Small increases in physical activity can reduce the risk of developing depression among patients with systemic lupus erythematosus (SLE). A recent study found a strong association between sedentary lifestyles and incident depression among SLE patients, signaling a need to promote exercise as an intervention.

This isn’t about setting rigorous exercise goals, but realistic expectations, Sarah Patterson, MD, the study’s lead author, said in an interview. A little goes a long way, as one of her young patients discovered. The patient was struggling with situational anxiety following an SLE diagnosis. “We discussed a lot of different treatment approaches, and she had a strong preference for avoiding medication. We thought she could start with increasing physical activity, since she was living a mostly sedentary lifestyle,” said Dr. Patterson, an instructor in the division of rheumatology at the University of California, San Francisco. Her intervention was a walking program: 5 days a week with her mother. After just 6 weeks, the patient’s mood improved significantly. “Her Patient Health Questionnaire [PHQ-8] scores no longer met criteria for depression,” Dr. Patterson said.

Dr. Sarah Patterson

Lifetime prevalence of depression in SLE is very high, averaging 40%-50% in U.S. patients, compared with 17% in the general population, wrote Dr. Patterson, Patricia Katz, MD, the study’s senior author, and colleagues in Arthritis Care & Research. The reasons are multifactorial: the disease’s impact on function and lifestyle, an increased risk of disability and unemployment, and possibly some biological mechanisms, Dr. Patterson said. Having a proinflammatory condition may predispose SLE patients to incident depression. Previous research has shown that exercise can improve mood, but this was the first study to show an association between sedentary lifestyles and greater risk of incident depression in SLE patients.

Study focuses on one important question In the first study to do so, “we wanted to get a clear understanding of the extent to which physical activity and inactivity plays a role as a risk factor in contributing to depression in a patient population already prone to depression,” Dr. Patterson said. Any findings would help guide patient counseling. Investigators recruited a racially and ethnically diverse cohort of 225 SLE patients from the California Lupus Epidemiology Study. Patients had to meet SLE criteria per American College of Rheumatology guidelines or have a documented confirmed SLE diagnosis. To examine risk factors for developing depression, they excluded patients with high depressive symptoms at baseline. Most were female, non-White, and averaged 45 years of age. For this study, the patients completed PHQ-8 health questionnaires. Anyone who responded that they “rarely or never” did any physical activities was classified as inactive. This metric comes from the Rapid Assessment of Physical Activity, a validated instrument that’s been used to quantify physical activity in prior studies. Dr. Patterson and colleagues used Cox proportional hazards regression models to chart an association between incident depression and physical inactivity over 2 years, accounting for factors such as disease activity and damage, comorbidities, age, sex, race, and income. ‘The most surprising finding to us’ Among all the variables explored, physical inactivity emerged as the strongest independent predictor of new-onset depression. The investigators observed new-onset depression among 38% of patients who were inactive, compared with 14% of nonsedentary patients. “Among this cohort of people with lupus who were sedentary, there was a greater than threefold increased risk of new-onset depression over the subsequent 2 years, even after adjusting for comorbidities, sociodemographic risk factors, and indices of disease severity and damage,” they summarized. The high correlation between physical activity and depression “was the most interesting and even surprising finding to us,” Dr. Patterson said. “We had anticipated an independent association between inactivity and depression, but the magnitude of the association was very dramatic.” The findings underscore the importance of physical activity in overall health, she continued. Based on research on the impact of excess fat or excess adipose tissue, “there’s possibly some anti-inflammatory properties associated with engaging in a regular exercise program, both from the activity itself and its impact on body composition.” Low-level activities make a difference Even patients engaging in relatively small amounts of physical activity had better outcomes than the sedentary SLE patients. “People facing the challenges of systemic lupus should not put undue pressure on themselves to start an aggressive exercise program. That isn’t the message for patients and clinicians. Any little bit of physical activity is likely to be helpful for overall health and improving mood symptoms,” she said. Simple things like incorporating a gentle walk each day, can make a difference. “Walking programs are a nice intervention because it’s accessible and free. And most people are able to engage in some type of walking,” Dr. Patterson said. The American College of Sports Medicine has an exercise prescription website and handbook that encourages clinicians to identify sedentary patients and craft a specific plan that meets their needs. Setting realistic, specific goals is important, she emphasized. Clinicians need to follow up with patients to ensure they’re receiving the support they need and address any challenges they have. This includes discussing the frequency of the exercise regimen (how many times per week, minutes per session), the type of activity, and how the patient will measure their activity. “Because this is a research interest and an important focus of my clinical practice, I often address lifestyle issues with my patients. Many of them have successfully initiated a regular physical activity program, and almost everyone feels better if they’re able to sustain that practice,” Dr. Patterson said. Top image credit: Leonardo Patrizi/Getty Images Image credit: kali9/Getty Images

Depression ‘can be multifactorial’ Given how often depression presents in SLE patients, physical activity is one viable strategy to mitigate its effects, said Rosalind Ramsey-Goldman, MD, DrPH, the Solovy/Arthritis Research Society research professor at Northwestern University, Chicago, who was not affiliated with the study. Depression, however, can be multifactorial, Dr. Ramsey-Goldman noted. Although the study’s investigators evaluated other possibilities, “they were constrained by what was available in the dataset used in this study.” They based their results on just a small number of individuals (n = 41) who did not have depression in the initial patient-reported survey (although approximately 25% reported a history of depression prior to the baseline visit) and identified as inactive. Additionally, the methods investigators used didn’t distinguish between recurring or new-onset depression. “This possible relationship was not discussed and raises concern about the strength of the relationship reported in this study,” she offered.

Dr. Rosalind Ramsey-Goldman

Focusing solely on physical activity could potentially miss other useful, concomitant treatments for depression, she continued. “For example, diet, sleep interference or disturbance, pain, psychotherapy or other modalities can contribute to depression. When one has a chronic illness that frequently requires multiple medications, many with side effects, and other lifestyle complaints, it may be difficult to become more physically active when you just do not feel well. Thus, a comprehensive and individualized approach may be another strategy to help these patients,” Dr. Ramsey-Goldman recommended. Nevertheless, the screening tools in the study by Dr. Patterson and colleagues could help identify patients who may need additional services for optimizing their health, either in a busy clinic setting or for large research studies, she suggested. Impact of exercise on RA patients In future research, Dr. Patterson hopes to explore how physical activity affects biological and inflammatory pathways in people with autoimmune conditions such as lupus and RA. “I’m currently working on a study to evaluate gene expression profiles from blood samples of RA patients. We are using this approach to determine whether there are differences in inflammatory signaling in RA patients who are active versus inactive, and plan to apply similar methods to investigate the biological effects of physical activity in people with lupus.” Dr. Patterson and coauthors had no financial disclosures. Dr. Ramsey-Goldman is leading a clinical trial on two different coaching approaches for helping lupus patients deal with lifestyle-related complaints. A control group will receive phone calls relating to SLE self-management education, whereas an intervention group will receive coaching on physical activity and nutrition.