title: Depression and anxiety and their association with healthcare utilization in pediatric lupus and mixed connective tissue disease patients: a cross-sectional study.
abstract: BACKGROUND
  Depression and anxiety adversely affects outcomes in systemic lupus erythematosus (SLE) and healthcare utilization is high for pediatric SLE. We aimed to characterize the prevalence of depression and anxiety in pediatric SLE, and their association with healthcare utilization.
  
  
  METHODS
  We conducted a cross-sectional analysis of pediatric SLE and mixed connective tissue disease (MCTD) subjects and healthy controls aged 8 years and above. We used the Patient Health Questionnaire 9 (PHQ-9) and the Screen for Childhood Anxiety Related Disorders (SCARED) to identify depression, suicidal ideation and anxiety symptoms, respectively. We compared symptom prevalence in SLE/MCTD and healthy subjects using logistic regression. For SLE/MCTD subjects, we calculated the rate of annual outpatient visits [rheumatology/nephrology, primary care provider (PCP) and emergency department], hospitalizations and rheumatology/nephrology telephone consultations in the preceding year. We compared these outcomes in those with and without depression and anxiety using negative binomial regression.
  
  
  RESULTS
  We identified depression symptoms in 10 (20%) SLE/MCTD and 4 (8%) healthy subjects, representing a trend towards increased prevalence in unadjusted analysis (OR = 2.9, 95% CI 0.8-9.9, p = 0.09). Adjusted analysis did not show a significant difference; however, non-white race was a statistically significant independent risk factor for depression symptoms compared to white race (OR = 5.4, 95% CI 1.1-27.2, p = 0.04). We identified anxiety symptoms in 11 (22%) SLE/MCTD and 13 (26%) healthy subjects, which was not statistically different. Suicidal ideation was present in 7 (14%) SLE/MCTD and 2 (4%) healthy subjects, which was a statistically significant difference (OR = 5.4, 95% CI 1.02-28.3, p = 0.047). Of the 34% of SLE/MCTD subjects with any symptoms, only 24% had previous mental health care. Those with depression symptoms had a statistically significant lower rate of visits to the PCP (IRR = 0.38, 95% CI 0.19-0.76, p < 0.001). Anxiety symptoms were not associated with the healthcare utilization outcomes.
  
  
  CONCLUSIONS
  Depression and anxiety symptoms were prevalent, and suicidal ideation significantly more common in SLE/MCTD than in healthy subjects. Non-white race was an independent risk factor for depression. Despite prevalent symptoms, there were poor rates of prior mental health treatment, and less frequent PCP visits among those with depression symptoms. Further investigation of barriers to mental health care and interventional strategies for symptomatic youth with SLE/MCTD is needed.
authors.affiliation: Division of Rheumatology, Children's Hospital of Philadelphia, 3405 Civic Center Blvd, Philadelphia, PA 19104 USA ; Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, 3535 Market St, 15th Flr, Philadelphia, PA 19104 USA ; Children's Hospital of Philadelphia PolicyLab, Children's Hospital of Philadelphia, 3535 Market St, 15th Flr, Philadelphia, PA 19104 USA ; Children's Hospital of Philadelphia, 3535 Market St, Ste 1527, Philadelphia, PA 19104 USA.
authors.forename: Andrea
authors.initials: A
authors.lastname: Knight
authors.affiliation: Division of Rheumatology, Children's Hospital of Philadelphia, 3405 Civic Center Blvd, Philadelphia, PA 19104 USA ; Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, 3535 Market St, 15th Flr, Philadelphia, PA 19104 USA ; Center for Clinical Epidemiology & Biostatistics, University of Pennsylvania, 8th Flr Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104 USA.
authors.forename: Pamela
authors.initials: P
authors.lastname: Weiss
authors.affiliation: Center for Clinical Epidemiology & Biostatistics, University of Pennsylvania, 8th Flr Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104 USA.
authors.forename: Knashawn
authors.initials: K
authors.lastname: Morales
authors.affiliation: Children's Hospital of Philadelphia PolicyLab, Children's Hospital of Philadelphia, 3535 Market St, 15th Flr, Philadelphia, PA 19104 USA ; Department of Child and Adolescent Psychiatry and Behavioral Science, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104 USA.
authors.forename: Marsha
authors.initials: M
authors.lastname: Gerdes
authors.affiliation: Florida International University, Herbert Wertheim College of Medicine, 11200 SW 8th Street, AHC2, Miami, FL 33199 USA.
authors.forename: Allyson
authors.initials: A
authors.lastname: Gutstein
authors.affiliation: Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, 3535 Market St, 15th Flr, Philadelphia, PA 19104 USA ; Children's Hospital of Philadelphia PolicyLab, Children's Hospital of Philadelphia, 3535 Market St, 15th Flr, Philadelphia, PA 19104 USA.
authors.forename: Michelle
authors.initials: M
authors.lastname: Vickery
authors.affiliation: Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, 3535 Market St, 15th Flr, Philadelphia, PA 19104 USA ; Center for Clinical Epidemiology & Biostatistics, University of Pennsylvania, 8th Flr Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104 USA ; Division of General Pediatrics, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104 USA.
authors.forename: Ron
authors.initials: R
authors.lastname: Keren
mesh_terms: D000293:Adolescent; D001007:Anxiety / Q000453:epidemiology*; D016022:Case-Control Studies; D002648:Child; D015331:Cohort Studies; D003430:Cross-Sectional Studies; D003695:Delivery of Health Care / Q000706:statistics & numerical data*; D003863:Depression / Q000453:epidemiology*; D005260:Female; D006801:Humans; D016015:Logistic Models; D008180:Lupus Erythematosus, Systemic / Q000523:psychology*; D008297:Male; D008947:Mixed Connective Tissue Disease / Q000523:psychology*; D017063:Outcome Assessment, Health Care; D010342:Patient Acceptance of Health Care / Q000523:psychology; D015995:Prevalence; D011788:Quality of Life / Q000523:psychology; D059020:Suicidal Ideation; D055815:Young Adult
keywords: Anxiety; Depression; Healthcare utilization; Pediatric; Suicide; Systemic lupus erythematosus