Psychiatry 73(4) Winter 2010

329

Depression in SLE
Schattner et al.

Depression in Systemic Lupus Erythematosus:

The Key Role of Illness Intrusiveness
and Concealment of Symptoms
Emanuel Schattner, Golan Shahar, Sheera Lerman, and Mahmoud Abu Shakra

Extant literature on depression in chronic illness points to the association between

depression and increased morbidity (Moussavi et al., 2007). There is to date little
research on the surmised reciprocal relationship between the two. This longitu-
dinal study of 30 women suffering from systemic lupus erythematosus (SLE) was
conducted using self-report measures as well as physical illness markers, in order
to place depression among SLE patients within what is known of the psychosocial
context of depression. The objective of this study was to differentiate between the
broadly illness-related and personality-related aspects of SLE depression. Results
show that depression is preceded by concealment of SLE symptoms and by illness
intrusiveness, a concept reflecting the subjective illness experience. Furthermore,
depression is shown to precede changes in illness intrusiveness. Thus, illness in-
trusiveness and symptom concealment – but not physical illness markers - emerge
as key factors in understanding the co-morbidity of SLE and depression. These
findings, viewed within the methodological limitations of this study, indicate the
centrality of perceptions, of the ‘lived experience’ of the illness, in the detection
and treatment of depression among women with SLE.

Over the last 50 years, chronic illness One of the most serious, and common,
has steadily overtaken acute medical condi- consequences of chronic illness is depression,
tions as the principal cause of disability and which has been found to affect sufferers of all
use of health services in the United States. ages (Miauton, Narring, & Michaud, 2003;
Currently affecting 45% of the population Sherman, 2003). Prevalence of a depressive
and accounting for 78% of health expen- episode among the chronically ill has been
diture (Anderson & Horvath, 2004; Hol- shown to average between 9.3% and 23%,
man, 2004), chronic illness is predicted to and to be significantly higher than the like-
become ever more prevalent as populations lihood of having depression in the absence
age across developed countries and effective of a chronic physical illness (Moussavi et al.,
treatment is found for acute conditions. 2007). A study among diabetics has found
Emanuel Schattner, MA, Golan Shahar, PhD, and Sheera Lerman, MA, are affiliated with the Personality, Risk, and
Resilience Research Group, Department of Psychology, at Ben-Gurion University of the Negev, in Beer-Sheva, Israel.
Dr. Shahar is also affiliated with the Department of Psychiatry, Yale University School of Medicine. Mahmoud Abu
Shakra, MD, is with the Lupus Clinic, Soroka Medical Center, and Ben Gurion University of the Negev.
This article is based on Emanuel Schattner’s doctoral dissertation, supervised by Golan Shahar. Address correspon-
dence to Emanuel Schattner or Golan Shahar, The Stress & Personality (StreP) Labratory, Department of Psychol-
ogy, Ben-Gurion University of the Negev, Beer-Sheva, Israel. Phone: 972-8-6472-037; Fax: 972-8-6472-037; E-mail:
e.schattner@gmail.com or shaharg@bgu.ac.il
330 Depression in SLE
them to be twice as prone to depression as
a non-diabetic comparison group (Anderson,
Freedland, Clouse, & Lustman, 2001). In ad-
dition, recent studies have associated depres-
sion with increased morbidity and mortality
(Bair, Robinson, Katon, & Kroenke, 2003;
Katon, 2003; Moussavi et al., 2007). Thus,
while the nature of the causal relationship
between chronic illness and depression re-
mains unclear, a reciprocal cycle of influence
may be surmised.
Clearly, longitudinal studies of the
relationship between chronic illness and
depression are much in need. Of the vari-
ous chronic illnesses, Systemic Lupus Ery-
thematosus (SLE) seems particularly suited
to such an investigation, since several of its
characteristics are arguably highly condu-
cive to depressive symptoms. For individuals
with SLE, the disorder presents a daunting
challenge to psychological coping, as it has
a highly variable pattern in terms of both
symptoms and severity, has no known cause,
lacks curative treatment, and follows an
unpredictable course (Schattner, Shahar, &
Abu Shakra, 2008). However, as Seawell and
Danoff-Burg (2004) have shown, despite the
critical importance of psychosocial factors to
understanding the illness experience of peo-
ple with SLE, there is a lack of longitudinal
research in this field.
SLE is an autoimmune disease, in
which the body produces pathogenic anti-
bodies and accompanying inflammatory cells
that can potentially affect tissues anywhere
in the body. When the illness affects internal
organs such as heart, lungs, kidneys, joints,
and nervous system, the condition is known
as SLE. The natural history of SLE varies
from a relatively benign disease to a rapid-
ly progressive and even fatal disease. In the
population of Israel, as elsewhere, 85% of
patients are women (Uramoto et al., 1999),
although the otherwise well-established dis-
parity between ethnic groups has not been
found (Abu Shakra, Lorber, Neumann, &
Buskila, 1997). Most patients are diagnosed
between the ages of 14 and 64 years, and
the disease often waxes and wanes in indi-
vidual patients throughout life. However, in
relapse the dominant symptoms are extreme
fatigue, weight change, rashes, renal disease,
headaches, depression, joint pain, muscle
aches, anemia, and general malaise (Tan et
al., 1982). Despite improvements in overall
survival rates, patients with SLE still have a
death rate that is 2-3 times that of the gener-
al population (Abu-Shakra, 2008). The sum
of these qualities makes SLE an ideal context
for the examination of depression in chronic
illness.
There has been, however, an incon-
sistent description of the status of depres-
sion in SLE. On the one hand, it has often
been assumed that the 35-85% comorbid-
ity of SLE and depression (Kozora, Ellison,
& West, 2006) is largely due to heightened
illness activity (Iverson & Anderson, 1994;
Ward, Marx, & Barry, 2004). Related hy-
potheses ascribe SLE depression to an under-
lying central nervous system disorder (Ko-
zora, Ellison, & West, 2006) or to the pain
symptoms which are known to be associated
with depression (Banks & Kerns, 1996). On
the other hand, several studies have pointed
to an apparent dissociation of depression
from physical illness markers (Da Costa et
al., 1999; Devins, Edworthy, & ARAMIS
Research Group, 2000; Guzman & Nicas-
sio, 2003; Shortall, Isenberg, & Newman,
1995), positing psychosocial factors as dom-
inant in the etiology of depression (Seawell
& Danoff-Burg, 2004).
In an attempt to shed further light on
this topic, we examined illness-related, self-
concept, and interpersonal predictors of de-
pression in SLE in a group of women with
SLE. A number of variables have been found
to be associated with, and to predict, de-
pression. One of the possible predictors for
depression in SLE is the level of illness ac-
tivity. Physical illness markers included two
validated indices for activity and damage in
SLE.
Illness intrusiveness (Devins et al.,
1984) is a concept encompassing illness- and
Schattner et al. 331
treatment-induced disruptions to the individ-
ual’s lifestyles, valued activities, and interests.
Conceptualized as a facet of the chronic ill-
ness experience that is common across con-
ditions, illness intrusiveness is a fundamental
determinant of subjective well-being. The
concept’s central assumption maintains that
illness and treatment factors affect subjective
experience through illness intrusiveness, an
intervening variable, which is also affected
by moderating psychological and social fac-
tors (Devins et al., 2001). The applicability
of the illness intrusiveness concept to this
study has been demonstrated through vari-
ous illness settings, including bone marrow
transplants (Beanlands et al., 2003), irritable
bowel syndrome (Dancey, Hutton-Young,
Moye, & Devins, 2002), rheumatic diseases
(Devins, 2006), SLE (Devins, Edworthy, &
ARAMIS Research Group, 2000), cardiac
events (Franche et al., 2004), and others
(Devins et al., 2001).
Illness-related interpersonal relation-
ships are widely recognized as major contrib-
utors to coping with physical illness (Holtz-
man & Delongis, 2007; Ishikura et al., 2001;
Lyons, Sullivan, Ritvo, & Coyne, 1995). In
particular, the intimacy between partners
is construed to be influential in buffering
stress (Prager, 1995). However, as Druley,
Stephens, and Coyne (1997) have shown,
women with SLE tend to conceal symptoms
from partners, and this tendency is related
to negative affect. This last study should be
seen in the context of the extensive literature
on the beneficial effects of self-disclosure of
information, thoughts and feelings about
personally meaningful topics (for a review
and meta-analysis, see Frattaroli, 2006).
Specifically, such sharing has been found to
be conducive to enhancement of health (Pen-
nebaker, Kiecolt-Glaser, & Glaser, 1988)
and marital relations (Jorgensen & Gaudy,
1980).
Physician-patient communication es-
pecially in chronic illness can have a pro-
found effect on such patient outcomes as
satisfaction with care, compliance with treat-
ment, and health status (see Ong, de Haes,
Hoos, & Lammes, 1995, for a review). In
addition, patients’ satisfaction with the phy-
sician-patient relationship has been found to
be associated with improved mental health
(Marshall, Hays, & Mazel, 1996).
Research indicates that self-criticism
stands out as a serious vulnerability factor to
depression and other related psychopatho-
logical conditions (suicidality, anxiety, and
eating disorders; see Blatt, 1995; Shahar,
Blatt, Zuroff, Krupnick, & Sotsky, 2004).
Self-criticism pertains to individuals' beliefs
that relationships cannot be trusted, so they
emphasize self-esteem and achievement at
the expense of interpersonal relatedness.
Furthermore, the vulnerability implicated in
self-criticism is active, rather than passive,
namely, that rather than being particularly
reactive to failure, self-critical individuals
appear to generate a host of stressful events,
both failure-related and interpersonal events
(Priel & Shahar, 2000; Shahar, Joiner, Zuroff,
& Blatt, 2004; Shahar & Priel, 2003).
Building on the aforementioned litera-
ture, we examined longitudinal associations
between these variables (i.e., illness activity
[SLEDAI] and damage [SLICC], illness in-
trusiveness, illness-related relationships, pa-
tient-doctor relationships, and self-criticism)
and depressive symptoms in a sample of SLE
female patients. These variables were mea-
sured at two points in time, separated by a
variable time (range: 3-14 months). This al-
lowed us to test the prospective-longitudinal
associations between the above predictors
and depression, as well as to examine inverse
associations, that is, between Time 1 depres-
sion and changes in illness activity, illness
intrusiveness, symptom sharing and conceal-
ment, and self-criticism.
Our hypothesis was that depression
would be predicted by factors linked to
dissatisfaction with interpersonal support
(self-criticism, symptom concealment, dis-
satisfaction with treatment, and illness in-
trusiveness), rather than by objective illness
markers.
332 Depression in SLE
Method
Participants and Procedure
Participants were 30 women treated
for SLE at the Soroka Medical Center Lupus
Clinic, Beer-Sheva, Israel (Director, Mah-
moud Abu-Shakra, MD). Since SLE runs a
different course for the male minority among
the patients, these were excluded from this
study. All participants met the American
College of Rheumatology classification cri-
teria for SLE (Tan et al., 1982) and had a
full command of the Hebrew language. Par-
ticipants’ mean age was 40.8 (median, 44).
The average duration of SLE was 15.5 years
(median, 13). Participants came from diverse
ethnic and socioeconomic backgrounds. Ex-
clusion criteria were the previous diagnosis
or presence of an organic or developmental
mental disorder, as defined by the DSM-IV-
TR (APA, 2000).
After securing approval from the hos-
pital’s ethics committee, an initial contact
with participants was made during a rou-
tine visit to the clinic. During the visit, an
appointment was set up in the participants’
home, where the questionnaires were ad-
ministered (Time 1). After several months,
another appointment was set (Time 2). Both
measurements were conducted up to one
month after medical data was obtained at a
routine visit to the clinic. Trained master’s or
bachelor’s-level research assistants admin-
istered the questionnaires. Each participant
was presented with a token gift in gratitude
of her participation--a self-care item from a
health store.
Instruments
Physical Illness Markers. Overall illness ac-
tivity was determined by the SLE Disease
Activity Index (SLEDAI), (Bombardier,
Gladman, Urowitz, Caron, & Chang, 1999),
which includes lab tests relevant to the mea-
sure of disease inflammation. SLE patients
are normally seen every 1-3 months, and at
each visit the following tests are performed:
full physical examination, urinalysis, and
complete blood count, chemistry, and serol-
ogy, including ANA. Measurement of cy-
tokines and C-reactive protein levels are not
part of routine lab tests and are thus exclud-
ed from the SLEDAI. End organ damage was
assessed by the Systemic Lupus International
Collaborating Clinics damage index (SLICC)
(Gladman et al., 1996). Both indices are vali-
dated, consensual instruments for activity
and damage in SLE.
Illness Intrusiveness. The Illness Intrusive-
ness Ratings Scale (IIRS–Devins, 1983) is
a 13-item self-report measure of the extent
to which chronic illness and/or its treatment
interfere with routines, activities, and inter-
ests. Ratings are made along a 7-point Lik-
ert scale, ranging from “not very much” (1)
to “very much” (7). Psychometric testing of
the Illness Intrusiveness Scale in a variety of
chronic illness populations, including SLE,
indicates high levels of reliability and valid-
ity (IIRS-Devins, 1983-84; Devins, 1994;
Devins et al., 2001). Specifically, a series of
analyses (n = 5,671) that estimated reliabil-
ity for each of the three IIRS subscales and
for the IIRS as a total displayed high internal
consistency (alpha coefficients consistently
exceeded 0.80 for total IIRS scores). More-
over, average inter-item correlations were
high for each of the subscales, indicating a
strong degree of internal consistency (Devins
et al., 2001).
Self-Criticism. Self-criticism was assessed
by measuring participants’ readiness to de-
scribe themselves as perfectionists, driven
by high, demanding internal standards. This
was done by using six items from the Depres-
sive Experiences Questionnaire (DEQ; Blatt,
D’Afflitti, & Quinlan, 1976). The DEQ is a
66-item scale devised to evaluate patterns of
experiences that cause predisposition to de-
pressive states and is therefore appropriate
for use with a non-clinical population. Ru-
Schattner et al. 333
dich, Lerman, Wexler, Gurevitch, and Shahar
(2008) report psychometric properties of 6
DEQ items that have straightforward content
validity in terms of measuring self-criticism.
These items are: 1) Often I find that I do not
live according to my standards or ideals. 2)
There is a significant gap between who I am
today and who I would like to be. 3) I tend
not to be content with what I have. 4) I find
it hard to accept my weaknesses. 5) I have a
tendency to be very self-critical. 6) I compare
myself often to standards or goals. These
findings, coupled with recent reports regard-
ing the predictive validity of other, very brief
measures of self-criticism (Cox, Fleet, &
Stein, 2004; Sachs-Ericsson, Verona, Joiner,
& Preacher, 2006) warranted the use of this
6-item measure in the present study.
Depression. Depression was defined broadly
in this study as the experience of elevated lev-
els of depressive symptoms, as measured by
the Center for Epidemiological Studies – De-
pression Scale (CES-D; Radloff, 1977), which
is used extensively to measure depression in
health psychology and behavioral medicine.
The CES-D scale requires participants to
state how often during the past two weeks
they felt experiences such as “I found it hard
to concentrate on what I was doing” and “I
talked less than usual.” The rating is on a
3-point Likert scale, ranging from “rarely”
(0) to “most of the time” (3). The CES-D has
been found to be free of item-content overlap
between depressive symptoms and the signs
of physical disease among individuals with
chronic conditions such as end-stage renal
disease (Devins et al., 1988) and rheuma-
toid arthritis (Devins, Edworthy, Guthrie, &
Martin, 1992).
Illness-Related Interpersonal Relationships.
We assessed the support interpersonal rela-
tionships provided by the extent to which
illness-related information was shared or
concealed from significant others. This was
done by asking participants to name the five
persons they regarded as closest to them.
Subsequently, the participants were asked
to consider to what extent they concealed
or shared illness- and treatment-related in-
formation with each of these persons. Rat-
ing was along a 4-point Likert scale, ranging
from “no concealment/sharing” (1), to “ex-
tensive concealment/sharing” (4). Finally,
participants were asked to consider whether
their relationship with each of the aforemen-
tioned persons had improved, deteriorated,
or remained unchanged compared to what it
was prior to the outbreak of SLE. In a study
of intimacy between women coping with
SLE and their partners (Druley, Stephens, &
Coyne, 1997), this measure was found to be
related to the level of negative affect.
Physician-patient relationship. We assessed
patients’ satisfaction with the communica-
tion they had with their medical caretakers,
as well as compliance to treatment. This was
done using the Patient Reactions Assessment
(PRA; Galassi, Schanberg, & Ware, 1992),
which consists of 15 items regarding pa-
tients’ perceptions of treatment-related in-
formation, communication with physician,
and overall satisfaction with the relationship.
Participants rated their agreement to such
statements as “I have a good understanding
of the expected changes in my health status”
and “I am sometimes offended when talk-
ing to the caretakers in my clinic” along a
7-point Likert scale, ranging from “strongly
agree” (1), to “strongly object” (7).
Results
Descriptive Statistics
In Table 1 we present means, standard
deviations, and correlations among Time 1
variables and Time 2 CES-D depression. As
shown in the table, the outcome variable
Time 2 depression correlated significantly
with Time 1 self-criticism (r = .65, p < .01),
Time 1 illness intrusiveness (r = .70, p < .01),
Time 1 symptom concealment (r = .52, p <
.05) and Time 1 depression (r = .84, p < .01).
 334

Table 1. Means, standard deviations, and correlations among the study variables
Time 1 Time 1 Time 1
Time 1 Self- Time 1 Time 1 Time 1 disease disease illness Time 1 PRA Time 1 PRA Time 1 PRA Time 2 De-
Variables criticism Sharing Concealment Depression activity damage intrusiveness information communication relationship pression
Time 1 Self- 1.00
criticism
Time 1 -.28 1.00
Sharing
Time 1 .18 -.74** 1.00
Concealment
Time 1 .66** -.25 .39* 1.00
Depression
Time 1 disease .23 -.51** .30 .29 1.00
activity
Time 1 disease -.15 -.01 .15 .05 .08 1.00
damage
Time 1 illness .69** -.25 .20 .68** .30 .13 1.00
intrusiveness
Time 1 PRA .19 -.08 .20 .10 -.30 -.03 .17 1.00
information
Time 1 PRA .05 -.01 .40* .36* -.16 .15 .20 .39* 1.00
communication
Time 1 PRA .17 -.13 .24 .19 -.18 -.08 .02 .37* .56** 1.00
relationship
Time 2 .65** -.32 .52** .84** .28 .18 .70** .19 .34 .11 1.00
Depression
Mean 4.57 2.96 2.00 26.66 4.35 1.52 41.75 1.93 2.34 1.68 25.69
SD 1.41 .96 .99 14.5 4.88 2.23 19.74 1.40 1.66 1.13 15.3
Range 2-7 1-4 1-4 3-51 0-29 0-11 13-91 1-5.6 1-6.8 1-5.8 0-53
*p < .05, **p < .01.
Depression in SLE
Schattner et al. 335
In addition, Time 1 self-criticism significantly
correlated with Time 1 illness intrusiveness (r
= .69, p < .01) and Time 1 depression (r =
.66, p < .01). Time 1 depression significantly
correlated with Time 1 illness intrusiveness
(r = .68, p < .01), Time 1 symptom conceal-
ment (r = .39, p < .05) and Time 1 PRA com-
munication (r = .36, p < .05). Time 1 PRA
communication also significantly correlated
with Time 1 symptom concealment (r = .40,
p < .05) and Time 1 PRA information (r =
.39, p < .05). Time 1 symptom sharing sig-
nificantly correlated with Time 1 symptom
concealment (r = -.74, p < .01) and Time 1
disease activity (r = .51, p < .01).
Regression Analysis
Time 2 CES-D depression was re-
gressed onto those variables with which it
evinced statistically significant associations,
namely, illness intrusiveness, self-criticism,
symptom concealment, and Time 1 depres-
sion. This regression model accounted for
76% of the variance of Time 2 CES-D de-
pression (R2 = .76, F[4,25] = 24.69, p < .001).
Illness intrusiveness (β = .23, t[25] = 1.72, p <
.05; one tailed), symptom concealment (β =
.26, t[25] = 2.70, p = .01), and Time 1 CES-
D depression (β = .51, t[25] = 3.63, p < .01)
emerged as statistically significant correlates
of CES-D depression. Self-criticism was not
a statistically significant correlate (β = .11,
t[25] = .82, N.S).
Zero-order correlations were com-
puted between Time 1 CES-D depression on
the one hand, and Time 2 levels of the study
variables on the other. Only two statistically
significant correlations were found, the first
between Time 1 depression and Time 2 self-
criticism (r = .51, p < .001), and the second
between Time 1 depression and Time 2 ill-
ness intrusiveness (r = .75, p < .001).
In order to examine the associations
between Time 1 depression and changes in
self-criticism and illness intrusiveness over
time, we conducted multiple regression anal-
yses of the Time 2 levels of these two vari-
ables onto (1) their respective Time 1 levels,
and (2) Time 1 depression. When Time 2
self-criticism was considered as an outcome,
it was preceded by Time 1 self-criticism (β
= .57, p < .001), but not by Time 1 depres-
sion (β = .16, p = .37). This regression equa-
tion accounted for 69% of the variance of
Time 2 self-criticism (R2 = .69; F[2,28] = 12.76,
p < .001). In contrast, when Time 2 illness
intrusiveness was considered as an outcome,
it was preceded by both Time 1 illness in-
trusiveness (β = .71, p < .001), and Time 1
depression (β = .25, p < .05). This regression
equation accounted for 81% of the variance
of Time 2 self-criticism (R2 = .81; F[2,28] =
62.24, p < .001).
Discussion
In this study, Time 1 illness intrusive-
ness and symptom concealment emerged as
variables preceding Time 2 depression. Fur-
thermore, Time 1 depression is associated
with an increase in illness intrusiveness over
time. Thus, our findings suggest a reciprocal
longitudinal relationship between depression
and illness intrusiveness in SLE. These find-
ings are suggestive of potentially causal rela-
tionships. The absence of pre-morbid mea-
sures of these variables precludes, however,
the conclusion that illness intrusiveness, or
symptom concealment, cause depression in
SLE.
Bearing in mind the crucial role of
depression to overall health and well-being
(Bair, Robinson, Katon, & Kroenke, 2003),
these findings hold the intriguing implica-
tion that illness intrusiveness and symptom
concealment matter more than the objective
medical markers in the detection and treat-
ment of depressive symptoms. That is, the
“lived experience” of the individual with
SLE, and the intimacy of her personal rela-
tionships, as reflected by illness intrusive-
ness and symptom concealment, respectively,
emerge as domains of considerable clinical
and research value.
336 Depression in SLE
The finding that involves illness intru-
siveness as a robust precedent to depression
in SLE is consistent with previous findings
as to strong associations between SLE pa-
tients’ disability and their depression status
(Da Costa et al., 1999; Devins, Edworthy, &
ARAMIS Research Group, 2000; Guzman
& Nicassio, 2003; Seawell & Danoff-Burg,
2004; Shortall, Isenberg, & Newman, 1995).
In contrast, we did not find the associations
reported in several studies (Iverson & Ander-
son, 1994; Kozora, Ellison, & West, 2006;
Ward, Marx, & Barry, 2004), between SLE
activity (SLEDAI) or damage (SLICC) and
depression. Our findings suggest that it is
the impact of SLE on lived experience, rather
than the illness per se, that carries a depres-
sogenic effect.
The implication of symptom conceal-
ment from significant others as a correlate of
depression in these findings is consistent with
the extensive literature on the detrimental ef-
fect of such concealment on health (Lyons,
Sullivan, Ritvo, & Coyne, 1995; Pennebaker,
Kiecolt-Glaser, & Glaser, 1988) and general
wellbeing (Frattaroli, 2006). Concealment
denies the individual the opportunity to
make sense of her experience through its re-
telling, to diminish the experience’s negativ-
ity through repeated exposure to it, and may
also deprive her of social support (Frattaroli,
2006). Of these, it is this last consequence
which, by contributing to a sense of isola-
tion, may play a large part in increasing the
vulnerability to depression.
Seen jointly, these findings are in con-
gruence with a growing realization among
researchers that physical attributes of health
do not fully measure disease status in chronic
conditions like SLE. Several studies regard-
ing health-related quality of life (HRQol) in
SLE have shown parallel findings, whereby
HRQol is unrelated to illness activity, illness
damage, or both (Abu Shakra et al., 1999;
Abu Shakra et al., 2006; for a review, see
McElhone, Abbot, & Teh, 2006).
However, the association found be-
tween physical illness markers and depres-
sion in several studies (Iverson & Anderson,
1994; Nery et al., 2007; Ward, Marx, & Bar-
ry, 2004) is not to be discounted, particularly
as our data, which is derived from routine
lab tests, do not include such depression-
related measurements as C-reactive protein
and cytokines. The inconsistent pattern of
results regarding the associations between
SLE activity or damage and depression may
be accounted for by the mediating role of a
subjective sense of distress, as evidenced by
HRQol or illness intrusiveness. In this mod-
el, physical illness status and support from
interpersonal relationships constitute risk
factors, contributing to a sense that the ill-
ness has harshly intruded into one’s life. It is
this sense that is the direct cause of depres-
sion, but it must be viewed in its proper con-
text of physical and interpersonal distress. A
third potential risk factor hinted at by our
findings is that of personality--namely, the
close associations of illness intrusiveness,
self-criticism, and symptom concealment
with depressive symptoms point to a pos-
sible underlying pattern of coping shared by
self-critical participants. SLE patients who
react self-critically to the hardships of illness
are less likely to share their symptoms with
their circle of support. Inadvertently, they
thus undermine their relationships with sig-
nificant others and contribute greatly to the
intrusiveness of their illness experience. Ad-
mittedly, self-criticism in this study was not
found to predict depression, though current
literature (Shahar, Joiner, Zuroff, & Blatt,
2004; Shahar & Priel, 2003) permits the
assumption that a larger sample size would
have provided different results. This aspect
of the lived illness experience merits further
research in order to gain a fuller understand-
ing of the varied aspects of risk factors in-
volved in SLE depression.
While these findings and the proposed
model have not been proposed by other re-
searchers of SLE depression, comparable
conclusions have been drawn by Shawaryn,
Schiaffino, LaRocca, and Johnston (2002)
regarding the role of illness intrusiveness in
multiple sclerosis. The robust effect of illness
intrusiveness on depression indicates the cen-
Schattner et al. 337
trality of perceptions, of the illness as experi-
enced daily by its sufferers, in any assessment
or treatment of depression. Explaining the
SLE-depression comorbidity in terms of CNS
disorder or plain reaction to physical stress
and disability overlooks the key role played
by individuals’ view of their illness as inter-
fering with their lives in bringing about de-
pression. Indeed, depressive symptoms may
be only one facet, albeit a prominent one, in
a wider disruption of sufferers’ internal lives,
brought about by the internalization of the
illness (Schattner, Shahar, & Abu Shakra,
2008). A possible application of this finding
to a clinical setting entails using the IIRS or
a comparable brief structured interview to
detect an approaching onset of depression
well before depressive symptoms are evident.
Once a high level of illness intrusiveness is
identified by caretakers, it can be addressed
by targeting the more approachable among
the intruded-upon domains of life. This pre-
ventive intervention may prove considerably
more helpful and cost-effective than han-
dling the manifest symptoms of either illness
or depression.
Methodological limitations of this
study prompt us to urge caution in interpret-
ing the results. First and foremost, replica-
tions of these results are in order. In addition,
the time interval existing between psychoso-
cial and medical measurements, as well as
the inconsistent time interval between Time
1 and Time 2 measurements, may have re-
sulted in a failure to capture the effects of
other variables. Further limitations include
References
Abu-Shakra, M. (2008). Do improved survival
rates of patients with systemic lupus erythema-
tosus reflect a global trend? Journal of Rheu-
matology, 35, 1906-1908
Abu Shakra, M., Keren, A., Livshitz, I., Delbar,
V., Bolotin, A., Sukenik, S., et al. (2006). Sense
of coherence and its impact on quality of life
of patients with systemic lupus erythematosus.
Lupus, 15, 32-37.
the small size of the sample and the lack
of control groups, both being drawbacks
common to many SLE studies (Seawell &
Danoff-Burg, 2004). As indicated above, the
absence of premorbid measurements of the
psychosocial variables in our design consid-
erably tempers causal inference. In addition,
we relied on self-report measures for both ill-
ness intrusiveness and depression, thus run-
ning a risk of conceptual overlap between
the two. While self-report belongs to the es-
sence of illness intrusiveness and is thus in-
escapable, a more objective measure for as-
sessing depression, such as the SCID (First,
Spitzer, Gibbon, & Williams, 2002), should
be incorporated in future research. Lastly,
as the CES-D includes somatic items, SLE
participants could potentially obtain a high
score regardless of the presence of depression
(Kathol et al., 1990).
In conclusion, this study has furthered
our understanding of the factors contribut-
ing to depression in SLE. Its main finding is
that illness intrusiveness, a subjective evalu-
ation of one’s experience as constricted by
illness, and concealment of symptoms from
significant others precede depression among
women with SLE independent of other dis-
tress-engendering factors. An increase in ill-
ness intrusiveness is also preceded by depres-
sion, thus indicating the reciprocal nature of
the relationship between these two concepts.
In view of the risk-prone nature of depres-
sion, this study carries practical implications
to its early detection and treatment.
Abu Shakra, M., Lorber, M., Neumann, L., &
Buskila, D. (1997) Features of SLE in various
ethnic groups in Israel. Clinical & Experimen-
tal Rheumatology, 15, 181-184.
Abu Shakra, M., Mader, R., Langevitz, P.,
Friger, M., Codish, S., Neumann, L., et al.
(1999). Quality of life in systemic lupus erythe-
matosus: A controlled study. Journal of Rheu-
matology, 26, 306-309.
338 Depression in SLE
American Psychiatric Association. (2000). Di-
agnostic and Statistical Manual of Mental Dis-
orders (4th ed.). Washington, DC: Author.
Anderson, G., & Horvath, J. (2004). The
growing burden of chronic disease in America.
Public Health Reports, 119, 263-270.
Anderson, R. J., Freedland, K. E., Clouse, R.
E., & Lustman, P. J. (2001). The prevalence of
comorbid depression in adults with diabetes.
Diabetes Care, 24, 1069-1078.
Bair, M. J., Robinson, R. L., Katon, W. J., &
Kroenke, K. (2003). Depression and pain co-
morbidity. Archives of Internal Medicine, 163,
2433-2445.
Banks, S. M., & Kerns, R. D. (1996). Explain-
ing high rates of depression in chronic pain: A
diathesis stress framework. Psychological Bul-
letin, 119, 95-110.
Beanlands, H. J., Lipton, J. H., McCay, E. A.,
Schimmer, A. D., Elliott, M. E., Messner, H. A.,
et al. (2003). Self-concept as a «BMT patient,”
illness intrusiveness, and engulfement in alloge-
neic bone marrow transplant recipients. Jour-
nal of Psychosomatic Research, 55, 419-425.
Blatt, S. J. (1995). The destructiveness of per-
fectionism: Implications for the treatment
of depression. American Psychologist, 50,
1003-1020.
Blatt, S. J., D’Afflitti, J. P., & Quinlan, D. M.
(1976). Experiences of depression in normal
young adults. Journal of Abnormal Psychology,
85, 383-389.
Bombardier, C., Gladman, D. D., Urowitz, M.
B., Caron, D., & Chang, C. H. (1999). Deriva-
tion of the SLEDAI. Arthritis & Rheumatism,
35, 630-640.
Cox, B. J., Fleet C., & Stein, M. B. (2004). Self-
criticism and social phobia in the U.S. national
comorbidity survey. Journal of Affect Disor-
ders, 82, 227-234.
Da Costa, D., Dobkin, P. L., Pinard, L., For-
tin, P. R., Danoff, D. S., Esdaile, J. M., et al.
(1999). The role of stress in functional disabil-
ity among women with systemic lupus erythe-
matosus: A prospective study. Arthritis Care &
Research, 12, 112-119.
Dancey, C.P., Hutton-Young, S.A., Moye, S.,
& Devins, G.M. (2002). Perceived stigma, ill-
ness intrusiveness and quality of life in men and
women with irritable bowel syndrome. Psy-
chology, Health & Medicine, 7, 381-395.
Devins, G. M., Binik, Y. M., Hutchinson, T. A.,
Hollomby, D. J., Barre, P. E., & Guttmann, R.
D. (1983-84). The emotional impact of end-
stage renal disease: Importance of patients’
perceptions of intrusiveness and control. Inter-
national Journal of Psychiatry in Medicine, 13,
327-343.
Devins, G. M., Dion, R., Pelletier, L. G., Sha-
piro, C. M., Abbey, S., Raiz, L. R., et al. (2001).
Structure of lifestyle disruptions in chronic dis-
ease: A confirmatory factor analysis of the Ill-
ness Intrusiveness Ratings Scale. Medical Care,
39, 1097–1104.
Devins, G. M., Edworthy, S. M., & ARAMIS
Lupus State Models Research Group (2000). Ill-
ness intrusiveness explains race-related quality-
of-life differences among women with systemic
lupus erythematosus. Lupus, 9, 534-541.
Devins, G. M., Edworthy, S. M., Guthrie, N.
G., & Martin, L. (1992). Illness intrusiveness
in rheumatoid arthritis: Differential impact on
depressive symptoms over the adult lifespan.
Journal of Rheumatology, 19, 709-715.
Devins, G. M., Orme, C. M., Costello, C. G.,
Binik, Y. M., Frizzell, B., Stam, H. J., et al.
(1988). Measuring depressive symptoms in ill-
ness populations: Psychometric properties of
the Center for Epidemiologic Studies Depres-
sion (CES-D) scale. Psychology and Health, 2,
139-156.
Devins, G. M. (1994). Illness intrusiveness and
the psychosocial impact of lifestyle disruptions
in chronic life-threatening disease. Advances in
Renal Replacement Therapy, 1, 251-263
Druley, J. A., Stephens, M. A. P., & Coyne, J.
C. (1997). Emotional and physical intimacy in
coping with lupus: Women’s dilemmas of dis-
closure and approach. Health Psychology, 16,
506-514.
Schattner et al. 339
First, M. B., Spitzer, R. L., Gibbon M., & Wil-
liams, J. B. W. (2002). Structured Clinical In-
terview for DSM-IV-TR Axis I Disorders, Re-
search Version, Non-patient Edition. (SCID-I/
NP). New York: Biometrics Research, New
York State Psychiatric Institute.
Franche, R.-L., Abbey, S., Irvine, J., Shnek, Z.
M., Grace, S. L., Devins, G. M., et al. (2004).
Sex differences in predictors of illness intru-
siveness 1 year after a cardiac event. Journal of
Psychosomatic Research, 56, 125-132.
Frattaroli, J. (2006). Experimental disclosure
and its moderators: A meta-analysis. Psy-
chologcal Bulletin, 132, 823-865.
Galassi, J.P., Schanberg, R., & Ware, W.B.
(1992). The Patient Reactions Assessment:
A brief measure of the quality of the patient-
provider medical relationship. Psychological
Assessment, 4, 346-351.
Gladman, D., Ginzler, E., Goldsmith, C., For-
tin, P., Liang, M., Sanchez-Guerrero, J., et al.
(1996). The development and initial validation
of the systemic lupus international collaborat-
ing clinics/American college of rheumatology
damage index for systemic lupus erythemato-
sus. Arthritis & Rheumatism, 39, 363-369.
Guzman, S. J., & Nicassio, P. M. (2003). The
contribution of negative and positive illness
schemas to depression in patients with end-
stage renal disease. Journal of Behavioral Med-
icine, 26, 517-534.
Holman, H. (2004). Chronic disease--the
need for a new clinical education. Journal
of the American Medical Association, 292,
1057-1059.
Holtzman, S., & Delongis, A. (2007). One day
at a time: The impact of daily satisfaction with
spouse responses on pain, negative affect and
catastrophizing among individuals with rheu-
matoid arthritis. Pain, 131, 202-213.
Ishikura, R., Morimoto, N., Kinukawa, N.,
Yoshizawa, S., Horiuchi, T., Nakashima, H.,
et al. (2001). Factors associated with anxiety,
depression and suicide ideation in female out-
patients with SLE in Japan. Clinical Rheuma-
tology, 20, 394-400.
Iverson, G. L., & Anderson, K. W. (1994). The
etiology of psychiatric symptoms in patients
with systemic lupus erythematosus. Scandina-
vian Journal of Rheumatology, 23, 277- 282.
Jorgensen, S. R., & Gaudy, J. C. (1980). Self-
disclosure and satisfaction in marriage. Family
Relations, 29, 281-287.
Kathol, R. G., Noyes, R., Williams, J., Mutgi,
A., Carroll, B., & Perry, P. (1990). Diagnosing
depression in patients with medical illness. Psy-
chosomatics, 31, 434-440.
Katon, W. J. (2003). Clinical and health ser-
vices relationships between major depression,
depressive symptoms, and general medical ill-
ness. Biological Psychiatry, 54, 216-226.
Kozora, E., Ellison, M. C., & West, S. (2006).
Depression, fatigue and pain in systemic lu-
pus erythematosus (SLE): Relationship to the
American college of Rheumatology SLE neu-
ropsychological battery. Arthritis & Rheuma-
tism, 55, 628-635.
Lyons, R. F., Sullivan, M. J. L., Ritvo, P. G., &
Coyne, J. C. (1995). Relationships in Chronic
Illness and Disability. Thousand Oaks, CA.:
Sage.
Marshall, G. N., Hays, R. D., & Mazel, R.
(1996). Health status and satisfaction with
health care: Results from the medical outcomes
study. Journal of Consulting & Clinical Psy-
chology, 64, 380-390.
McElhone, K., Abbot, J., & Teh, L-S., (2006).
A review of health related quality of life in
systemic lupus erythematosus. Lupus, 15,
633-643.
Miauton, L., Narring, F., & Michaud, P.A.
(2003). Chronic illness, life style and emotional
health in adolescence: Results of a cross-sec-
tional survey on the health of 15-20-year-olds
in Switzerland. European Journal of Pediatrics,
162, 682-689.
Moussavi, S., Chatterji, S., Verdes, E., Tandon,
A., Patel, V., & Ustun, B. (2007). Depression,
chronic diseases, and decrements in health: Re-
sults from the World Health Surveys. The Lan-
cet, 370, 851-858.
340 Depression in SLE
Nery, F. G., Borba, E. F., Hatch, J. P., Jair, C.
S., Bonfa, E., & Lotufo Neto, F. (2007). Ma-
jor depressive disorder and disease activity in
systemic lupus erythematosus. Comprehensive
Psychiatry, 48, 14-19.
Ong, L. M. L., de Haes, J. C. J. M., Hoos, A.
M., & Lammes, F. B. (1995). Doctor-patient
communication: A review of the literature. So-
cial Science and Medicine, 40, 903-918.
Pennebaker, J. W., Kiecolt-Glaser, J. K., &
Glaser, R. (1988). Disclosure of traumas and
immune function: Health implications for psy-
chotherapy. Journal of Consulting and Clinical
Psychology, 56, 239-245.
Prager, K. J. (1995). The Psychology of Inti-
macy. New York: Guilford.
Priel, B., & Shahar, G. (2000). Dependency,
self-criticism, social context and distress: Com-
paring moderating and mediating models.
Personality and Individual Differences, 28,
515-525.
Radloff, L. S. (1977). The CES-D scale: A self-
report depression scale for research in the gen-
eral population. Applied Psychological Mea-
surement, 1, 385-401.
Rudich, Z., Lerman, S. F., Wexler, N., Gurev-
ich, B., & Shahar, G. (2008). Patients’ self-
criticism is a stronger predictor of physician’s
evaluation of prognosis than pain diagnosis
or severity in chronic pain patients. Journal of
Pain, 9, 210-216.
Sachs-Ericsson N., Verona, E., Joiner, T., &
Preacher, K. J. (2006). Parental verbal abuse
and the mediating role of self-criticism in adult
internalizing disorders. Journal of Affective
Disorders, 93, 71-78.
Schattner, E., Shahar, G., & Abu Shakra, M.
(2008). “I used to dream of lupus as some sort
of creature”: Chronic illness as an internal ob-
ject. American Journal of Orthopsychiatry, 78,
466-472.
Seawell, A. H., & Danoff-Burg, S. (2004). Psy-
chosocial research on systemic lupus erythema-
tosus: A literature review. Lupus, 13, 891-899.
Shahar, G., Blatt, S. J., Zuroff, D. C., Krupnick,
J. L., & Sotsky, S. M. (2004). Perfectionism
impedes social relations and response to brief
treatment for depression. Journal of Social and
Clinical Psychology, 23, 140-154.
Shahar, G., Joiner, T. E., Zuroff, D. C., & Blatt,
S. J. (2004). Personality, interpersonal behavior,
and depression: Co-existence of stress-specific
moderating and mediating effects. Personality
and Individual Differences, 36, 1583-1596.
Shahar, G., & Priel, B. (2003). Active vulner-
ability, adolescent distress, and the mediating/
suppressing role of life events. Personality and
Individual Differences, 35, 199-218.
Shawaryn M.A., Schiaffino, K.M., LaRocca,
N.G., & Johnston, M.V. (2002). Determinants
of health-related quality of life in multiple scle-
rosis: The role of illness intrusiveness. Multiple
Sclerosis, 4, 269-270.
Sherman, A. M. (2003). Social relations and
depressive symptoms in older adults with knee
osteoarthritis. Social Science and Medicine, 56,
247-257.
Shortall, E., Isenberg, D., & Newman, S. P.
(1995). Factors associated with mood and
mood disorders in SLE. Lupus, 4, 272-279.
Tan, E. M., Cohen, A. S., Fries, J. F., Masi,
A. T., McShane, D. J., Rothfield, N. F., et al.
(1982). The 1982 revised criteria for the clas-
sification of systemic lupus erythematosus. Ar-
thritis & Rheumatism, 25, 1271-1277.
Uramoto, K. M., Michet, C. J., Thumboo, J.,
Sunku, J., O’Fallon, W. M., & Gabriel, S. E.
(1999). Trends in the incidence and mortality
of systemic lupus erythematosus, 1950-1992.
Arthritis & Rheumatism, 42, 46-50.
Ward, M. M., Marx, A. S., & Barry, N. N.
(2004). Psychological distress and changes in
the activity of systemic lupus erythematosus.
Rheumatology, 41, 184-188.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.