | −0.55 | <0.0001 | −0.52 | <0.0001 |
BP | −0.05 | 0.66 | 0.05 | 0.65 |
GH | −0.36 | 0.001 | −0.37 | 0.0009 |
VT | −0.4 | 0.0003 | −0.43 | 0.0001 |
SF | −0.49 | <0.0001 | −0.57 | <0.0001 |
RE | −0.63 | <0.0001 | −0.64 | <0.0001 |
MH | −0.31 | 0.005 | 0.34 | 0.003 |
SAS: revised Self-Rating Anxiety Scale; SDS: revised Self-Rating Depression Scale; PCS: physical components summary; MCS: mental components summary; PF: physical functioning; RP: role limitations due to physical problems; RE: role limitations due to emotional problems; SF: social functioning; MH: mental health; VT: energy/vitality; BP: body pain; GH: general health perception.
Previous studies have shown that low socioeconomic factors (SES) were generally associated with high psychiatric morbidity, depression, and anxiety [
Disease status and quality of life in the anxious and depressed subgroups.
Variables | SAS | SDS | ||||
---|---|---|---|---|---|---|
<50 | ≥50 |
|
<53 | ≥53 |
| |
Agea | 32.3 ± 10.3 | 35.2 ± 9.6 | 0.32 | 32.4 ± 10.6 | 34.0 ± 9.4 | 0.51 |
Sexb | ||||||
Male | 6 (9.5) | 1 (6.3) | 0.68 | 7 (13.2) | 0 (0.0) | 0.05 |
Female | 57 (90.5) | 15 (92.7) | 46 (86.8) | 26 (100.0) | ||
BMI | 21.2 ± 2.7 | 21.1 ± 2.9 | 0.93 | 21.1 ± 2.8 | 21.4 ± 2.6 | 0.61 |
Marital statusb | ||||||
Single | 15 (23.8) | 1 (6.3) | 0.25 | 14 (26.4) | 2 (7.7) | 0.11 |
Married | 48 (76.2) | 15 (93.7) | 38 (73.6) | 24 (92.3) | ||
Educationb | ||||||
<9 years | 29 (46.0) | 14 (87.5) | 0.003 | 23 (43.4) | 20 (76.9) | 0.005 |
≥9 years | 34 (54.0) | 2 (12.5) | 30 (56.6) | 6 (23.1) | ||
Work statusb | ||||||
Working | 15 (23.8) | 0 (0) | 0.03 | 13 (24.5) | 2 (7.7) | 0.07 |
Unemployed | 48 (76.2) | 16 (100.0) | 40 (75.5) | 24 (92.3) | ||
Income/personb | ||||||
≤2000 yuan | 36 (57.1) | 14 (87.5) | 0.02 | 28 (52.8) | 22 (84.6) | 0.006 |
>2000 yuan | 27 (42.9) | 2 (12.5) | 25 (47.2) | 4 (15.4) | ||
Menstrual historyb | ||||||
Normal | 39 (68.4) | 9 (60.0) | 0.54 | 36 (79.2) | 12 (46.2) | 0.006 |
Abnormal | 18 (31.6) | 6 (40.0) | 10 (20.8) | 14 (53.8) | ||
Years since diagnosis of SLEb | ||||||
<1 | 11 (17.5) | 2 (12.5) | 0.85 | 10 (18.9) | 3 (11.5) | 0.63 |
1–5 | 31 (49.2) | 9 (56.3) | 27 (50.9) | 13 (50.0) | ||
>5 | 21 (33.3) | 5 (31.2) | 16 (30.2) | 10 (38.5) | ||
SLEDAIa | 10.4 ± 7.3 | 17.1 ± 14.7 | 0.01 | 10.3 ± 7.7 | 14.8 ± 12.1 | 0.046 |
Domains of SF-36 | ||||||
PCSa | 256.7 ± 60.7 | 158.1 ± 51.7 | <0.0001 | 264.0 ± 58.6 | 181.1 ± 61.5 | <0.0001 |
MCSa | 282.8 ± 67.0 | 161.7 ± 60.1 | <0.0001 | 295.1 ± 56.9 | 183.3 ± 72.9 | <0.0001 |
PFa | 86.8 ± 14.1 | 61.3 ± 28.8 | <0.0001 | 88.9 ± 12.2 | 66.9 ± 26.1 | <0.0001 |
RPa | 52.4 ± 42.5 | 4.7 ± 13.6 | 0.0001 | 57.1 ± 43.1 | 13.5 ± 23.7 | <0.0001 |
BPa | 63.8 ± 26.8 | 54.0 ± 20.0 | 0.18 | 63.6 ± 26.6 | 58.2 ± 24.4 | 0.38 |
GHa | 53.6 ± 14.0 | 38.1 ± 13.3 | 0.0001 | 54.4 ± 12.6 | 42.5 ± 16.8 | 0.0007 |
VTa | 66.6 ± 16.1 | 48.1 ± 19.5 | 0.0002 | 68.8 ± 15.0 | 50.8 ± 18.7 | <0.0001 |
SFa | 86.7 ± 29.3 | 64.1 ± 34.4 | 0.01 | 91.7 ± 26.8 | 62.5 ± 31.6 | 0.0001 |
REa | 67.2 ± 38.1 | 0 ± 0 | <0.0001 | 71.7 ± 36.0 | 16.7 ± 33.0 | <0.0001 |
MHa | 62.3 ± 15.1 | 49.5 ± 19.4 | 0.006 | 62.9 ± 13.9 | 53.4 ± 20.3 | 0.017 |
SAS: revised Self-Rating Anxiety Scale; SDS: revised Self-Rating Depression Scale; PCS: physical components summary; MCS: mental components summary; PF: physical functioning; RP: role limitations due to physical problems; RE: role limitations due to emotional problems; SF: social functioning; MH: mental health; VT: energy/vitality; BP: body pain; GH: general health perception.
Multiple stepwise regression analysis revealed that VT, PF, and RP scales of SF-36 were the most powerful predictors of anxiety of SLE patients (Table
Stepwise regression analyses of medical and psychological variables and their relationship to SAS in SLE patients.
SAS | Coef. | Std. Err. |
|
|
[95% CI] |
---|---|---|---|---|---|
VT | −0.15 | 0.05 | −3.00 | 0.004 | −0.25, −0.05 |
PF | −0.11 | 0.05 | −2.27 | 0.026 | −0.22, −0.01 |
RP | −0.09 | 0.02 | −3.64 | <0.001 | −0.14, −0.04 |
SAS: revised Self-Rating Anxiety Scale; VT: energy/vitality; PF: physical functioning; RP: role limitations due to physical problems.
Stepwise regression analyses of medical and psychological variables and their relationship to SDS in SLE patients.
SDS | Coef. | Std. Err. |
|
|
[95% CI] |
---|---|---|---|---|---|
SLEDAI | 0.19 | 0.09 | 2.08 | 0.04 | 0.01, 0.37 |
VT | −0.19 | 0.05 | −3.48 | 0.001 | −0.30, −0.08 |
PF | −0.13 | 0.05 | −2.60 | 0.01 | −23.8, −0.03 |
SF | −0.09 | 0.03 | −2.69 | 0.009 | −0.15, −0.02 |
RE | −0.08 | 0.02 | −3.13 | 0.003 | −0.12, −0.03 |
SDS: revised Self-Rating Depression Scale; SLEDAI: Systemic Lupus Erythematosus Disease Activity Index; VT: energy/vitality; PF: physical functioning; SF: social functioning; RE: role limitations due to emotional problems.
The present study confirmed that Chinese SLE patients were more likely to suffer from anxiety and depression than healthy individuals. Psychological problems significantly correlated with SES, disease status, and quality of life. SLE patients with anxiety and depression were in low SES and had worse disease status, lower quality of life. Among the assessed parameters, VT, PF, and RP scales of SF-36 were major contributors to anxiety in SLE patients, while disease activity and VT, PF, SF, and RE domains of SF-36 contributed to depression.
SES is broadly employed in health research, signaling the importance of socioeconomic factors for health outcomes. Previous study has found that poorer coping styles, ongoing life events, stress exposure, and weaker social support were some examples of depression risk factors that were more prevalent in lower SES groups [
Notably, the results of the present study demonstrated that anxiety in Chinese SLE patients differs from SLE patients in other countries. This could be explained by some cultural features which may influence mental disease diagnosis and management in China. We have found that the prevalence of depression was higher than Hong Kong, and it might be due to cultural differences and SES such as income and medical insurances policy.
In order to identify which variables were most significantly correlated with anxiety and depression, stepwise regression analysis was used. We have found that VT, PF, and RP scales of SF-36 were the most powerful predictors of anxiety of SLE patients. Meanwhile, SLEDAI, VT, PF, SF, and RE domains of SF-36 were significantly accounted for anxiety. It could be explained that impaired quality of life and functional disability were independent risk factors for psychological disorders.
A possible limitation of the present study was that all patients involved in the survey were from only one center and its failure to differentiate between men and women; the gender differences in SLE patients require further analysis in a future study. Another limitation of the study was that we did not detect the impact of proinflammatory cytokines on depression. Recent study reported that higher serum TNF-
In summary, our study indicated that psychological problems were frequent in Chinese SLE patients. Severe disease status and reduced quality of life significantly correlated with anxiety and depression. Disease activity was higher in anxious and depressed subgroups. Quality of life was decreased in depressed subgroups. Impaired mental health and pain were the most powerful predictors of anxiety and depression. Low SES was independently associated with poor mental health. These findings confirmed the importance of psychosocial interventions in combination with medical therapy for SLE patients.
Biyu Shen and Wei Tan contribute equally to this work.
The authors want to thank Liren Li, Xinghang Zhu, Genkai Guo, Jie Qian, Haixia Cao, and Yunfei Xia for their assistance with this paper. This work was supported by the National Natural Science Foundation of China (Grant no. 81172841), the Natural Science Foundation of Jiangsu Colleges and Universities Grant no. 09KJB320010, “Top Six Types of Talents” Financial Assistance of Jiangsu Province Grant no. 6, and Jiangsu province’s Outstanding Medical Academic Leader Program (LJ201136). This work was also supported by the Science Foundation of Nantong City Grant no. HS2011054, the Beijing Medical Award foundation (FSMYYSNT-001), a project of College graduate research and innovation of Jiangsu Province (CXLX12-0891), the Nantong University Graduate Innovation Program (YKC12037), the Nantong Science and Technology Board (HS12966), and the Bureau of Jiangsu Province (Z2010005), Preventive Medicine Research of Jiangsu province (Y2012083).