Post-COVID-19 depression and anxiety in patients with systemic lupus erythematosus

Abstract

Objectives

This study aimed to evaluate depression and anxiety in patients with systemic lupus erythematosus (SLE) in the post-coronavirus disease-2019 (COVID-19) period and their potential association with the disease activity and related organ damage.

Patients and Methods

This is a case–control study including 120 adult Egyptian patients with SLE: sixty patients with SLE who were proven previously to be positive for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) by polymerase chain reaction (PCR) and recovered during the 3 months prior to the study were included in the case group and an equal number of age- and sex-matched patients with SLE and no evidence of SARS-CoV-2 infection were included in the control group. Patients’ clinical history was collected, and they underwent clinical evaluation, including SLE disease activity, damage assessment, and psychological assessment.

Results

The mean depression and anxiety scores were significantly higher in cases than in the control group. Both scores showed a significant positive correlation with age, disease duration, the Systemic Lupus International Collaborating Clinics/American College of Rheumatology (SLICC/ACR) Damage Index for SLE (SDI), and SLE disease activity index (SLEDAI) and a significant negative correlation with education years. Hierarchical multivariate regression analyses revealed that COVID-19 infection was a predictor for severe depression and moderate-to-severe anxiety.

Conclusions

Patients with SLE, who are already vulnerable to physiological stressors, are especially predisposed to more risk of anxiety and depression when they are contracted with COVID-19 disease. Furthermore, anxiety and depression are associated with SLE activity and damage scores, and COVID-19 infection is a significant predictor for their severity. These results suggest that healthcare providers should give special attention to the mental health of SLE patients, especially during the COVID-19 pandemic.

Keywords

Systemic lupus erythematosus depression anxiety COVID-19

Introduction

Systemic lupus erythematosus (SLE) is an inflammatory autoimmune disease with no specific data about its etiopathogenesis. However, it is thought to be the consequence of a complex interaction among hormonal, genetic, and environmental elements.¹ The clinical course of SLE is unpredictable, with subsequent challenges in understanding the disease activity and progression.²

SLE often implicates multiple organs with different levels of severity, with a clinical presentation ranging from mild mucocutaneous disorder to organ failure and devastating fatal illness.³

SLE patients usually describe their experienced fatigue and pain to be negatively impacting their quality of life.⁴ It seems that there have been several issues linking depression and anxiety to SLE. These include neurological damage, autoantibodies and certain cytokine effects, the occurrence of rashes, and skin disfigurement. The socioeconomic status could modulate this link.⁵ These data collectively designate the contribution of a complex blending of biological, socioeconomic, and environmental factors in the occurrence of depression and anxiety in patients with SLE.⁶

The newly emerging severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and its resultant coronavirus disease-2019 (COVID-19) have seriously impacted public health. However, scarce data are available concerning SARS-CoV-2 infections in patients with SLE.^7–10 Patients with SLE are specifically vulnerable to COVID-19 health complications, essentially those with kidney failure or obesity.⁹ The psychological impact of COVID-19 on a healthy population was rated moderate to severe.¹¹ Patients with SLE exhibited more aggravated psychological symptoms during the COVID-19 pandemic than the healthy population, including depression and anxiety, among others.¹²

To the best of our knowledge, no previous studies assessed depression and anxiety in patients with SLE who contracted SARS-CoV-2 during the post-COVID-19 period. In view of this, this study aimed to evaluate depression and anxiety in patients with SLE in the post-COVID-19 period and their potential association with the disease activity and related organ damage for better management of these cases.

Materials and methods

Study design

This is a case–control study conducted on Egyptian adult patients with systemic lupus erythematosus (SLE) between April 2021 and October 2021. The study was approved by the Research Ethics Committee of Armed Forces College of Medicine (AFCM) (No. V-G-IRB-01-010) and followed the Declaration of Helsinki.

Study participants

Consecutive adult patients who attended the outpatient clinics or were admitted to the inpatient wards of Kobry Al-Kobba Hospital and El-Demerdash Hospital with SLE, based on the 1997 American College of Rheumatology (ACR) revised criteria,¹³ were eligible for the study. Patients with SLE who were positive for SARS-CoV-2 by polymerase chain reaction (PCR) and recovered during the 3 months prior to the study were included in the case group (group I), while an equal number of age- and sex-matched patients with SLE and no evidence of SARS-CoV-2 infection were included in the control group (group II). In group I, patients’ recovery criteria were judged as having COVID-19 symptoms onset at least 10 days before, in addition to being free of fever and respiratory symptoms for 3 days.¹⁴ Patients of the control group who contracted SARS-CoV-2 infection during the study period were excluded. Patients with serious psychological disorders affecting their mental capacity, such as psychotic disorders or comorbid substance use, were excluded.

Informed written consent was obtained from all participants before starting the study. The participants were ensured that they had the chance to decide withdraw from this study at any moment without giving any justification and without affecting the offered treatment services.

Data collection

Full history

History of patients including name, age, sex, residence, marital status, special habits, disease age of onset and duration, and family and therapeutic history was collected.

SLE disease activity and damage assessment

Patients underwent clinical evaluation, including SLE disease activity, damage assessment, and psychiatric assessment. SLE disease activity was assessed using the Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K) score. SLEDAI-2 K index is based on an assessment of twenty-four descriptors in nine organ systems. SLEDAI-2 K descriptors are recorded as present or absent. Each of the descriptors has a weighted score. The SLEDAI-2K total score is the sum of the scores of the 24 descriptors. This total score lies between 0 and 105, with higher scores reflecting higher activity of the disease.¹⁵

SLE accumulated damage was assessed according to the Systemic Lupus International Collaborating Clinics/American College of Rheumatology (SLICC/ACR) Damage Index for SLE (SDI). Through this index, 12 systems are evaluated using 41 items for damage outlined as the non-reversible change, which is not attributed to an active inflammatory process, which has been exhibited since the SLE onset, ensured by clinical evaluation and present for at least 6 months. If damage evidence is noticed for one item, a score of 1 is given. Some items may occur more than once, so they are given a score of 2.¹⁶

Psychiatric assessment

Depression and anxiety impact were evaluated using the Hamilton Depression Rating Scale (HAM-D) and the Hamilton Anxiety Rating Scale (HAM-A), respectively. The HAM-D is designed to rate the depression severity through a total of seventeen items, eight of which are scored on a five-point scale, with a range from 0 (not present) to 4 (severe), and the remaining nine are scored from 0 to 2. The total score is interpreted as a normal condition if 0–7, mild depression if 8–13, moderate depression if 14–18, severe depression if 19–22, or very severe depression if > 23.¹⁷ In the HAM-A, the scale consists of 14 items; each of them is defined by a set of symptoms that measure both somatic anxiety, which is anxiety-related physical complaints, and psychic anxiety, which is psychological distress and mental agitation. Each item is scored on a five-point scale, from 0 (not present) to 4 (severe). The total score is interpreted as mild anxiety if ≤ 17, mild to moderate anxiety if 18–24, and moderate-to-severe anxiety if 25–30.¹⁸

Statistical analysis

Data were analyzed using SPSS version 25 (IBM, Armonk, NY, United States). Quantitative data were summarized as means and standard deviations or medians and ranges. The normality of data was assessed using the Kolmogorov–Smirnov test and direct data visualization methods. Categorical data were summarized as numbers and percentages. Independent t-test or Mann–Whitney U test was used to compare quantitative data between study groups, while the Chi-square or Fisher’s exact test was used to compare categorical data. Correlation analyses were carried out using Pearson’s or Spearman’s correlation. Hierarchical multivariate regression analyses were performed to predict depression and anxiety scores,¹⁹ with variables added hierarchically. Variables were added hierarchically as follows: step one included age, sex, employment, and education level. In step two, disease duration, SDI score, and SLEDAI score were added. In step three, COVID-19 infection was added. R2 change with its significance was calculated at each step. Regression coefficients with 95% confidence intervals were calculated. All statistical tests were two-sided. p-Values less than 0.05 were considered significant.

Study outcome(s)

The primary outcome of the study was the differences between the case and control groups regarding SLE disease activity and damage, depression and anxiety scales, while the secondary outcome was the potential association of depression and anxiety scales with SLE disease activity and damage scales.

Results

Demographic and clinical characteristics of the studied patients

The socio-demographic data of the patients are illustrated in Table 1. According to the table, 120 patients were included in the study, sixty patients in each group. The patients had a mean age of 32 ± 7 years and a female predominance, with females constituting 93.3% of patients. Significant differences were observed between case and control groups in the distribution of employment status and education years (Table 1).The patients' clinical data are demonstrated in Table 2. The patients also showed a disease duration ranging from 1 to 26 years, with a median of 9 years. SDI and SLEDAI scores ranged from 1 to 10, and the median scores were 4 and 5, respectively. Statistically significant differences were noted between both groups in the SDI and SLEDAI scores. These findings provide important baseline characteristics of the studied population and help understand the patients’ overall demographics and clinical features.

Table 1.

Socio-demographic characteristics in the studied groups.

		Total (n = 120)	Group I (n = 60)	Group II (n = 60)	p-Value
Age in years (mean ± SD)		32 ± 7	32 ± 8	32 ± 7	0.75
Gender	Males, n (%)	8 (6.7)	5 (8.3)	3 (5.0)	0.717
Gender	Females, n (%)	112 (93.3)	55 (91.7)	57 (95.0)	0.717
Marital status	Unmarried, n (%)	31 (25.8)	16 (26.7)	15 (25.0)	0.698
	Married, n (%)	59 (49.2)	31 (51.7)	28 (46.7)
	Divorced, n (%)	30 (25.0)	13 (21.7)	17 (28.3)
Number of children (median, range)		1, 0–3	1, 0–3	1, 0–3	0.37
Employment status	Employed, n (%)	55 (45.8)	22 (36.7)	33 (55.0)	0.044*
Employment status	Not-employed, n (%)	65 (54.2)	38 (63.3)	27 (45.0)	0.044*
Education years (mean ± SD)		10 ± 2	9 ± 2	11 ± 2	<0.001*

Table 2.

Clinical data of the studied groups.

	Total (n = 120)	Group I (n = 60)	Group II (n = 60)	p-Value
Disease duration (median, range)	9, 1 – 26	9, 1–26	9, 1 – 25	0.317
SDI score (median, range)	4, 1 – 10	5, 1 – 10	3, 1 – 7	<0.001
SLEDAI score (median, range)	5, 1 – 10	7, 3 – 10	4, 1 – 9	<0.001

Higher depression and anxiety scores in group I than group II

The results in Table 3 indicate that the mean depression and anxiety scores for the patients in this study were 17 ± 4 and 15 ± 5, respectively. Group I patients had significantly higher mean scores for depression and anxiety than group II patients (p < 0.001 for each). Specifically, group I patients had a mean depression score of 19 ± 4 compared to 14 ± 3 in group II. Similarly, group I patients had a mean anxiety score of 18 ± 5 compared to 12 ± 4 in group II.

Table 3.

Depression and anxiety scores in the studied groups.

	Total (n = 120)	Group I (n = 60)	Group II (n = 60)	p-Value
Depression (mean ± SD)	17 ± 4	19 ±4	14 ± 3	<0.001
Anxiety (mean ± SD)	15 ± 5	18 ± 5	12 ± 4	<0.001

Correlation between depression and anxiety scores and demographic/clinical variables in patients with SLE disease

The results of the study showed that depression scores had a significant positive correlation with age (r = 0.401, p < 0.001), disease duration (r = 0.594, p < 0.001), SDI scores (r = 0.673, p < 0.001), and SLEDAI scores (r = 0.603, p < 0.001) Figure 1. Furthermore, depression scores had a significant negative correlation with education years (r = −0.672, p < 0.001). However, the correlation between depression scores and the number of children was statistically non-significant (r = 0.069, p = 0.453).Regarding anxiety scores, there was a significant positive correlation with age (r = 0.233, p = 0.011), disease duration (r = 0.395, p < 0.001), SDI scores (r = 0.485, p < 0.001), and SLEDAI scores (r = 0.503, p < 0.001) Figure 1. In addition, there was a significant negative correlation between anxiety scores and education years (r = −0.594, p < 0.001). However, the correlation between anxiety scores and the number of children was found to be statistically non-significant (r = −0.01, p = 0.91).

Figure 1.

Correlation of depression and anxiety scores with SDI and SLEDAI scores.

These findings suggest that in patients with systemic lupus erythematosus, depression and anxiety scores are associated with several demographic and clinical factors. In particular, higher levels of depression and anxiety were associated with older age, longer disease duration, higher SDI and SLEDAI scores, and fewer years of education.

Multivariate regression analysis for depression and anxiety scores in patients with SLE

The hierarchical multivariate regression analysis for the prediction of depression score was performed (Table 4). The analysis was conducted in three steps, with additional independent variables added at each step. In the first step, age, sex, employment, and education level were included as independent variables. The R² change for this step was 0.672, indicating that these variables accounted for a significant proportion (67.2%) of the variance in the depression score. However, only employment and education level were significant predictors of depression score at this step, with both showing negative associations. In the second step, three additional independent variables were added, including duration of disease, SDI score, and SLEDAI score. The overall R² increased by 7.5%, with disease indicating that these additional variables accounted for a significant but smaller proportion of the variance in depression score. Only the duration of disease was a significant predictor of depression score at this step, with duration of disease showing a positive association. In the third step, the analysis included all of the variables from the previous steps plus one additional variable, COVID infection. The overall R² increased by 1.9%, indicating that the additional variable only accounted for a small increase in the variance in the depression score. Duration of disease and COVID infection remained significant predictors of depression score at this step, with both variables showing a positive association.

Table 4.

Hierarchical multivariate regression analysis for the prediction of depression score.

Step	R² change	Sig of change	OR (95% CI)	p-Value
Step one
Age	0.672	<0.001	0.04 (−0.035–0.116)	0.293
Sex			−0.655 (−2.7–1.389)	0.527
Employment			−4.395 (−5.526–−3.263)	<0.001
Education level			−0.94 (−1.2–−0.68)	<0.001
Step two
Age	0.075	<0.001	−0.154 (−0.259–−0.05)	0.004
Sex			−0.959 (−2.792–0.873)	0.302
Employment			−3.328 (−4.409–−2.247)	<0.001
Education level			−0.778 (−1.019–−0.537)	<0.001
Dis duration			0.224 (0.059–0.389)	0.008
SDI score			0.246 (−0.144–0.636)	0.214
SLEDAI score			0.24 (−0.026–0.507)	0.077
Step three
Age	0.019	0.004	−0.098 (−0.206–0.01)	0.076
Sex			−0.283 (−2.111–1.545)	0.76
Employment			−3.592 (−4.652–−2.532)	<0.001
Education level			−0.67 (−0.914–−0.426)	<0.001
Dis duration			0.255 (0.095–0.416)	0.002
SDI score			0.054 (−0.344–0.452)	0.789
SLEDAI score			−0.014 (−0.322–0.294)	0.929
COVID infection			2 (0.671–3.33)	0.004

B: Regression coefficient; 95% CI: 95% confidence interval.

These findings suggest that employment, education level, duration of disease, and COVID infection are important/significant predictors of depression score, with duration of disease and COVID infection showing positive associations and the employment and education level variables showing negative associations. The results also suggest that the additional variables added in steps two and three did not significantly improve the prediction of depression score beyond the variables included in step one. However, it is important to note that these results are specific to the sample and may not generalize to other populations.

Furthermore, the hierarchical multivariate regression analysis was performed to predict anxiety scores (Table 5). The analysis involves three steps, each adding additional predictor variables to the model. For anxiety score, in step 1, age, sex, employment, and education level were significant predictors, accounting for 48.5% of the variance (R² = 0.485), indicating that these variables collectively explain a significant proportion of the variance in anxiety scores (p < 0.001). Only employment and education level were significant predictors of anxiety scores, with higher levels of education and employment associated with lower anxiety scores. In step two, the variables from step one and disease duration, SDI, and SLEDAI scores were included. The R² increased by 2.7% (R2 = 0.027), indicating that adding these variables to the model did not significantly improve prediction (p = 0.105). None of these variables were found to be significant predictors of anxiety scores. In step 3, COVID infection was included, and the overall R² increased by 10.7%, with COVID infection being a significant predictor (ß = 5.866, p < 0.001). COVID infection status was a significant predictor of anxiety scores, with individuals who had been infected with COVID-19 reporting higher anxiety scores. These findings suggest that education level, employment status, and COVID-19 infection status are significant predictors of anxiety scores in this sample. It is important to note that the study used a hierarchical approach to identify the unique contribution of each set of predictors after accounting for the effects of the previous set of predictors.

Table 5.

Hierarchical multivariate regression analysis for the prediction of anxiety score.

Step	R² change	Sig of change	B (95% CI)	p-Value
Step one
Age	0.485	<0.001	−0.053 (−0.169 - 0.063)	0.368
Sex			−0.551 (−3.694–2.592)	0.729
Employment			−4.644 (−6.385–−2.904)	<0.001
Education level			−1.13 (−1.53–−0.731)	<0.001
Step two
Age	0.027	0.105	−0.143 (−0.321–0.035)	0.114
Sex			−0.694 (−3.813–2.424)	0.66
Employment			−4.039 (−5.879–−2.199)	<0.001
Education level			−0.988 (−1.398–−0.578)	<0.001
Dis duration			0.067 (−0.213–0.347)	0.637
SDI score			0.079 (−0.585–0.743)	0.814
SLEDAI score			0.383 (−0.07–0.837)	0.097
Step three
Age	0.107	<0.001	0.023 (−0.145–0.192)	0.785
Sex			1.29 (−1.565–4.144)	0.373
Employment			−4.813 (−6.468–−3.158)	<0.001
Education level			−0.669 (−1.05–−0.288)	<0.001
Dis duration			0.159 (−0.091–0.41)	0.211
SDI score			−0.485 (−1.107–0.137)	0.125
SLEDAI score			−0.362 (−0.843–0.119)	0.139
COVID infection			5.866 (3.79–7.942)	<0.001

B: Regression coefficient; 95% CI: 95% confidence interval.

Discussion

SLE is a multisystem autoimmune disease that is well documented to be frequently associated with psychological disorders, of which depression and anxiety are commonly encountered.²⁰

Patients with SLE are uniquely vulnerable when considering the COVID-19 risks and outcomes.²¹ COVID-19 elicits a systemic inflammatory state, resulting in an immunological response involving the whole body.²² Moreover, the COVID-19 pandemic was reported to be associated with increased rates of depression and anxiety.²³

Data in the literature concerning the effect of COVID-19 exposure on patients with established SLE are scarce. More specifically, only four studies could be reached in the literature assessing the psychological impact of COVID-19 on patients with SLE.^12,24–26 All of them assessed the effect of the COVID-19 pandemic regardless of whether the patients had SARS-CoV-2 infection. These studies assessed patients with SLE during the COVID-19 pandemic, and compared them retrospectively with the data of patients with SLE before the emergence of the COVID-19 pandemic,^12,25 or compared them to the general population.^24,26 To our knowledge, this is the first study assessing depression and anxiety in two groups, one having SLE and recovered from COVID-19 and the other having SLE only.

The patients in the current study had a mean age of 32 ± 7 years, with females constituting 93.3% of patients. This is consistent with the well-documented female predominance of SLE, and our figures are close to the reported 9:1, or even higher, female-to-male ratio of disease incidence.²⁷

Significant differences were noted between case and control groups in the distribution of employment status and education years. Within the same context, Santos-Ruiz et al. (2021) reported a significant difference between patients with SLE during the pandemic and the year before in the education years.¹²

The patients in the current study showed a median disease duration of 9 years, with no significant differences between both groups. Similarly, Rubio et al. (2021)²⁸ and Ramirez et al. (2021)²⁹ reported no significant differences between patients having SLE with and without COVID-19 regarding the disease duration.

The present study showed that statistically significant differences were noted between both groups in the SDI and SLEDAI scores. SDI median scores were 5 and 6 in the cases and control groups, respectively, and SLEDAI median scores were 7 and 4 in the cases and control groups, respectively, denoting worse SLE activity and damage in the COVID-19 group.

It was stated that SLE activity may be exacerbated by infection.³⁰ In line with our findings, Alharthy et al. (2020)³¹ and Khalid et al. (2021)³² reported that COVID-19 was associated with worsening SLE activity. This was also found in various recent studies.^33–36 However, it was argued that the attribution of SLE flares to COVID-19 exposure is doubtful. The flaring association was explained by the fact that during the COVID-19 pandemic, there was difficulty encountered by patients with SLE in accessing healthcare services and a shortage of some medications that control the disease besides the effect of the pandemic psychosocial stressors.³⁷ This suggestion is made away with our study’s findings since both groups were subjected to the same conditions aroused by the pandemic. This finding could favor the biological effect of SARS-CoV-2 infection itself on patients with SLE rather than the effect of the COVID-19 state alone on the overall healthcare system. However, it is also possible that some of the increase in variance accounted for by infection is due to greater isolation and stress during the pandemic or other psychosocial factors that differ in the two groups.

In this study, statistically significant higher mean depression and anxiety scores were noted in the COVID-19 group. This significance was preserved when we conducted a stepwise regression analysis since COVID-19 was a predictor of severe depression and moderate-to-severe anxiety in the patients of this study.

Depression and anxiety are frequently encountered in patients with SLE.⁶ Given the persistent media stress on COVID-19 disease complications and rapid mortality, together with the special warnings implied by health authorities for patients with immune disorders, being more vulnerable to contracting infection and exhibiting worse outcomes,³⁸ the burden of acquiring SARS-CoV-2 infection on the psychological status of the involved patients is expected to a great extent. This psychological burden is further intensified in persons with a pre-existing predisposition to psychiatric disorders,³⁹ which is the case in patients with SLE.⁶

Our findings align with the previous studies that assessed the impact of the COVID-19 pandemic on patients with SLE. However, none of the described studies assessed patients with SLE and COVID-19. Three of the four studies revealed that the COVID-19 pandemic had a negative psychological impact on patients with SLE.^12,24,25 Only the study of Quartuccio et al. (2021)²⁶ found that COVID-19 pandemic-associated lockdown had no differing psychological impact on patients with SLE compared to the general population.

Depression and anxiety in SLE are influenced by a complicated mix of biological, social, and psychological factors. In the present study, depression and anxiety scores showed significant positive correlations with age, disease duration, SDI, and SLEDAI scores and significant negative correlations with education years. The significant association of depression scores with disease duration and education years was further confirmed by the hierarchical multivariate regression analysis for the prediction of severe depression. Likewise, the hierarchical multivariate regression analyses ensured the significant association of anxiety scores with education years for the prediction of moderate-to-severe anxiety . The regression models also revealed employment state as a predictor of severe depression and moderate-to-severe anxiety in patients of this study.

Our findings agree with the study of Bai et al. (2016) that found a significant association of anxiety scores with age,⁴⁰ and the study of Shen et al. (2013), which found a significant association between depression and anxiety scores with the education years.⁴¹ This was also reported by the recent study of Ratanasiripong et al. (2020).⁴² Unemployment was stated by Maneeton et al. (2013) to be a predictor of depression.⁴³

In accordance with the current work, the study of Shen et al. (2013)⁴¹ and the most recent study of Khedr et al. (2021) reported a significant association of depression and anxiety scores with disease activity as scored by SLEDAI.⁴⁴ In variance with our findings, the study of Moldovan et al. (2011) conducted on the SLE cohort revealed that depression was negatively correlated with all SF-36 domains and that the SLEDAI did not show this correlation.⁴⁵

Limitations and strength

We acknowledge that our study is limited by non-assessment of other parameters, such as the use of hydroxychloroquine and corticosteroids in treatment and the effect on the quality of life and that information about the severity of COVID-19 symptoms and complications among patients was not included in the study. Also, the possibility of subclinical SARS-CoV-2 infection and post-COVID-19 syndrome (long COVID-19) were not addressed. Post-COVID-19 syndrome symptoms might be confused with disease activity since both are presented by fever, fatigue, and joint pain. Moreover, post-COVID-19 syndrome manifestations may include anxiety and depression or exacerbation of preexisting anxiety and depression, which might impact this study’s findings. The study is also limited by being cross-sectional. Thus, it is not possible to infer a definite cause-effect relationship. However, we believe that these limitations did not preclude the strength of this study as being a multi-centric study and that we evaluated anxiety and depression in patients with SLE and confirmed SARS-CoV-2 infection during the post COVID-19 period and compared them with patients with SLE in a case–control study for the first time. In addition, we assessed the impact of depression and anxiety on disease severity.

Conclusions

The current study revealed that depression and anxiety are prevalent in patients with SLE, particularly those infected with COVID-19. The severity of depression and anxiety is significantly associated with disease activity and damage scores. Age, sex, education level, and employment status were significant predictors of depression and anxiety. COVID-19 infection was a significant predictor of depression and anxiety in SLE patients. Therefore, healthcare providers should pay close attention to the mental health of SLE patients, especially during the COVID-19 pandemic. Early identification and intervention for depression and anxiety may improve SLE patients’ quality of life and long-term outcomes. Further research using longitudinal designs with larger samples is needed to confirm our findings and examine the predictive value of these factors over time.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Data availability

Primary data are available upon the editor request.

ORCID iD

Dina M. Abd EL-Khalik

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