New research supports a role for psychiatric assessment and resources for youth newly diagnosed with systemic lupus erythematosus.
Psychiatric disorders often precede a diagnosis of systemic lupus erythematosus (SLE) in youth, and appear to be strongly associated with heavy use of healthcare services in the pre-diagnosis year for nonpsychiatric problems suggestive of underlying SLE, according to research published in Arthritis Care & Research.
Additionally, childhood-onset SLE has been shown to be associated with high risk for organ damage, which may be mitigated by early diagnosis and treatment. To pursue better avenues on how to treat this patient population, Joyce Chang, MD, and colleagues compared pre-diagnosis healthcare utilization patterns of youth with SLE with those of matched controls.
Using US administrative claims (OPTUM) from 2000 to 2013, Dr. Chang and colleagues identified 682 youths aged 10-24 with an incident diagnosis of SLE and 1,364 controls, matched 2:1 by age and sex. Incidence of ambulatory, emergency, and inpatient visits 1 year before SLE diagnosis, and the frequency of primary diagnosis codes, were compared. Researchers then examined associations of SLE patient characteristics with pre-diagnosis healthcare use.
“We were surprised by the high prevalence of psychiatric disorders in this cohort that were identified before SLE diagnosis,” says Dr. Chang. “We are not sure whether this is because lupus directly caused psychiatric symptoms in these patients or if other untreated lupus symptoms led to depression and anxiety. I also think there is a large, unfilled need for thorough psychiatric assessments and mental health resources for youth with SLE. It is a disease that can directly cause neuropsychiatric manifestations and can also take a heavy physical and emotional toll on youth and their families, which places them at high risk for depression and anxiety.”
Complications of the disease, along with treatments for it, can do even more harm in youth because they are in a critical period of growth and development, says Dr Chang. She adds that opportunities for earlier diagnosis, especially among those with neuropsychiatric or renal manifestations, are essential in treating these patients.
“We know that onset of SLE at a young age is associated with more severe disease, including a higher risk of end-stage renal disease and mortality,” says Dr. Chang. “That is why we think it is important for studies to specifically target this age group.”
According to the study, youth with SLE had significantly more visits in the year preceding diagnosis than controls across ambulatory, emergency, and inpatient settings (Figure). The differences increased as diagnosis approached. Inpatient utilization was greater for SLE subjects with subsequent seizure/stroke and nephritis. Fever, venous thromboembolism, thrombocytopenia, chest pain, and acute kidney failure were the most frequent diagnoses in acute care settings.
Communication Is Key
Dr. Chang also adds that physicians should have a heightened awareness of the various ways in which lupus can present in order to initiate screening and diagnostic evaluations appropriately. Youth with SLE tend to have a more aggressive disease than adults, making it even more critical that they begin appropriate treatment as soon as possible, she notes.
“One of the most important lessons from this study is that the road to lupus diagnosis for youth is a journey,” says Dr. Chang. “The youth in our study had an average of 14 visits in one year—that’s more than one encounter with a physician per month. Many of those visits were associated with diagnosis codes that should raise red flags. For example, hospitalizations for things like venous thromboembolic disease and acute kidney injury are otherwise quite uncommon in this age group and should prompt further work-up.”
Chang J, Mandell D, Knight A. “High Health Care Utilization Preceding Diagnosis of Systemic Lupus Erythematosus in Youth.” Arthritis Rheumatol. 2017; 69(suppl 4) Available at: http://acrabstracts.org/abstract/high-health-care-utilization-preceding-diagnosis-of-systemic-lupus-erythematosus-in-youth/