Psychiatric Effects of Sjögren’s Syndrome – Depression and Anxiety

Sjögren’s Syndrome can affect several aspects of life, including physical function, role function, social function, mental health, health perception, and pain and fatigue.  These are all determinants of health-related quality of life, and therefore contribute to the overall mental impact of the disease.

The most common psychiatric complications of Sjögren’s Syndrome have been identified as depression, anxiety, sleep disturbance, irritability and headaches.  With respect to depression, low mood appears to be the most common disturbance and seems to be correlated with fatigue.  Patients have generally reported less cheerfulness, such as not enjoying reading a good book, or losing interest in their own appearance.  In terms of anxiety, patients report feeling more restless, tense, having more difficulty relaxing and having feelings of panic.  Fatigue is a very serious problem in primary Sjögren’s Syndrome and may be composed of different elements including general fatigue, mental fatigue, physical fatigue, reduced activity and reduced motivation.  It may also be related to low blood pressure, which can develop when Sjögren’s Syndrome starts to affect the autonomic nervous system.

Clinical Depression is said to have developed when one has a number of symptoms that meet criteria for the diagnosis of a depressive episode.  There are 2 hallmark symptoms of depression: 1) a pervasively depressed mood, for most of the day almost every day, sustained over a period of 2 weeks or more; 2) a tremendous lack of interest in previously enjoyable activities, or lack of ability to experience joy in previously pleasurable activities.  This latter symptom is called anhedonia.  If either of these symptoms exist, physicians should screen for other symptoms of depression.  These include disturbance of appetite, sleep, energy, self-esteem, decision-making capabilities, concentration, psychomotor activity and pathological guilt.  In severe cases some people may feel that life is not worth living and may act on these thoughts.  This is considered an emergency and patients who have such thoughts should be brought to immediate medical attention.

What causes depression in Sjögren’s Syndrome?

Depression does not have a single cause but is usually a manifestation of a number of biological, social and psychological factors which interact in a complex manner to culminate in depression.  In other words, not because one has a family member with depression, means they will necessarily have it too, but the presence of other environmental factors (social factors) as well as personal coping style, temperament, resilience (psychological factors) have a roll in the expression of depression too.

Social factors in Sjögren’s Syndrome which contribute to depression include the inability to fulfill various role functions including work, family, social and personal.  Social interaction is at a risk of being diminished because of issues around eating, swallowing, chewing food and sustaining prolonged conversation.  Fatigue and genitourinary sicca symptoms can also cause difficulties in personal relationships.  Lack of support or unsupportive environments can perpetuate low mood anxiety.

Depressive symptoms in Sjögren’s Syndrome may not be purely a response to illness however, and there are biological factors which may be contributing.  Inflammatory processes involving cytokines such at interleukin-6 and interferon-a are noted to be associated with depression.  Their involvement in depression in Sjögren’s Syndrome has been postulated, but not empirically proven.  The most common hypothesis is that central nervous system involvement is Sjögren’s Syndrome leads to decreased levels of plasma adrenaline.  This can correlate with depressive symptoms as well as fatigue, in which case noradrenergic antidepressants can be preferably chosen first, if medications are being considered.

The coexistence of depression with a chronic medical illness can have adverse effects on the course of the medical illness.  It is therefore important to recognize and treat comorbid clinical depression.

Depression, low mood and anxiety are known to:

  • Negatively affect disease outcome by affecting compliance with treatment, decreasing physical, social and mental activity, decreasing motivation and compounding fatigue
  • Decrease health-related quality of life by increasing pain perception and perception of illness burden
  • Slow recovery from physical illness because of the additive physical effects of depression

Treatment of Depression in Sjögren’s Syndrome

Not everyone who is depressed needs antidepressant treatment.  Some cases of mild or even moderate depression may respond well to psychotherapy alone, depending on individual circumstances.  There are various forms of psychotherapy and referral to a psychiatrist might be helpful in choosing the type which conforms best to the individual patient, and in administering the psychotherapy.  In the case of medications, some antidepressants are xerogenic, meaning they can worsen dryness symptoms, especially dry mouth.  Physicians must exercise caution therefore, when choosing antidepressants for patients with SS.  Noradrenergic antidepressants or serotonergic antidepressants with superior tolerability are generally better choices.

Conclusions

  • Sjögren’s Syndrome can be associated with several mental health issues such as difficulty coping, low mood, anxiety, irritability, sleep disturbance and fatigue.
  • Acceptance of the chronic nature of Sjögren’s Syndrome is a process and therefore takes time.  Acceptance is however, a necessary initial step in helping to cope with having a chronic medical illness.
  • Some coping mechanisms are more adaptive than others. Bringing one’s instinctive and subconscious forms of coping into conscious awareness is helpful in determining if reframing views of illness may improve psychological outcome.
  • Screening for depression and referral for full clinical assessment where necessary is important.
  • Early recognition and appropriate intervention is important to reduce the negative impact on quality of life and outcome of disease.
  • Depression and anxiety are safely treatable in Sjögren’s Syndrome.
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