0
Original Article |

Subsequent Risk of Hospitalization for Neuropsychiatric Disorders in Patients With Rheumatic Diseases:  A Nationwide Study From Sweden FREE

Kristina Sundquist, MD, PhD; Xinjun Li, MD, PhD; Kari Hemminki, MD, PhD; Jan Sundquist, MD, PhD
[+] Author Affiliations

Author Affiliations: Center for Family and Community Medicine, Karolinska Institute, Huddinge, Sweden (Drs K. Sundquist, Li, Hemminki, and J. Sundquist), and Division of Molecular Genetic Epidemiology, German Cancer Research Center, Heidelberg, Germany (Dr Hemminki).


Arch Gen Psychiatry. 2008;65(5):501-507. doi:10.1001/archpsyc.65.5.501.
Text Size: A A A
Published online

Objective  To analyze the association between rheumatoid arthritis, systemic lupus erythematosus, and ankylosing spondylitis and hospitalization for psychiatric disorders, as well as the association between hospitalization for dementia or delirium and systemic lupus erythematosus, by using a novel, large-scale approach.

Design  Cohort study with follow-up between 1973 and 2004.

Participants  The entire Swedish population.

Main Outcome Measures  Affective, psychotic, neurotic, and personality disorders as well as dementia and delirium.

Results  Individuals with rheumatic diseases had a higher risk of psychiatric disorders than the general population. Those with systemic lupus erythematosus and ankylosing spondylitis had a higher risk of subsequent psychiatric disorders than did patients with rheumatoid arthritis. The significant standardized incidence ratios for rheumatoid arthritis, systemic lupus erythematosus, and ankylosing spondylitis were 1.45, 2.38, and 1.69, respectively, for men, and 1.36, 2.16, and 1.95, respectively, for women. Differences were also found based on subtypes of the rheumatic disease and the psychiatric disorder, sex, and various follow-up intervals. Systemic lupus erythematosus carried an increased risk of dementia and delirium. Only women with rheumatoid arthritis and systemic lupus erythematosus had an increased risk of psychotic disorders and severe depression.

Conclusion  Health care providers who encounter patients with rheumatic diseases should be aware that these patients are more likely to develop neuropsychiatric disorders and that some subgroups seem to be more vulnerable than others.

Figures in this Article

Rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and ankylosing spondylitis (AS), also known as Bekhterev disease, are caused by misdirected autoimmune inflammation in the joints and/or spine. Concurrent inflammation in the internal organs is associated with nephritis, myocarditis, colitis, and other diseases.

These 3 rheumatic diseases are relatively common in the general population. The prevalence of RA and AS in industrialized countries is 1% to 2% and 0.5% to 4%, respectively.1 Both RA and SLE are more common among women, whereas AS is more common among men. However, SLE exhibits the strongest sex difference; the prevalence rates are approximately 4 per 100 000 men and 45 per 100 000 women.2,3

In most cases, the medication for these diseases is lifelong, rigorous, and often associated with adverse effects. In addition, these chronic diseases cause long-lasting suffering for many of the affected individuals, which is characterized by chronic pain, a worsened quality of life,47 and neurological and psychiatric disorders.4,810 For example, SLE is associated with affective disorders810 and psychosis.8,10 There is evidence that neuropsychiatric disorders in patients with SLE are caused by immunological mechanisms11 and a decreased regional cerebral blood flow.12 However, psychological distress and stressful life events are also important factors in the development of maladaptive coping styles, according to a study of patients with RA and SLE from Denver, Colorado.13 A study of patients with AS found that disease status scores correlated significantly with anxiety and depression.14 It is, therefore, likely that these diseases have a negative effect on the mental health of affected individuals and possibly on their risk of hospitalization for psychiatric disorders.

Results from previous studies are relatively consistent. However, a novel approach of the present study is that we included all hospitalizations in Sweden for these rheumatic diseases between 1973 and 2004 as well as hospitalizations for subsequent affective, psychotic, neurotic, and personality disorders. The aim was to analyze the association between RA, SLE, or AS and severe psychiatric disorders leading to hospitalization. In addition, we also analyzed these associations by sex, age, and various follow-up intervals between the first hospitalization for RA, SLE, or AS and for psychiatric disorders and the association between hospitalization for SLE and dementia or delirium.

MIGMED RESEARCH DATABASE

Patients were followed up from January 1, 1973, until hospital diagnosis, death, emigration, or the end of the study on December 31, 2004. Patients with RA, SLE, or AS were defined as those who, during the study period, were hospitalized for RA, SLE, or AS for the first time before being hospitalized for a neuropsychiatric disorder for the first time.

Data used in this study were retrieved from the MigMed database, Center for Family and Community Medicine, Karolinska Institute. MigMed is a single, comprehensive database that has been constructed using several national Swedish data registers, including, but not limited to, the Total Population Register and the Swedish Hospital Discharge Register.15,16 Information from the various registers in the database is linked at the individual level via the 10-digit national registration number assigned to each person in Sweden for his or her lifetime. Before inclusion in the MigMed database, national registration numbers were replaced by serial numbers to ensure the anonymity of all individuals, and serial numbers were used for all data linkages. This study was approved by the Ethics Committee of the Karolinska Institute.

Diagnostic codes were retrieved from the Swedish Hospital Discharge Register according to the 8th (1973-1986), 9th (1987-1996), and 10th (1997-2004) editions of the International Classification of Diseases (Table 1).1719 The Swedish Hospital Discharge Register covers all hospitals in Sweden. Only first hospitalizations during the study period were included. Hospitalization for the diagnostic subcategories are referred to by the name of the disease.

INDIVIDUAL VARIABLES

Age at hospital diagnosis of neuropsychiatric disorders was categorized in 5-year groups, and the groups were merged as necessary. Geographic regions were divided into large cities (cities with a population of >200 000, ie, Stockholm, Gothenburg, and Malmö), Southern Sweden, and Northern Sweden. Geographic region was included as an individual variable to adjust for possible differences with regard to hospital admissions. In addition, time period was included to adjust for possible differences in hospitalization rates over time. The follow-up interval between first hospitalizations for RA, SLE, or AS and for any psychiatric disorder was categorized as less than 1, 1 to 4, 5 to 9, and 10 or more years.

STATISTICAL ANALYSIS

Person-years were calculated from the start of follow-up on January 1, 1973, until hospital diagnosis, death, emigration, or the end of the study on December 31, 2004. Age-standardized incidence ratios (SIRs) were calculated for the entire follow-up period, divided into 3-year periods. The SIRs were calculated as the ratio of the observed to the expected number of cases of subsequent neuropsychiatric disorders20 in patients with rheumatic diseases. The expected number of cases was based on the expected number of cases in the general population, calculated for age (in 5-year groups), sex, time period, and geographic region. Confidence intervals (95% CIs) were calculated assuming a Poisson distribution. Interaction tests were performed to determine whether the association between the 3 rheumatic diseases and psychiatric disorders differed by age. No interaction was found.

Table 2 shows the number of cases and hospitalization rates for rheumatic diseases, hospitalization rates for psychiatric disorders in the general population, and hospitalization rates for psychiatric disorders following rheumatic diseases. Mean age at diagnosis was higher for RA than for AS and SLE. Hospitalization rates for RA, SLE, and AS varied by sex.

Table Graphic Jump LocationTable 2. Psychiatric Disorders in the General Population and Following Rheumatic Diseases

We compared age-specific rates of psychiatric disorders in the general population and subsequent psychiatric disorders following rheumatic diseases (Figure). Rates of psychiatric disorders following rheumatic diseases tended to be higher than rates of psychiatric disorders in the general population.

Place holder to copy figure label and caption
Figure.

Age-specific hospitalization rates for psychiatric disorders (PDs) in the general Swedish population and subsequent PDs in patients with rheumatic diseases.

Graphic Jump Location

In most age groups, an increased risk was found among men and women with RA, SLE, and AS compared with the reference group (the general population, matched for age, sex, and other factors) (Table 3). Overall, the highest risks were found among men and women with SLE. Their significant SIRs were 2.38 and 2.16, respectively. For RA, the overall significant SIRs were 1.45 and 1.36 for men and women, respectively.

Table Graphic Jump LocationTable 3. Psychiatric Disorder Following Rheumatic Diseases by Age at Diagnosis

Men with AS had increased risks of affective, neurotic, and personality disorders (Table 4). Women with AS had increased risks of affective and neurotic disorders. Men with SLE had increased risks of affective and personality disorders, whereas women with SLE had an increased risk of psychotic, affective, neurotic, and personality disorders. Men and women with RA had an increased risk of affective, neurotic, and personality disorders. Women with RA also had an increased risk of psychotic disorders. The risk of severe depression was increased among women with SLE and women with RA.

Table Graphic Jump LocationTable 4. Subtypes of Psychiatric Disorders Following Rheumatic Diseases

Among men and women, the highest SIRs were observed when the follow-up interval between first hospitalization for RA, SLE, or AS and subsequent psychiatric disorder was less than 1 year (Table 5). This tendency was especially strong among patients with SLE.

Table Graphic Jump LocationTable 5. Psychiatric Disorders Following Rheumatic Diseases by Follow-up

For dementia, the SIR was significantly increased only among women with SLE (Table 6). However, the SIRs for delirium were particularly high among men and women with SLE. The significant SIRs were 3.73 and 4.99 for men and women, respectively.

Table Graphic Jump LocationTable 6. Dementia and Delirium Following Systemic Lupus Erythematosus

In an additional analysis, we investigated whether multiple (>3) hospitalizations for RA implied an increased risk of psychiatric disorders. We found that the risk was similar compared with that of patients hospitalized only once for RA (data not shown).

This study shows that patients with rheumatic diseases have a higher risk of psychiatric disorders than the general population. Patients with SLE or AS tended to have a higher risk of subsequent psychiatric disorders than patients with RA, after accounting for age. In addition, differences were found in the risk of subsequent psychiatric disorders by subtype of the rheumatic disease, psychiatric disorder, sex, and various follow-up intervals. For example, only women with RA or SLE had an increased risk of psychotic disorders and severe depression. In addition, SLE carried an increased risk of dementia and delirium.

A key strength of the present study is that the study population represented the entire population of Sweden. This allowed us to present risk estimates by sex and subtypes of the 3 rheumatic diseases and the psychiatric disorders. In addition, the data in the Swedish Hospital Discharge Register are nearly 100% complete. In 2001, the main diagnosis was missing in only 0.9% of the hospitalized cases.15 Because of the national registration number assigned to each individual in Sweden, it was possible to track the records of every person for the whole follow-up period and calculate the exact risk-time. Finally, we analyzed the associations between RA, SLE, or AS and psychiatric disorders by various follow-up intervals. We have not found similar previous studies for comparison. However, a possible explanation for the finding that the highest SIRs were observed when the follow-up interval was less than 1 year is that the individuals go through a psychological crisis when they receive their diagnosis.

This study also has limitations. First, we were unable to draw any conclusions about causal relationships; although an advantage of this study is that it shows that certain subgroups seem to be more vulnerable than others. Second, we lacked information on environmental risk factors for rheumatic diseases and psychiatric disorders. Third, we had no data on psychological distress and stressful life events because this study was based on the entire population. Fourth, data on outpatients are not available in nationwide registers, such as the registers used in this study. This implies that only the most severe cases were included in the present study, ie, those requiring hospitalization. The “true” incidence rates in the population were thus underestimated. Fifth, some associations may not have been detected because of insufficient numbers of cases in certain diagnostic subgroups, especially among men with SLE. Sixth, data on medication were not available to us, which is a limitation because psychosis is sometimes induced by corticosteroids. Finally, we were not able to test for the validity of the diagnoses because our data were based on the entire population. For example, there is an interobserver variability in clinical settings. In addition, diagnostic criteria were changed several times during the follow-up. However, we only used main diagnoses recorded in the hospital registers, which partly increases the probability that the diagnoses are valid. In addition, 61% of RA patients had more than 1 hospitalization for RA.

The results of previous studies are consistent with those of the present study. For example, the purpose of a recent case report was to remind health care providers of the strong association between depression and chronic medical illness, such as RA.21 A cohort study observed 537 patients from Brazil and showed that acute psychosis is related to SLE.22 A recent review study from Belgrade in Serbia and Montenegro found that psychiatric abnormalities are common in SLE with a prevalence of 17% to 75%.23 Other studies have also demonstrated the association between SLE and psychiatric disorders.4,810,2427 A cross-sectional study of 82 patients with RA found a significantly increased prevalence of anxiety and depression compared with the control group.27 Other studies of patients with RA have confirmed these findings.2831 Previous studies of the association between AS and psychiatric disorders are rare, although some studies based on questionnaires and depression scores have shown that the psychological status of patients with AS is affected.14,32 The findings of an increased risk of dementia and delirium among patients with SLE suggest a primary involvement of the brain.

To sum up, this study adds further knowledge to the literature because of its novel approach; it is the first study of an entire population examining the association between 3 different rheumatic diseases and the most common neuropsychiatric disorders in men and women.

Patients with rheumatic diseases have a higher risk of hospitalization for psychiatric disorders than the general population, and patients with SLE have a higher risk of hospitalization for dementia and delirium. Differences in risk magnitudes were found by subtype of the rheumatic disease and psychiatric disorder, by sex, and by various follow-up intervals. These results show that health care providers who encounter patients with rheumatic diseases should be aware that these patients are more likely to develop severe neuropsychiatric disorders than the general population and that some subgroups seem to be more vulnerable than others.

Correspondence: Kristina Sundquist, MD, PhD, Center for Family and Community Medicine, Karolinska Institute, Alfred Nobels alle 12, SE-14183, Huddinge, Sweden (kristina.sundquist@ki.se).

Submitted for Publication: July 27, 2007; final revision received October 31, 2007; accepted November 29, 2007.

Author Contributions: All authors take responsibility for the integrity of the data and the accuracy of the data analysis. All authors had full access to all the data in the study.

Financial Disclosure: None reported.

Funding/Support: This study was supported by grant K2005-27X-15428-01A from the Swedish Research Council (Dr K. Sundquist), ALF projektmedel, and the Stockholm County Council.

Additional Contributions: We thank Leena Maria Johansson, MD, PhD, at the Center for Family and Community Medicine, Karolinska Institute, and Jehns Christian Martinéus, MD, at the Rheumatologic Clinic, University Hospital, Lund, Sweden.

Braun  JSieper  J Ankylosing spondylitis. Lancet 2007;369 (9570) 1379- 1390
PubMed
Hopkinson  NDDoherty  MPowell  RJ The prevalence and incidence of systemic lupus erythematosus in Nottingham, UK, 1989-1990. Br J Rheumatol 1993;32 (2) 110- 115
PubMed
Nightingale  ALFarmer  RDde Vries  CS Systemic lupus erythematosus prevalence in the UK: methodological issues when using the General Practice Research Database to estimate frequency of chronic relapsing-remitting disease. Pharmacoepidemiol Drug Saf 2007;16 (2) 144- 151
PubMed
Hanly  JGFisk  JDMcCurdy  GFougere  LDouglas  JA Neuropsychiatric syndromes in patients with systemic lupus erythematosus and rheumatoid arthritis. J Rheumatol 2005;32 (8) 1459- 1466
PubMed
Ariza-Ariza  RHernandez-Cruz  BNavarro-Sarabia  F Physical function and health-related quality of life of Spanish patients with ankylosing spondylitis. Arthritis Rheum 2003;49 (4) 483- 487
PubMed
Bostan  EEBorman  PBodur  HBarca  N Functional disability and quality of life in patients with ankylosing spondylitis. Rheumatol Int 2003;23 (3) 121- 126
PubMed
Kobelt  GAndlin-Sobocki  PMaksymowych  WP Costs and quality of life of patients with ankylosing spondylitis in Canada. J Rheumatol 2006;33 (2) 289- 295
PubMed
Brey  RLHolliday  SLSaklad  ARNavarrete  MGHermosillo-Romo  DStallworth  CLValdez  CREscalante  Adel Rincón  IGronseth  GRhine  CBPadilla  PMcGlasson  D Neuropsychiatric syndromes in lupus: prevalence using standardized definitions. Neurology 2002;58 (8) 1214- 1220
PubMed
Ainiala  HLoukkola  JPeltola  JKorpela  MHietaharju  A The prevalence of neuropsychiatric syndromes in systemic lupus erythematosus. Neurology 2001;57 (3) 496- 500
PubMed
Sanna  GBertolaccini  MLCuadrado  MJ  et al.  Neuropsychiatric manifestations in systemic lupus erythematosus: prevalence and association with antiphospholipid antibodies. J Rheumatol 2003;30 (5) 985- 992
PubMed
Hanly  JG Neuropsychiatric lupus. Rheum Dis Clin North Am 2005;31 (2) 273- 298
PubMed
Oda  KMatsushima  EOkubo  YOhta  KMurata  YKoike  RMiyasaka  NKato  M Abnormal regional cerebral blood flow in systemic lupus erythematosus patients with psychiatric symptoms. J Clin Psychiatry 2005;66 (7) 907- 913
PubMed
Kozora  EEllison  MCWaxmonsky  JAWamboldt  FSPatterson  TL Major life stress, coping styles, and social support in relation to psychological distress in patients with systemic lupus erythematosus. Lupus 2005;14 (5) 363- 372
PubMed
Martindale  JSmith  JSutton  CJGrennan  DGoodacre  LGoodacre  JA Disease and psychological status in ankylosing spondylitis. Rheumatology (Oxford) 2006;45 (10) 1288- 1293
PubMed
Rosen  MHakulinen  T Use of disease registers. Ahrens  WPigeot  IHandbook of Epidemiology. Berlin, Germany Springer-Verlag2005;
The National Board of Health and Welfare, The Swedish Hospital Discharge Register and the Cause of Death Register (1961-2001). http://www.sos.se/epc/english/ParEng.htm. Accessed July 27, 2007
World Health Organization, International Classification of Diseases, Eighth Revision (ICD-8).  Geneva, Switzerland World Health Organization1967;
World Health Organization, International Classification of Diseases, Ninth Revision (ICD-9).  Geneva, Switzerland World Health Organization1977;
World Health Organization, International Classification of Diseases, 10th Revision (ICD-10).  Geneva, Switzerland World Health Organization1992;
Rothman  KJGreenland  S Modern Epidemiology. 2nd ed. Philadelphia, PA Lippincott-Raven Publishers1998;
Copsey Spring  TRYanni  LMLevenson  JL A shot in the dark: failing to recognize the link between physical and mental illness. J Gen Intern Med 2007;22 (5) 677- 680
PubMed
Appenzeller  SCendes  FCostallat  LT Acute psychosis in systemic lupus erythematosus. Rheumatol Int 2008;28 (3) 237- 243
PubMed
Stojanovich  LZandman-Goddard  GPavlovich  SSikanich  N Psychiatric manifestations in systemic lupus erythematosus. Autoimmun Rev 2007;6 (6) 421- 426
PubMed
Haupt  MMillen  SJanner  MFalagan  DFischer-Betz  RSchneider  M Improvement of coping abilities in patients with systemic lupus erythematosus: a prospective study. Ann Rheum Dis 2005;64 (11) 1618- 1623
PubMed
Sweet  JJDoninger  NAZee  PCWagner  LI Factors influencing cognitive function, sleep, and quality of life in individuals with systemic lupus erythematosus: a review of the literature. Clin Neuropsychol 2004;18 (1) 132- 147
PubMed
Hanly  JG ACR classification criteria for systemic lupus erythematosus: limitations and revisions to neuropsychiatric variables. Lupus 2004;13 (11) 861- 864
PubMed
Isik  AKoca  SSOzturk  AMermi  O Anxiety and depression in patients with rheumatoid arthritis. Clin Rheumatol 2007;26 (6) 872- 878
PubMed
VanDyke  MMParker  JCSmarr  KLHewett  JEJohnson  GESlaughter  JRWalker  SE Anxiety in rheumatoid arthritis. Arthritis Rheum 2004;51 (3) 408- 412
PubMed
Abdel-Nasser  AMAbd El-Azim  STaal  EEl-Badawy  SARasker  JJValkenburg  HA Depression and depressive symptoms in rheumatoid arthritis patients: an analysis of their occurrence and determinants. Br J Rheumatol 1998;37 (4) 391- 397
PubMed
Takeda  TMorimoto  NKinukawa  NNagamine  RShutou  TTashiro  N Factors affecting depression and anxiety in female Japanese patients with rheumatoid arthritis. Clin Exp Rheumatol 2000;18 (6) 735- 738
PubMed
Parker  JCSmarr  KLSlaughter  JRJohnston  SKPriesmeyer  MLHanson  KDJohnson  GEHewett  JEHewett  JEIrvin  WSKomatireddy  GRWalker  SE Management of depression in rheumatoid arthritis: a combined pharmacologic and cognitive-behavioral approach. Arthritis Rheum 2003;49 (6) 766- 777
PubMed
Cakar  EDincer  UKiralp  MZTaskaynatan  MAYaser  EBayman  EOOzgul  ADursun  H Sexual problems in male ankylosing spondylitis patients: relationship with functionality, disease activity, quality of life, and emotional status. Clin Rheumatol 2007;26 (10) 1607- 1613
PubMed

Figures

Place holder to copy figure label and caption
Figure.

Age-specific hospitalization rates for psychiatric disorders (PDs) in the general Swedish population and subsequent PDs in patients with rheumatic diseases.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 2. Psychiatric Disorders in the General Population and Following Rheumatic Diseases
Table Graphic Jump LocationTable 3. Psychiatric Disorder Following Rheumatic Diseases by Age at Diagnosis
Table Graphic Jump LocationTable 4. Subtypes of Psychiatric Disorders Following Rheumatic Diseases
Table Graphic Jump LocationTable 5. Psychiatric Disorders Following Rheumatic Diseases by Follow-up
Table Graphic Jump LocationTable 6. Dementia and Delirium Following Systemic Lupus Erythematosus

References

Braun  JSieper  J Ankylosing spondylitis. Lancet 2007;369 (9570) 1379- 1390
PubMed
Hopkinson  NDDoherty  MPowell  RJ The prevalence and incidence of systemic lupus erythematosus in Nottingham, UK, 1989-1990. Br J Rheumatol 1993;32 (2) 110- 115
PubMed
Nightingale  ALFarmer  RDde Vries  CS Systemic lupus erythematosus prevalence in the UK: methodological issues when using the General Practice Research Database to estimate frequency of chronic relapsing-remitting disease. Pharmacoepidemiol Drug Saf 2007;16 (2) 144- 151
PubMed
Hanly  JGFisk  JDMcCurdy  GFougere  LDouglas  JA Neuropsychiatric syndromes in patients with systemic lupus erythematosus and rheumatoid arthritis. J Rheumatol 2005;32 (8) 1459- 1466
PubMed
Ariza-Ariza  RHernandez-Cruz  BNavarro-Sarabia  F Physical function and health-related quality of life of Spanish patients with ankylosing spondylitis. Arthritis Rheum 2003;49 (4) 483- 487
PubMed
Bostan  EEBorman  PBodur  HBarca  N Functional disability and quality of life in patients with ankylosing spondylitis. Rheumatol Int 2003;23 (3) 121- 126
PubMed
Kobelt  GAndlin-Sobocki  PMaksymowych  WP Costs and quality of life of patients with ankylosing spondylitis in Canada. J Rheumatol 2006;33 (2) 289- 295
PubMed
Brey  RLHolliday  SLSaklad  ARNavarrete  MGHermosillo-Romo  DStallworth  CLValdez  CREscalante  Adel Rincón  IGronseth  GRhine  CBPadilla  PMcGlasson  D Neuropsychiatric syndromes in lupus: prevalence using standardized definitions. Neurology 2002;58 (8) 1214- 1220
PubMed
Ainiala  HLoukkola  JPeltola  JKorpela  MHietaharju  A The prevalence of neuropsychiatric syndromes in systemic lupus erythematosus. Neurology 2001;57 (3) 496- 500
PubMed
Sanna  GBertolaccini  MLCuadrado  MJ  et al.  Neuropsychiatric manifestations in systemic lupus erythematosus: prevalence and association with antiphospholipid antibodies. J Rheumatol 2003;30 (5) 985- 992
PubMed
Hanly  JG Neuropsychiatric lupus. Rheum Dis Clin North Am 2005;31 (2) 273- 298
PubMed
Oda  KMatsushima  EOkubo  YOhta  KMurata  YKoike  RMiyasaka  NKato  M Abnormal regional cerebral blood flow in systemic lupus erythematosus patients with psychiatric symptoms. J Clin Psychiatry 2005;66 (7) 907- 913
PubMed
Kozora  EEllison  MCWaxmonsky  JAWamboldt  FSPatterson  TL Major life stress, coping styles, and social support in relation to psychological distress in patients with systemic lupus erythematosus. Lupus 2005;14 (5) 363- 372
PubMed
Martindale  JSmith  JSutton  CJGrennan  DGoodacre  LGoodacre  JA Disease and psychological status in ankylosing spondylitis. Rheumatology (Oxford) 2006;45 (10) 1288- 1293
PubMed
Rosen  MHakulinen  T Use of disease registers. Ahrens  WPigeot  IHandbook of Epidemiology. Berlin, Germany Springer-Verlag2005;
The National Board of Health and Welfare, The Swedish Hospital Discharge Register and the Cause of Death Register (1961-2001). http://www.sos.se/epc/english/ParEng.htm. Accessed July 27, 2007
World Health Organization, International Classification of Diseases, Eighth Revision (ICD-8).  Geneva, Switzerland World Health Organization1967;
World Health Organization, International Classification of Diseases, Ninth Revision (ICD-9).  Geneva, Switzerland World Health Organization1977;
World Health Organization, International Classification of Diseases, 10th Revision (ICD-10).  Geneva, Switzerland World Health Organization1992;
Rothman  KJGreenland  S Modern Epidemiology. 2nd ed. Philadelphia, PA Lippincott-Raven Publishers1998;
Copsey Spring  TRYanni  LMLevenson  JL A shot in the dark: failing to recognize the link between physical and mental illness. J Gen Intern Med 2007;22 (5) 677- 680
PubMed
Appenzeller  SCendes  FCostallat  LT Acute psychosis in systemic lupus erythematosus. Rheumatol Int 2008;28 (3) 237- 243
PubMed
Stojanovich  LZandman-Goddard  GPavlovich  SSikanich  N Psychiatric manifestations in systemic lupus erythematosus. Autoimmun Rev 2007;6 (6) 421- 426
PubMed
Haupt  MMillen  SJanner  MFalagan  DFischer-Betz  RSchneider  M Improvement of coping abilities in patients with systemic lupus erythematosus: a prospective study. Ann Rheum Dis 2005;64 (11) 1618- 1623
PubMed
Sweet  JJDoninger  NAZee  PCWagner  LI Factors influencing cognitive function, sleep, and quality of life in individuals with systemic lupus erythematosus: a review of the literature. Clin Neuropsychol 2004;18 (1) 132- 147
PubMed
Hanly  JG ACR classification criteria for systemic lupus erythematosus: limitations and revisions to neuropsychiatric variables. Lupus 2004;13 (11) 861- 864
PubMed
Isik  AKoca  SSOzturk  AMermi  O Anxiety and depression in patients with rheumatoid arthritis. Clin Rheumatol 2007;26 (6) 872- 878
PubMed
VanDyke  MMParker  JCSmarr  KLHewett  JEJohnson  GESlaughter  JRWalker  SE Anxiety in rheumatoid arthritis. Arthritis Rheum 2004;51 (3) 408- 412
PubMed
Abdel-Nasser  AMAbd El-Azim  STaal  EEl-Badawy  SARasker  JJValkenburg  HA Depression and depressive symptoms in rheumatoid arthritis patients: an analysis of their occurrence and determinants. Br J Rheumatol 1998;37 (4) 391- 397
PubMed
Takeda  TMorimoto  NKinukawa  NNagamine  RShutou  TTashiro  N Factors affecting depression and anxiety in female Japanese patients with rheumatoid arthritis. Clin Exp Rheumatol 2000;18 (6) 735- 738
PubMed
Parker  JCSmarr  KLSlaughter  JRJohnston  SKPriesmeyer  MLHanson  KDJohnson  GEHewett  JEHewett  JEIrvin  WSKomatireddy  GRWalker  SE Management of depression in rheumatoid arthritis: a combined pharmacologic and cognitive-behavioral approach. Arthritis Rheum 2003;49 (6) 766- 777
PubMed
Cakar  EDincer  UKiralp  MZTaskaynatan  MAYaser  EBayman  EOOzgul  ADursun  H Sexual problems in male ankylosing spondylitis patients: relationship with functionality, disease activity, quality of life, and emotional status. Clin Rheumatol 2007;26 (10) 1607- 1613
PubMed

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Topics