Perceived stigma linked to depression in female SLE patients



Depression in women with systemic lupus erythematosus has been linked by a cross-sectional study to their perceptions of being stigmatized by their illness.

The findings indicate that when overt central nervous system manifestations of SLE are not present, depression in this patient population is attributable to nonorganic causes and not the disease, according to the study investigators.

"Dealing with this stigma may be important in promoting optimal coping for these women," wrote Dr. Mohammad G. Sehlo and his associates. Dr. Sehlo is a psychiatrist and professor of medicine at King Adbulaziz University in Jeddah, Saudi Arabia.

The investigators noted that between 10.8% and 39.6% of women with SLE also have depression, making it one of the most common psychiatric comorbidities in SLE. The authors referenced several studies showing that while depression can result in SLE from brain damage directly related to the disease, as well as the high doses of corticosteroids often used in treatment, SLE’s prototypical skin rash, uneven pigmentation, vitiligo, scars, tooth loss, alopecia, increased facial hair, and other physical manifestations "may contribute to higher levels of perceived illness stigma that subsequently may be associated with depression in these patients" (J. Psychosomatic Res. 2013;74:248-51).

Fifteen of the 80 patients randomly selected by Dr. Sehlo and his colleagues were found to have depression according to the Structured Clinical Interview for DSM-IV Axis 1 Disorders, Clinician Version (SCID-1-CV). The women, whose average age was 34.8 years, were regular attendees of a rheumatology outpatient clinic in Jeddah between March 2011 and March 2012. Patients with neuropsychiatric lupus-related neurologic syndrome, as well as those with any other serious medical comorbidities, were excluded, as were those who demonstrated a language barrier.

"...adequate coping strategies, social support, and the ability to deal with stress can reduce the perceived illness stigma and its serious consequences for patients with SLE."

Depression severity was measured in the study group by the Hospital Anxiety and Depression Scale-Depression Subscale (HADS-D), a self-assessment composed of seven questions. Illness stigma was measured using a 4-point Likert-type scale by the Stigma Impact Scale (SIS), covering perceived stigma from social rejection, financial insecurity, internalized shame, and social isolation.

Dr. Sehlo and his associates recorded significantly higher mean scores on HADS-D and SIS in the patients with depression, compared with patients who were not found to have depression (P less than .001). Other differences between the two groups such as age, duration of illness, daily prednisone dosage, and physical damage as measured by the SLEDAI (Systemic Lupus Erythematosus Disease Activity Index) and the SLICC/ACR (Systemic Lupus International Collaborating Clinics/American College of Rheumatology) Damage Index were not found to be significant.

The investigators noted a significant positive relationship between SIS and HADS-D scores (P = .002) and between perceived illness stigma and a diagnosis of depression (odds ratio, 3.2; P = .002), leading to an increase in the severity of depressive symptoms (P less than .001).

Although the cross-sectional design of the study did not allow for causal conclusions or for the measurement of a third causative variable such as neuroticism, the authors concluded that their data were important, because "adequate coping strategies, social support, and the ability to deal with stress can reduce the perceived illness stigma and its serious consequences for patients with SLE."

Dr. Sehlo and his colleagues said they had no conflicts of interest to disclose.

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