Psych Disorders Often Precede Lupus Diagnosis

Classical lupus with typical malar rash and other well-known symptoms is extremely rare. This autoimmune ailment may start insidiously in some and may develop gradually in others. In some, it may begin as a renal problem, or heart disease, while in others various psychiatric issues may precede the more classic symptoms of lupus. No doubt, that early diagnosis is often missed, especially in primary care settings with physicians ill-prepared to diagnose this condition.

For months or even several years, physicians may treat various symptoms and misdiagnose a patient. The physician may think that thrombocytopenia is rather a result of a recent viral infection or they may even look for some other cause behind it. If the disease presents itself as psychiatric issues like depression or a seizure, the physician is more likely to think about epilepsy or another problem of the central nervous system. Usually, it takes time for physicians to understand the underlying cause of presenting symptoms when the reason is actually lupus.

The American Academy of Family Physicians and American College of Rheumatology state that the role of the physician is critical in early diagnosis to monitor the warning signs and initiate prompt treatment. However, in reality, they are often fail to diagnose lupus early.

In the age of information, automation, big data, patient identification, artificial intelligence, it would be great if we could develop an early warning system for physicians. This is exactly what Chang and his team are trying to do. In the recent research published in journal Arthritis Care & Research, Chang et al. attempted to study the difference between the quality of life a year before the diagnosis of lupus and compared it with the healthy subjects from the similar demographic group. They sought to identify the early red flags or anything that could show the risk of developing lupus.

From studies done earlier, it is well known that annual healthcare costs of those living with lupus are much higher as compared to those living with other diseases. However, Chang et al. turned their attention to analyzing the healthcare costs year before the diagnosis of lupus, since it is no secret that certain ailments often precede lupus. For example, psychosis or other emotional disorders are present in the majority of cases, before being diagnosed with lupus. However, physicians rarely associate psychosis, seizures or other symptoms of the central nervous system with lupus. Physicians utterly fail to understand that many patients can initially present with psychiatric symptoms in lupus. In fact, some psychiatric symptoms like depression, anxiety, cognitive dysfunction, and even psychosis are present in one-third of cases of lupus.

The study found that those diagnosed with lupus started to visit medical or healthcare institutions with various health issues and complaints long before they were diagnosed with lupus.  When looking into the year prior to diagnosis, we find that those who are developing lupus, visit hospitals, emergency wards, or physician’s offices several times more than those never diagnosed with lupus. There is a higher number of visits to all clinical settings:

• Ambulatory incidences were 2.8 times higher
• Emergency department visits were 3.42 times higher
• Visits to inpatient department were 3.02 times higher

These findings show the importance of understanding the various early psychiatric and emotional distress syndromes that precede lupus. Use of modern data tools can help further in identifying the high-risk patients.

In the study, Chang and his team found that clinical symptoms and autoantibodies preceded the diagnosis of SLE by several years. But the intensity of symptoms is not enough to allow the early recognition of lupus. If we could study the pattern of early signs that are characteristic in most cases, we can provide clinicians with the information and tools that could help to identify the high-risk situations, and thus accelerating the diagnosis of SLE.

For their study, Chang et al. analyzed the claims data from Clinformatics DataMart for the years 2000-2013. They identified the 682 patients who were insured and diagnosed with lupus, who were patients between 10-24 years. Eighty-eight percent of them were females. Further, they identified 1364 individuals with similar demographics, that is similar in both age and sex, as a control group to compare. Once the individuals have been finalized, they analyzed the data for both the groups, paying particular attention to the frequency of emergency department visits, ambulatory, inpatient visits, and causes behind such visits.

They found that those diagnosed with SLE visited clinics far more often, with various health problems, in comparison to the control group during the same period. Further, they noticed that the intensity of visits to clinics increased sharply before being finally diagnosed with SLE. Below were the most common preceding health issues and their average frequency in days for 682 patients in a year:

• Venous thromboembolism – 313 days
• Thrombocytopenia – 278 days
• Chest pain – 73 days
• Fever – 52 days
• Acute kidney failure – 14 days

The figures above indicate that most of the preceding clinical conditions are included in the diagnostic criteria of SLE, though physicians failed in most cases to understand the cause. Hence, research by Chang et al. provides the new insight into the subject of early diagnosis. It tells us more about the early red flags in SLE.

Several earlier studies have also demonstrated that psychiatric problems like depression and anxiety are much more prevalent in those who are diagnosed with SLE later in life, in compared to their healthier peers. So, if we take into consideration the early physical signs and combine them with a higher prevalence of psychiatric issues, it can help in a more timely diagnosis in many cases.

Further, it should be noticed that when SLE is diagnosed in an early age, symptoms like nephritis, seizures, thrombosis (or stroke), and psychiatric disorders are all quite common. Chang and his team also noted that in control group visits to clinics for psychiatric reasons were much sporadic as compared to SLE group.

This research by Chang and his team provides useful information for early diagnosis. It demonstrated that the disease pattern should raise a red flag. It also indicates that physicians and patients must understand that lupus can often present itself in a very sophisticated and non-classical manner. Therefore, instead of looking for malar rash and muscular aches, there is a need to pay high attention to psychiatric problems, thromboembolic disorders, diseases of the kidney.

In fact, the data analysis demonstrated that particular attention should be paid to any youth coming to the clinic more often than average, and an alarm should be raised regarding SLE if psychiatric problems are present along with the physical symptoms.

References

1. Kan HJ, Song X, Johnson BH, Bechtel B, O’Sullivan D, Molta CT. Healthcare Utilization and Costs of Systemic Lupus Erythematosus in Medicaid. BioMed Research International. 2013;2013:8. doi:10.1155/2013/808391
2. Chang JC, Mandell DS, Knight AM. High Health Care Utilization Preceding Diagnosis of Systemic Lupus Erythematosus in Youth. Arthritis Care Res (Hoboken). December 2017. doi:10.1002/acr.23485
3. Hawro T, Krupińska-Kun M, Rabe-Jabłońska J, et al. Psychiatric disorders in patients with systemic lupus erythematosus: association of anxiety disorder with shorter disease duration. Rheumatol Int. 2011;31(10):1387-1391. doi:10.1007/s00296-010-1689-6
4. Pego-Reigosa JM, Isenberg DA. Psychosis due to systemic lupus erythematosus: characteristics and long-term outcome of this rare manifestation of the disease. Rheumatology (Oxford). 2008;47(10):1498-1502. doi:10.1093/rheumatology/ken260
5. Lam N-CV, Ghetu MV, Bieniek ML. Systemic Lupus Erythematosus: Primary Care Approach to Diagnosis and Management. AFP. 2016;94(4):284-294.