Depression in Lupus
Howard S. Shapiro MD
Assistant Clinical Professor of Psychiatry and Human Behavior, University of Southern California, Los Angeles, CA
Senior Attending Staff, Department of Psychiatry, Cedars Sinai Medical Center, Los Angeles, CA
A reprint from the Lupus Foundation of America Article Library 1998
People with lupus often ask: "What amount of depression is normal?" "When should I seek professional help?" The person with lupus is often aware that depression may be brought on :
- by the lupus, itself
- by the various medications used to treat lupus
- by the many factors and forces in a patient's life that are unrelated to lupus.
However, there is also an uncertainty as to whether being depressed is to be expected, because of the stresses and sacrifices imposed by having a chronic illness.
Understanding depression
What is meant by the term "depression ?"
The medical condition referred to as clinical depression is not to be confused with the transitory everyday experience of a mild mood swing that everyone experiences during difficulties. Just as we feel happy or fearful or jealous or angry, we are all "depressed" from time to time.
On the other hand, clinical depressive illness is a very disabling, unpleasant and prolonged state.
Symptoms of depression
Clinical depression may bring on a variety of physical and psychological symptoms.
Psychological symptoms may include :
- sadness and gloom
- spells of crying (often without a cause)
- insomnia or restless sleep, or sleeping too much
- loss of appetite, or eating too much
- uneasiness or anxiety
- irritability
- feelings of guilt or regret
- lowered self-esteem
- inability to concentrate
- diminished memory and recall
- indecisiveness
- lack of interest in things formerly enjoyed
- fatigue
Physical symptoms may include :
- headache
- heart palpitations
- diminished sexual interest and/or performance
- body aches and pains
- indigestion
- constipation
- diarrhea
Not all people who suffer from clinical depression have all of the above symptoms.
Patients are considered to be clinically depressed when they have:
- a depressed mood
- disturbances in sleep and appetite, and
- at least one or two of the symptoms mentioned above which last for several weeks and are severe enough to disrupt daily life.
The challenges of diagnosing depression
Even in those individuals without chronic medical conditions, most cases of depressive illness go unrecognized and untreated until the later stages of the illness. This is when the severity of the depression becomes unbearable to the patient, and/or until the family or physician can no longer ignore it.
In fact, several studies indicate that 30-50 percent of cases of major depressive illness go undiagnosed in medical settings. Perhaps more disturbing is that many studies indicate that even when recognized, major depressive disorders in the medically ill are undertreated and/or inadequately treated.
Determining the severity of the depression
While there are many symptoms associated with clinical depression, these seven symptoms indicate the depth and degree of depression:
- sense of failure
- loss of social interest
- sense of punishment
- suicidal thoughts
- dissatisfaction
- indecision
- crying.
Two of the most common psychological signs of clinical depression are hopelessness and helplessness.
- People who feel hopeless believe that their distressing symptoms may never get better.
- People who feel helpless think they are beyond help, that no one cares enough to help them or could succeed in helping, even if they tried.
Hiding depression
Many people refuse to acknowledge that they are in a depressive state and will actually deny that they are feeling unhappy, demoralized or depressed. This group of individuals often experience what physicians called "masked depression. " These people resist the notion of emotional distress, and will use various physical complaints to explain their feelings.
Physicians who are familiar with a patient's usual mood and personality, as well as their lifestyle and situation, are more likely to recognize changes associated with depressive illness. Similarly, patients are more likely to open up about their feelings when they are encouraged to do so by a physician they trust and with whom they are familiar.
Depression and chronic illness
How common is depression in people with chronic illness ?
Some psychiatric and medical studies state that 15 percent of those with a chronic illness suffer from clinical depression; others place this figure as high as 60 percent. Although clinical depression is certainly more common in people with chronic medical illness, (e.g., lupus) than in the general population, not every patient with a chronic illness suffers from clinical depression.
Episodes of clinical depression usually last for only a few months in patients with a chronic illness. However, a flare of the disease can also trigger depression because a person may feel he/she is never going to be free of the illness.
Isn't having chronic illness a good reason to be depressed ?
Unfortunately, all too common is a distorted notion that those with a chronic illness have "reason to feel depressed because they are sick." This belief interferes with early recognition, early treatment, and early relief of suffering from clinical depression. This belief also ignores the facts that clinical depression in people who are physically ill generally responds well to standard psychiatric treatments and that patients treated only for their physical illness can suffer needlessly from clinical depression.
Depression and lupus
Is it lupus or is it depression ?
Depressive illness often goes unrecognized in those who have other medical illnesses because it presents symptoms so similar to those of the underlying medical condition.
For patients with systemic lupus erythematosus (SLE), symptoms of depressive illness that quite naturally can be attributed to the lupus condition include :
- inactivity
- loss of energy and interest
- insomnia
- pain intensification
- diminished sexual interest and/or performance.
What causes depression in lupus?
There is no one cause of clinical depression in lupus; rather, there are various and different factors contributing to depression in chronic illnesses such as lupus.
- The most common cause is the emotional drain from the continuous series of stresses and strains associated with coping with the chronic illness and medical condition.
- Other causes may be the many sacrifices and losses required by the continuous life adjustments that a patient with a chronic illness must make.
- Various medications used to treat lupus, such as steroids (e.g., prednisone), may bring about depression.
- Lupus involvement of certain organs (e.g., the brain, heart, or kidneys) can lead to clinical depression.
- There also are many unrecognized or unknown factors (which may or may not be related to lupus) which may cause depressive illness.
Of course, there are people who would develop clinical depression whether or not they had lupus. In fact, it is the most common psychiatric condition seen in the general population - 20 percent of women and 10 percent of men - as well as in medical practice.
Can depression in lupus be treated ?
Today, effective treatment is available for depressive illness and usually consists of psychotropic medication, psychotherapy and, most often, a combination of both.
Effective treatment requires early diagnosis and early intervention. Fortunately, most episodes of depressive illness in people with lupus subside on their own within a few months. Just as some people with lupus can tolerate a lot of pain, some seem to be able to accept and tolerate major symptoms of depressive illness without complaint.
However, depression is very stressful and anxiety-producing, which may aggravate the lupus activity.
Depressive reactions should be treated with the same aggressiveness and persistence that one would use to treat a lupus flare, or any other medical complaint. Naturally, any underlying medical condition that could contribute to the depression must be identified and controlled.
Anti-depressant medications :
Anti-depressant medications are the drugs that are most often used to treat depression. The four categories of medications are :
- tricyclics
- newer-generation non-tricyclic anti-depressants called SSRIs-selective serotonin reuptake inhibitors. These are best known by brand name: Prozac, Zoloft, Paxil, etc.
- MAO (monomine oxidase) inhibitors
- lithium
Other types of anti-depressant medications :
- Effexor
- Serzone (nefazodone)
- Wellbutrin
- Remeron
- Desyrel, etc.
Newer, potent anti-anxiety medications are now available and, when used in combination with the anti-depressant medications, offer significant and rapid mood stabilization and anxiety reduction.
Also, newer and safer hypnotics contribute to insomnia relief and offer uninterrupted and longer sleep.
Medication side effects
Anti-depressant medications can have side effects and may intensify various symptoms associated with lupus (e.g., increase in the drying of mucous membranes in Sjogren's Syndrome). When anti-depressant medications are effective, there is a welcome improvement in the individual's sense of well-being and overall attitude and adjustment.
Additional treatment requirements
Adequate and aggressive treatment involves many other components:
- blood tests to determine the appropriate dosages of medication
- open communication between the patient and treatment team
- encouragement, patience, availability and perseverance between patient, physician, family and close friends
- identifying and addressing any underlying medical factors that contribute to the depressive state
Cognitive changes
In people with depressive illness, there is often a general slowing and clouding of mental functions (cognition). These troublesome and not infrequent disruptions in mental functioning tend to be under-reported to physicians and are rarely confirmed to be due to any specific structural change. Fortunately, these transient alterations in mental functioning improve as the depressive condition improves.
"Lupus fog"
Changes in cognition often occur in people with lupus, including subtle changes in :
- memory
- concentration
- other cognitive functions such as:
- diminished attention
- lapses in awareness
- impairment in recall, problem-solving, calculations, planning, and/or visual-spatial functioning.
These are quite a nuisance and can have a profound impact upon the person's self-image, daily life and planning, and in their relationships with friends, co-workers, and loved ones.
Such changes often do not come to the physician's attention unless formal mental status testing is done. The true incidence of cognitive impairment is unknown, other than that it is common.
There is no specific or characteristic cognitive deficit found in people with SLE; rather, there is a wide spectrum, variety, and combination. These deficits, though, do not appear to be related to emotional stress or use of medication such as corticosteroids.
Occasionally in SLE patients with no overt central nervous system pathology, cognitive functioning improves with anti-malarial drugs or low doses of corticosteroids.
Prognosis for recovery
Recovery from depression is usually a gradual process. Dramatic improvements do not usually occur in a few days; however, one begins to see some progress after a few weeks.
Medication
Even when signs of clinical depression seem to clear quickly, it is not unusual for an individual to relapse when the medication is stopped. For this reason, medication should be continued for approximately six months or longer and the dosage should be tapered slowly over a 3-4 week period when treatment is discontinued.
Psychotherapy
Psychotherapy, often in combination with anti-depressant and/or anti-anxiety medication, can be very helpful. Therapists are able to assist people with clinical depression in :
- working through and understanding their illness, feelings, and relationships
- learning to cope more effectively with stress and their life situation.
The benefits to the patient are best attained when the primary care physician maintains a close relationship with the individual's psychiatrist or psychologist. Such a working relationship maximizes the quality of patient care and provides the most powerful approach to the management of depression.
Disclaimer :
The Lupus Group of W.A. (Inc.) does not recommend or endorse any products, drugs, treatments, procedures, medical or health professional in this article. We suggest you discuss this information with your doctor or specialist.