Fabiano Nery, M.D., a Brazilian psychiatrist who also completed a residency
in internal medicine, has long been fascinated by the interface between
psychiatric and medical illnesses—and especially by the interface
between depression and the autoimmune disease systemic lupus
In 2004, while affiliated with the University of Sao Paulo Medical School,
he designed a study to get more insight into possible causes of depression in
lupus patients—say, stressful life events or damage to the brain
inflicted by lupus. He was particularly interested in the latter possibility
since lupus, unlike the autoimmune disease rheumatoid arthritis, is known to
be capable of damaging the brain. The brain involvement can be either
widespread or focal and may involve inflammation of small blood vessels or
interaction of autoantibodies with antigens on neuronal cell membranes.
Seventy-one subjects with lupus were evaluated for the presence of major
depressive disorder, the intensity of depression, life events during the
previous six months that had had a negative and pronounced impact on their
lives, and lupus disease activity. Other health information about the
subjects, such as medication use, was also collected.
Sixteen of the 71 subjects (23 percent) met DSM-IV diagnostic
criteria for a current major depressive disorder. This finding did not
surprise the investigators since other studies have found high rates of major
depression in lupus subjects.
Prednisone, a medication used to treat lupus and known sometimes to produce
depression, did not seem to explain this high rate of depression because the
amount of prednisone used by subjects with and without depression was
essentially the same. Yet nine of the 16 subjects with major depression
reported having experienced at least one major negative life event during the
previous six months, compared with 13 of the 55 subjects without a major
depression—a statistically significant difference. This finding
suggested that potent negative events might have precipitated the depression.
Also, the severity of subjects' depression was associated with having
experienced negative life events, which likewise strengthened the argument
that negative events could trigger such depression.
Subjects with major depression, however, had more severe lupus disease
activity than did those without a major depression, with a trend toward
statistical significance. This finding implied that lupus disease activity
might have triggered the depression, and another result bolstered this
possibility: Even when stressful life events were taken into consideration,
there was still a highly significant link between depression severity and
Thus, it looks as if both negative life events and lupus disease activity
may lead to major depression in lupus patients, Nery and his group concluded
in their study, which is in press with Comprehensive Psychiatry.
Nonetheless, as Nery told Psychiatric News, "if a lupus
flare-up can truly trigger depression, then there is still the question of
whether the depression is due to brain damage by the disease or whether the
patient becomes depressed in reaction to the disease. I would say that both
can occur, probably at the same time in the same patient.
"My plan," he continued, "is to use neuroimaging tools to
determine whether specific brain areas associated with mood regulation are
damaged during a lupus flare, and try to use these tools to disentangle
factors such as psychosocial stress and biological and psychological factors
in the development of mood disorders."
When asked whether these findings have any practical implications for
clinical psychiatrists, he replied, "Yes, absolutely. When evaluating
depressed patients with systemic lupus erythematosus, consider that the
disease activity is an important risk factor for the worsening of the
The study was funded by Fundacao de Amparo a Pesquisa do Estado de Sao
Paulo and Conselho de Desenvolvimento Tecnologico e Cientifico.
An abstract of "Major Depressive Disorder and Disease Activity
in Systemic Lupus Erythematosus" can be accessed at<www.sciencedirect.com>
by clicking on "Browse A-Z of journals," then "C,"
then "Comprehensive Psychiatry." ▪