Neuropsychiatric events in systemic lupus erythematosus: A longitudinal analysis of outcomes in an international inception cohort using a multistate model approach

Research output: Contribution to journalArticle


Objectives: Using a reversible multistate model, we prospectively examined neuropsychiatric (NP) events for attribution, outcome and association with health-related quality of life (HRQoL), in an international, inception cohort of systemic lupus erythematosus (SLE) patients. Methods: Annual assessments for 19 NP events attributed to SLE and non-SLE causes, physician determination of outcome and patient HRQoL (short-form (SF)-36 scores) were measured. Time-to-event analysis and multistate modelling examined the onset, recurrence and transition between NP states. Results: NP events occurred in 955/1827 (52.3%) patients and 592/1910 (31.0%) unique events were attributed to SLE. In the first 2 years of follow-up the relative risk (95% CI) for SLE NP events was 6.16 (4.96, 7.66) and non-SLE events was 4.66 (4.01, 5.43) compared with thereafter. Patients without SLE NP events at initial assessment had a 74% probability of being event free at 10 years. For non-SLE NP events the estimate was 48%. The majority of NP events resolved over 10 years but mortality was higher in patients with NP events attributed to SLE (16%) versus patients with no NPSLE events (6%) while the rate was comparable in patients with non-SLE NP events (7%) compared with patients with no non-SLE events (6%). Patients with NP events had lower SF-36 summary scores compared with those without NP events and resolved NP states (p<0.001). Conclusions: NP events occur most frequently around the diagnosis of SLE. Although the majority of events resolve they are associated with reduced HRQoL and excess mortality. Multistate modelling is well suited for the assessment of NP events in SLE.


  • John G. Hanly
  • Murray B. Urowitz
  • Caroline Gordon
  • Sang Cheol Bae
  • Juanita Romero-Diaz
  • Jorge Sanchez-Guerrero
  • Sasha Bernatsky
  • Ann E. Clarke
  • Daniel J. Wallace
  • David A. Isenberg
  • Anisur Rahman
  • Joan T. Merrill
  • Paul R. Fortin
  • Dafna D. Gladman
  • Ian N. Bruce
  • Michelle Petri
  • Ellen M. Ginzler
  • Mary Anne Dooley
  • Rosalind Ramsey-Goldman
  • Susan Manzi
  • Graciela S. Alarcón
  • Ronald F. Van Vollenhoven
  • Cynthia Aranow
  • Meggan MacKay
  • Guillermo Ruiz-Irastorza
  • Sam Lim
  • Murat Inanc
  • Kenneth C. Kalunian
  • Søren Jacobsen
  • Christine A. Peschken
  • Diane L. Kamen
  • Anca Askanase
  • Vernon Farewell
External organisations
  • Dalhousie University
  • University of Toronto
  • University of Birmingham
  • Hanyang University
  • McGill University
  • University of Calgary
  • University of California, Los Angeles
  • Oklahoma Medical Research Foundation
  • Laval University
  • University of Manchester
  • Johns Hopkins University School of Medicine
  • State University of New York Downstate Medical Center
  • University of North Carolina
  • Northwestern University Feinberg School of Medicine
  • Allegheny Health Network
  • University of Alabama
  • Feinstein Institute for Medical Research
  • University of the Basque Country
  • Emory University
  • University of California, San Diego
  • Copenhagen University Hospital
  • University of Manitoba
  • Medical University of South Carolina
  • University of Cambridge
  • Instituto Nacional de Ciencias Médicas y Nutrición
  • Toronto Western Hospital
  • University College London
  • Manchester Academic Health Science Centre
  • Academic Medical Center of University of Amsterdam (AMC)
  • Istanbul University
  • NYU Hospital for Joint Diseases
Research areas and keywords

Subject classification (UKÄ) – MANDATORY

  • Rheumatology and Autoimmunity


  • autoimmune diseases, epidemiology, outcomes research, systemic lupus erythematosus
Original languageEnglish
Pages (from-to)356-362
Number of pages7
JournalAnnals of the Rheumatic Diseases
Issue number3
Early online date2020 Jan 8
Publication statusE-pub ahead of print - 2020 Jan 8
Publication categoryResearch