Depression is the most frequent among neuropsychiatric complaints in patients with Systemic Lupus Erythematosus (SLE) (1, 2). Point prevalence rates range from 2 to 91.7%, depending upon the context, setting, and assessment tool (2, 3). While 8 to 24% of patients could be diagnosed with depressive disorders (3, 4), and induce 12% of suicidal thoughts (5). A previous study in northern Thailand revealed that the prevalence of depressive symptoms among patients with SLE was 45.2% (6). Depression is the most frequent and profoundly impactful comorbidity for SLE patients' health and well-being (7), of which depression is a common manifestation, with higher levels of fatigue, more significant pain, and poor sleep quality (8, 9, 10), including increased suicide ideation (5). The associated factors with depression in patients with SLE are controversial (2). Clinical factors related to disease activities, psychobiological factors, and psychosocial factors were hypothesized as factors that might underline the plausibility of associations. The biological, psychological, and social predictors of depression among patients with SLE are rarely reported simultaneously.
SLE is the prototypical autoimmune disease affecting multi-organ systems. A complex interaction of genetics, environment, and hormones leads to immune dysregulation and breakdown of tolerance to self-antigens, resulting in autoantibody production, inflammation, and destruction of end-organs. It is a significant disease burden across the world among different ethnic, racial, and age groups (11). SLE is troubling 1 to 12 people per 5000 worldwide (12), and the incidence of the disease was 0.9 to 3.1 cases per 100,000 populations per year (13). Usually, patients with SLE are first diagnosed in early adulthood. Most cases of this disease are found in 80 to 90% of females between the ages of 20 and 40 years (mean age at diagnosis: 29 years) (14), and it is more common in Afro-Caribbean, Chinese and Asian populations compared with Whites (15).
The nature of SLE is a complex disease that can affect the body without limitation, and the disease causes many different clinical symptoms (14). Typically patients with SLE have an inflammatory illness that occurs in various organ systems and complications from treatments. At the same time, patients with this disease need treatment with long-term monitoring of symptoms since the diagnosis of SLE is more accurate nowadays. The treatment of this disease emphasizes the adjustment of the level of the drug per the results of biomarkers and disease manifestations, as well as impacts of SLE signaling appropriate treatment recommendations. However, one treatment may not continuously address the patient's overall health condition due to the generalized and chronic nature of the disease. This state has long-term effects, with significant impacts on physical and mental health, including the patient's quality of life (14). A previous study reported that more than 2 out of 3 patients with SLE experience emotional illness such as sadness, depression, fear, anxiety, guilt, anger, and wrath (14). These morbidities may seriously affect their ability, leading to significant psychological problems (5).
Depressive symptoms are the most common psychological symptoms complaint in patients with SLE (2). A study found that 24% of patients with SLE were diagnosed together with major depressive disorder (4). Depressive symptoms can intensify pain, as well as fatigue, insomnia, and sluggishness (16). At the same time, it limits a person's physical performance and ability to interact with others (16). In addition, the burden of SLE comorbid with depression may increase the risk of suicide (17). A study found that depression was associated with disease activity, and SLE disease activity might reveal the covert damage of the central nervous system in SLE (3). Biopsychosocial factors that are critical and related to the depressive symptoms of patients with SLE are presented in figure 1.
Malfunction and injuries in various body organs are essential factors that cause patients to face grave disease prognoses. The severity of SLE, including active disease or disease flare and disability of organ damage (21, 22), and pain suffering and fatigue increase the risk of depressive symptoms (19). Changes in physiology and the immune system are common in patients with SLE. Patients with SLE fear the disease progression, another aggravation or spreading to new organs, and insecurity regarding one's future life. It is often related to unpleasant experiences (14, 20). Fatigue and pain are also common symptoms in SLE; 50 to 90% of patients with SLE experience constant fatigue (14), and over 90% of patients with SLE suffer from joint pain (14, 23). These problems cause patients to struggle with fatigue as paralyzing, insurmountable with sleep or rest. It limits everyday activities, often forcing patients to resign from earlier interests, hobbies, or work. Sometimes, patients feel helpless, powerless, angry, and guilty. Therefore, fatigue and pain were the two most reported symptoms affecting patients' quality of life with SLE, limiting everyday life activities (24). According to the studies, fatigue was a significant contributor to depression in patients with SLE (19), and over 82% of these patients with depressive symptoms experience moderate to severe pain (25).
Patients with SLE are often treated with glucocorticoids as monotherapy or in combination with hydroxychloroquine, NSAIDs, and immunosuppressants. Studies show that immunosuppressants (methotrexate, cyclophosphamide) reduce disease activity (26). However, the unpleasant side effects of high doses of steroid therapy can cause symptoms of neuropsychiatric lupus but more often cause milder emotional changes, such as anxiety or depression. The studies found that taking prednisolone doses more than 15 to 40 mg per day was a factor that could predict depression in patients with SLE (21, 27).
Changing physical appearance from disease progression and its treatment leads to low self-esteem and increases the risk of depressive symptoms (28, 29). Unsightly skin lesions such as classic erythema on the face, discoid rash, lesions with a tendency to scarring, skin atrophy, and hair loss are symptoms that cause patients with SLE to feel embarrassed. Patients also report bruising susceptibility and increased photosensitivity. In addition, the side effect of glucocorticosteroid medicine also is a cause of unsightly skin lesions and obesity (23). This appearance change may make patients feel less attractive and cause concern about adverse reactions from their partners (23). As a result, many patients tend to lose confidence and have lower satisfaction with their self-image.
Living with SLE hurts partnerships, family relationships, and social life. Due to increasing disability, the patients spend less quality time and diminished time with their partners (25). The unpredictable course of SLE is the reason why patients' social life is limited. It frustrates them, fear rejection, and increases their isolation. Patients with SLE who lack good social support often face conflicts with family members that cause mental health problems, particularly depressive symptoms (22). On the contrary, relevant support ensured by the family or close persons makes it possible for the patients to avoid excessive burden (18).
Poor financial status or insufficiency of household income is a factor associated with depressive symptoms in patients with SLE (30). After five years with SLE, 15 to 40% of patients had lost their jobs. After 10 or 15 years, this percentage increased to 36% and 52%, respectively (14, 31). Many patients with SLE are distressed that the disease will adversely affect their planned development path (14). The patients are also concerned about illness costs, such as medical and additional healthcare insurance costs (24).
Previous studies about depressive symptoms in patients with SLE have mainly been conducted in Western ethnic patients that may influence the results of these studies. Genetics, characteristics, beliefs, cultures, and lifestyles of patients in the East, including Thais, may have different effects (32). In addition, most studies focused on analyzing only the psychological factors (2). The analysis of biopsychosocial factors simultaneously was rare. The results are not sufficiently conclusive for clinical application.
The present study aimed to analyze the prevalence of depressive symptoms and determine biopsychosocial factors associated with depressive symptoms among patients living with SLE in clinical settings in urban Thailand.
This study used the conceptual framework of the Biopsychosocial model (BPS) by George Libman Engel (33) (Figure 1). Therefore, the analysis of comprehensive factors can further develop interventions to prevent mental health problems in patients with SLE and encourage them to live healthy lives.