What should people with lupus know about anxiety and depression

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By Dr. Robert Katz, Chair Lupus Society of Illinois Board of Directors and Medical Advisory Board

The holidays can increase anxiety and depression in many people. We thought an article highlighting what we know about lupus, anxiety and depression would be helpful this time of year.

In a study on anxiety and depression in lupus, Liao and others in the journal BMC Psychiatry (2022), found that among 325 patients with lupus involved in the study, patients with depression or anxiety have significantly higher lupus activity and more frequent musculoskeletal and neuropsychiatric symptoms. In addition to body injury from lupus, there is an increased risk of mental disorders including depression and anxiety. In the study, family income, disease activity, and musculoskeletal and neuropsychiatric symptoms were related to depression. Lupus disease activity was associated with anxiety.

In other studies, depression or anxiety in lupus has been linked to age, fatigue, sleep quality, specific organ involvement, disease activity, steroid use, and other factors. Therefore, there is a complex mixture of biological, social, economical, psychological, and environmental factors leading to anxiety and depression in lupus. Aside from calming down lupus disease activity, other measures such as cognitive behavioral therapy, psychotherapy in general, other non-medication strategies including meditation and exercise as well as medication such as sertraline and Prozac and sometimes tranquilizers in low dosage can be helpful. Certainly higher doses of corticosteroids can contribute significantly to anxiety.

In another study in the Journal of Medicine on depression and anxiety in systemic lupus, Figueriredo-Braga and other authors found that anxiety levels were significantly higher in lupus patients compared to healthy and also rheumatoid arthritis control patients. Relationships with others and fatigue severity were two factors found to be associated with depression in fibromyalgia. Lupus patients often rate fatigue and pain as having a strong negative effect on the quality of life. Lupus can be associated with depression at times from the physical effect of autoimmunity on the nervous system and discomfort due to pain and disability. Disease activity, level of fatigue, quality of sleep, and physical activity can also contribute to mood disorders.

Studies have noted the importance of social support, both familial and non-familial, with regard to depression and anxiety. This may be improved or exacerbated during the holidays when lupus patients are spending time with family members. Relationship satisfaction is a factor in anxiety and depression in lupus. Social support is an important environmental resource that is necessary for mental health. Depression symptoms can also occur with a decrease in peer-related social support.

There is a higher mental disease burden in active lupus, but even when lupus is under control, it can certainly be associated with anxiety and the need for diagnosis and treatment. Fatigue, cognitive difficulties, work issues, functional disability, and reduced self-related quality of life all play a role in creating anxiety and depression in lupus patients.

Also, there is an association between depression and anxiety and lower treatment adherence, which is a known driver for lupus flare and activity. Seeing your rheumatologist, a primary care doctor, or a psychiatrist can be helpful if the levels of anxiety and depression are expressed and not hidden. The authors found that paid employment status was protective against anxiety and depression independent of lupus severity and lupus activity. Socioeconomic factors can play a role, and certainly family issues are important in determining the level of anxiety and depression.

Again, it is worth mentioning that higher levels of anxiety and depression can correlate with lower medication treatment adherence, which is established as resulting in adverse disease outcomes and flares.

Zhang and other authors in BMC Psychiatry found that there is a two times higher prevalence of depression in lupus compared to patients compared to the general population. Anxiety disorders are also approximately twice as present among these patients.

There is a relationship between lupus disease activity and depression and anxiety, but the results are somewhat inconsistent between studies. In any event, treatment is indicated, both non-pharmacological therapy such as cognitive behavioral therapy, psychotherapy, exercise, relaxation techniques, etc., as well as (in some cases) medications such as sertraline or Prozac, and sometimes controlled substance tranquilizers.

A study by Arroll in BJGP Open, the authors find that in lupus and other challenging situations is a patient with depression or anxiety and a coexisting substance use disorder, which alcohol is the most common. Sometimes involvement of family members is necessary for a better understanding of a lupus patient’s mental condition. The use of illegal drugs or medication should also be considered as these patients may require different medication to achieve a therapeutic effect.

There is a considerable overlap in symptoms between depression and anxiety disorders, but the first-line drug treatments are identical for both depression and anxiety as are the psychological therapies. Cognitive behavioral therapy protocols have been developed to deal with anxiety.

In lupus patients, detecting anxiety and depression can be difficult even if psychosocial issues are the main reason for a doctor visit. They are likely to be left until the last minute and mentioned as the patient is about to leave the authors. There may only be enough time to ask a couple of questions or preferably to schedule a subsequent visit. People who feel depressed or hopeless need to express their feelings as fully as possible during their doctor visit or even to family members who can help them. Sometimes the question, “Over the past month have you been bothered by feeling down, depressed or hopeless or having little interest or pleasure in doing things?” can be helpful in bring out depression and anxiety problems in lupus patients.

It is worth noting that most people do not benefit from antidepressants. A placebo response is common. Along with other issues such as sleep hygiene, individualized self-help principles of cognitive behavioral therapy or computerized cognitive behavioral therapy with or without a facilitator, physical activity especially exercise can be beneficial for depression and anxiety including yoga, stretching and mild aerobic activity.

Referral to a specialist dealing with anxiety and depression as well as attempting to control lupus disease activity are important approaches to treating anxiety and depression in lupus patients.

Psychological therapies are the first choice for most patients with mild to moderate depression or significant anxiety. Drug treatment should be used only in moderate to severe depression or significant anxiety, but recognizing that lupus patients may experience anxiety especially in certain situations such as being with peers or family during the holidays needs to be recognized.

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