|
 
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| REVIEW |
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| Year : 2015 | Volume
: 5
| Issue : 2 | Page : 21-27 |
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Depression in systemic lupus erythematosus: A systematic review
Mridul Gupta
Department of Medicine, R. C. S. M. Government Medical College, Kolhapur, Maharashtra, India
| Date of Submission | 23-Sep-2015 |
| Date of Acceptance | 08-Apr-2016 |
| Date of Web Publication | 14-Jul-2017 |
Correspondence Address:
Mridul Gupta
Department of Medicine, R. C. S. M. Government Medical College, Kolhapur, Maharashtra
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/2321-6662.210493
Depression is the most common psychological symptom in patients with systemic lupus erythematosus (SLE). A large fraction of these patients remains undiagnosed due to subclinical presentation or is missed in the routine workup of SLE. Many factors have been reported in the literature which can be used as predictor of depression in SLE. Lupus patients also have higher risk of suicidal tendencies than the general population. Pathogenesis of depression in SLE is multifactorial and involves complex interactions between cytokines, antibodies, genetic factors, etc. Approach to such patients consists of studies that establish diagnosis of SLE, distinguish between organic and functional etiologies, and exclude symptoms not due to SLE. Various hematological, cerebrospinal fluid investigations, electroencephalography, psychometric testing, as well as neuroimaging modalities are involved in diagnostic workup of lupus patients with depression. Patients with only psychological causes for depression are treated with antidepressants. While in case of organic disease, one treats with glucocorticoids, immunosuppressants, and antidepressants. Electroconvulsive therapy can be considered in very severe cases not responding to maximum therapy. Keywords: Antidepressants, depression, systemic lupus erythematosus
How to cite this article:
Gupta M. Depression in systemic lupus erythematosus: A systematic review. Int J Stud Res 2015;5:21-7 |
| Introduction | |  |
Systemic lupus erythematosus (SLE) is a chronic autoimmune disorder with multi-organ involvement, predominantly seen in females and with a relapsing-remitting course [1]. Its most common manifestations are arthritis, cutaneous lesions, renal disease, and neuropsychiatric symptoms [1].
One of the presentations of SLE is central nervous system (CNS) involvement. CNS involvement in SLE or lupus can be in a wide spectrum of clinical presentations such as mood disorders, anxiety, and cerebrovascular accidents [2]. The first description of mental changes in lupus was reported by Kaposi in 1872 [3]. Since then, a lot of research has been done into this topic, but still CNS involvement in lupus is largely unrecognized and misunderstood [4].
The first attempt towards classification and nomenclature of nervous system disorders in lupus was done in 1979 by Kassan and Lockshin [5]. Later in 1999, the American College of Rheumatology (ACR) developed a nomenclature system for 19 neuropsychiatric syndromes in SLE: neuropsychiatric SLE (NPSLE) [2]. Case definitions including diagnostic criteria, important exclusions, and methods of ascertainment were developed for 19 NPSLE syndromes.
Depression is the most common psychological symptom in patients with lupus [6]. It falls under the case definition of mood disorders in ACR classification [2]. Detailed diagnostic criteria for mood disorders in SLE was given by ACR [7]. Several studies that have looked into the prevalence of depression in lupus patients have reported point prevalence rate in the range of 11–65.8% [Table 1] [8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24]. This wide variation may be due to difference in the epidemiology of various sample populations as well as variations in the diagnostic methods employed by various groups. In one of the studies, lifetime prevalence of depression in SLE was reported to be 69% [25]. | Table 1: Studies describing prevalence of depression in systemic lupus erythematosus patients
Click here to view |
| Risk Factors | | |
Depression by itself is an excellent example of the iceberg phenomenon. There is slow progression from subclinical depression to clinically significant disease. For every case of depression in SLE diagnosed, there are many more which are subclinical or are missed in the routine workup of lupus. Many cases remain undiagnosed due to delay and hesitancy in seeking medical care [17],[26]. In a significant number of cases, depression may be present when patient is diagnosed of lupus [26].
Many factors which can be used as predictors of depression in lupus have been reported in the literature. Most important ones are appearance concerns, inadequate pain control, illness intrusiveness, perceived severity of disease, concealment of symptoms, and major life events [27],[28],[29],[30]. Depression is more likely in the setting of poor quality of medical care [28]. Diabetes mellitus, vascular disease, unemployment, and lower levels of education are also found to be associated with depression in isolated studies [18],[22],[23],[31].
A significant proportion of these cases also has suicidal tendencies. SLE patients are at five times higher risk of having suicidal tendencies [32]. Suicidal thoughts are present in around 10–12% of SLE patients [19],[33]. Psychosis, insomnia, history of photosensitivity, incompletely controlled disease, tapering corticosteroids dose, major life events in the preceding month, previous suicide attempt, diffuse slowing on electroencephalogram, and presence of hypocomplementemia are risk factors for attempting suicide in SLE [33],[34].
| Pathogenesis | | |
Pathogenesis of depression in lupus is highly debated and is not clearly understood. There are mainly two theories which are put forth as an explanation for the pathogenesis of depression. First theory states that depression in SLE is due to psychosocial factors due to the stress of being diagnosed with a chronic disease at a very young age. Some of the studies support this theory [6],[35],[36] while others have failed to establish any significant association between depression and psychosocial factors [37]. Other theory suggests that depression in lupus patients is due to organic damage taking place in the CNS. This damage is most likely thought to be immune mediated. Here, as well, there are studies which support this hypothesis [18],[30],[38]. On the other hand, some investigators disagree to this proposal [19],[23],[36].
Various autoantibodies have been investigated to determine if they are pathogenic for depression. Some investigators believe that a strong association exists between the occurrence of neuropsychiatric symptoms and the presence of antineuronal and other antibodies [39]. Antiribosomal P antibody is believed to have strong association with depression in SLE in some [40],[41] but not most studies [42],[43]. A few studies have also suggested an association between antibodies against human N-methyl-D-aspartate receptor types (anti-NR2 antibodies) and depressed mood [12],[44]. However, other studies have not confirmed these observations [13]. Antiganglioside (aGM1-IgM) [45] and antiendothelial cell antibodies [39] are also reported to have association with depression. However, these findings need to be confirmed in larger controlled studies.
Proinflammatory cytokines released from monocytes/macrophages (tumor necrosis factor-alpha [TNF-α], interleukin-1 beta [IL-1β], IL-1, IL-6, IL-8, etc.,) may play an important role in the development of depression in lupus patients [46],[47]. Blood–brain barrier disruption is an essential component of NPSLE pathogenesis [48]. TNF-α, TNF-like weak inducer of apoptosis (TWEAK) may play important role in this process [46],[49]. Once blood–brain barrier is compromised, other autoantibodies may gain access to intrathecal space.
Depression in SLE patients is also reported to be associated with central blood flow reductions in discrete temporal and frontal regions [50]. It is not clearly understood if this reduction in central blood flow is caused by cytokines/autoantibodies/or some other unknown factor.
Depression can also be caused by treatment with corticosteroids through downregulation of the brain-derived neurotrophic factor [51]. The role of various environmental factors (retrovirus, ultraviolet light, stress, medicines) can also not be ruled out [4],[52].
Hereditary predisposition can also be present in lupus patients for developing depression [53],[54]. Link polymorphism of serotonin transporter gene promoter region (PR-5HHT) is associated with depression in lupus patients [55].
To sum up, pathogenesis of depression cannot be explained on the basis of a single theory/mechanism. Mechanism for this disease is essentially multifactorial, which involves complex interactions between cytokines, antibodies, genetic factors, and environmental factors. Multifactorial pathogenesis of depression in SLE is described in [Figure 1].
| Diagnosis | | |
Diagnostic tests that establish a specific diagnosis of neuropsychiatric lupus do not exist. Approach to a patient with neuropsychiatric symptoms consists of studies that establish diagnosis of SLE, distinguish between organic and functional etiologies, and exclude symptoms not due to SLE [56].
Careful history and physical examination should be done with special emphasis to look for depressive mental state/suicidal thoughts. A large proportion of these cases does not seek medical care for their depression [26]. Primary care doctors/rheumatologists taking care of the patients must be proactive to pick up the disease early. These patients often have treatment adherence problems [57]. So any treatment plan should be ensured through strict follow-up.
Initial evaluation of SLE patient with (new) signs or symptoms suggestive of neuropsychiatric disease is comparable to that in non-SLE patient with the same manifestation to rule out secondary causes such as infections, metabolic, endocrine, and adverse drug reaction [58]. ACR has provided guidelines for diagnostic workup of patients with NPSLE [2],[59]. A battery of hematological, cerebrospinal fluid (CSF) investigations, electroencephalography (EEG), psychometric testing, as well as neuroimaging modalities are involved in diagnostic workup of lupus patients with depression [56],[59].
These tests are divided into two categories. First one involves investigations which should be done in routine while other is investigational which is done in special conditions to rule out other differentials. Important part of this diagnostic workup is to exclude other systemic illnesses and medications which might be confounding with the diagnosis of NPSLE. Psychometric testing can be used in setting of depression to rule out organic from psychosocial disease [56]. Recommendations for laboratory evaluation and diagnostic imaging in SLE patients with depressive symptoms are summarized in [Table 2]. | Table 2: Laboratory evaluation and diagnostic imaging in neuropsychiatric systemic lupus erythematosus
Click here to view |
Neuroimaging is reserved for refractory cases who do not respond to initial treatment of depression. Magnetic resonance imaging (MRI) is the gold standard for neuroimaging in NPSLE [60]. If MRI is not available, computed tomography can be done [55]. European League Against Rheumatism (EULAR) recommends that MRI protocol (brain and spinal cord) should include conventional MRI sequences (T1/T2, fluid attenuated inverse recovery, diffusion-weighted imaging) and gadolinium-enhanced T1 sequences [61].
ACR recommends the use of Center for Epidemiological Studies - Depression Scale for evaluation of depression in NPSLE patients [62].
| Management | | |
The management of depression in SLE depends on whether the physician thinks that the depression has a neurological basis (inflammation of the brain, a stroke, seizure, perhaps the presence of autoantibodies, elevated cytokines) versus a psychological cause(where signs of neurological basis are absent). One can differentiate neurological from psychological causes by imaging (MRI), EEG, CSF analysis, and psychometric testing [56]. Patients with only psychological causes are treated with antidepressants while in case of organic disease, one treats with glucocorticoids, immunosuppressants, and antidepressants [61].
At present, there is a paucity of published controlled trials for treatment of depression in SLE patients [60]. In a study, combination of celecoxib (anti-inflammatory) and fluoxetine (antidepressant) has been reported to have greater antidepressant effect than fluoxetine alone [63]. EULAR recommends treatment of depression in SLE patients with a combination therapy of glucocorticoids, immunosuppressant, and antidepressant [60].
Electroconvulsive therapy (ECT) can be used in very severe cases who do not respond to the maximum therapy. There is a case series of three patients in which SLE patients with psychosis were treated successfully with ECT, but there is no study or case report describing use of ECT in SLE-associated depression [64].
Most of these SLE patients with depression recover within a year with the help of social support along with medical care [65]. Other patients may incorporate depression into their personality, thereby developing psycho(somatic) complaints such as insomnia, anorexia, constipation, myalgia, and arthralgia [65]. Many of these patients develop chronic fatigue syndrome [23],[66]. Patients may also develop “psychotic features” with increasing despair, loss of hope, and even suicidal tendencies [65]. It is recommended that such patients should be managed in psychiatric facilities. Psychological interventions are found to be efficient in the management of depression in SLE [67].
| Discussion | | |
Various theories have been suggested in the literature to explain pathogenesis of depression in SLE. Actual mechanism is more likely to be multifactorial with complex interaction of various variables. [Figure 2] also explains relation between stress and depression forming cyclic sequence of events. It is very difficult to determine starting point of this cycle. Health-related quality of life in these patients is affected by fatigue, disease activity, and psychiatric disease [68],[69]. There is very little literature which describes diagnostic workup and management of depression in SLE. Most of the guidelines available are for NPSLE which is a broader aspect of this disease. In a patient who presents with depression, only a few specific investigations are required out of the whole battery of investigations recommended by ACR. Treatment of such cases is with a combination of glucocorticoids, immunosuppressants, and antidepressants.
| Conclusion | | |
Depression is the most common psychiatric presentation of SLE. A large proportion of these cases still remains undetected. Suicidal thoughts are very common in such patients. Numerous red flag signs have been described in the literature to suspect such events. Finally, primary objective of patient care in this setting is to improve quality of life for the patients. Better control of disease activity, psychiatry disease, and stringent pain control can help in ensuring better quality of life for patients.
Acknowledgment
I dedicate this work to Dr. Peter H. Schur, Professor, Harvard Medical School, for his guidance and supervision during this paper and the clinical rotation at Brigham and Women's Hospital, Boston, MA, USA.
Competing Interests
The authors declare that they have no competing interests.
Funding
Sources of Funding: None.
| References | | |
| 1. | Cervera R, Khamashta MA, Font J, et. al. Morbidity and mortality in systemic lupus erythematosus during a 10-year period: a comparison of early and late manifestations in a cohort of 1,000 patients. Medicine (Baltimore) 2003;82(5):299-308.  |
| 2. | American College of Rheumatology Ad Hoc Committee on Neuropsychiatric Lupus Nomenclature. The American College of Rheumatology Nomenclature and Case Definition for Neuropsychiatric Lupus Syndromes. Arthritis Rheum 1999;42(4):599-608. |
| 3. | Kaposi EA. New contributions to the knowledge of lupus erythematosus. Arch Dermatol Syph 1872;4(1):36-78. |
| 4. | Meszaros ZS, Perl A, Faraone SV, et. al. Psychiatric symptoms in systemic lupus erythematosus: a systematic review. J Clin Psychiatry 2012;73(7):993-1001. |
| 5. | Kassan SS, Lockshin MD. Central nervous system lupus erythematosus. The need for classification. Arthritis Rheum 1979;22(12):1382-5. |
| 6. | Jennekens FG, Kater L. The central nervous system in systemic lupus erythematosus. Part 1. Clinical syndromes: a literature investigation. Rheumatology (Oxford) 2002;41(6):605-18. |
| 7. | |
| 8. | Miguel EC, Pereira RM, Pereira CA, et. al. Psychiatric manifestations of systemic lupus erythematosus: clinical features, symptoms, and signs of central nervous system activity in 43 patients. Medicine (Baltimore) 1994;73(4):224-32. |
| 9. | Ainiala H, Loukkola J, Peltola J, Korpela M, Hietaharju A. The prevalence of neuropsychiatric syndromes in systemic lupus erythematosus. Neurology 2001;57(3):496-500. |
| 10. | Brey RL, Holliday SL, Saklad AR, et. al. Neuropsychiatric syndromes in lupus: prevalence using standardized definitions. Neurology 2002;58(8):1214-20. |
| 11. | Hanly JG, Fisk JD, McCurdy G, Fougere L, Douglas JA. Neuropsychiatric syndromes in patients with systemic lupus erythematosus and rheumatoid arthritis. J Rheumatol 2005;32(8):1459-6. |
| 12. | Lapteva L, Nowak M, Yarboro CH, et. al. Anti-N-methyl-D-aspartate receptor antibodies, cognitive dysfunction, and depression in systemic lupus erythematosus. Arthritis Rheum 2006;54(8):2505-14. |
| 13. | Harrison MJ, Ravdin LD, Lockshin MD. Relationship between serum NR2a antibodies and cognitive dysfunction in systemic lupus erythematosus. Arthritis Rheum 2006;54(8):2515-22. |
| 14. | Waheed A, Hameed K, Khan AM, Syed JA, Mirza AI. The burden of anxiety and depression among patients with chronic rheumatologic disorders at a tertiary care hospital clinic in Karachi, Pakistan. J Pak Med Assoc 2006;56(5):243-7. |
| 15. | Bachen EA, Chesney MA, Criswell LA, et. al. Prevalence of mood and anxiety disorders in women with systemic lupus erythematosus. Arthritis Rheum 2009;61(6):822-9. |
| 16. | Petri M, Naqibuddin M, Carson KA, et. al. Depression and cognitive impairment in newly diagnosed systemic lupus erythematosus. J Rheumatol 2010;37(10):2032-8. |
| 17. | Julian LJ, Gregorich SE, Tonner C, et. al. Using the center for epidemiologic studies depression scale to screen for depression in systemic lupus erythematosus. Arthritis Care Res (Hoboken) 2011;63(6):884-90. |
| 18. | Julian LJ, Tonner C, Yelin E, et. al. Cardiovascular and disease-related predictors of depression in systemic lupus erythematosus. Arthritis Care Res (Hoboken) 2011;63(4):542-9. |
| 19. | Jarpa E, Babul M, Calderón J, et. al. Common mental disorders and psychological distress in systemic lupus erythematosus are not associated with disease activity. Lupus 2011;20(1):58-66. |
| 20. | Karol DE, Criscione-Schreiber LG, Lin M, Clowse ME. Depressive symptoms and associated factors in systemic lupus erythematosus. Psychosomatics 2013;54(5):443-50. |
| 21. | Sehlo MG, Bahlas SM. Perceived illness stigma is associated with depression in female patients with systemic lupus erythematosus. J Psychosom Res 2013;74(3):248-51. |
| 22. | Maneeton B, Maneeton N, Louthrenoo W. Prevalence and predictors of depression in patients with systemic lupus erythematosus: a cross-sectional study. Neuropsychiatr Dis Treat 2013;2013(9):799-804. |
| 23. | van Exel E, Jacobs J, Korswagen LA, et. al. Depression in systemic lupus erythematosus, dependent on or independent of severity of disease. Lupus 2013;22(14):1462-9. |
| 24. | Shen B, Tan W, Feng G, et. al. The correlations of disease activity, socioeconomic status, quality of life, and depression/anxiety in Chinese patients with lupus erythematosus. Clin Dev Immunol 2013; 2013(2013):270878. [About 6 p]. [Last accessed on 2015 May 30]. |
| 25. | Nery FG, Borba EF, Viana VS, et. al. Prevalence of depressive and anxiety disorders in systemic lupus erythematosus and their association with anti-ribosomal P antibodies. Prog Neuropsychopharmacol Biol Psychiatry 2008;32(3):695-700. |
| 26. | van Dam AP, Wekking EM, Callewaert JA, et. al. Psychiatric symptoms before systemic lupus erythematosus is diagnosed. Rheumatol Int 1994;14(2):57-62. |
| 27. | Ji L, Lili S, Jing W, et. al. Appearance concern and depression in adolescent girls with systemic lupus erythematous. Clin Rheumatol 2012;31(12):1671-5. |
| 28. | Philip EJ, Lindner H, Lederman L. Confidence in medical care linked to depression in lupus sufferers. J Allied Health 2009;38(2):106-12. |
| 29. | Schattner E, Shahar G, Lerman S, Shakra MA. Depression in systemic lupus erythematosus: the key role of illness intrusiveness and concealment of symptoms. Psychiatry 2010;73(4):329-40. |
| 30. | Nery FG, Borba EF, Hatch JP, et. al. Major depressive disorder and disease activity in systemic lupus erythematosus. Compr Psychiatry 2007;48(1):14-9. |
| 31. | Greco CM, Li T, Sattar A, et. al. Association between depression and vascular disease in systemic lupus erythematosus. J Rheumatol 2012;39(2):262-8. |
| 32. | Karassa FB, Magliano M, Isenberg DA. Suicide attempts in patients with systemic lupus erythematosus. Ann Rheum Dis 2003;62(1):58-60. |
| 33. | Mok CC, Chan KL, Cheung EF, Yip PS. Suicidal ideation in patients with systemic lupus erythematosus: incidence and risk factors. Rheumatology (Oxford) 2014;53(4):714-21. |
| 34. | Matsukawa Y, Sawada S, Hayama T, Usui H, Horie T. Suicide in patients with systemic lupus erythematosus: a clinical analysis of seven suicidal patients. Lupus 1994;3(1):31-5. |
| 35. | Seguí J, Ramos-Casals M, García-Carrasco M, et. al. Psychiatric and psychosocial disorders in patients with systemic lupus erythematosus: a longitudinal study of active and inactive stages of the disease. Lupus 2000;9(8):584-8. |
| 36. | Hanly JG, Su L, Farewell V, et. al. Prospective study of neuropsychiatric events in systemic lupus erythematosus. J Rheumatol 2009;36(7):1449-59. |
| 37. | Ward MM, Marx AS, Barry NN. Psychological distress and changes in the activity of systemic lupus erythematosus. Rheumatology (Oxford) 2002;41(2):184-8. |
| 38. | Kozora E, Ellison MC, Waxmonsky JA, Wamboldt FS, Patterson TL. Major life stress, coping styles, and social support in relation to psychological distress in patients with systemic lupus erythematosus. Lupus 2005;14(5):363-72. |
| 39. | Conti F, Alessandri C, Bompane D, et. al. Autoantibody profile in systemic lupus erythematosus with psychiatric manifestations: a role for anti-endothelial-cell antibodies. Arthritis Res Ther 2004;6(4):R366-72. |
| 40. | Karassa FB, Afeltra A, Ambrozic A, et. al. Accuracy of anti-ribosomal P protein antibody testing for the diagnosis of neuropsychiatric systemic lupus erythematosus: an international meta-analysis. Arthritis Rheum 2006;54(1):312-24. |
| 41. | Schneebaum AB, Singleton JD, West SG, et. al. Association of psychiatric manifestations with antibodies to ribosomal P proteins in systemic lupus erythematosus. Am J Med 1991;90(1):54-62. |
| 42. | Gerli R, Caponi L, Tincani A, et. al. Clinical and serological associations of ribosomal P autoantibodies in systemic lupus erythematosus: prospective evaluation in a large cohort of Italian patients. Rheumatology (Oxford) 2002;41(12):1357-66. |
| 43. | Mahler M, Kessenbrock K, Raats J, et. al. Characterization of the human autoimmune response to the major C-terminal epitope of the ribosomal P proteins. J Mol Med (Berl) 2003;81(3):194-204. |
| 44. | Omdal R, Brokstad K, Waterloo K, et. al. Neuropsychiatric disturbances in SLE are associated with antibodies against NMDA receptors. Eur J Neurol 2005;12(5):392-8. |
| 45. | Galeazzi M, Annunziata P, Sebastiani GD, et. al. Anti-ganglioside antibodies in a large cohort of European patients with systemic lupus erythematosus: clinical, serological, and HLA class II gene associations. European Concerted Action on the Immunogenetics of SLE. J Rheumatol 2000;27(1):135-41. |
| 46. | Mak A, Tang CS, Ho RC. Serum tumour necrosis factor-alpha is associated with poor health-related quality of life and depressive symptoms in patients with systemic lupus erythematosus. Lupus 2013;22(3):254-61. |
| 47. | Buras A, Waszkiewicz N, Szulc A, Sierakowski S. Monocytic parameters in patients with rheumatologic diseases reflect intensity of depressive disorder. Pol Merkur Lekarski 2012;33(198):325-9. |
| 48. | Abbott NJ, Mendonça LL, Dolman DE. The blood-brain barrier in systemic lupus erythematosus. Lupus 2003;12(12):908-15. |
| 49. | Stephan D, Sbai O, Wen J, et. al. TWEAK/Fn 14 pathway modulates properties of a human microvascular endothelial cell model of blood brain barrier. J Neuroinflammation 2013;10(9):14. Available from: http://www.jneuroinflammation.com/content/10/1/9. [Last accessed on 2014 May 22]. |
| 50. | Giovacchini G, Mosca M, Manca G, et. al. Cerebral blood flow in depressed patients with systemic lupus erythematosus. J Rheumatol 2010;37(9):1844-51. |
| 51. | Huang TL, Lee CT, Liu YL. Serum brain-derived neurotrophic factor levels in patients with major depression: effects of antidepressants. J Psychiatr Res 2008;42(7):521-5. |
| 52. | Lim L, Ron MA, Ormerod IE, et. al. Psychiatric and neurological manifestations in systemic lupus erythematosus. Q J Med 1988;66(249):27-38. |
| 53. | Jennekens FG, Kater L. The central nervous system in systemic lupus erythematosus. Part 2. Pathogenetic mechanisms of clinical syndromes: a literature investigation. Rheumatology 2002;41(6):619-30. |
| 54. | Steup-Beekman G, Steens S, van Buchem M, Huizinga T. Anti-NMDA receptor autoantibodies in patients with systemic lupus erythematosus and their first-degree relatives. Lupus 2007;16(5):329-34. |
| 55. | Xu J, Cheng YQ, Chen B, et. al. Depression in systemic lupus erythematosus patients is associated with link-polymorphism but not methylation status of the 5HTT promoter region. Lupus 2013;22(10):1001-10. |
| 56. | Schur PH. Diagnostic approach to the neuropsychiatric manifestations of systemic lupus erythematosus. Waltham: Wolters Kluwer Health; 2015. Available from: http://www.tinyurl.com/psgucul. [Last accessed on 2015 Sep 23]. |
| 57. | Julian LJ, Yelin E, Yazdany J, et. al. Depression, medication adherence, and service utilization in systemic lupus erythematosus. Arthritis Rheum 2009;61(2):240-6. |
| 58. | Bertsias G, Ioannidis JP, Boletis J, et. al. EULAR recommendations for the management of systemic lupus erythematosus. Report of a Task Force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics. Ann Rheum Dis 2008;67(2):195-205. |
| 59. | |
| 60. | Bertsias GK, Boumpas DT. Pathogenesis, diagnosis and management of neuropsychiatric SLE manifestations. Nat Rev Rheumatol 2010;6()6:358-67. |
| 61. | Bertsias GK, Ioannidis JP, Aringer M, et. al. EULAR recommendations for the management of systemic lupus erythematosus with neuropsychiatric manifestations: report of a task force of the EULAR standing committee for clinical affairs. Ann Rheum Dis 2010;69(12):2074-82. |
| 62. | |
| 63. | Akhondzadeh S, Jafari S, Raisi F, et. al. Clinical trial of adjunctive celecoxib treatment in patients with major depression: a double blind and placebo controlled trial. Depress Anxiety 2009;26(7):607-11. |
| 64. | Tan LP, Tan LE. Electroconvulsive therapy for severe neuropsychiatric lupus with psychosis. J ECT 2013;29(3):243-6. |
| 65. | Schur PH. Neuropsychiatric manifestations of systemic lupus erythematosus. Waltham:Wolters Kluwer Health;2015. Available from: http:// www.tinyurl.com/nplhzwq. [Last accessed on 2015 Sep 15]. |
| 66. | Jump RL, Robinson ME, Armstrong AE, et. al. Fatigue in systemic lupus erythematosus: contributions of disease activity, pain, depression, and perceived social support. J Rheumatol 2005;32(9):1699-705. |
| 67. | Zhang J, Wei W, Wang CM. Effects of psychological interventions for patients with systemic lupus erythematosus: a systematic review and meta-analysis. Lupus 2012;21(10):1077-87. |
| 68. | Shen B, Feng G, Tang W, et. al. The quality of life in Chinese patients with systemic lupus erythematosus is associated with disease activity and psychiatric disorders: a path analysis. Clin Exp Rheumatol 2014;32(1):101-7. |
| 69. | Tam LS, Wong A, Mok VC, et. al. The relationship between neuropsychiatric, clinical, and laboratory variables and quality of life of Chinese patients with systemic lupus erythematosus. J Rheumatol 2008;35(6):1038-45. |
[Figure 1], [Figure 2]
[Table 1], [Table 2]
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