Mood Disorders and Lupus
Defining mood disordersMood disorders include depression and generalised anxiety and are one of the most frequently experienced type of psychological problem for people with lupus. Other common neuropsychiatric manifestations of lupus such as cognitive impairment, epilepsy, psychosis and catatonia are outlined elsewhere.
See pages - CNS Involvement in Lupus and Antiphospholipid (Hughes) Syndrome.
It is important to establish diagnostic criteria for mood disorders before it is possible to plan effective strategies to enable people with these conditions to make sustainable improvements in their mood.
An effective initial screening method (prior to appointments) can make use of a retrospective questionnaire assessment such as Zigmond and Snaith’s 14-symptom Hospital Anxiety and Depression Scale, which takes little time to complete. This provides information on how severe these symptoms are but is not a diagnostic tool per se. Simple mood diaries are an effective way of selfmonitoring daily mood; these can be completed as frequently as the person wishes (e.g. three times a day) and giving as much or little detail as they want (e.g. a single numerical rating on a 0-10 scale and/or free narrative).
The terms depressed and anxious have been assimilated into everyday language but the mood disorders these symptoms reflect are based on clear medical diagnoses. Whilst these may be the most salient term for a person experiencing an acute episode of mood disturbance, health professionals must listen to the mood symptoms their patients are describing and map these along the parallel continuums from happiness and calmness to enduring sadness or generalised anxiety. However, people with lupus are rarely at the extreme ends of the continuum and will often report moderately depressed or anxious mood states and judgment is required to determine if these require help.
An episode of major depression is classified by the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM) as a period of at least 2 weeks of having depressed mood or lack of interest in activities and anhedonia (the lack of pleasure from previously enjoyed activities). These problems should be experienced most of the day and every day for this period. In addition to this, classification requires the individual to have four or more of the following associated problems:
• Change in appetite or change in weight
• Hypersomnia or insomnia (especially waking early)
• Restlessness or feeling slowed down
• Fatigue or loss of energy
• Guilt and feelings of worthlessness
• Inability to concentrate or indecisiveness
• Suicidal ideation
The World Health Organization’s International Statistical Classification of Diseases and Related Health Problems (ICD) section on mental and behavioural disorders codes depressive episodes as mild, moderate or severe (F32.0, F32.1 and F32.2, respectively). All three codes are outlined as sharing the features of depressed mood, loss of interest and enjoyment and reduced energy levels leading to diminished activity due to increased fatigability after only slight effort is common. Other common symptoms are reduced concentration and attention, reduced self-esteem and self-confidence, ideas of guilt and unworthiness, bleak and pessimistic views of the future, ideas or acts of self-harm or suicide, disturbed sleep and diminished appetite. For all three severity grades of depressed mood it is stated that a duration of at least 2 weeks is usually required for diagnosis unless the onset is rapid and severe.
The symptoms within both of these sets of diagnostic criteria have to be seen in the context of the disease process where a person with lupus might experience sleep disturbance and diminished appetite, especially within a flare. There is some potential for overlap with fatigue and disability from lupus, but the criterion of feeling slowed down might be best interpreted and explained as referring to a cognitive experience rather than as physical problems. These symptoms are defined as ‘somatic’ in the ICD and consideration of these will help avoid ‘false positive’ diagnoses. It is assumed that these criteria are being applied to individuals who have already received a diagnosis of lupus. Research indicates that people with lupus in their early journey to obtaining the diagnosis, when symptoms may fluctuate and objective tests prove inconclusive, can be wrongly misdiagnosed with a mood disorder and this may impact on satisfaction with healthcare interactions in the future.
A less intense but prolonged version of depression is called dysthymic disorder or minor depression; this is classified as depressed mood most of the day, more days than not for at least 2 years in the DSM, and very similarly in the ICD where it is not so strictly defined (code F34.1).This will probably be the most common type of depressed mood that will be seen in a clinical practice.
Generalised anxiety disorder is distinct from phobias and pure obsessive thought disorders and can be classified in a very similar way to depression. The DSM classifies this using the criteria of excessive, uncontrollable worry about several events (which could include one’s state of health) more days than not for a period of at least 6 months that has an impact on social functioning or work ability. In addition to this, to be classified the individual is required to have four or more of the following associated problems:
• Feeling restless or ‘edgy’
• Experiencing fatigue easily
• Having difficulty concentrating
• Being irritable without reason
• Experiencing muscle tension (particularly of the shoulders/neck)
• Having disturbed sleep (especially onset insomnia)
The criterion of muscle tension may be experienced in rheumatic disease. It is also clear that (major) depression and (generalised) anxiety have a large overlap in content of their listed symptom and associated thought processes. This will, hopefully, be clarified in the forthcoming revision to the DSM criteria, which are being redeveloped.The ICD already defines concomitant anxiety and depressive disorder (code F41.2). Fortunately, both conditions can be tackled by similar medical treatments and psychological therapies.
Given that there are problems with accurate recall of psychological processes, the criteria for depression and anxiety ideally require some form of daily mood assessment. There are many good measures of mood available; two classic measures are Watson and colleagues’ Positive and Negative Affect Schedule and Lorr and McNair’s Profile of Mood States. Both of these questionnaires cover depression (versus elation) and anxiety (versus calmness) although it is feasible, and indeed may be preferable, to allow patients to define a diary system for recording aspects of their mood without the formality of such scales.
A further simple method of getting to the heart of the issue of depression (reflecting the above criteria) is the use of two screening questions composed by Arroll and colleagues:
• "During the past month have you often been bothered by feeling down, depressed, or hopeless?"
• "During the past month have you often been bothered by little interest or pleasure in doing things?"
These questions can allow therapeutic skills to be directed to either or both of these issues, as will now be considered further. Alternatively, patients’ responses to these questions may be used as the basis for suggesting a referral to local psychological services.
MedicationsAntidepressant medications have traditionally been the first-line treatment for mood disorders given the ease of access and known cost-effectiveness. The British National Institute for Health and Clinical Excellence (NICE) currently recommends specific serotonin reuptake inhibitors (SSRIs) over tricyclic antidepressants due to reports of fewer side-effects from the former. However, tricyclics are sometimes given in small doses to reduce muscle tension and thus aid sleep in rheumatic disease, but there is no clear evidence of whether this regimen improves outcomes of mood disorders. Some SSRIs are also suitable for treatment of generalised anxiety. Moreover, people with lupus who also experience fibromyalgia syndrome may well benefit from the improvements in pain and function that certain antidepressants can provide in fibromyalgia.
See page - the Joints and Lupus
The Talking TherapiesPeople with lupus may not be keen to take antidepressants given the number of other medications that they may be taking. NICE suggests offering Cognitive Behavioural Therapy (CBT) for recurrent depression (ICD code F33) when the person is not happy to take antidepressants again. Indeed, NICE recommends psychological therapy over antidepressants as the first option for treatment of new cases of mild to moderate depression; NICE also recommends a combination of antidepressants along with psychological therapy when the case of depression is severe.
The psychological approaches, known collectively as talking therapies, include CBT, Motivational Interviewing, Counselling (from a variety of perspectives i.e. Freudian; Jungian; Humanistic) and Brief Solution-Focused Therapy. The essence of these approaches is to allow people with a mood disorder (or other issue) a safe space to talk over their situation, map out goals about what they want to change and provide them with methods of helping themselves to work towards this change. The application of one of the talking therapies is known to provide improvements in mood for people with lupus if they are willing and able to access such services, particularly if their spouse is also allowed to attend. Local rheumatology departments may have access to a health psychologist or other professional who can deliver a specialised form of talking therapy for people with lupus that may be more able to meet their needs than a general service at the primary care level. In the UK, a health psychologist is someone who specialises in the psychology of physical health, having completed accredited undergraduate, masters and doctoral degree programmes (or equivalent).
‘Standards of Care’ have been published by the Arthritis and Musculoskeletal Alliance (ARMA) in the UK for a variety of specific rheumatic diseases, including systemic lupus erythematosus. These standards define what evidence-based services and interventions are appropriate for people with lupus and suggest ways of providing them effectively. ARMA propose that CBT-based selfmanagement training should be available for individuals with any rheumatic disease at any stage of their illness via the Challenging Arthritis programme run by the charity Arthritis Care (for information on local courses see their website) or via the generic Expert Patient Programmes, which are now available throughout the UK within Primary Care Trusts. Cognitive-behavioural approaches can be applied on an individual basis or within small group settings (i.e. between 4 and 10 members) and focus upon accessing those cognitions (thought processes), moods and behaviours that lead to depression and anxiety. Many people with lupus will be happy to seek information and learn strategies for self-care through these group-based interventions. However, not all individuals will be able or comfortable with attending such courses.There are computerised CBT interfaces available, one of which (Beating the BluesTM) has been approved by NICE and may be an ideal format for people with lupus who want to be flexible about the time, place and level of contact they engage with for psychotherapy to improve their mood.
SummaryMood disorders, particularly depression and generalised anxiety, are common among people with lupus but there is much that can be done to ameliorate the effects of these conditions. Firstly, it is necessary to actively enquire about people’s mood, offer a label for any conditions they describe and discuss whether they wish to receive help. Following this, the sources of help depend on local availability across the modalities described within this chapter.
Chartered Health Psychologist
Dept of Rheumatology
Clinical Research Unit
Russells Hall Hospital
Dept of Psychology
University of Otago
Dept of Rheumatology
Clinical Research Unit
Russells Hall Hospital