Burden of Autoimmune Diseases on Psychological Wellbeing

doi:10.21203/rs.3.rs-4839985/v1

Background

Patients with autoimmune disorders (systemic lupus erethymatosus (SLE), rheumatoid arthritis (RA), Psoriasis and Scleroderma) are prone to psychiatric conditions where psychosis and schizophrenia were the most common psychiatric associated with autoimmune diseases. The underlying mechanism of this association is still unknown but may be related to elevated inflammatory cytokine in autoimmune patients.

Objective: to assess the prevalence of psychiatric disorders among patients with rheumatic and musculoskeletal diseases .

Results: the study showed that the most frequent psychiatric disorders in RA patients were panic attack 61.3%, social anxiety 54.5%, major depressive disorder 51.3%, obsessive compulsive disorders (OCD)47.6%, social troubles 44% and delusion 43.2%. While panic attacks 55.2%, Delusion 54.3%, Major depressive disorder 51.3%, OCD 50%, social anxiety 47.4% are the most common psychiatric manifestation among SLE patients. Bechet’s disease is associated with delusion 66.7%, social troubles 65.2%, major depressive disorder 65.2%, panic attacks 65.2%, OCD 60.9% and social troubles 56.5%. Panic attacks78.6%, major depressive illness 57.1%, social troubles 57.1% and GAD 50% are the commonest psychiatric manifestation among ankylosing spondylitis patients while social anxiety 75%, panic attack 62.5%, OCD 50% and major depressive disorder 50% are the commonest in primary systemic vacuities. All scleroderma patients had panic attacks 100%, major depressive disorder 75%, social anxiety 75% and OCD 75%. Other psychiatric disorders as suicidal tendency, dysthymia, hypomania and anorexia nervosa were less common in all studied groups.

Conclusion

there is a high prevalence of psychological disorders (as panic attack, social anxiety and major depressive disorder), among patients with autoimmune diseases, so frequent screening about these psychiatric disorders is recommended.

Autoimmune Diseases

Psychosis

Suicidal Tendency

Anxiety

Depression

Rheumatic and musculoskeletal diseases (RMDs) are a wide range of conditions that primarily affect people's joints and result in pain, disability, and a decrease in quality of life in terms of their health. RMDs are one of the main causes of disability worldwide, according to the Global Burden of Disease study (Smolen et al 2018). Patients with autoimmune disorders are prone to psychiatric conditions, psychosis and schizophrenia were the most common psychiatric associated with autoimmune diseases, the underlying mechanism is still evolving, with many different aspects being investigated. Elevated level of inflammatory markers has been found both in the blood and CSF of patients with psychosis, with higher level in patients in the first episode psychosis or acute relapse (Goldsmith et al 2016). Systemic lupus erythematosus is an autoimmune disease with high grade of neuropsychiatric problem such as depression, anxiety, psychosis and schizophrenia (Ho et al 2016). Rheumatoid arthritis is another autoimmune disease with psychiatric problems; it had been found to be negative association with schizophrenia (Matcham et al 2016), however other studies didn’t confirm this association (Marrie et al 2018). Both a Swedish and Danish nationwide study has shown that the same negative association can be found with other musculoskeletal diseases (Sellgren et al 2014), suggest that underreporting, or underdiagnosis, is an important factor for the inverse intraindividual association of schizophrenia and RA. Associations have been found between psychotic disorders and other autoimmune diseases as well e.g psoriasis has been associated with risk of developing schizophrenia (Cullen et al 2018). To shed light on the association of autoimmunity and psychiatric disorder regardless the underlying etiology, it will be a valuable impact on improve of heath care and prognosis of this vulnerable autoimmune patients. Also, to expend the field of immune psychiatry to increase the health gap between somatic symptoms and psychotic disorder.

Objective:

To assess the prevalence of psychiatric disorders among patients with rheumatic and musculoskeletal diseases.

Type of study:

Cross-sectional observational study

Duration of the study:

One-year duration.

Sample Size:

Sample was calculated to be 371 participants, sample size was calculated using Epi info software at confidence interval 95% and power of test 80%.

Participants’ recruitment:

400 Participants were recruited from Rheumatic and musculoskeletal diseases (RMDs) patients attending rheumatology and immunology unit in internal medicine department and outpatient’s clinic by simple random sampling technique, the study design and objectives were explained in details to every patient by research team members, then in case of acceptance an informed consent was signed by every participant to insure complete satisfaction.

Inclusion criteria:

patients diagnosed as Rheumatic and musculoskeletal diseases according to European League Against Rheumatism (EULAR)-American College of Rheumatology working group (ACR) criteria

Rheumatic and musculoskeletal diseases are chronic systemic diseases that commonly affect the joints but can affect any organ of the body, There are more than 200 different RMDs, affecting both children and adults; systemic lupus erythematosus, rheumatoid arthritis (RA), osteoarthritis (OA) and gout, Psoriasis, Psoriatic arthritis, Ankylosing spondylitis, dermatomyositis, Vascuilitis .criteria attending Rheumatology &Immunology unit in internal medicine department and outpatient’s clinic.

Exclusion criteria:

Patients not fulfilling previous criteria for diagnosis of autoimmune rheumatic diseases, previous history of psychiatric problem or on antipsychotic medication and previous neurological diseases affecting mental capacity.

Methods

All participants were subjected to the following:

Through history taking: Personal history (age, gender, socioeconomic standard and special habits), Past history (autoimmune diseases, psychiatric problem and neurological diseases) and Family history (autoimmune, neurological diseases)
Autoimmune and Rheumatic diseases: Type, duration, medication, complication, Diseases activity of each type and Line of management of autoimmune diseases: Traditional DMARDs, Steroid, biological medication and multivitamin.
Psychiatric history: Assess the mental health of patients: -

o Modified Mini International Neuropsychiatric Interview (MINI); (10)

A generic screening measure for mood, anxiety, and psychotic spectrum disorders.

o Hamilton' s checklist of symptoms of Depressive illness (HAM-D): (11)

Assessment of different depressive symptoms during interview and scoring them.
HAM-D score level of depression: 10–13 mild; 14–17 mild to moderate; >17 moderate to severe.

o Hamilton Anxiety Rating Scale (HAM-A): (12)

The scale assesses psychic anxiety (mental agitation and psychological distress) and somatic anxiety (physical complaints related to anxiety)
HAM-A score level of anxiety: Each item is scored on a scale of 0 (not present) to 4 (severe)

Ethical considerations:

Ethical approval: An ethical approval was taken by Mansoura Medical Ethics Research Committee (MMERC) of faculty of Medicine, IRB Mansoura

Code number: R.22.11.1955 , Date: 04/01/2023

All methods were performed in accordance with the relevant guidelines and regulations

Consent to participate:

An informed consent was signed by every participants before participation in the study.

Statistical analysis: -

Data were entered and analyzed using IBM-SPSS software (IBM Corp. Released 2017. IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp.). Data expression: Qualitative data will be expressed as N and percentage (%).

Quantitative data were initially tested for normality using Kolmogorov-Smirnov test. Quantitative data will be expressed as mean ± standard deviation (SD) if normally distributed or median and range if not. Data comparison: Qualitative data: Chi-Square test or Fisher’s exact test will be used.

Table (1): Socio-demographic data of studied patients (n=400): -

Parameter			n (%)
Age*	Median (Min-Max)		37.5 (13-73)
Gender		Male	21 (5.3%)
Gender		Female	379 (94.8%)
Marriage		Single	36 (9.0%)
Marriage		Married	364 (91.0%)
Children*		Median (Min-Max)	3.0 (0-7)
Residency		Rural	190 (47.5%)
Residency		Urban	210 (52.5%)
Education		Non educated	36 (9.0%)
Education		Educated	364 (91.0%)
Special habit		No	380 (95.0%)
Special habit		Smoking	20 (5.0%)

*median(min-max)

Table (1) showed that 400 rheumatic patients included in the study, median age 37.5 (13-73), 94.8% of rheumatic patients were females. 91.0% of patients were married. 47.5% of patients from rural and the rest 52.5% from urban area. Most of patients (91.0%) were educated. Only 5.0% of patients are smokers.

Table (2): Past history, pregnancy history and family history of studied patients (n=400)

Parameter			n (%)
Pregnancy history	Psychpreg	Negative	279 (78.8%)
	Psychpreg	Positive	75 (21.2%)
	Psychmenses	Negative	283 (74.7%)
	Psychmenses	Positive	96 (25.3%)
	Contraception	Negative	120 (34.2%)
	Contraception	Positive	230 (65.8%)
Family history	Family hx of autoimmune dse	Negative	297 (74.4%)
	Family hx of autoimmune dse	Positive	102 (25.6%)
	Family hx of Psychiatric dse	Negative	273 (93.5%)
	Family hx of Psychiatric dse	Positive	26 (6.5%)
Past history	Past history of admission	Negative	315 (79.1%)
	Past history of admission	Positive	83 (20.9%)
	Past hx of operation	Negative	379 (96.4%)
	Past hx of operation	Positive	14 (3.6%)
	Past history of psychiatric dse	Negative	380 (95.0%)
	Past history of psychiatric dse	Positive	20 (5.0%)
	Past hx of neurological dse	Negative	392 (98.0%)
	Past hx of neurological dse	Positive	8 (2.0%)

Table (2) showed psychiatry disease was observed in 21.2% of patients during pregnancy and 25.3% during menses. 65.8% of female patients received method of contraception, the most frequent method was IUD in (64.8%), complication of contraception detected in 98.3% of female patients. Family history of autoimmune disease and psychiatric disease were positive in 25.6% and 6.5% respectively. 20.9% of patients had past history of hospital admission and only 3.6% of patients had past history of operation. 5.0% of patients had positive past history of psychiatric dse and only 2.0% of patients had past history of neurological disease.

Table (3): Characteristics of Rheumatic diseases of studied patients (n=400):-

Parameter		n(%)
RA		191 (47.8%)
SLE		154 (38.5%)
Behcet disease		23 (5.8%)
Scleroderma		4 (1.0%)
Sarcoidosis		1 (0.2%)
Ankylosing spondylitis		14 (3.5%)
Sjogren’s syndrome		1 (0.2%)
Vasculitis		8 (2.0%)
Psoriatic Arthritis		2 (0.5%)
DM		2 (0.5%)
Duration of rheumatic disease*	Median (Min-Max)	4.0 (0.5-35.0)
Controlled	Negative	41 (10.5%)
	Positive	350 (89.5%)
Complication	Negative	143 (36.7%)
	Positive	247 (63.3%)

*median (min-max)

Table (3) showed rheumatic disease; the most frequent disease was RA in (47.8%) of patients followed by, SLE (38.5%) and Behcet (5.8%). 350 patients were controlled. 63.3% of patients had complication.

Table (4): Medications used in management of studied patients (n=400):-

Parameter		n (%)
Medications	Methotrexate	64 (16.0%)
	Hydroxychloroquine	39 (9.8%)
	Leflunomide	50 (12.5%)
	Sulfasalazine	2 (0.5%)
	Cyclophosphamide	34 (8.5%)
	Combination #	97 (24.3%)
	Mycophenolate Mofetil	40 (10.0%)
	Azathioprine	54 (13.5%)
	Cyclosporine	8 (2.0%)
	Biological therapy	12 (3.0%)
Corticosteroid	No	79 (19.8%)
Corticosteroid	Yes	321 (80.3%)
Duration of administration (months)*	Median (Min-Max)	48.0 (2.0-360)
SE of medication	Anorexia/Nausea/Vomiting	110 (27.5%)
	Leucopenia	170 (42.5%)
	Skin allergy	3 (0.8%)
	Eye problem	19 (4.8%)
	Combination#	98 (24.5%)

*median(min-max), # combination include more than one of the above.

Table (4) showed the medications had been administrated by patients; most frequent medication was MTX (16.0%), followed by Azathioprine (13.5%), leflunomide (12.5%), MMF (10.0%) and HCQ (9.8%). The most common side effect of the medication was leucopenia in (42.5%) of all patients. Steroid had been administrated in 321 patients.

Table (5): Comparison of different psychological data among rheumatic diseases:

Positive of	RA (N=191)	SLE (N=154)	Behcet (N=23)	Scleroderma (N=4)	Sarcoidosis (N=1)	AS (N=14)	Sjogren’s syndrome (N=1)	Primary systemic Vasculitis (N=8)	PSA (N=2)	DM (N=2)	P-value
Major depressive disorder	98 (51.3%)	79 (51.3%)	15 (65.2%)	3 (75.0%)	1 (100.0%)	8 (57.1%)	1 (100.0%)	4 (50.0%)	0 (0.0%)	1 (50.0%)	0.672
Temporary depression	97 (50.8%)	79 (51.3%)	15 (65.2%)	3 (75.0%)	1 (100.0%)	8 (57.1%)	1 (100.0%)	4 (50.0%)	0 (0.0%)	1 (50.0%)	0.661
Dysthymia	52 (27.2%)	40 (26.0%)	3 (13.0%)	1 (25.0%)	1 (100.0%)	3 (21.4%)	0 (0.0%)	1 (12.5%)	1 (50.0%)	1 (50.0%)	0.586
Suicidal tendency	39 (20.4%)	33 (21.4%)	6 (26.1%)	0 (0.0%)	0 (0.0%)	5 (35.7%)	0 (0.0%)	1 (12.5%)	0 (0.0%)	0 (0.0%)	0.812
Hypomanic	48 (25.1%)	31 (20.1%)	4 (17.4%)	2 (50.0%)	0 (0.0%)	5 (35.7%)	1 (100.0%)	1 (12.5%)	0 (0.0%)	0 (0.0%)	0.360
Panic attack	117 (61.3%)	85 (55.2%)	15 (65.2%)	4 (100.0%)	0 (0.0%)	11 (78.6%)	1 (100.0%)	5 (62.5%)	0 (0.0%)	1 (50.0%)	0.226
Agoraphobia	40 (20.9%)	24 (15.6%)	4 (17.4%)	1 (25.0%)	0 (0.0%)	1 (7.1%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	1 (50.0%)	0.630
Social anxiety	104 (54.5%)	73 (47.4%)	13 (56.5%)	3 (75.0%)	0 (0.0%)	6 (42.9%)	1 (100.0%)	6 (75.0%)	0 (0.0%)	1 (50.0%)	0.426
Obsessive compulsive disorder	91 (47.6%)	77 (50.0%)	14 (60.9%)	3 (75.0%)	0 (0.0%)	4 (28.6%)	1 (100.0%)	4 (50.0%)	0 (0.0%)	2 (100.0%)	0.281
Posttraumatic disorder	48 (25.1%)	47 (30.5%)	5 (21.7%)	1 (25.0%)	0 (0.0%)	4 (28.6%)	0 (0.0%)	3 (37.5%)	1 (50.0%)	0 (0.0%)	0.906
Psychotic disorder	29 (15.2%)	26 (16.9%)	7 (30.4%)	1 (25.0%)	0 (0.0%)	3 (21.4%)	1 (100.0%)	2 (25.0%)	0 (0.0%)	0 (0.0%)	0.358
Anorexia nervosa	56 (29.3%)	45 (29.2%)	4 (17.4%)	2 (50.0%)	1 (100.0%)	3 (21.4%)	0 (0.0%)	3 (37.5%)	0 (0.0%)	1 (100.0%)	0.619
Bulimia nervosa	17 (8.9%)	9 (5.8%)	5 (21.7%)	1 (25.0%)	0 (0.0%)	2 (14.3%)	0 (0.0%)	1 (12.5%)	0 (0.0%)	1 (50.0%)	0.173
Generalized anxiety disorder	66 (34.6%)	44 (28.6%)	9 (39.1%)	1 (25.0%)	1 (100.0%)	7 (50.0%)	0 (0.0%)	2 (25.0%)	1 (50.0%)	1 (50.0%)	0.617
Social troubles	84 (44.0%)	54 (35.1%)	15 (65.2%)	2 (50.0%)	0 (0.0%)	8 (57.1%)	1 (100.0%)	2 (25.0%)	0 (0.0%)	1 (50.0%)	0.108
Delusion	32 (43.2%)	25 (54.3%)	6 (66.7%)	1 (25.0%)	-	1 (25.0%)	1 (100.0%)	2 (25.0%)	-	-	0.465
Hallucination	34 (54.9%)	26 (56.5%)	6 (66.7%)	1 (25.0%)	-	2(28.6%)	1 (100.0%)	1 (12.5%)	-	-	0.518
Excitement	41 (55.4%)	23 (50.0%)	4 (44.4%)	1 (25.0%)	-	1 (25.0%)	1 (100.0%)	1 (12.5%)	-	-	0.569
Grandiosity	31 (41.9%)	17 (37.0%)	3 (33.3%)	1 (100.0%)	-	2 (50.0%)	1 (100.0%)	2 (25.0%)	-	-	0.717
Holisity	43 (58.1%)	19 (41.3%)	4 (44.4%)	1 (100.0%)	-	1 (25.0%)	0 (0.0%)	1 (12.5%)	-	-	0.282
Blunted effect	35 (47.3%)	25 (54.3%)	3 (33.3%)	1 (100.0%)	-	0 (0.0%)	1 (100.0%)	1 (12.5%)	-	-	0.237
Poor rapport	38 (51.4%)	28 (60.9%)	4 (44.4%)	1 (100.0%)	-	1 (25.0%)	1 (100.0%)	2 (25.0%)	-	-	0.610
Difficulty in abstract	40 (54.1%)	29 (63.0%)	4 (44.4%)	1 (100.0%)		1 (25.0%)	0 (0.0%)	2 (25.0%)	-	-	0.522
Somatic concern	36 (48.6%)	23 (50.0%)	4 (44.4%)	1 (100.0%)	-	1 (25.0%)	1 (100.0%)	1 (12.5%)	-	-	0.678
Anxiety	33 (44.6%)	22 (47.8%)	3 (33.3%)	1 (100.0%)	-	1 (25.0%)	1 (100.0%)	2 (25.0%)	-	-	0.708
Guilt	38 (51.4%)	24 (52.2%)	4 (44.4%)	1 (100.0%)	-	1 (25.0%)	0 (0.0%)	2 (25.0%)	-	-	0.778
Depressed mood	37 (50.0%)	26 (56.5%)	5 (55.6%)	1 (100.0%)	-	1 (25.0%)	1 (100.0%)	1 (12.5%)	-	-	0.580
Motor retardation	39 (52.7%)	25 (54.3%)	5 (55.6%)	0 (0.0%)	-	1 (25.0%)	1 (100.0%)	1 (12.5%)	-	-	0.609
Unresponsiveness	39 (52.7%)	23 (50.0%)	4 (44.4%)	0 (0.0%)	-	0 (0.0%)	1 (100.0%)	2 (25.0%)	-	-	0.388
Disorientation	38 (51.4%)	25 (54.3%)	5 (55.6%)	1 (100.0%)	-	1 (25.0%)	1 (100.0%)	2 (25.0%)	-	-	0.787
Poor attention	33 (44.6%)	26 (56.5%)	5 (55.6%)	1 (100.0%)	-	1 (25.0%)	1 (100.0%)	3 (37.5%)	-	-	0.452
Preoccupation	43 (58.1%)	27 (58.7%)	6 (66.7%)	1 (100.0%)	-	3 (75.0%)	1 (100.0%)	4 (50.0%)	-	-	0.589

P value: chi square test. RA; Rheumatoid arthritis, SLE; systemic lupus erythematosus, AS; Ankylosing spondylitis, PSA; psoriatic arthritis, DM; Diabetes mellitus.

Table (5) showed the different psychological data among studied patients: the most frequent manifestation in RA was panic attack 61.3%, social anxiety 54.5%, major depressive disorder 51.3%, OCD47.6%, social troubles 44% and delusion 43.2% in descending order. While panic attack 55.2%, Delusion 54.3%, Major depressive disorder 51.3%, OCD 50%, social anxiety 47.4% are the most common psychiatric manifestation among SLE. Bechet’s disease is characterized by Delusion 66.7%, social troubles 65.2%, major depressive disorder 65.2%, panic attack 65.2%, OCD 60.9% and social troubles 56.5% in descending order. Panic attack78.6%, major depressive illness 57.1%, social troubles 57.1% and GAD 50% are the common psychiatric manifestation among ankylosing spondylitis while social anxiety 75%, panic attack 62.5%, OCD 50% and major depressive disorder 50% in descending order are common in primary systemic vasculitis. All scleroderma patients had panic attack 100%, major depressive disorder 75%, social anxiety 75% and OCD 75%in descending order. Other psychiatric disorders suicidal tendency, dysthymia, hypomania and AN were less common in all studied groups.

Table (6): Comparison of H-depression index among rheumatic diseases:

Positive of	RA (N=191)	SLE (N=154)	Behcet (N=23)	Scleroderma (N=4)	Sarcoidosis (N=1)	AS (N=14)	Sjogren’s syndrome (N=1)	Primary systemic Vasculitis (N=8)	PSA (N=2)	DM (N=2)	P-value
No	11 (5.8%)	9 (5.8%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	1 (7.1%)	0 (0.0%)	2 (25.0%)	0 (0.0%)	1 (50.0%)	0.594
Mild	81 (42.4%)	65 (42.2%)	12 (52.2%)	1 (25.0%)	1 (100.0%)	5 (35.7%)	0 (0.0%)	4 (50.0%)	1 (50.0%)	0 (0.0%)
Moderate	43 (22.5%)	33 (21.4%)	5 (21.7%)	3 (75.0%)	0 (0.0%)	3 (21.4%)	0 (0.0%)	1 (12.5%)	1 (50.0%)	0 (0.0%)
Sever	16 (8.4%)	16 (10.4%)	3 (13.0%)	0 (0.0%)	0 (0.0%)	1 (7.1%)	0 (0.0%)	1 (12.5%)	0 (0.0%)	0 (0.0%)
Marked	40 (20.9%)	31 (20.1%)	3 (13.0%)	0 (0.0%)	0 (0.0%)	4 (28.6%)	1 (100.0%)	0 (0.0%)	0 (0.0%)	1 (50.0%)

RA; Rheumatoid arthritis, SLE; systemic lupus erythematosus, AS; Ankylosing spondylitis, PSA; psoriatic arthritis, DM; Diabetes mellitus.

Table (6) showed comparison of H- depression index among studied patients, most of studied patients had mild grade of depression 42% RA, 42% SLE, 52.2% Bechet’s disease, 50% vasculitis, 50% PSA. About 20% of them had moderate and sever grade of depression according to H-depression index.

Table (7): Comparison of H-anxiety index among rheumatic diseases:

Positive of	RA (N=191)	SLE (N=154)	Behcet (N=23)	Scleroderma (N=4)	Sarcoidosis (N=1)	AS (N=14)	Sjogren’s syndrome (N=1)	Primary systemic Vasculitis (N=8)	PSA (N=2)	DM (N=2)	P-value
No	8 (4.2%)	9 (5.8%)	0 (0.0%)	1 (25.0%)	0 (0.0%)	1 (7.1%)	0 (0.0%)	1 (12.5%)	0 (0.0%)	1 (50.0%)	0.115
Mild	41 (21.5%)	26 (16.9%)	2 (8.7%)	0 (0.0%)	0 (0.0%)	1 (7.1%)	0 (0.0%)	1 (12.5%)	0 (0.0%)	0 (0.0%)
Moderate	36 (18.8%)	29 (18.8%)	6 (26.1%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	1 (100.0%)	2 (25.0%)	2 (100.0%)	0 (0.0%)
Sever	35 (18.3%)	27 (17.5%)	7 (30.4%)	0 (0.0%)	1 (100.0%)	4 (28.6%)	0 (0.0%)	1 (12.5%)	0 (0.0%)	0 (0.0%)
Marked	71 (37.2%)	63 (40.9%)	8 (34.8%)	3 (75.0%)	0 (0.0%)	8 (57.1%)	0 (0.0%)	3 (37.5%)	0 (0.0%)	1 (50.0%)

RA; Rheumatoid arthritis, SLE; systemic lupus erythematosus, AS; Ankylosing spondylitis, PSA; psoriatic arthritis, DM; Diabetes mellitus.

Table (7) showed comparison of H-anxiety index of studied patients where most of studied patients had marked grade of anxiety 75% Scleroderma, 57% AS, 50% DM, 40%SLE, 37.5% vasculitis and 37.2% RA. Less than 20% of them had moderate and sever grade of anxiety.

Although wide spread of neuropsychiatric manifestation among Rheumatic and musculoskeletal diseases, the exact prevalence in them are often not addressed, due to several reasons; physician not asked about it and by patients being reluctant to report their neuropsychiatric symptoms. To assess the burden of autoimmune diseases on psychiatric health’s of systemic autoimmune rheumatic patients, a survey was conducted over one year on 400 autoimmune Rheumatic patients. It was noticed the middle-aged married female from urban countries were at risk for rheumatic autoimmune that was agreement with ( Moroni et al 2012) who concluded that incidence of autoimmune diseases in women was 60% higher as compared to men.

Studying psychological troubles in studied female patients; showed that majority of them not suffer from any psychological issue either during menstruation nor pregnancy, that was in contrast to (Silva et al 2022) Who stated that Common mental disorder and postnatal depressive symptoms are common in the second and third trimesters It was noticed that most of studied patients had family history of autoimmune diseases that was confirmed by (Cárdenas-Roldán et al 2013) that Familial autoimmunity is a frequently seen in autoimmune diseases.

In accordance with the results of our study, other studies showed that there is a relationship between physical health and psychological aspects (Abdelsamea et al 2023), (Soliman et al 2024).

In the opposite to the study (McGrath et al 2014) concluded that familial factors may underpin both cognitive ability and the risk of a wide range of psychiatric disorders, our work doesn’t confirm this postulation. Fortunately; our studied patients had no past specific risk factor that lead to psychiatric problem that may postulate the autoimmune disease is a risk factor.

It was noticed that panic attack, social anxiety and major depressive disorder were the most common psychiatric disorder associated with autoimmune diseases especially RA, SLE and Bechet’s disease, the underlying mechanism was explained by the study (Pryce et al 2016) stated that Majority of patients with autoimmune rheumatic diseases subsequently develop psychiatric symptoms such as depression and anxiety as a result of prolonged illness, excessive pain, sleep disturbance and from medications used to treat autoimmune diseases such interferon type I and corticosteroid.

Fortunately, Suicidal tendency and hypomania were to some extant is low (20%) in studied autoimmune patients; RA, SLE and Bechet’s disease, unlike the study (Meszaros et al 2012) stated that Increased rates of suicidality in autoimmune disorders such as systemic lupus erythematosus (SLE), MS and celiac disease, about 40% of them.

The most prevalence psychiatric disorder in RA was major depressive disorders, temporary depression, OCD and social troubles, that was in agreement with (Lok EY et al 2010) who concluded that Depression and anxiety are common in Chinese patients with RA, added that the underlying cause may be low socioeconomic status.

SLE is characteristic by neuropsychiatric manifestation as panic attack, major depressive disorder, OCD, social anxiety and social troubles that was (Ravan et al 2021) concluded that Systemic Lupus Erythematosus (SLE) is known to have neuropsychiatric symptoms such as anxiety, depression, cognitive dysfunction, and psychosis.

The incidence of depression either major or temporary depressive symptoms was similar in both RA and SLE that was concluded also by study (Arias et al 2011) stated the depression is common in both. Also, the incidence of psychiatric illness in Bechet’s disease was to some extant high such as major depressive symptoms, panic attack, social troubles, OCD and social anxiety (Monastero R etal; 2004) who concluded that psychiatric and cognitive involvement in BD seems possible without the morphological involvement observed in MRI for other autoimmune or inflammatory disorders such as lupus.

Panic attack , social troubles, major depressive disorder and GAD were the most common associated psychiatric issue in Ankylosing spondylitis, that was agreed by (Omar et al 2023) who concluded that Patients with AS are at a higher risk of developing psychiatric disorders, with increased risk of depression and lower risk of schizophrenia and added that the medication like cDMARDs and TNF-inhibitors are not predictors of psychiatric disorders in AS patients.

It was noticed that Vasculitis patients also had a potential for psychiatric problem such as social anxiety, panic attack, major depressive disorder and preoccupation which contrasted with study (Pittam et al 2020) who stated that Depression is highly prevalent among patients with primary systemic vasculitis and associated with poorer outcomes. Sarcoidosis is another autoimmune disease associated with fatigue, sleepiness, fibromyalgia, and a high rate of psychiatric comorbidity as concluded by (Bosse-Henck et al 2017), unlike our observation where major depressive symptoms, dysthymia, GAD and AN.

It was noticed that DM was associated with OCD, major depressive illness, dysthymia, agoraphobia, social anxiety, bulimia nervosa, GAD and social troubles that was confirmed by (Kanwar et al 2019) stated that Prevalence of the psychiatric comorbidity in T2DM patients was high and the most common comorbid psychiatric illness was depression followed by generalized anxiety disorder.

The severity of the depression among studied autoimmune patients was assessed by H depression index where most of them had mild severity of depression in RA 42.4%, SLE 42.2%and Bechet’s disease 52.2%. Small group of studied patients 20% had moderate and marked severity, that may be related to different reasons as studied by (Liu et al 2018) World Health Organization concluded that Psychosocial factors, long periods of disablement and chronic pain are the three most common causes of depressive symptoms in them.

Our work concluded that all studied patients (RA, SLE, Bechet’s disease, AS and Scleroderma) suffered from marked grade of anxiety that may be related to long disease duration, polypharmacy and complicated disease that may have a burden on patients.

There is a high prevalence of psychological disorders (as panic attack, social anxiety and major depressive disorder), among patients with autoimmune diseases, so frequent screening about these psychiatric disorders is recommended.

Limitation of the study: The study was conducted in a single center.

ACR= American College of Rheumatology working group

AS= Ankylosing spondylitis

DMARDs= Disease modifying antirheumatic drugs

EULAR= European League Against Rheumatism

RMD= Rheumatic and musculoskeletal diseases

RA= rheumatoid arthritis

OA= osteoarthritis

SLE= systemic lupus erythematosus

T2DM= Type2 diabetes mellitus

DM= diabetes mellitus

OCD= Obsessive-compulsive disorder

GAD= generalized anxiety disorder

MINI= Hamilton Anxiety Rating Scale

HAM-D= Hamilton' s checklist of symptoms of Depressive illness

CSF= cerebrospinal fluid

MTX=methotrexate

MMF= mycophenolate mofetil

MS= multiple sclerosis

HCQ=hydroxychloroquine.

Ethics approval: An ethical approval was taken by Mansoura Medical Ethics Research committee (MMERC) of faculty of Medicine, IRB Mansoura

Code number: R.22.11.1955 Date: 04/01/2023

All methods were performed in accordance with the relevant guidelines and regulations

Consent to participate:

An informed consent was signed by every participants before participation in the study.

Consent to publication:

All authors agree on publishing the research in the journal

Data Availability:

The datasets used and/or analysed during the current study is available from the corresponding author on reasonable request at [email protected]

Competing interests:

No competing interest

Funding:

No external funds.

Authors' contributions:

Amir Soliman Designed and conceptualized the study , analyzed and interpreted data, Marwa Abo Elmaaty Besar Collected data and wrote manuscript, Youssef Mohammed Metwally Abulatta, Mohamed Issam Hafez Hussein, and Mahmoud Ali Ali Abdelhadi: collected data and revised final version, Omnia khaled collected the data, statistical analysis of it and approved the final version. Sabrien hamza had significant contribution in data collection, revision and editing final version.

Abdelsamea GA, Amr M, Tolba AMN, Elboraie HO, Soliman A, Al-Amir Hassan B, Ali F and Osman DA (2023) Impact of weight loss on sexual and psychological functions and quality of life in females with sexual dysfunction: A forgotten avenue. Front. Psychol. 14:1090256. doi: 10.3389/fpsyg.2023.1090256
Arias S, Fonsalía V, Asteggiante N, Bartesaghi V.Systemic auto-immune diseases and depressive disorders. Reumatología Clínica (English Edition) 2011. November 1;7(6):389–91
Bosse-Henck A, Koch R, Wirtz H, Hinz A. Fatigue and excessive daytime sleepiness in sarcoidosis: prevalence, predictors, and relationships between the two symptoms. Respiration 2017;94(2):186- 97.
Cárdenas-Roldán J, Rojas-Villarraga A, Anaya JM. How do autoimmune diseases cluster in families? A systematic review and meta-analysis. BMC Med. 2013 Mar 18;11:73. doi: 10.1186/1741-7015-11-73. PMID: 23497011; PMCID: PMC3655934.
Care Res. (2018) 70:970–8. doi: 10.1002/acr.23539.
Cullen AE, Holmes S, Pollak TA, Blackman G, Joyce DW, Kempton MJ, et al. Associations between non-neurological autoimmune disorders and psychosis: a meta-analysis. Biol Psychiatry. (2018) 85:35–48. doi: 10.1016/j.biopsych.2018.06.016
Goldsmith DR, Rapaport MH, Miller BJ. A meta-analysis of blood cytokine network alterations in psychiatric patients: comparisons between schizophrenia, bipolar disorder and depression. Mol Psychiatry. (2016) 21:1696–709. doi: 10.1038/mp.2016.3
Ho RC, Thiaghu C, Ong H, Lu Y, Ho CS, Tam WW, et al. A meta-analysis of serum and cerebrospinal fluid autoantibodies in neuropsychiatric systemic lupus erythematosus. Autoimmun Rev. (2016) 15:124–38. doi: 10.1016/j.autrev.2015.10.003.
Kanwar N, Sharma RC, Sharma DD, Ramesh, Mokta K, Mokta JK. Prevalence of Psychiatric Comorbidity among Patients of Type 2 Diabetes Mellitus in a Hilly State of North India. Indian J Endocrinol Metab. 2019 Nov-Dec;23(6):602-608. doi: 10.4103/ijem.IJEM_521_19. PMID: 32042695; PMCID: PMC6987773.
L. Moroni, I. Bianchi, A. Lleo etal; Geoepidemiology, gender and autoimmune disease Autoimmun. Rev., 11 (2012), pp. A386-A392.
Liu Y, Tang X. Depressive Syndromes in Autoimmune Disorders of the Nervous System: Prevalence, Etiology, and Influence. Front Psychiatry. 2018 Sep 25;9:451. doi: 10.3389/fpsyt.2018.00451. PMID: 30319458; PMCID: PMC6168717.
Lok EY, Mok CC, Cheng CW, Cheung EF. Prevalence and determinants of psychiatric disorders in patients with rheumatoid arthritis. Psychosomatics. 2010 Jul-Aug;51(4):338-338.e8. doi: 10.1176/appi.psy.51.4.338. PMID: 20587762.
Marrie RA, Hitchon CA, Walld R, Patten SB, Bolton JM, Sareen J, Walker JR, Singer A, Lix LM, El-Gabalawy R, Katz A, Fisk JD, Bernstein CN; Canadian Institutes of Health Research Team in Defining the Burden and Managing the Effects of Psychiatric Comorbidity in Chronic Immunoinflammatory Disease. Increased Burden of Psychiatric Disorders in Rheumatoid Arthritis. Arthritis Care Res (Hoboken). 2018 Jul;70(7):970-978. doi: 10.1002/acr.23539. Epub 2018 May 21. PMID: 29438604; PMCID: PMC6033023.
Matcham F, Norton S, Scott DL, Steer S, Hotopf M. Symptoms of depression and anxiety predict treatment response and long-term physical health outcomes in rheumatoid arthritis: secondary analysis of a randomized controlled trial. Rheumatology (Oxford) 2016; 55: 268–78.
McGrath JJ, Wray NR, Pedersen CB, Mortensen PB, Greve AN, Petersen L. The association between family history of mental disorders and general cognitive ability. Transl Psychiatry. 2014 Jul 22;4(7):e412. doi: 10.1038/tp.2014.60. PMID: 25050992; PMCID: PMC4119227.
Meszaros ZS, Perl A, Faraone SV. Psychiatric symptoms in systemic lupus erythematosus: a systematic review. J Clin Psychiatry 2012; 73:993–100.
Monastero R., Camarda C., Pipia C., Lopez G., Camarda L.K.C., Baiamonte V., Ferrante A., Triolo G., Camarda R. Cognitive Impairment in Behçet’s Disease Patients without Overt Neurological Involvement. J. Neurol. Sci. 2004;220:99–104. doi: 10.1016/j.jns.2004.02.021
Omar M, Ben-Shabat N, Tsur AM, Cohen AD, Watad A, Amital H, Sharif K. The association between ankylosing spondylitis and psychiatric disorders: Insights from a population based cross-sectional database. J Affect Disord. 2023 Feb 15;323:788-792. doi: 10.1016/j.jad.2022.12.024. Epub 2022 Dec 12. PMID: 36521665.
Pittam B, Gupta S, Ahmed AE, Hughes DM, Zhao SS. The prevalence and impact of depression in primary systemic vasculitis: a systematic review and meta-analysis. Rheumatol Int. 2020 Aug;40(8):1215-1221. doi: 10.1007/s00296-020-04611-7. Epub 2020 Jun 4. PMID: 32494889; PMCID: PMC7316669.
Pryce CR, Fontana A. Depression in autoimmune diseases. InInflammation-associated depression: Evidence, Mechanisms and Implications 2016 (pp. 139–154). Springer, Cham.
Ravan JR, Chatterjee S, Singh P, Maikap D, Padhan P. Autoimmune Rheumatic Diseases Masquerading as Psychiatric Disorders: A Case Series. Mediterr J Rheumatol. 2021 Jun 30;32(2):164-167. doi:10.31138/mjr.32.2.164. PMID: 34447914; PMCID: PMC8369283.
Sellgren C, Frisell T, Lichtenstein P, Landen M, Askling J. The association between schizophrenia and rheumatoid arthritis: a nationwide populationbased swedish study on intraindividual and familial risks. Schizophr Bull. (2014) 40:1552–9. doi: 10.1093/schbul/sbu054.
Silva BP, Matijasevich A, Malta MB, Neves PAR, Mazzaia MC, Gabrielloni MC, et al. Common mental disorders in pregnancy and postnatal depressive symptoms in the MINA-Brazil study: occurrence and associated factors Rev Saude Publica. 2022;56:83 https://doi.org/10.11606/s1518 8787.2022056004028.
Smolen JS, Aletaha D, Barton A, et al. Rheumatoid arthritis. Nat Rev Dis Primers 2018; 4:18001.
Soliman, A., AboAli, S.E.M., Abdel Karim, A.E. et al. Effect of adding telerehabilitation home program to pharmaceutical treatment on the symptoms and the quality of life in children with functional constipation: a randomized controlled trial. Eur J Pediatr (2024). https://doi.org/10.1007/s00431-024-05639-8

No competing interests reported.

Burden of Autoimmune Diseases on Psychological Wellbeing

Status:

Version 1

Abstract

Introduction

Objective:

Patients and methods

Type of study:

Duration of the study:

Sample Size:

Participants’ recruitment:

Inclusion criteria:

Exclusion criteria:

Methods

All participants were subjected to the following:

o Modified Mini International Neuropsychiatric Interview (MINI); (10)

o Hamilton' s checklist of symptoms of Depressive illness (HAM-D): (11)

o Hamilton Anxiety Rating Scale (HAM-A): (12)

Ethical considerations:

Results

DISCUSSION

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1