Elsevier

Joint Bone Spine

Volume 83, Issue 6, December 2016, Pages 681-685
Joint Bone Spine

Original article
Sicca symptoms are associated with similar fatigue, anxiety, depression, and quality-of-life impairments in patients with and without primary Sjögren's syndrome

https://doi.org/10.1016/j.jbspin.2015.10.005Get rights and content

Abstract

Objective

To compare quality of life (QoL), depression, anxiety, and fatigue in prospectively included patients with primary Sjögren's syndrome (pSS) or with sicca but no diagnosis of Sjögren's syndrome.

Methods

Patients undergoing a multidisciplinary evaluation at a single university center in Brest, France, for suspected pSS and having sicca symptoms were included prospectively between November 2006 and December 2013. The same standardized investigations were performed in all patients. pSS and sicca not due to pSS diagnoses were based on evaluating physician opinion. Each patient completed three validated questionnaires on QoL (SF-36), fatigue (MFI), depression and anxiety (HADS).

Results

Of the 95 included patients, 55 (57.9%) had pSS and 40 (42.1%) had sicca without pSS. Gender distribution, age, disease duration, and sicca symptoms were similar in the two groups. The pSS group had a significantly higher proportion of patients with abnormal objective tests for dryness (Schirmer's test and salivary flow rate). The SF-36, HADS, and MFI scores were similarly altered in the two groups. Anxiety was more common than depression in both groups. The most affected domains were vitality in the SF-36 and general/physical fatigue in the MFI. Extraglandular systemic involvement was not a major determinant of QoL alteration in patients with pSS.

Conclusions

Sicca symptoms are associated with severe alterations in SF-36, HADS, and MFI scores regardless of objective test abnormalities and pSS diagnosis. Anxiety is more common than depression and should be taken into account when managing all patients with sicca symptoms.

Introduction

Primary Sjögren's syndrome (pSS) is a chronic autoimmune disorder that decreases the water content of salivary and lacrimal gland secretions, thereby inducing dryness of the mouth (xerostomia) and eyes (keratoconjunctivitis sicca). Chronic lymphocytic infiltration of the affected glands is the histological hallmark of pSS. A wide variety of clinical manifestations, including neurological disorders [1], may develop, and autoantibodies may be produced. The prevalence of pSS is debated in the literature [2] and a recent meta-analysis reported a global worldwide prevalence of 0.06% [3] and 0.04% when taking into account only population-based studies performed in Europe [4]. Adult women are predominantly affected. In addition to disabling symptoms related to the oral and ocular dryness, pSS causes fatigue [5], [6], which severely impairs quality of life (QoL) [7], [8]. Diffuse pain and fibromyalgia are present in pSS patients [9], with a frequency similar to that seen in systemic lupus erythematosus (SLE) [6]. None of these symptoms are specific of pSS and the prevalence of dry eye and/or dry mouth symptoms varies from 5% to more than 30% depending on the population studied [10]. They are particularly common in elderly individuals, with a prevalence of dry eye or dry mouth of up to 27% after 65 years [11], [12]. Thus, pSS accounts for only a small part of the patients complaining from oral or ocular dryness. Objective oral and ocular dryness without pSS is known as Dry Eyes and Mouth Syndrome (DEMS) or Sicca, Asthenia, and Polyalgia Syndrome (SAPS) [13], [14].

Most patients with pSS report dryness-related discomfort and severe fatigue responsible for QoL impairments, depression, and anxiety. Abnormalities in several QoL indexes have been reported in patients with pSS [15], [16], [17]. The 36-item Short Form Health Survey (SF-36) is widely used to assess QoL in patients with pSS. The fatigue frequently reported by the patients and used as an inclusion criteria for therapeutic trials of rituximab [18], [19] can be easily self-evaluated using a visual analog scale (VAS). However, specific tools have been validated, such as the Multidimensional Fatigue Inventory (MFI). In patients with pSS, studies have shown fatigue on all MFI dimensions [5], [20]. Depression and anxiety can also be assessed using the validated Hospital Anxiety and Depression Scale (HADS). Two studies indicated that depression and anxiety were more common in patients with pSS than in healthy controls or patients with rheumatoid arthritis [17], [21].

Sicca syndrome without pSS can induce psychological disturbances consisting chiefly in anxiety and depression, which in turn adversely affect QoL [22]. Very few studies have compared QoL, fatigue, anxiety, and depression in patients with pSS and in patients with sicca syndrome but no pSS [7], [23], [24], [25].

Here, our objective was to compare QoL, fatigue, anxiety, and depression in patients with sicca syndrome with or without pSS. To this end, we used validated tools to assess patients with suspected pSS included in the Brittany cohort.

Section snippets

Study population

Between November 2006 and December 2013, 241 patients with suspected pSS were included prospectively in the single-center Brittany cohort. The same standardized investigations were performed in all patients. Inclusion criteria were subjective oral and/or ocular dryness, recurrent or bilateral parotid gland swelling, and/or extraglandular symptoms or laboratory abnormalities suggesting pSS.

Written informed consent was obtained from all participants before inclusion. The study was conducted in

Patient characteristics (Table 1)

Of the 241 patients, 95 (39.4%) completed the questionnaires, including 55 (57.9%) with pSS and 40 (42.1%) without pSS. Among the 55 patients with pSS according to the physician, 48 (87%) fulfilled AECG criteria, compared to none of the patients without pSS. Concordance between AECG criteria and the physician diagnosis was good (kappa coefficient = 0.85). Diagnoses in the group without pSS were idiopathic sicca syndrome (n = 26), connective tissue diseases (n = 8; SLE, n = 3; rheumatoid arthritis, n = 2;

Discussion

Oral and ocular dryness is associated with QoL impairments in both patients with autoimmune disorders and those with idiopathic sicca [7], [25]. We compared QoL, fatigue, depression, and anxiety in patients referred to a specialized center for suspected pSS. The patients completed three validated questionnaires. Alterations in the results of all three questionnaires were found in the groups with and without a diagnosis of pSS.

The study participation rate of only 39.4% may be related to several

Disclosure of interest

The authors declare that they have no competing interest.

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