Question

20. Provide a brief integrative explanation that involves genetic, biological, psychological and social processes (at least two) that best explains the greater prevalence of anxiety and mood disorders among women relative to men.

Answer 1

Objective

• To examine the lifetime prevalence of mood and anxiety disorders in patients with SLE. Demographic and disease-related variables were examined for association with lifetime major depressive disorder and the presence of any mood or anxiety disorder.

Methods

• Three-hundred and twenty-six Caucasian women with SLE completed the Composite International Diagnostic Interview (CIDI) and the Systemic Lupus Activity Questionnaire (SLAQ), a self-report measure of disease activity in SLE. The binomial test was used to compare the prevalence of psychiatric diagnoses in SLE patients to a population sample of Caucasian women.

Results

• Sixty-five percent of participants received a lifetime mood or anxiety diagnosis. Major depressive disorder (47%), specific phobia (24%), panic disorder (16%), obsessive-compulsive disorder (9%), and bipolar I disorder (6%) were more common among the SLE patients compared to Caucasian women (p = 0.00009 for specific phobia, all other p values = 0.00001).
• Although most patients with histories of mood disorders reported their psychiatric symptoms to a medical provider, a substantial number of patients with anxiety disorders did not. Self-reported disease activity was associated with a lifetime history of major depression (p = 0.001) and presence of a mood or anxiety disorder (p = 0.001), after controlling for demographic and clinical characteristics.

Conclusion

• Several mood and anxiety disorders are more common in women with SLE compared to the general population, and disease activity may contribute to this higher risk. Brief self-report questionnaires may help providers identify patients with these conditions, particularly when patients are reluctant to disclose their symptoms.
• Systemic lupus erythematosus (SLE) is a chronic, relapsing autoimmune disorder that is most prevalent in women and involves multiple organ systems. Due to the potentially debilitating nature of the disease and relatively early onset for many women, SLE can pose multiple challenges and disrupt life goals throughout adulthood. Previous studies have found higher levels of psychiatric disturbance in patients with SLE, particularly depression or distress (2–10).
• The reported prevalence of depressive symptomatology in SLE varies widely across studies, from 17 to 71% (11). This variation is likely due to divergent criteria used to define distress or psychiatric disturbance, differences in sample characteristics, the assessment tools used, and small sample sizes. Some studies, but not all, have found that greater disease activity, SLE severity or longer disease duration increases vulnerability for clinical depression in SLE (4–12).
• Although most research has focused on depressed mood or clinical unipolar depression in SLE, others suggest that symptoms of anxiety may be equally important in this population. In an Icelandic study of 62 SLE patients, diagnoses of agoraphobia with and without panic, specific phobia and social phobia were more prevalent in SLE patients than the general population .
• Segui et al. reported that among 20 female SLE patients, 40% met criteria for a psychiatric disorder, with generalized anxiety disorder and panic disorder being the most common diagnoses. Higher levels of social introversion and obsessive-compulsive disorder have also been reported in patients with SLE , compared to healthy controls or population rates. Because population prevalence rates of some anxiety and depressive disorders are low, employing larger sample sizes to examine rates of these disorders in SLE is advantageous.
• In the United States, epidemiological studies indicate that comorbidity of psychiatric disorders is common, with more than half of all lifetime disorders occurring in 14% of the population who have a history of three or more comorbid disorders and only 21% of lifetime disorders occurring in respondents with a history of just one disorder. These findings suggest that while a history of psychiatric disorders is common (affecting nearly 50%), the major burden of such disorders is concentrated in a highly comorbid group. No studies to date have examined the comorbidity of psychiatric disorders among patients with SLE.
• In addition to high rates of psychiatric comorbidity, U.S. studies also find an underutilization of professional services for emotional problems (15–16). Fewer than 40% of respondents with any lifetime psychiatric disorder receive professional treatment (15). Physicians provide the most care for psychiatric problems in the U.S. and primary care physicians are responsible for almost all referrals to mental health specialists (17–18).
• Because rheumatology patients may visit their rheumatologists as often or more often than primary care providers , rheumatologists can also play an important role in identifying and facilitating the treatment of psychiatric problems. Recently, Sleath et al. found that only 19% of depressed patients with rheumatoid arthritis discussed depression with their rheumatologists during medical visits, and that patients initiated the discussion each time.
• The purpose of this study is to investigate lifetime prevalence rates of anxiety and depressive disorders in patients with SLE. It extends previous work by simultaneously assessing multiple lifetime anxiety and mood disorders in a large sample of SLE patients, using a reliable and validated structured clinical interview, and diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV, 21).
• In addition, we determine rates of comorbidity for lifetime disorders and the prevalence of symptom reporting to medical providers in the sample. Finally, demographic and clinical characteristics of SLE, including duration of disease, recent self-reported disease activity, history of renal involvement (as an indicator of SLE severity), and current prednisone use are examined as potential correlates of lifetime major depression and presence of a psychiatric disorder.