|Year : 2017 | Volume
| Issue : 1 | Page : 50-54
Depression and suicidal ideation in patients with acne, psoriasis, and alopecia areata
Amit Jagtiani1, Parmil Nishal2, Purshottam Jangid1, Sujata Sethi1, Surabhi Dayal3, Anu Kapoor3
1 Department of Psychiatry, Pt. B.D. Sharma PGIMS, Rohtak, Haryana, India
2 Assistant Professor, Department of Dermatology and Venereology, World College of Medical Sciences and Research and Hospital, Jhajjar, Haryana, India
3 Department of Dermatology, Pt. B.D. Sharma PGIMS, Rohtak, Haryana, India
|Date of Web Publication||14-Jul-2017|
House No. 82, Sector 9, Sikandra, Agra - 282 007, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Background: Depression is a common yet often underdiagnosed psychiatric comorbidity in patients with chronic skin disorders. Presence of depression can be an aggravating and perpetuating factor for these conditions. Aim: To determine the frequency of depressive disorder and suicidal ideation in adult dermatology outpatients with acne, psoriasis, and alopecia areata and also to determine the correlation between severity and duration of the skin disease with the severity of depressive disorder. Materials and Methods: A total of 174 new patients attending the dermatology outdoor clinic of our hospital diagnosed with acne, psoriasis, and alopecia areata were assessed by the psychiatrist for comorbid depressive disorder and suicidal ideations using Beck Depression Inventory (BDI) and Beck Scale for Suicide Ideation, respectively. Results: Depressive disorder was found in 8.8%, 26.8%, and 13.2% of patients with acne vulgaris, psoriasis, and alopecia areata, respectively, whereas suicidal ideation was found in 1.2%, 5.4%, and 2.6% patients, respectively. Significant correlation of BDI score was found with the severity of psoriasis and alopecia areata and with the duration of alopecia areata. Conclusion: Diagnosing and treating the hidden psychiatric comorbidity in patients with dermatological illnesses can help achieve better control of dermatological disorder and provide holistic care to such patients.
Keywords: Acne, alopecia areata, depression, psoriasis, suicidal ideation
|How to cite this article:|
Jagtiani A, Nishal P, Jangid P, Sethi S, Dayal S, Kapoor A. Depression and suicidal ideation in patients with acne, psoriasis, and alopecia areata. J Mental Health Hum Behav 2017;22:50-4
|How to cite this URL:|
Jagtiani A, Nishal P, Jangid P, Sethi S, Dayal S, Kapoor A. Depression and suicidal ideation in patients with acne, psoriasis, and alopecia areata. J Mental Health Hum Behav [serial online] 2017 [cited 2022 Dec 7];22:50-4. Available from: https://www.jmhhb.org/text.asp?2017/22/1/50/210700
| Introduction|| |
Skin is the largest and the most visible organ of our body. It determines our appearance and plays a major role in sexual attractiveness and self-esteem.
Psychiatric illnesses are highly prevalent among patients with dermatological problems. The frequency of psychiatric diseases in the patients presenting to dermatology clinics has been reported to be 25%–43%., Comorbidity of depression and dermatological disorders is around 30%. Stress may even aggravate the cutaneous lesions in several patients. Suicidal ideation is not rare among dermatology patients, studies have reported a frequency of 5%–10% in adult dermatology outpatient clinics.,
Unfortunately, for most of these patients, their psychiatric diagnosis remains unrecognized and untreated. Due to stigma of psychiatric illnesses, patients prefer the treatment of their dermatological diseases rather than their psychiatric disorders. This results in immense psychic and somatic suffering, social and occupational dysfunction, poor academic performance, drug abuse, suicide, homicide, aggression, and an increase in mortality. Many studies have shown that these disorders have an important negative impact on the quality of life., Comorbid depression may also adversely affect the management of dermatological disorder as it may lead to onset or the aggravation of skin lesions  and poor drug compliance. Hence, effective management of dermatological illnesses often requires combined evaluation and management of emotional factors.
There is a plethora of data in Western literature; however, there is a dearth of Indian studies on the frequency of depression and suicidal ideation in dermatology patients. Hence, we conducted this study with the aim of determining the frequency of depression and suicidal ideation in adult dermatology outpatients with acne, psoriasis, and alopecia areata, and also to determine the correlation between severity and duration of the skin disease with the severity of depression.
| Materials and Methods|| |
This cross-sectional study was carried out at a tertiary care hospital of North India which provides both outdoor and indoor services to the people of the region. The plan of the study was approved by the Institute's Ethical Committee.
A total of 174 new patients attending the dermatology outdoor clinic for the first time and fulfilling the inclusion criteria were assessed by the psychiatrist for comorbid depression and suicidal ideation as per the International Classification of Diseases-10th Revision (ICD-10) diagnostic guidelines.
Participants were included if they: (i) were 13–50 years of age; (ii) were clinically diagnosed as having acne vulgaris, psoriasis vulgaris, or alopecia areata; (iii) were not taking any treatment for their dermatological illness in the past 1 month; (iv) suffered from no other somatic disease; (v) had no history of any psychiatric illness before developing the skin disease; (vi) had no history of any substance abuse; (vii) had no ongoing psychosocial problems in family (as reported by the patient); (viii) had no family history of psychiatric illness; and (ix) provided written informed consent.
- The severity of dermatological condition was assessed using Indian Acne Alliance grading for acne, Psoriasis Area Severity Index score  for psoriasis, and the Severity of Alopecia Tool score  for alopecia areata
- The diagnosis of depressive disorder was made according to ICD-10 criteria by a semi-structured clinical interview. The severity of depression was assessed using Beck Depression Inventory (BDI). BDI is a 21-question multiple-choice self-report inventory, one of the most widely used instruments for measuring the severity of depression. BDI contains 21 questions, each answer being scored on a scale value of 0–3. The cutoffs used are 0–13: minimal depression; 14–19: mild depression; 20–28: moderate depression; and 29–63: severe depression.
The patients were screened for the presence of suicidal ideation using the first five items of Beck Scale for Suicide Ideation (BSSI). BSSI is a 21-item, interviewer-administered rating scale that measures the current intensity of patients' specific attitudes, behaviors, and plans to commit suicide on the day of the interview. Each item consists of three options graded according to suicidal intensity on a 3-point scale ranging from 0 to 2. The SSI consists of five screening items. Three items assess the wish to live or the wish to die and two items assess the desire to attempt suicide. The study participants were only screened for suicidal ideation so as to determine the frequency of suicidal ideation in each study group. Those patients that were found to have depression or suicidal ideation were offered treatment. Although BSSI was developed for use in adults, it has been found to be a reliable and a valid measure of suicidal ideation for depressed adolescents.
Somatic illness was ruled out by taking a detailed history followed by a complete physical examination and routine laboratory tests such as complete blood counts, liver function test, and renal function test. Information regarding past or family history of psychiatric illness and psychosocial problems in the family was collected from the patients only as majority of patients had come alone for seeking treatment for their dermatological illness in the outpatient clinic.
Correlation between different parameters was performed using Pearson's rank correlation coefficient. Statistical analysis was performed with the aid of the Statistical Product and Service Solutions computer program (SPSS for Windows, Version 16.0. Chicago, SPSS Inc). P< 0.05 was considered statistically significant.
| Results|| |
Of the 174 enrolled patients, 80 patients had acne, 56 patients had psoriasis, and 38 patients had alopecia areata. [Table 1] depicts the sociodemographic characteristics of the patients. [Table 2] depicts clinical characteristics of the patients.
Correlation of severity of depression (BDI score) with dermatological disease severity was significant in psoriasis (Pearson correlation = 0.59, P= 0.000) and alopecia areata (Pearson's correlation = 0.47, P= 0.003) but not in acne vulgaris (Pearson's correlation = −0.10, P= 0.377) [Table 3] and [Figure 1], [Figure 2],[Figure 3]. Correlation of depression severity (BDI score) with duration of dermatological disease was found to be insignificant in all groups except alopecia areata, in which a statistically significant positive correlation was found (Pearson's correlation = 0.32; P= 0.046) [Table 3] and [Figure 4], [Figure 5], [Figure 6].
|Table 3: Correlation of depression severity (Beck Depression Inventory scores) with severity and duration of skin disease|
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|Figure 1: Scatter plot of severity of depression versus severity of acne|
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|Figure 2: Scatter plot of severity of depression versus severity of psoriasis|
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|Figure 3: Scatter plot of severity of depression versus severity of alopecia areata|
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|Figure 4: Scatter plot of severity of depression versus duration of acne vulgaris|
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|Figure 5: Scatter plot of severity of depression versus duration of psoriasis|
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|Figure 6: Scatter plot of severity of depression versus duration of alopecia areata|
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| Discussion|| |
This study examined the frequency of depression and suicidal ideation among the three groups of cosmetically disfiguring dermatological diseases - acne vulgaris, psoriasis, and alopecia areata. These illnesses present quite commonly in dermatology clinics of our hospital; hence, we chose them for the study. The mean age of patients with acne vulgaris was lower than the other three groups [Table 1] because acne has a peak incidence during adolescence.
The frequency of depression and suicidal ideation was 8.8% and 1.2% among acne vulgaris patients, 26.8% and 5.4% in psoriasis, and 13.2% and 2.6% in alopecia areata, respectively [Table 2]. Other studies have reported similar findings. Frequency of depression has been reported to be 9.7% and 25.6% in patients with acne, 22.3% and 30% in patients with psoriasis, and 16% and 25.5% in patients with alopecia areata. This highlights that depression is fairly common among these dermatological disorders. Other studies have reported higher rates of suicidal ideation than our study. Rehn et al. reported suicidal ideation in 14.5% acne patients. Gupta et al. reported death wishes in 9.7% and active suicidal ideation in 5.5% psoriasis patients. An Egyptian study  reported suicidal ideation to be present in 8% psoriasis and 8% alopecia areata patients. This difference could be due to different scales used to assess suicidality by different studies. The mean BDI scores as depicted in [Table 2] indicate that moderately severe depression was present in each of these groups.
A statistically significant positive correlation was noticed between the severity of psoriasis and alopecia areata with the severity of depression, but no significant correlation was found between severity of acne and severity of depression [Table 3] and [Figure 1], [Figure 2], [Figure 3]. Gupta and Gupta  reported high depression ratings in severely affected psoriasis inpatients and in patients with mild to moderate acne. Similarly, Aktan et al. and Rehn et al. also reported that severity of acne was not correlated with the depression severity scores. However, few studies have also found a positive relationship between severity of acne and severity of depression. Acne has a peak incidence during adolescence, a time when people are normally highly concerned with their appearance and body image. In some vulnerable adolescents, even mild acne could add to their existing psychological burden and result in severe depression. This explains the lack of a consistent correlation between acne severity and severity of depression scores in cross-sectional studies.
Although a statistically significant positive correlation between duration of alopecia areata and severity of depression was noticed, the same was not true for acne and psoriasis [Table 3] and [Figure 4], [Figure 5], [Figure 6]. Similar to our findings, Taner et al. also found no correlation between duration of psoriasis and severity of depression. Our findings are in contrast to those of Do et al. who reported depression scores to be significantly increased in long-persisted acne patients. Thus, in addition to severity of skin problem, its chronicity can be a factor contributing to depressive features.
Our study highlights the importance of recognizing comorbid depression and suicidality in cosmetically disfiguring dermatological conditions. The high visibility of skin diseases increases the likelihood of stigmatization. Skin diseases should be measured not only by the symptoms but also by their psychological and social impact. The collaboration of the dermatologist and psychiatrist in such diseases can enhance the quality of life of the patients. A dermatologist's lack of knowledge on the psychiatric comorbidity rates in dermatological diseases may delay the diagnosis of psychiatric condition and hinder the treatment. Dermatologists should be more sensitive about the possible psychiatric morbidity in their patients. Knowledge of mind–body interactions and interventions can help to improve patients' skin conditions and ultimately their quality of life. Counseling and psychotropic medications can benefit patients with depression or anxiety related to their skin problems, and consultation with a dermatologist, and in some cases, a psychiatrist can be beneficial.
Some of the limitations of our study are: (i) being a hospital-based study, the estimates of psychiatric comorbidity in dermatological patients could be falsely inflated (Berksonian bias); (ii) no prevalidated checklist was used to rule out ongoing psychosocial problems in the family.
| Conclusion|| |
Depression and suicidal ideation is common in patients with acne, psoriasis, and alopecia areata. Diagnosing and treating the hidden psychiatric comorbidity can help in achieving better control of dermatological disorder and providing holistic care to such patients. Physicians must apply the biopsychosocial model to skin diseases for better therapeutic alliance and treatment outcomes in patients.
The authors thank the following people for their contribution to the implementation of this study: Dr. V. K. Jain (general support as department chair), Dr. Raghu Gandhi (provided valuable suggestions for implementation of study), and Mr. Sanjay Tanwar (statistician).
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Porter J. The psychological effects of vitiligo: Response to impaired appearance. In: Hann SK, Nordlund JJ, editors. Vitiligo: A Monograph on the Basic and Clinical Science. 1st
ed. Oxford: Blackwell Science; 2000. p. 97-100.
Picardi A, Abeni D, Renzi C, Braga M, Puddu P, Pasquini P. Increased psychiatric morbidity in female outpatients with skin lesions on visible parts of the body. Acta Derm Venereol 2001;81:410-4.
Woodruff PW, Higgins EM, du Vivier AW, Wessely S. Psychiatric illness in patients referred to a dermatology-psychiatry clinic. Gen Hosp Psychiatry 1997;19:29-35.
Gupta MA, Gupta AK. Psychiatric and psychological co-morbidity in patients with dermatologic disorders: Epidemiology and management. Am J Clin Dermatol 2003;4:833-42.
Koo J, Lee CS. Pychotropic agents. In: Wolverton SE, editor. Comprehensive Dermatologic Drug Therapy. Philadelphia: WB Saunders Company; 2001. p. 402-22.
Picardi A, Mazzotti E, Pasquini P. Prevalence and correlates of suicidal ideation among patients with skin disease. J Am Acad Dermatol 2006;54:420-6.
Gupta MA, Gupta AK. Depression and suicidal ideation in dermatology patients with acne, alopecia areata, atopic dermatitis and psoriasis. Br J Dermatol 1998;139:846-50.
Gascón MR, Ribeiro CM, Bueno LM, Benute GR, Lucia MC, Rivitti EA, et al.
Prevalence of depression and anxiety disorders in hospitalized patients at the dermatology clinical ward of a university hospital. An Bras Dermatol 2012;87:403-7.
Pärna E, Aluoja A, Kingo K. Quality of life and emotional state in chronic skin disease. Acta Derm Venereol 2015;95:312-6.
Karelson M, Silm H, Kingo K. Quality of life and emotional state in vitiligo in an Estonian sample: Comparison with psoriasis and healthy controls. Acta Derm Venereol 2013;93:446-50.
Fried RG, Gupta MA, Gupta AK. Depression and skin disease. Dermatol Clin 2005;23:657-64.
DiMatteo MR, Lepper HS, Croghan TW. Depression is a risk factor for noncompliance with medical treatment: Meta-analysis of the effects of anxiety and depression on patient adherence. Arch Intern Med 2000;160:2101-7.
Tutakne MA, Chari KV. Acne, rosacea and perioral dermatitis. In: Valia RG, Valia AR, editor. IADVL Textbook and Atlas of Dermatology. 2nd
ed. Mumbai: Bhalani Publishing House; 2003. p. 689-710.
Fredriksson T, Pettersson U. Severe psoriasis – Oral therapy with a new retinoid. Dermatologica 1978;157:238-44.
Olsen EA, Hordinsky MK, Price VH, Roberts JL, Shapiro J, Canfield D, et al.
alopecia areata investigational assessment guidelines – Part II. National Alopecia Areata Foundation. J Am Acad Dermatol 2004;51:440-7.
Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry 1961;4:561-71.
Beck AT, Kovacs M, Weissman A. Assessment of suicidal intention: The scale for suicide ideation. J Consult Clin Psychol 1979;47:343-52.
Holi MM, Pelkonen M, Karlsson L, Kiviruusu O, Ruuttu T, Heilä H, et al.
Psychometric properties and clinical utility of the scale for suicidal ideation (SSI) in adolescents. BMC Psychiatry 2005;5:8.
James WD, Berger T, Elston D. Andrew's Diseases of the Skin: Clinical Dermatology. Philadelphia: Elsevier Health Sciences; 2015.
Rehn LM, Meririnne E, Hüük-Nikanne J, Isometsä E, Henriksson M. Depressive symptoms, suicidal ideation and acne: A study of male Finnish conscripts. J Eur Acad Dermatol Venereol 2008;22:561-7.
Golchai J, Khani SH, Heidarzadeh A, Eshkevari SS, Alizade N, Eftekhari H. Comparison of anxiety and depression in patients with acne vulgaris and healthy individuals. Indian J Dermatol 2010;55:352-4.
] [Full text]
Mattoo SK, Handa S, Kaur I, Gupta N, Malhotra R. Psychiatric morbidity in vitiligo: Prevalence and correlates in India. J Eur Acad Dermatol Venereol 2002;16:573-8.
Saleh HM, Salem SA, El-Sheshetawy RS, El-Samei M. Comparative study of psychiatric morbidity and quality of life in psoriasis, vitiligo and alopecia areata. Egypt Dermatol Online J 2008;4:1-28.
Huang KP, Mullangi S, Guo Y, Qureshi AA. Autoimmune, atopic, and mental health comorbid conditions associated with alopecia areata in the United States. JAMA Dermatol 2013;149:789-94.
Gupta MA, Schork NJ, Gupta AK, Kirkby S, Ellis CN. Suicidal ideation in psoriasis. Int J Dermatol 1993;32:188-90.
Aktan S, Ozmen E, Sanli B. Anxiety, depression, and nature of acne vulgaris in adolescents. Int J Dermatol 2000;39:354-7.
Do JE, Cho SM, In SI, Lim KY, Lee S, Lee ES. Psychosocial aspects of acne vulgaris: A community-based study with Korean adolescents. Ann Dermatol 2009;21:125-9.
Taner E, Cosar B, Burhanoglu S, Calikoglu E, Onder M, Arikan Z. Depression and anxiety in patients with Behçet's disease compared with that in patients with psoriasis. Int J Dermatol 2007;46:1118-24.
Barankin B, DeKoven J. Psychosocial effect of common skin diseases. Can Fam Physician 2002;48:712-6.
Bilkis MR, Mark KA. Mind-body medicine. Practical applications in dermatology. Arch Dermatol 1998;134:1437-41.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2], [Table 3]
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