Psychiatric comorbidity in child onset lupus

1. Psychiatric
Comorbidity in
Childhood Onset
Systemic Lupus
Erythematosus
Samar Tharwat Radwan
Ass. Professor of Rheumatology & Immunology
(Internal Medicine Department)
Musculoskeletal Ultrasound-EULAR
Mansoura University

2. Childhood onset SLE (cSLE)
• SLE is the prototypic systemic autoimmune disease
• The overall incidence of cSLE : 0.36 to 2.5 per 100,000.
• The low prevalence of cSLE makes clinical research challenging
• Represents 10% to 20% of all cases of SLE
• The average age of onset is 12 years, with rare cases occurring at 5 years of age
or under
• The gender distribution is 5:1 (female: male)

3. Common Clinical
Manifestations
by Organ
Involvement

4. Malar erythema Photosensitive
rash
Discoid rash. Subacute
cutaneous lupus
Vasculitis Vasculitic
purpura
Mucocutaneous
ulcerations

5. EULAR/ACR Criteria for Classification of SLE
Aringer, Martin, et al. "2019 European League Against Rheumatism/American College of Rheumatology classification criteria for systemic lupus erythematosus." Arthritis & rheumatology 71.9 (2019): 1400-1412.

6. • Included studies measured depressive and/or anxiety symptoms prospectively among children and
youth aged 8 to 21 years with a diagnosis of cSLE
• 14 studies
• Prevalence rates for depressive symptoms ranged from 6.7% to 59%.
• Anxiety symptom prevalence was 34% to 37%.
Depressive and anxiety symptoms may be common comorbidities
of cSLE

7. Retrospective chart review was performed among 34 pediatric SLE patients who received psychiatric
consultation at Siriraj Hospital during the 2003 to 2012

10. Pathogenesis

11. Primary Or
Secondary
• Uremia or hypertension
• Therapy (e.g. Corticosteroids)
• Unrelated to SLE (e.g . infections, metabolic
abnormalities, or adverse medication effects)

12. The pathogenesis of neuropsychiatric lupus : unknown
Increased permeability of blood brain barrier
Microvasculopathy and thrombosis
?Pro-inflammatory cytokines
? autoantibodies

13. A total of 90 juvenile lupus patients was selected (30 with neuropsychiatric symptoms)

14. Increased pain provokes anxiety, and
depression by decreasing well being in
patients with JSLE

15. Psychiatric
Comorbidity
• Psychosis disorder
• Mood disorder
• Anxiety disorder
• Cognitive dysfunction

16. Psychosis

17. Psychosis
• 12–40% of NP-cSLE children develop psychosis
• The hallmarks of cSLE-associated psychosis are
visual hallucinations (Lupus /idiopathic )
• May be accompanied by auditory hallucinations
(threatening nature)
• MRI : 50% of children does not show any abnormality

18. Mood
Disorder

19. Mood
Disorder
• Depression
Organic (lupus)
Reactive (chronic disease )
Corticosteroid use
• Mania and bipolar disorder are uncommon.

20. • Depression symptoms were present in 23%, suicidal ideation in 15%, and anxiety in 27% of
participants (lower rates compared to T1 D).
• Non-White race/ethnicity and longer disease duration were independent risk factors for
depression and suicidal ideation.
• Depression was associated with poor disease control.

21. Depression symptoms in 10 (20%) SLE/MCTD and 4 (8%) healthy subjects (p = 0.09)
Anxiety symptoms in 11 (22%) SLE/MCTD and 13 (26%) healthy subjects
Suicidal ideation was present in 7 (14%) SLE/MCTD and 2 (4%) healthy subjects (p = 0.047)
Those with depression symptoms had a statistically significant lower rate of visits to the primary care
provider

22. Patients with cSLE (n=51) completed validated screening questionnaires
Better recognition and treatment of depression
to increase rates of medication adherence and
improve outcomes in cSLE.

23. Anxiety
Disorder

25. Cognitive
Dysfunction

26. Cognitive
Dysfunction

27. Other
Psychiatric
Symptoms and
Conditions

28. • Steroid induced /Lupus related
• A retrospective chart review (Hospital for Sick Children in Toronto 1989 -2011) ….7
cases
• One patient developed AN 15 months after diagnosis with SLE that was attributed
to prednisone-induced weight gain
Treatment of SLE resulted in improvement of AN in all
patients

33. • Most patients responded to immunosuppressive
treatment
• Median time to remission was > 1 year
• 20% of patients developed neuropsychiatric damage

34. Special
Consideration of
Corticosteroid-
Induced Psychiatric
Disorder

35. • Steroid-induced psychosis in a 12-year-old patient with lupus erythematosus (40 mg)
• Neurology consultation ruled out lupus cerebritis.
• Psychosis was treated with haloperidol 5 mg.
• Psychosis did not resolve until the steroid taper was complete and the patient was no longer taking
any prednisone

36. Mechanisms

37. Reported Cases of Steroid-Induced Psychosis in the Pediatric
Population

38. Steroid-induced psychosis
• A rare but serious adverse effect of glucocorticoids in the child and
adolescent population
• There are no widely accepted guidelines for management
• Discontinuation of steroids is the gold standard (not all cases)
• Psychopharmacologic interventions
• These children may require steroids in the future for flare-ups of disease
(? Prophylactic antipsychotics)

41. Diagnostic
work-up
Psychiatric/neuropsychological
assessment
Immunological/medical
investigations
Neuroimaging

43. • Records were retrieved from 24 children referred to neuropsychology due to clinical indications.
• Data from 15 children enrolled in a prospective structure–function association study were also
analyzed
We cannot assess causal relationships or statistical associations between structural changes and neurocognitive
impairments

44. Treatment

45. `
Barriers
• Stigma
• Fear
• Uncertainty about getting help
• Parental emotional burden
• Limited mental healthcare access
Facilitators
• Strong clinician relationships
• Clinician initiative
• Increased patient/family awareness
of mental health issues in
SLE/MCTD

46. • Screening for mental disorders is acceptable to patients and parents of youth with rheumatologic diseases
• Treatment: case series
Immunosuppressants : severe neuropsychiatric manifestations
Anti-depressants and anxiolytics : no RCT

47. • Psychotic manifestations associated with severe disease presentations were successfully treated by child
psychiatrists.
• Atypical antipsychotics were well-tolerated and used as an adjunct to immunosuppressive regimens in these
patients.

48. After 2 cycles of
pulse solumedrol and
cyclophosphamide

49. The treatment involved one-hour individual sessions held weekly with a doctoral level psychologist who
specializes in CBT (2-6 sessions /week)
Participants who completed CBT experienced significant reductions
in symptoms of fatigue and depressive symptoms at post treatment

50. Family
psychoeducation and
social support
interventions

51. Complementary
and alternative
medicine