Psychosis in Systemic Lupus Erythematosus Is Rare, Manageable

Risk factors for psychosis in SLE included male sex and African ancestry.

Recent data show that psychosis is an infrequent manifestation of neuropsychiatric systemic lupus erythematosus (SLE), generally occurring early after disease onset. In addition, more than 80% of psychotic events resolved by physicians’ second assessment following event onset, according to a study published in Arthritis & Rheumatology.

In a large, multi-ethnic, prospective, inception cohort of patients with SLE, investigators sought to determine the frequency, attribution, clinical, and autoantibody associations with psychosis in SLE. The researchers recruited 1826 patients between October 1999 and December 2011. Data were collected per protocol at enrollment and annually from 31 medical centers in 10 countries that were part of the network within Systemic Lupus International Collaborating Clinics (SLICC). Demographics and lupus-related variables, including the SLE Disease Activity Index 2000 and SLICC/American College of Rheumatology (ACR) damage index were collected for patients who had been diagnosed with SLE up to 6 months prior to enrollment in the study. During the study, neuropsychiatric events were determined using the ACR case definitions for 19 neuropsychiatric syndromes. Using 3 factors to determine attribution of neuropsychiatric events, investigators used decision rules of different stringency.

At least 1 neuropsychiatric event occurred in 52.1% of patients over the study period. There were 1902 unique neuropsychiatric events that encompassed all 19 neuropsychiatric syndromes in ACR case definitions, 91.6% of which involved the central nervous system. Neuropsychiatric events attributed to SLE varied from 17.8% to 31.1% depending on attribution model. Significant positive associations with lupus psychosis were prior SLE neuropsychiatric events (hazard ratio [HR], 3.59; 95% CI, 1.16-11.14), male sex (HR, 3.0; 95% CI, 1.20-7.50), younger age at SLE diagnosis (per 10 years, HR, 1.45; 95% CI, 1.01-2.07), and African ancestry (HR, 4.59; 95% CI, 1.79-11.76). After adjusting for demographic predictors, anti-ribosomal P antibodies at enrollment (HR, 2.29; 95% CI, 0.81-6.46; P =.11) and over time (HR, 2.17; 95% CI, 0.79-5.97) were no longer significantly associated with lupus psychosis risk.

Limitations of this study include the limited ability to precisely estimate potential associations with clinical or lab variables of interest, due to the small number of patients with lupus psychosis. Nevertheless, the SLICC cohort is the largest inception cohort of patients with SLE. Specialized testing, such as advanced neuroimaging or colony-stimulating factor cytokine profiling, were not routinely performed.

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The researchers concluded that these findings suggest that though psychosis does not commonly occur in patients with SLE, it can have a significant effect on health status. However, both short- and long-term outlooks are good for these patients, assuming they receive careful follow-up.

Please see original reference for a full list of authors’ disclosures.

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Hanly JG, Li Q, Su L, et al. Psychosis in systemic lupus erythematosus [published online October 30, 2018]. Arthritis Rheum. doi:10.1002/art.40764