Careful follow-up is key in lupus psychosis

Psychosis, a rare manifestation of systemic lupus erythematosus (SLE), generally appears early in the disease course. But treatment can lead to good outcomes for most patients with careful follow-up, according to a large international study.

The findings “confirm and expand upon the results of previous cross-sectional and historical studies of psychosis in SLE,” John G. Hanly, MD, and his associates wrote in Arthritis & Rheumatology.

The prospective study involved 1,826 patients enrolled in the Systemic Lupus International Collaborating Clinics (SLICC) network who were seen at 31 centers across 10 countries, including the United States and Canada.

Patients were followed for an average of 7.4 years, the majority were women (88.8%), almost half the cohort were white (48.8%), and the mean age was 35.1 years, reported Dr. Hanly, of Dalhousie University, Halifax, N.S., and his associates.


The researchers used the American College of Rheumatology definition of psychosis: delusions or hallucinations without insight; (ii) causing clinical distress or impairment in social, occupational or other relevant areas of functioning; (iii) disturbance should not occur exclusively during delirium; (iv) not better accounted for by another mental disorder.

During study follow-up, 28 patients experienced 31 psychotic events (1.53%); 26 of these patients had one event, one patient had two, and one had three events, Dr. Hanly and his associates said.

Using two attribution models, the investigators found that most psychotic events were directly attributed to SLE, and (80%) had their first episode either in the year prior to or within 3 years following a diagnosis of SLE.

The factors positively associated with psychosis on multivariate analysis were African ancestry (hazard ratio, 4.59; 95% confidence interval, 1.79-11.76), previous SLE neuropsychiatric events (HR, 3.59; 95% CI, 1.16-11.14), male sex (HR 3, 95% CI, 1.20-7.50), and younger age at the time of SLE diagnosis (per 10 years, HR, 1.45; 95% CI. 1.01-2.07).

More than 80% of the psychotic events had resolved by the second annual assessment after onset of the event, the investigators reported.

In terms of impact on quality of life, all subscales of the 36-Item Short-Form Health Survey (SF-36) were negatively affected in patients with lupus psychosis.

However, after treatment, patients generated SF-36 scores that showed a “remarkable reversal when averaged over time,” the investigators said.

“Psychosis is an infrequent manifestation of [neuropsychiatric SLE]. Generally, it occurs early after SLE onset and has a significant negative impact on health status,” they concluded. “As determined by patient and physician report, the short- and long-term outlook is good for most patients, though careful follow-up is required.”

Dr. Hanly disclosed grant support from the Canadian Institutes of Health. His associates reported financial support from several entities, including the Basque Government, the Danish Rheumatism Association, the Hopkins Lupus Cohort, and the National Institute for Health Research/Wellcome Trust Birmingham Clinical Research Facility.

SOURCE: Hanly JG et al. Arthritis Rheumatol. 2018. doi: 10.1002/art.40764.

Psychosis, a rare manifestation of systemic lupus erythematosus (SLE), generally appears early in the disease course. But treatment can lead to good outcomes for most patients with careful follow-up, according to a large international study.

The findings “confirm and expand upon the results of previous cross-sectional and historical studies of psychosis in SLE,” John G. Hanly, MD, and his associates wrote in Arthritis & Rheumatology.

The prospective study involved 1,826 patients enrolled in the Systemic Lupus International Collaborating Clinics (SLICC) network who were seen at 31 centers across 10 countries, including the United States and Canada.

Patients were followed for an average of 7.4 years, the majority were women (88.8%), almost half the cohort were white (48.8%), and the mean age was 35.1 years, reported Dr. Hanly, of Dalhousie University, Halifax, N.S., and his associates.


The researchers used the American College of Rheumatology definition of psychosis: delusions or hallucinations without insight; (ii) causing clinical distress or impairment in social, occupational or other relevant areas of functioning; (iii) disturbance should not occur exclusively during delirium; (iv) not better accounted for by another mental disorder.

During study follow-up, 28 patients experienced 31 psychotic events (1.53%); 26 of these patients had one event, one patient had two, and one had three events, Dr. Hanly and his associates said.

Using two attribution models, the investigators found that most psychotic events were directly attributed to SLE, and (80%) had their first episode either in the year prior to or within 3 years following a diagnosis of SLE.

The factors positively associated with psychosis on multivariate analysis were African ancestry (hazard ratio, 4.59; 95% confidence interval, 1.79-11.76), previous SLE neuropsychiatric events (HR, 3.59; 95% CI, 1.16-11.14), male sex (HR 3, 95% CI, 1.20-7.50), and younger age at the time of SLE diagnosis (per 10 years, HR, 1.45; 95% CI. 1.01-2.07).

More than 80% of the psychotic events had resolved by the second annual assessment after onset of the event, the investigators reported.

In terms of impact on quality of life, all subscales of the 36-Item Short-Form Health Survey (SF-36) were negatively affected in patients with lupus psychosis.

However, after treatment, patients generated SF-36 scores that showed a “remarkable reversal when averaged over time,” the investigators said.

“Psychosis is an infrequent manifestation of [neuropsychiatric SLE]. Generally, it occurs early after SLE onset and has a significant negative impact on health status,” they concluded. “As determined by patient and physician report, the short- and long-term outlook is good for most patients, though careful follow-up is required.”

Dr. Hanly disclosed grant support from the Canadian Institutes of Health. His associates reported financial support from several entities, including the Basque Government, the Danish Rheumatism Association, the Hopkins Lupus Cohort, and the National Institute for Health Research/Wellcome Trust Birmingham Clinical Research Facility.

SOURCE: Hanly JG et al. Arthritis Rheumatol. 2018. doi: 10.1002/art.40764.

Psychosis, a rare manifestation of systemic lupus erythematosus (SLE), generally appears early in the disease course. But treatment can lead to good outcomes for most patients with careful follow-up, according to a large international study.

The findings “confirm and expand upon the results of previous cross-sectional and historical studies of psychosis in SLE,” John G. Hanly, MD, and his associates wrote in Arthritis & Rheumatology.

The prospective study involved 1,826 patients enrolled in the Systemic Lupus International Collaborating Clinics (SLICC) network who were seen at 31 centers across 10 countries, including the United States and Canada.

Patients were followed for an average of 7.4 years, the majority were women (88.8%), almost half the cohort were white (48.8%), and the mean age was 35.1 years, reported Dr. Hanly, of Dalhousie University, Halifax, N.S., and his associates.


The researchers used the American College of Rheumatology definition of psychosis: delusions or hallucinations without insight; (ii) causing clinical distress or impairment in social, occupational or other relevant areas of functioning; (iii) disturbance should not occur exclusively during delirium; (iv) not better accounted for by another mental disorder.

During study follow-up, 28 patients experienced 31 psychotic events (1.53%); 26 of these patients had one event, one patient had two, and one had three events, Dr. Hanly and his associates said.

Using two attribution models, the investigators found that most psychotic events were directly attributed to SLE, and (80%) had their first episode either in the year prior to or within 3 years following a diagnosis of SLE.

The factors positively associated with psychosis on multivariate analysis were African ancestry (hazard ratio, 4.59; 95% confidence interval, 1.79-11.76), previous SLE neuropsychiatric events (HR, 3.59; 95% CI, 1.16-11.14), male sex (HR 3, 95% CI, 1.20-7.50), and younger age at the time of SLE diagnosis (per 10 years, HR, 1.45; 95% CI. 1.01-2.07).

More than 80% of the psychotic events had resolved by the second annual assessment after onset of the event, the investigators reported.

In terms of impact on quality of life, all subscales of the 36-Item Short-Form Health Survey (SF-36) were negatively affected in patients with lupus psychosis.

However, after treatment, patients generated SF-36 scores that showed a “remarkable reversal when averaged over time,” the investigators said.

“Psychosis is an infrequent manifestation of [neuropsychiatric SLE]. Generally, it occurs early after SLE onset and has a significant negative impact on health status,” they concluded. “As determined by patient and physician report, the short- and long-term outlook is good for most patients, though careful follow-up is required.”

Dr. Hanly disclosed grant support from the Canadian Institutes of Health. His associates reported financial support from several entities, including the Basque Government, the Danish Rheumatism Association, the Hopkins Lupus Cohort, and the National Institute for Health Research/Wellcome Trust Birmingham Clinical Research Facility.

SOURCE: Hanly JG et al. Arthritis Rheumatol. 2018. doi: 10.1002/art.40764.