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Year : 2019  |  Volume : 8  |  Issue : 3  |  Page : 168-173

Anxiety, depression, and suicidal ideations among patients with dermatological problems

1 Department of Dermatology, ARV Skin Clinic, Jammu, Jammu and Kashmir, India
2 Department of Psychiatry, Vardhaman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
3 Department of Dermatology, Lady Hardinge Medical College, New Delhi, India

Date of Submission27-Nov-2017
Date of Acceptance07-Jun-2019
Date of Web Publication05-Aug-2019

Correspondence Address:
Dr. Shaily Mina
Department of Psychiatry, Vardhaman Mahavir Medical College and Safdarjung Hospital, New Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijhas.IJHAS_153_17

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BACKGROUND: High comorbidity is seen in psychiatric illness and dermatological problems ranging between 21% and 43%, which could be due to cosmetic impact/body image perception/disfigurement due to disease per se; majority of the cases go undetected due to overshadowing of mental illness by physical ailment, stigma, or improper assessment. The present research attempted to evaluate the comorbidity of anxiety, depression, and suicidal ideations among dermatological conditions
METHODS: A population-based cross-sectional study with consecutive sampling was conducted in the outpatient department of a dermatology clinic. The Primary Care Evaluation of Mental Disorders (Patient Health Questionnaire-9 and Generalized Anxiety Disorder- 7) was used to assess the presence of psychiatric symptoms in these patients.
RESULTS: A total of 1076 patients were included in the study, with age ranging between 10 and 82 years. Females had significantly more depression, anxiety, and suicidal ideation among individuals suffering from dermatitis. Males had significantly more anxiety among individuals suffering from lichen simplex chronicus. Females had significantly more depression and suicidal ideation among individuals suffering from hair disorders. Overall, 22% of individuals had suicidal ideation, of which 4.2% had active suicidal ideations.
CONCLUSION: Significant active suicidal ideations were observed among individual dermatological conditions. Female reported having more depressive symptoms with no gender difference in anxiety disorder.

Keywords: Anxiety, depression, dermatological problems, psychiatric comorbidity, suicide

How to cite this article:
Jabeen MZ, Mina S, Chander R. Anxiety, depression, and suicidal ideations among patients with dermatological problems. Int J Health Allied Sci 2019;8:168-73

How to cite this URL:
Jabeen MZ, Mina S, Chander R. Anxiety, depression, and suicidal ideations among patients with dermatological problems. Int J Health Allied Sci [serial online] 2019 [cited 2022 May 17];8:168-73. Available from: https://www.ijhas.in/text.asp?2019/8/3/168/263941

  Introduction Top

In the substantial literature concerning skin disease and psychological morbidity, it has been observed that skin diseases are strongly linked with psychological problems and illness.[1] The incidence of psychiatric disorders among dermatological patients is estimated in range of 30%–60%.[2] Studies have linked chronic illnesses such as cancer, diabetes, hypertension, lung disease, renal disease, neurological disease, and dermatological illness with psychological distress in the form of adverse adaptive situation affecting coping skills of the patient, emotional disturbance, and in others, full-blown psychiatric illness.[3] Among dermatological conditions, concomitant psychiatric illness is predominantly observed in patients with acne, pruritus, urticaria, alopecia, psoriasis, or vitiligo.[4] Among these comorbidities, it is often difficult to comment whether skin disease causes psychiatric illness or vice versa. Skin conditions commonly associated with psychosomatic responses are psoriasis, atopic dermatitis, and chronic idiopathic urticaria. Psycho-neuro-immunological factor is responsible for the causation of these responses.[5] Neurotransmitter serotonin has also been linked with skin disorders. It has pro-inflammatory, vasodilatation, and pruritic action on the skin. Stress induced by skin problem is also linked with serotonin receptor.[6]

On assessment of the risk factors causing the skin diseases, psychological stress has been found to play a significant role as a precipitating or aggravating factor.[7] Stress is proposed to be mediated by the nervous system including autonomic nervous system, immune system, and hormonal system.[8] The commonly associated psychiatric comorbidities are depression, anxiety, and many subsyndromal psychiatric illnesses (stigma, shame, embarrassment, and decrements in self-image) which are difficult to detect through the existing criteria in psychiatric classifications.[9] Due to the combined effect of both subsyndromal and severe physical symptoms, psychiatric symptoms comorbid with skin disorders go undetected.[10] the prevalence of self-harm is markedly increasing due to the chronicity of illness and body image deformities in skin disorder patients.[11] A study by Humphreys et al. reported 341 patients with skin problems and found suicidal attempt among more than half of the study group, of which 15% committed suicide.[12] Gupta et al. also reported a higher prevalence of depression and suicidal ideations in patients with skin disorders, especially psoriasis.[13] Picardi et al. assessed high-risk factors among dermatological patients for suicide which were women with high psychological distress and impaired social functioning.[14]

Lack of awareness of psychiatric illness, despite being present frequently among dermatologists, further delays proper diagnosis and treatment, in turn, increasing the burden of disease and deteriorating the quality of life of the patient. Therefore, through this study, we would like to acknowledge the significance of biopsychological approach which takes into account the psychological (e.g., psychiatry comorbidity such as major depression and the impact of skin disorder on the psychological aspects of quality of life) and social (e.g., impact upon social and occupational functioning) factors, in addition to the primary dermatologic factors, in the management of the dermatological disease which would aid in having early diagnosis and proper treatment.[15]

  Methods Top

This cross-sectional study was done in an outpatient setting in the department of dermatology in a tertiary care hospital. The study group included patients attending general dermatology, vitiligo clinic, psoriasis clinic, sexually transmitted disease (STD) clinic, and leprosy clinic. The study was spread over a period of 8 months. Those giving the consent, a brief semi-structured pro forma for collecting demographic and clinical information, were used. The study was initiated after the due permission from the institution. A total of 1076 patients were enrolled in the study by consecutive sampling method. The Primary Care Evaluation of Mental Disorders (PRIME-MD) was used to assess the presence of psychiatric symptoms in these patients. Inclusion criteria were individuals not suffering from chronic illness other than skin disease, individuals with no history of psychiatric illness, and individuals with no apparent life stress other than the skin disease.

The PRIME-MD is an instrument developed and validated in the early 1990s to efficiently diagnose five of the most common types of mental disorders presenting in medical populations: depressive, anxiety, somatoform, alcohol, and eating disorders. Patients first completed a one-page 27-item screener and for those disorders, for which they screened positive, were asked additional questions by the clinician using a structured interview guide. However, this two-stage process took an average of 5–6 min of clinician time in patients without a mental disorder diagnosis and 11–12 min in patients with a diagnosis. This proved to be a barrier to use given the competing demands in busy clinical practice settings. To overcome this barrier, individuals' screening tools for each psychiatric illness were assessed for their validation.

Through various studies, the Patient Health Questionnaire (PHQ-9) and the Generalized Anxiety Disorder (GAD-7) have been validated to effectively assessing depression and anxiety disorders when applied alone instead of the whole PRIME-MD. In our study, we have used these two components of PRIME MD, as these two psychiatric illnesses were found concurrently with skin disorders.[16]

PHQ-9 total score for the nine items ranges from 0 to 27. This is calculated by assigning scores of 0, 1, 2, and 3, to the response categories of not at all, several days, more than half the days, and nearly every day, respectively. Scores of 5, 10, 15, and 20 represent cut points for mild, moderate, moderately severe, and severe depression, respectively.

GAD-7 is calculated by assigning scores of 0, 1, 2, and 3, to the response categories of not at all, several days, more than half the days, and nearly every day, respectively. GAD-7 total score for the seven items ranges from 0 to 21. Scores of 5, 10, and 15 represent cut points for mild, moderate, and severe anxiety, respectively.[17]

The data were imputed and analyzed using SPSS version 17.0 (UNICOM Global and IBM). Descriptive analysis was done for the sociodemographic profile, and independent sample t-test was carried out to find in between-group differences for antepartum and postpartum females. The level of statistical significance was kept at P < 0.05.

  Results Top

A total of 1076 patients were included in the study, with age ranging between 10 and 82 years. They presented with illness duration ranging between 0.25 and 252 months [Table 1].
Table 1: Age and illness duration distribution

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The details of sociodemographic profile which included gender, education, and occupation are mentioned in [Table 2]. Of the 1076 patients included, majority of the patients presented with acne vulgaris (21.4%), followed by melasma (8.4%) and dermatitis (7.5%). Details of other skin disorders are mentioned in [Table 2]. More than half of the patients had illness persisting for more than 6 months (56%).
Table 2: Sociodemographic profile and diagnosis

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Overall, 22% of individuals had suicidal ideation, of which 4.2% had active suicidal ideations. About 1.2% of patients with dermatitis, 3.8% of patients with hair disorder (alopecia), 7.8% of patients with melasma, 7.1% of patients with leprosy, 9.1% of patients with lichen simplex chronicus, 5.7% of patients of acne, 8.3% of patients of STD, and 7.1% of patients with psoriasis had active suicidal ideations. Most diagnostic groups consisted of only a few patients, and this severely limits the precision of these prevalence estimates and does not allow meaningful comparisons between groups.

Females had significantly more depression, anxiety, and suicidal ideation than males among individuals suffering from dermatitis (P = 0.04, P = 0.05, and P = 0.04, respectively). Males had significantly more anxiety than females among individuals suffering from lichen simplex chronicus (P = 0.03). Females had significantly more depression and suicidal ideation than males among individuals suffering from hair disorders (P = 0.04). There were no significant gender differences in depression, anxiety, or suicidal ideation for individuals suffering from any other dermatological disorders. According to the PHQ-9, depression scores ranged from 0 to 27 [Table 3] and [Figure 1]. As mentioned in [Table 4], almost half of the participants reported depressive symptoms (51.7%). According to the GAD-7, anxiety score ranges from 0 to 21 [Figure 2]. As mentioned in [Table 4], again, nearly half of the participants had anxiety symptoms (45.5%).
Table 3: Gender comparison for depression, anxiety, and suicidal ideation

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Figure 1: Pie chart representing the severity of depression in the study population

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Table 4: Depression and anxiety severity distribution

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Figure 2: Pie chart representing the severity of anxiety in the study population

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  Discussion Top

Varied presentation was noted in patients presenting to dermatologists depending up the duration, site, and severity of the condition. The profile of the present study was young, educated female having skin lesions for >6 months.

In the present study, no significant difference was observed in education, occupation, and chronicity of the dermatological illness, and more females participated in the study (58.7% vs. 41.3%). It was also noted that participants were more educated (illiterate and primary school vs. secondary school education and above, 25.3% vs. 45.4%) and of younger age group (mean age: 30.81 years). These findings were replication of the study by Sampogna et al. with exception of no significance in gender.[18] A comparatively higher proportion of females were expected as females are more concerned regarding their external appearance due to societal factors.

The mean age of the participants was comparable to the studies done so far, with a mean age of 30.8 ± 13.14 in a study by Seyhan et al. and 36 years in the present study.[19] Acne and atopic dermatitis were the most common presentations in the present study duplicating the findings of existing literature.[20]

Woodruff et al. reported the prevalence of 30%–40% for the psychiatric problems among the dermatology patients attending their clinic, and in the current study also, the higher percentage was seen; nearly half of the patients reported psychiatric problems.[21] Previous research on psychiatric co-morbidities in skin disorders have also reported a higher percentage of comorbidity, similar to the present study. Studies by Hughes et al. reported 30% and Wessely et al. 40.2% patients having psychiatric illness.[22],[23] In the study by Gupta et al., almost one-third of patients had psychiatric illness.[24]

Comparable result was observed in both the present study and a study by Wancata et al. about the fact that depression tends to be recognized more frequently in comparison to anxiety whereas differed from that of Picardi et al. who stated just opposite of the above statement.[25],[26] These numerals further confirm the findings of other studies reporting the highest prevalence of depression, followed by anxiety than other psychiatric illness in dermatology patients.[22],[24]

In both the present study and a study by Maan et al., overall, females had higher depressive symptoms as compared to their male counterpart (P = 0.009) whereas the findings were dissimilar in anxiety scoring where no significant difference was found in the present study.[27] The present study emphasizes a higher prevalence of psychiatric illness in females in comparison to males, and the findings were similar to the study by Seyhan et al.[19] Reason for the higher prevalence of psychiatric illness in females in our community could be due to society accepting fare and better-looking females more, leading to rejection of those disfigured by any kind of dermatological conditions, in turn, increasing the burden of the disease. Another reason could be that males tend to hide their emotions, thinking that they would be considered weak by expressing their true feelings.

Skin diseases are among the most widespread health problems universally associated with a substantial burden that encompasses psychological, social, and financial consequences of the skin disease on the patients, their families, and society. The result of such burden could be disastrous in the form of increased rate of suicides if lack of proper attention is there. Therefore, the present study attempted to assess the suicidal ideation and find significant depressive symptoms and suicidal ideations in dermatological conditions specifically dermatitis and alopecia. Higher suicidal ideation was reported in patients suffering from acne and psoriasis in comparison to other dermatological conditions with overall prevalence to be 4%. The above findings were in concordance with the study by Gupta et al. (1998).[13] As no extensive studies have been conducted so far comparing psychiatric comorbidity among dermatological conditions, therefore it was difficult to compare all the conditions included in the present study, but among those which have been studied, similarity was found for acne (5.6% vs. 5.7%) and dissimilarity for psoriasis (7.1% vs. 2.5%), dermatitis (1.2% vs. 2.1%), and alopecia (3.8% vs. 0) for the presence of the active suicidal ideations. Overall, these findings could be a pointer that there can be a significant impact of dermatological conditions on the perception of once body image, in turn, causing psychological trauma of adjusting to cosmetic problems imposed by dermatological condition, especially in the younger age group. These findings suggest the need for thorough assessment of the impact of dermatological conditions on body image in the context of the patients' life and developmental stage. When compared with studies of suicidal ideations on general medical patients, rates were higher for dermatological patients. The prevalence rates of acute suicidal ideation were 3.3%,[28] 2.6%,[29] and 2.4%[30] in three of the studies, whereas in our studies, it was 4%. These findings were similar to the study by Gupta et al.[13]

The difference was noted between the present study and a study by Picardi et al.[26] in depression severity distribution; nearly one-third of the participants were free from psychiatric morbidity in comparison to nearly half in our study, while on comparison of anxiety severity, an almost similar result was observed (45.5% in our study vs. 58%).

Our study had certain limitations as the measurement of suicidal ideation was limited as a result of the use of only one question to assess it. Furthermore, the cross-sectional design prevented causal inferences. We recommend that larger prospective studies should be carried out to detect the disease burden with sociopsychological consequences in this particular subgroup of patients to provide better preventive and therapeutic services.

  Conclusion Top

Overall females expressed more depressive symptoms in comparison to males with no significant gender difference in expression of anxiety symptoms. Significant active suicidal ideations were observed among individual dermatological conditions which signify the need for further studies to assess the impact of dermatological problems on patient's quality of life and also to assess the psychiatric co-morbidity among patients with skin problems to hasten the treatment outcome.

Present study attempts to highlight that active Suicidal ideation was noticed in some of the dermatological conditions (life threatening psychiatric illness) which were even higher in comparison to that of general medical patients and could have been missed if not properly screened for the presence of the psychiatric illness. Therefore there is an emergent need for training the medical doctors to screen the co-morbid psychiatric illness in chronic medical condition.

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Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4]


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