PHILADELPHIA – Patients with lupus have a high prevalence of depression, which may be linked to the cardiovascular disease that's also highly prevalent in lupus patients.
Cardiovascular disease and cardiovascular risk “may precipitate development of depression in patients with lupus,” Laura Julian, Ph.D., said at the annual meeting of the American College of Rheumatology. It's also possible that depression in patients with systemic lupus erythematosus (SLE) exacerbates cardiovascular disease by making patients poorly compliant with treatment. “The relationship between cardiovascular disease and depression [in lupus patients] may be bidirectional,”she said.
Because of this apparent interrelationship, physicians who care for SLE patients should regularly screen them for depression and treat it when diagnosed. Physicians should also be diligent about screening for and treating cardiovascular disease risks in lupus patients, said Dr. Julian, a neuropsychologist at the University of California, San Francisco.
“Our working hypothesis is that accumulation of vascular disease in specific white-matter regions of the brain might precipitate development of depression. In lupus patients there is a very high risk of cardiovascular outcomes, so we think this is reasonable,” she said in an interview. This etiology has been called vascular depression.
Evidence supporting the occurrence of vascular depression in SLE patients came from following patients who were enrolled in the Lupus Outcomes Study, which enrolled patients with SLE at the University of California, San Francisco. Dr. Julian and her associates collected data from 725 lupus patients who were followed for more than 5 years. More than 90% of the patients were women, and average age at entry to the study was 51.
At entry and regularly during follow-up, the patients were assessed for depression by having them complete the CES-D (Center for Epidemiology Studies–Depression) scale, a commonly used, self-report, 20-question survey. People who scored 23 or higher on the CES-D were considered to have probable depression. In the series, 23% met this set of criteria at baseline.
During follow-up, about 12% of the SLE patients developed depression each year, but another 10% who had been previously identified with depression remitted. Dr. Julian said this pattern is typical for depression, which generally occurs and remits over time.
Dr. Julian and her associates analyzed a variety of demographic and clinical variables to see which factors were linked with new-onset depression during the 5 years of follow-up. A multivariate analysis identified three measures that had a significant association: a socioeconomic status below the poverty level, which linked with a greater than threefold risk for incident depression; a history of myocardial infarction or stroke, linked with a twofold greater rate of new depression; and greater SLE disease activity, linked with a 12% higher rate of new depression.
Analyzing the data a different way, the researchers found that through the 5 years of follow-up, 25% of the SLE patients without a history of cardiovascular disease or poverty had an episode of new depression. Among those with either cardiovascular disease or poverty, the rate for a new depression episode was about 40%. And in patients with a history of both cardiovascular disease and poverty, 80% had an episode of incident depression during the study.
The CES-D could also be used to diagnose depression in a routine-practice setting, and it would be reasonable for physicians to screen patients with SLE for depression every few months, Dr. Julian said. So far, there is no evidence proving that conventional behavioral and medical treatments for depression are effective in SLE patients, but until this is evaluated in a study, it is reasonable to use these treatments on depressed SLE patients, she said.
Dr. Julian said that she had no financial disclosures.
◊ Watch a video interview with Dr. Julian at http://www.youtube.com/watch?v=jm4KZ6KFoMM
Laura Julian, Ph.D., says vascular disease in specific white-matter regions may cause the depression.
Source Mitchel L. Zoler/Elsevier Global Medical News