Depression and Quality of Life in Patients with Systemic Lupus Erythematosus

Sung Hae Chang; Ja Hyun Cho; Na Hee Shin; Hye Jin Oh; Byoong Yong Choi; Myeong Jae Yoon; Eun Young Lee; Eun Bong Lee; Yun Jong Lee; Tae Jin Lee; Bong Jin Hahm; Young Wook Song

doi:10.4078/jrd.2015.22.6.346

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Chang, Cho, Shin, Oh, Choi, Yoon, Lee, Lee, Lee, Lee, Hahm, and Song: Depression and Quality of Life in Patients with Systemic Lupus Erythematosus

Original Article

J Rheum Dis 2015;22(6):346-355.

Published online: 31 October 2015

DOI: https://doi.org/10.4078/jrd.2015.22.6.346

Depression and Quality of Life in Patients with Systemic Lupus Erythematosus

Sung Hae Chang¹, Ja Hyun Cho², Na Hee Shin², Hye Jin Oh³, Byoong Yong Choi⁴, Myeong Jae Yoon³, Eun Young Lee³, Eun Bong Lee³, Yun Jong Lee⁵, Tae Jin Lee², Bong Jin Hahm⁶, Young Wook Song^3,⁷

¹Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Korea

²Graduate School of Public Health, Seoul National University, Seoul, Korea

³Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea

⁴Department of Internal Medicine, Seoul Medical Center, Seoul, Korea

⁵Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea

⁶Department of Neuropsychiatry, Seoul National University Hospital, Seoul, Korea

⁷Department of Molecular Medicine and Biopharmaceutical Sciences, Graduate School of Convergence Science and Technology, Medical Research Center, Seoul National University, Seoul, Korea

Corresponding to: Yeong Wook Song, Department of Internal Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea. E-mail: ysong@snu.ac.kr

Received 7 April 2015 Revised 8 June 2015 Revised 4 July 2015 Accepted 6 July 2015

This is a Free Access article, which permits unrestricted non-commerical use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Objective

The objective of this study is to examine the prevalence of depression and its related factors including quality of life, brain-derived neurotrophic factor (BDNF), and vitamin D in patients with systemic lupus erythematosus (SLE).

Methods

Depression was assessed using the center for epidemiologic studies depression (CES-D) scale. Disease activity, disease-related organ damage, the EuroQol-5 dimensions (EQ-5D), sociodemographic features, and laboratory tests including serum vitamin D level were surveyed. Serum BDNF was measured using an enzyme-linked immunosorbent assay.

Results

Depression was observed in 22.8% of 180 SLE patients (n=41). Patients with marital status of single/divorced/separated/widowed, a higher patient global assessment (PGA) score, and extreme pain/discomfort showed significant association with depression. The EQ-5D index showed negative correlation with CES-D score (r=−0.56, p＜0.05). In each EQ-5D dimension, depression showed significant association with moderate to severe problems in self-care and usual activities, and extreme pain/discomfort. Serum BDNF levels were not associated with depression (p=0.75) but associated with SLE disease activity index (SLEDAI; r=−0.21, p＜0.05). Serum vitamin D levels were not associated with depression (p=0.60) but showed negative correlation with SLEDAI (r=−0.23, p＜0.05) and mean glucocorticoid dose over the previous 3 months (r=−0.21, p＜0.05) after adjustment for use of vitamin D supplement.

Conclusion

Depression was prevalent in patients with SLE and was associated with low quality of life, and a higher PGA but not with SLEDAI. Serum BDNF and vitamin D levels were not associated with depression but showed negative correlation with SLEDAI.

Keywords: Systemic lupus erythematosus, Depression, Quality of life, Brain-derived neurotrophic factor, Vitamin D

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Figure 1.

Association between serum levels of brain-derived neurotrophic peptide (BDNF) and depression in the patients with systemic lupus erythematosus (SLE). The serum levels of BDNF were comparable between the healthy subjects and SLE patients with depression or without depression (A). When the patients were divided into active and inactive disease, no difference in serum BDNF levels was found between patients with depression and those without depression (B).

Table 1.

Sociodemographic factors of the patients with SLE with or without depression

Variable	All subjects (n=180)	Depression (n=41)	No depression (n=139)	p-value^*
Female	160 (88.9)	39 (95.1)	121 (87.1)	0.15
Age (yr)	43.3±13.9	42.0±18.0	43.5±12.6	0.22
Disease duration (yr)	11.0±7.6	10.4±7.34	11.2±7.69	0.54
Educational level
Less than college graduates	84 (46.7)	25 (61.0)	59 (42.4)	0.04
At least college graduates	96 (53.3)	16 (39.0)	80 (57.6)
Marital status
Married	110 (61.1)	16 (39.0)	94 (67.6)	9.63×10⁻⁴
Single/divorced /separated/widowed	70 (38.9)	25 (61.1)	45 (32.4)
Living arrangement
Alone	8 (4.4)	2 (4.9)	6 (4.3)	1.00
With others	172 (95.6)	39 (95.1)	133 (95.7)
Unemployed	111 (61.7)	32 (78.0)	79 (56.8)	0.01
Annual income (n=161)
≤18,000,000 KRW	26 (16.1)	9 (25.7)	17 (13.5)	0.08
＞18,000,000 KRW	135 (83.9)	26 (74.3)	109 (86.5)

Values are presented as number (%) or mean±standard deviation. KRW: Korean Won, SLE: systemic lupus erythematosus.

^* p-value comparing patients with SLE with depression vs. those without depression by χ²-test or student t-test.

Table 2.

Clinical factors of the patients with SLE with or without depression

Variable	All subjects (n=180)	Depression (n=41)	No depression (n=139)	p-value^*
Clinical manifestation
Mucocutaneous^†	121 (67.2)	25 (61.0)	96 (69.1)	0.33
Renal	62 (34.4)	12 (29.3)	50 (36.0)	0.43
Arthritis	97 (53.9)	23 (56.1)	74 (53.2)	0.75
Serositis	28 (15.6)	7 (17.1)	21 (15.1)	0.76
Neurological	10 (5.6)	3 (7.3)	7 (5.0)	0.7
SLEDAI	3.5±3.9	4.0±4.2	3.4±3.8	0.37
Active SLE (SLEDAI ≥6)	41 (22.8)	12 (29.3)	29 (20.9)	0.26
PGA	18.0±20.0	31.9±23.8	13.9±16.6	3.80×10⁻⁵
PhyGA	0.93±1.80	1.46±3.12	0.77±1.11	0.03
SDI	1.5±1.7	1.8±1.6	1.8±1.7	0.34
Medications^‡
Glucocorticoid	157 (87.2)	38 (92.7)	119 (85.6)	0.37
Daily dose^§	6.7±6.7	7.8±6.7	6.3±6.7	0.23
Hydroxychloroquine	126 (70.0)	30 (73.2)	96 (69.1)	0.73
Cyclophosphamide	30 (16.7)	7 (17.1)	23 (16.5)	0.98
Azathioprine	29 (16.1)	10 (24.4)	19 (13.7)	0.09
Mycophenolate mofetil	15 (8.3)	5 (12.2)	10 (7.2)	0.33
Methotrexate	19 (10.6)	7 (17.1)	12 (8.6)	0.13
Current use of antidepressant	15 (8.3)	12 (29.3)	3 (2.2)	1.28×10⁻⁶

Values are presented as number (%) or mean±standard deviation. PGA: patient's global assessment, PhyGA: physician's global assessment, SDI: Systemic Lupus International Collaborating Clinics/American College of Rheumatology damage index, SLE: systemic lupus erythematosus, SLEDAI: SLE disease activity index.

^* p-value comparing patients with SLE with depression vs. those without depression by χ²-test or student t-test.

^† Mucocutaneous (malar rash, discoid rash, photosensitivity, and oral ulcers), renal, and neurological involvement is defined as in the 1997 updated American College of Rheumatology criteria for the classification of SLE.

^‡ Medications prescribed during a year before the study.

^§ Mean daily prednisolone dose over the previous 3 months (mg/d).

Table 3.

Comparison of health related quality of life in the patients with SLE with or without depression

Variable	All subjects (n=180)	Depression (n=41)	No depression (n=139)	p-value^*
EQ-5D index	0.68±0.19	0.49±0.27	0.73±0.12	1.23×10⁻⁶
Mobility
I have no problems walking	122 (67.8)	22 (53.7)	100 (71.9)	0.02
I have some problems in walking	57 (31.7)	18 (43.9)	39 (28.1)
I am confined to bed	1 (0.6)	1 (2.4)	0 (0.0)
Self-care
I have no problems with self-care	161 (89.4)	32 (78.0)	129 (92.8)	0.01
I have some problems in washing or dressing myself	16 (8.9)	7 (17.1)	9 (6.5)
I am unable to wash or dress myself	3 (1.7)	2 (4.9)	1 (0.7)
Usual activities
I have no problems in performing my usual activities	120 (66.7)	19 (46.3)	101 (72.7)	4.40×10⁻⁴
I have some problems performing my usual activities	58 (32.2)	20 (48.8)	38 (27.3)
I am unable to perform my usual activities	2 (1.1)	2 (4.9)	0 (0.0)
Pain/discomfort
I have no pain or discomfort	65 (36.1)	7 (17.1)	58 (41.7)	1.17×10⁻⁵
I have moderate pain or discomfort	99 (55.0)	23 (56.1)	76 (54.7)
I have extreme pain or discomfort	16 (8.9)	11 (26.8)	5 (3.6)
Anxiety/depression
I am not anxious or depressed	79 (43.9)	5 (12.2)	74 (53.2)	1.87×10⁻¹⁰
I am moderately anxious or depressed	90 (50.0)	25 (61.0)	65 (46.8)
I am extremely anxious or depressed	11 (6.1)	11 (26.8)	0 (0.0)

Values are presented as mean±standard deviation or number (%). EQ-5D: the EuroQol-5 dimensions, SLE: systemic lupus erythematosus.

^* p-value assessing the trend using linear by linear association comparing the patients with SLE with depression vs. those without depression.

Table 4.

Multiple logistic regression analysis for depression in the patients with SLE

Variable	Coefficient	OR (95% CI)	p-value
Age	−0.02	0.98 (0.93∼1.03)	0.42
Sex (female)	−0.31	0.74 (0.12∼4.56)	0.74
Educational level (less than college graduate)	1.00	2.71 (0.90∼8.15)	0.08
Marital status (single/divorced/separated/widowed)	1.51	4.53 (1.19∼17.25)	0.03
Unemployment	0.47	1.61 (0.51∼5.07)	0.42
Annual income (≤18,000,000 KRW)	0.12	1.12 (0.25∼5.11)	0.88
Patient's global assessment	0.05	1.05 (1.02∼1.08)	2.13×10⁻⁴
Physician's global assessment	−2.8×10⁻³	1.00 (1.02∼1.00)	0.48
Use of azathioprine	−0.24	0.79 (0.21∼2.96)	0.73
Mobility (moderate to severe problems)	0.19	1.21 (0.37∼3.94)	0.75
Self-care (moderate to severe problems)	0.71	2.04 (0.37∼11.23)	0.41
Usual activity (moderate to severe problems)	1.04	2.83 (0.86∼9.35)	0.09
Pain/discomfort (extreme pain/discomfort)	2.00	7.38 (1.30∼42.06)	0.02

CI: confidence interval, KRW: Korean Won, OR: odds ratio, SLE: systemic lupus erythematosus.

Table 5.

Correlation analysis for serum brain-derived neurotrophic factor levels and associated factors with adjustment for platelet count in patients with SLE (n=151)

Variable	Correlation coefficient	p-value
Age Disease duration	0.17 −0.02	0.03 0.85
SLEDAI	−0.21	0.01
Patient's global assessment	−0.00	0.98
Physician's global assessment	−0.06	0.46
SDI	−0.01	0.87
CES-D score	−0.06	0.49
EQ-5D index	0.03	0.71
White cell	−0.15	0.06
Hemoglobin	−0.30	1.75×10⁻⁴
Anti-dsDNA titer	−0.09	0.30
C3	0.03	0.69
C4	−0.01	0.96
Serum 25(OH)D levels	−0.04	0.73
Daily glucocorticoid dose^*	−0.22	0.01

C: complement, CES-D: the center for epidemiologic studies depression, EQ-5D: the EuroQol-5 dimensions, SDI: Systemic Lupus International Collaborating Clinics/American College of Rheumatology damage index, SLE: systemic lupus erythematosus, SLEDAI: SLE disease activity index. *Mean daily pre-dnisolonedose over the previous 3 months (mg/d).

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