Depression and Lupus

By Howard S. Shapiro, M. D.

People with lupus often ask: "What degree of depression is 'normal' and when should a patient seek professional help?" These questions reflect an awareness that depression occurs frequently in the course of lupus and that there is often an uncertainty as to whether or not it is "to be expected" because of the stresses, strains, continuous adjustments, and frequent sacrifices imposed by the illness. The person with lupus is often well aware that states of depression may be induced by the lupus, itself, by various medications used to treat lupus, and by various factors and forces in a patient's life that are unrelated to lupus.

Depression can be understood as a natural, although unpleasant experience which can vary in intensity, duration and in the degree that it is tolerated by the individual, but most important, by the degree to which it interferes with ability to function and maintain a reasonable sense of well being. Therapeutic assistance or intervention is indicated when the degree and duration of the depression is disruptive to the individual's sense of well-being and interferes with overall functioning and adjustment.

The medical condition that we refer to as depression is not to be confused with the transitory, everyday experience of a mild mood swing that everyone experiences during a difficult time of life. We all feel depressed from time to time, just as we feel happy, fearful, jealous, or angry.

Although depressive illness is more common in people with chronic medical illness than it is in the general population, not every person with a chronic illness (e.g. lupus) suffers from clinical depression.

Clinical depression may bring on a variety of physical and psychological symptoms: sadness and gloom, spells of crying (often without provocation), insomnia or restless sleep (or sleeping too much), loss of appetite (or eating too much), uneasiness or anxiety, irritability, feelings of guilt and remorse, lowered self-esteem, inability to concentrate, diminished memory and recall, indecisiveness, lack of interest in things one formerly enjoyed, fatigue, and a variety of physical symptoms such as headache, palpitation, diminished sexual interest and/or performance, other body aches and pains, indigestion, constipation or diarrhea, etc.

Two of the most common psychological signs of clinical depression are hopelessness and helplessness. People who feel hopeless believe that their distressing symptoms may never get better, whereas people who feel helpness think they are beyond help, that no one cares enough to help them or could succeed in helping, even if they tried.

Not all depressed people have all of these symptoms. But someone is considered to be clinically depressed if he or she experiences a depressed mood, disturbances in sleep and appetite, and at least one or two related symptoms which persist for several weeks and are severe enough to disrupt normal daily life. Many people who come for treatment have been depressed for a good deal longer than this; some people stay depressed for years and life seems flat and meaningless. Thoughts of death and deformity often are present and occasionally turn into self destructive urges.

While there are many symptoms associated with depression, there are seven which indicate the depth and degree of depression. These are: sense of failure, loss of social interest, sense of punishment, suicidal thoughts, dissatisfaction, indecision, and crying.

Depressive illness in the medically ill often goes unrecognized because it presents symptoms so similar to those of the underlying medical condition. In lupus (SLE), depressive symptoms such as lethargy, loss of energy and interest, insomnia, pain intensification, diminished libido, etc., can quite naturally be attributed to the lupus condition.

Unfortunately, many people with lupus refuse to acknowledge themselves to be in a depressed state; in fact, most depressive illness goes unrecognized and untreated until the later stages when the severity becomes unbearable to the patient and/or until the family or physician can no longer ignore it. In fact, several studies indicate that between 30-50 percent of major depressive illness goes undiagnosed in medical settings. Perhaps more disturbing is that many studies indicate that major depressive disorders in the medically ill are undertreated and inadequately treated, even when recognized.

Stress of all sorts has long been known to exacerbate lupus and the stress and suffering of depressive illness is no exception to this. People with lupus must take some responsibility to inform their physicians about the stress(es) and stressors in their lives, and must also openly and honestly reveal their true emotional condition.

Physicians who are familiar with their patients' usual mood and personality, as well as their lifestyle and situation, are more likely to recognize changes associated with depressive illness. Similarly, patients are more apt to open up about their feelings when they are encouraged to do so by a physician they trust and with whom they are familiar. This is especially important with that group of depressed individuals without the subjective complaints of unhappy mood who often deny or "resist" the notion of "emotional distress", substituting in its place various "physical" complaints. Physicians suspect "masked depression" in such patients, especially when they appear with a saddened facial expression, have lost interest in and are withdrawn from their usual activities, and are preoccupied with painful somatic complaints.

Failure to recognize and diagnose depression in the medically ill reinforces the acceptance that they have "reason to feel depressed because they are sick," and therefore discourages appropiate help. This error ignores the fact that clinical depression in the physically ill generally responds well to standard psychiatric treatments and that patients treated only for their physical illness will suffer needlessly the effects of current depression. Depression should not be used as a synonym for "sadness".

Today, effective treatment is available for depressive illness and usually consists of psychotropic medication, psychotherapy and, most often, a combination of both. Antidepressant medication is the major class of drugs used; the four categories are: tricyclics, newer-generation non-tricyclic antidepressants, MAO inhibitors, and lithium. The effectiveness of these medications may be increased by using them in combination or by the addition of other medications. Not infrequently, depressed patients are undertreated and/or inadequately treated, reflecting a therapeutic uncertainty and pessimism.

Adequate and aggressive treatment is vigilant and involves the cooperation of the patient. Such treatment may involve blood tests to determine the appropriate dosages of medication, open communication, trial and error, and a large ration of optimistic support in the form of encouragement, patience, availability and perseverance. Naturally, any underlying organic factors that contribute to the depressive state must be identified and addressed. Antidepressant medications are associated with various side effects and may intensify various symptoms associated with lupus (e.g., increase in the drying of mucous membranes in Sjogren's Syndrome). When antidepressant medications are effective, there is a welcome improvement in the patient's sense of well-being and overall attitude and adjustment.

Recovery from depression usually is a gradual process. You can't expect dramatic improvements in a few days; however, one begins to see some progress after a few weeks. Even when depression seems to clear quickly, it is not unusual to relapse when the medication is stopped. For this reason, medication should be continued for approximately six months or longer and dosage should be tapered slowly over a 3 or 4 week period when treatment is discontinued. Patients who are resistant to those treatments mentioned above have several other effective options.

Often in depressive illness, there is a general slowing and clouding of mental functions (cognition) and many people with lupus worry about changes in their alertness, attention span, capacity for concentration, orientation, memory and recall, reasoning abilities, and use of language and calculations. These troublesome and not infrequent disruptions in mental functioning tend to go underreported to their physicians and are rarely confirmed to be due to any specific structural change. Fortunately, these transient alterations in mental functioning improve as the depressive condition improves.

Psychotherapy can be very helpful in assisting depressed people to work through and understand their feelings, their illness and their relationships and to cope more effectively with stress and their life situation. The benefits to the patient are best served when the primary care physician maintains a close relationship with a psychiatrist or psychologist for consultation about and referral of depressed patients presenting difficult diagnostic and treatment problems. Such a working relationship maximizes the quality of patient care and provides the most powerful approach to management of depression.

Howard S. Shapiro is Clinical Professor of Psychiatry at the U.S.C. School of Medicine.