Research Letter
Mental health issues are not well described in cutaneous lupus erythematosus (CLE) and dermatomyositis (DM), though patients with CLE and DM have decreased quality of life1,2. Mental disorders have an increased prevalence in dermatology patients, with 10.1% and 17.2% of dermatology outpatients having clinical depression and anxiety respectively3. The aim of this cross-sectional study was to characterize mental health in CLE and DM and to determine the unmet need for and barriers to mental health care.
Three questionnaires were used for this study. The PHQ-9 and the GAD-7 are questionnaires that have been validated for the screening, diagnosis, and severity determination of depression and anxiety, respectively4,5. The Mental Health Care Assessment Questionnaire (MHCAQ), a novel survey developed for this study, determines current psychiatric treatment, indication for treatment, and barriers to treatment. Subjects were able to select all barriers that applied.
Of note, an important and novel aspect of this study was how psychiatric comorbidities were examined. This study examined depression and/or anxiety “with need,” i.e. mental health comorbidities with need for psychiatric intervention. The threshold scores to determine this “need for intervention” were based on the PHQ-9 and the GAD-7 guidelines. Furthermore, this study also included patients with low symptomatology (i.e. low scores on the PHQ-9 and GAD-7) but with current psychiatric medication and/or talk therapy. The authors believe that a more comprehensive rate of comorbid mental disorders may be determined by including these patients. Thus, the CLE and DM groups’ PHQ-9 and GAD-7 scores were calculated using a cutoff ≥10 indicative of depression “with need” for treatment and ≥8 indicative of anxiety “with need” for treatment4,5. Patients with scores lower than these cutoffs but with current psychiatric medication and/or talk therapy for these disorders also met criteria for depression and/or anxiety “with need” for mental health care. Thus, rates of depression/anxiety “with need” were the sum of subjects with high scores (PHQ≥10, GAD-7≥8) and subjects with low scores (PHQ<10, GAD-7<8) but with current psychiatric treatment. Rates of depression and anxiety were compared between CLE and DM using Fisher’s exact test.
Patients recruited for this study were seen at the Penn Autoimmune Skin Disease Clinic. Patients had established diagnoses of their diseases. 49 CLE and 41 DM patients were included in this study (Table 1).
Table 1.
CLE and DM Patient Characteristics
| CLE | DM | |
|---|---|---|
| Age | 48.5 ± 14.3 | 58.9 ± 13.5 |
| Sex | ||
| Female | 38 (77.6%) | 37 (90.2%) |
| Male | 11 (22.4%) | 4 (9.8%) |
| Race | ||
| Asian | 1 (2.0%) | 0 (0.0%) |
| Black | 18 (36.7%) | 1 (2.4%) |
| Multiracial/other | 3 (6.1%) | 0 (0.0%) |
| White | 27 (55.1%) | 40 (97.6%) |
| Ethnicity | ||
| Hispanic | 3 (6.1%) | 2 (4.9%) |
| Subtype | ||
| Skin-Predominant CLE | Amyopathic DM | 25 (51.0%) | 21 (51.2%) |
| SLE overlap | Classic DM | 24 (49.0%) | 20 (48.8%) |
The results of mood and anxiety measures as well as rates of treatment are displayed (Table 2). Depression and anxiety were highly correlated in both CLE and DM (Spearman’s ρ > 0.70 in both groups). Overall, 34.7% (17/49) CLE and 43.9% (18/41) DM patients met criteria for depression and/or anxiety “with need” (p=0.39). Of those patients, 41.2% (7/17) CLE patients and 33.3% (6/18) DM patients were receiving no mental health care (p=0.73). The percentages of patients with untreated depression and/or anxiety were comparable between CLE and DM groups (14.3% vs. 14.6%).
Table 2.
Mood and anxiety outcomes and treatment rates
| CLE (n=49) | DM (n=41) | |
|---|---|---|
| Correlation | ||
| Spearman’s ρ for depression and anxiety (p<0.0001) | 0.73 | 0.79 |
| Depression | ||
| Percentage of patients meeting criteria for depression with “need for treatment” out of total (p=1.00) | 26.5% (13/49) | 26.8% (11/41) |
| Percentage of patients receiving no psychiatric treatment out of the above group (p=0.41) | 30.8% (4/13) | 54.6% (6/11) |
| Anxiety | ||
| Percentage of patients meeting criteria for anxiety with “need for treatment” out of total (p=0.37) | 28.6% (14/49) | 39.0% (16/41) |
| Percentage of patients receiving no psychiatric treatment out of the above group (p=1.00) | 42.9% (6/14) | 31.2% (5/16) |
| Depression and/or anxiety | ||
| Patients meeting criteria for depression and/or anxiety with “need for treatment” (p=0.39) | 34.7% (17/49) | 43.9% (18/41) |
| Percentage of patients receiving no psychiatric treatment out of the above group (p=0.73). | 41.1% (7/17) | 33.3% (6/18) |
| Percentage of untreated patients with depression and/or anxiety meeting criteria for need out of total (p=1.00) | 14.3% (7/49) | 14.6% (6/41) |
The most frequently selected barrier to psychiatric medication in both the CLE and DM groups was “I am afraid of the side effects of this type of medication.” The most frequently selected barriers to therapy were “I don’t want or need treatment for these problems” in the CLE group and “These problems will get better with time” in the DM group.
In conclusion, this study highlights the existence of psychiatric comorbidities and barriers to mental health care in CLE and DM. A high proportion of patients with CLE and DM have depression and/or anxiety that may benefit from intervention. Undiagnosed and undertreated mood and anxiety disorders may be a contributing factor to the quality of life found in the CLE and DM populations.
Acknowledgments
Funding/Support: This study was based upon work supported by the Lupus Foundation of America, Philadelphia Tri-State Chapter, the Department of Veterans Affairs Veterans Health Administration, Office of Research and Development, Biomedical Laboratory Research and Development, and the National Institutes of Health (NIH K24-AR 02207) (VPW).
We are indebted to the Lupus Foundation of America, Philadelphia Tri-State Chapter, the Department of Veterans Affairs Veterans Health Administration, Office of Research and Development, Biomedical Laboratory Research and Development, and the National Institutes of Health (NIH K24-AR 02207) (VPW).
Footnotes
This study has been approved by the IRB of the University of Pennsylvania
Competing Interests: The authors declare that they have no competing interests.
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References
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