Background/Purpose . Systemic lupus erythematosus (SLE) is a chronic disease that disproportionately strikes black women. Depression is a potentially debilitating co-morbidity that affects 15-75% of SLE patients and is more severe and unrecognized among blacks compared to whites. Data from a mostly white SLE cohort suggests an association between depression and high emergency department (ED) use. However, no study has assessed the impact of depression on healthcare utilization among patients representative of the SLE population in the Southeastern United States (US). We examined the relationship between depression and healthcare utilization in a predominantly black SLE cohort, expecting depression to be associated with increased ED and inpatient usage.

Methods . Georgians Organized Against Lupus (GOAL) is a longitudinal cohort of validated SLE patients largely drawn from a population-based lupus registry established in Atlanta, Georgia. Annual patient-reported surveys furnish data on demographics, disease outcomes and healthcare utilization from GOAL participants, of whom 78% are black, 35% live under the Federal Poverty Level and 11% are uninsured. All cases fulfilled at least 4 of the American College of Rheumatology (ACR) Classification Criteria for SLE, or 3 ACR criteria with a final diagnosis of SLE by the attending rheumatologist. We used data from the 2013-14 annual survey to examine the relationship between depression, as assessed by the 9-item Patient Health Questionnaire (PHQ-9), and utilization of inpatient and ED resources in the past year.

Results . 566 participants were included in this analysis. Nearly half (46%) of the GOAL participants had visited the ED, while 27% had been admitted to the hospital. Among those with depression (PHQ-9 score =/>10), 58% had visited the ED, as compared to 41% of those with a score <10 (p=0.0001). Patients with and without depression had a mean of 1.7 ED visits and 1.1 ED visits annually, respectively (p<0.0001).

Conclusion . A greater proportion of depressed SLE patients had accessed ED resources for care. In addition, increasing depression severity was associated with higher frequency of ED visits. We did not find an association between depression and hospitalization as was hypothesized, suggesting that depressed patients who visited the ED did not meet inpatient admission criteria. Our data gesture toward deficiencies in the routine care of depressed SLE patients that may contribute to avoidable ED utilization, and suggest the potential utility of depression screening modalities in the assessment of SLE patients who resort to the ED for care. Further research is needed to determine whether demographic factors have an effect on the association between depression and ED visits and whether increased ED utilization may be due to subpar quality, coordination or type of care for those with depressive symptoms.