The Effect of Everyday Discrimination on Systemic Lupus Erythematosus Disease Activity and Mental Health Outcomes

Systemic lupus erythematosus (SLE) disproportionately affects racial and ethnic minority populations in the United States. Though discrimination is linked to worse SLE outcomes, the mechanisms of this association remain underexplored. Among a multiracial, multiethnic cohort with SLE, we explored relationships between discrimination and patient-reported outcomes (PROs) and if mental health affects these relationships.

We analyzed data from the California Lupus Epidemiology Study, comprising Asian (31%), Black (10%), Hispanic (24%), and White (34%) participants (N = 245). Participants completed the Everyday Discrimination Scale (EDS) and the following PROs: Systemic Lupus Activity Questionnaire (SLAQ), Patient-Reported Outcome Measurement Information System (PROMIS) Pain Interference and Fatigue scales, 8-item Patient Health Questionnaire (PHQ-8) for depression and 7-item Generalized Anxiety Disorder (GAD-7) for anxiety. Multivariable linear regressions modeled associations between discrimination and PROs. Mediation analyses evaluated if depression or anxiety mediated associations between discrimination and SLAQ, pain, or fatigue.

EDS scores were highest among Black and Asian participants. Among multivariable models, higher discrimination was associated with worse SLAQ (β 0.25, P < 0.001), PHQ-8 (β 0.21, P < 0.001), GAD-7 (β 0.27, P < 0.001), pain (β 0.24, P = 0.01), and fatigue (β 0.30, P = 0.007). By racial and ethnic subgroups, discrimination was significantly associated with higher SLAQ among Black and Asian participants. Discrimination was no longer significantly associated with SLAQ, pain, or fatigue after adjusting for PHQ-8 or GAD-7.

In this diverse SLE cohort, discrimination was associated with greater patient-reported disease activity, pain, fatigue, depression, and anxiety. Mediation analyses suggest that mental health mediates the relationship between discrimination and PROs. These results highlight the effect of discrimination as a psychosocial stressor on disease outcome variables.