A study of psychiatric morbidity in patients of psoriasis

 

 

Abstract               Background: Psoriasis is common, chronic dermatological disorder with no permanent cure may contribute to psychiatric co-morbidity in these patients especially moderate to severe type of psoriasis. Aim and Objective: The study was conducted to assess the psychiatric morbidity and their prevalence amongst psoriasis patients. To determine the co-relation of psychiatric co-morbidity with sociodemographic and clinical profile of the psoriasis. Methodology: fifty consecutive clinically diagnosed patients of psoriasis were interviewed by “Mini International Psychiatric Interview (MINI)” questionnaire to determine psychiatric co-morbidity as per ICD 10 DCR. Results: Our study found an overall prevalence of psychiatric morbidities of 48% (n=24) in patients of psoriasis. 8 patients (16%) were having diagnosis of Anxiety NOS, 10% were having Depressive episode -mild. other comorbid Psychiatric diagnosis were generalised anxiety disorder(n=12, 6%), Depressive episode - moderate (n=4,8%), Dysthymia (n=2, 4%) and Alcohol dependence (n=2, 4%). Conclusion: Due to chronicity, relapsing course and no permanent cure to psoriasis, (especially moderate to severe) is often associated with psychiatric co-morbidities. Hence moderate to severe type of psoriasis patients must undergo psychiatric evaluation for better outcome of psoriasis management.

Key Words: Psoriasis, Psychiatric co-morbidity, MINI, Depression, Anxiety

 

 

INTRODUCTION

Psoriasis affects approximately 1–6% of peoples in the world. There are two-peak age of onset for the psoriasis; the first peak of onset is between 16–22 years, and second peak of onset is between 57–60 years.¹ In India the prevalence of psoriasis varies from 0.44 to 2.8%, it is twice more common in males than females. Most of the patients presents during their third or fourth decade.² Skin acts as an organ of sensation, sexuality and social interaction. The condition of the skin affects body-image and self-esteem, as well as aspects of social life such as participation and interaction at work or at school. Social rejection is a common feeling experienced by people with psoriasis. Several studies have described common reactions to psoriasis as including embarrassment, impaired daily activities, anxiety, anger, and depression.^3-5Several factors in combination contribute to the development of psoriasis, like genetic factors, trauma, infection, certain medicines, such as non-steroidal anti-inflammatory drugs (NSAIDs), betablockers, antimalaria medicine, and lithium, endocrine factors, sunlight, metabolic factors, alcohol, cigarette, and psychological factors etc. The role of psychological problems in aetiology and exacerbation of psoriasis is debatable, although it is widely believed that stress has an important role in triggering psoriasis. The mechanism of stress-related exacerbations of psoriasis involved the nervous, endocrine and immune systems.⁶ Psoriasis causes stress and in turn, stress can worsen psoriasis. Most of the patients suffering from psoriasis report disease related stress, arising mainly from the cosmetic disfigurement and social stigma of psoriasis.¹ The adverse mental health aspects of psoriasis have multiple dimensions ranging from direct psychological bearing on the sufferer to potentially worsening the disease process. Patient's disturbed psychological state can hamper their ability to comply to and respond to given treatment regime. The burden of disease ranging from physical pain, psychological distress and social stigma further escalates it. It is found that control of psoriasis symptoms has been associated with improvement in psychological symptoms. Thus identification and management of the psychological symptoms can decrease both the financial burden and therapeutic period.⁷Hence, management of patients with psoriasis requires a multidisciplinary approach, involving dermatological and psychological treatments simultaneously. Most of the research regarding psychological aspects of Psoriasis is from western world. The psychosocial factors in the developing countries like India are different from that of the developed countries. As there are very few Indian studies regarding psychiatric morbidity in patients suffering from Psoriasis, the present study was carried out. Our study aimed to measure the prevalence of psychiatric morbidity and its correlation with sociodemographic and clinical variables in patients of psoriasis attending a Tertiary Care Hospital of Ahmednagar, in Maharashtra, India.

METHODOLOGY

The study was conducted by the Departments of Psychiatry and Dermatology, of a Tertiary Care Hospital of Ahmednagar in Maharashtra, India. It was an observational cross-sectional study. The study protocol was approved by the Institutional Ethics Committee and the study period was 6 months. All consecutive patients of Psoriasis aged 18-64 years, attending Dermatology OPD, were considered for the study. Patients with comorbid skin disorders and chronic medical conditions were excluded from the study. Total 50 patients were included in study and a written informed consent was obtained from them. A semi-structured proforma was used to record the sociodemographic data and clinical details of the patients. The Psoriasis Area and Severity Index (PASI) was used by the consultant dermatologist, to rate the severity of psoriasis.⁸ Then the patients were evaluated by consultant psychiatrist by using MINI Plus.⁹ The diagnosis of comorbid psychiatric condition was done using ICD-10 Diagnostic Criteria for Research (WHO, 1993). The results obtained were tabulated and statistical analysis was done with the help of Statistical Package for Social Sciences (SPSS) for Windows (version 11.5) and 2007.

RESULTS

 

Table 1: Distribution of Sociodemographic Variables in Patients of Psoriasis

Table 2: Clinical Variables of Psoriasis

 

Table 3: Distribution of comorbid Psychiatric diagnosis in patients of Psoriasis

 

Table 4: The type and distribution of comorbid psychiatric diagnosis in patients of Psoriasis

 

Table 5: Correlation between Sociodemographic Variables and Comorbid Psychiatric Diagnosis in Patients of Psoriasis

Table 6: Correlation between Clinical Variables and Comorbid Psychiatric Diagnosis in Patients of Psoriasis

 

A statistically significant association was found between age (p value: 0.001), marital status (p value: 0.011) and comorbid psychiatric diagnosis in patients of psoriasis. No significant association was found between other sociodemographic variables and comorbid psychiatric diagnosis. Age of onset (p value: 0.002) and PASI score (p value: 0.021) were significantly associated with comorbid psychiatric diagnosis in patients of psoriasis. (Table 5 & 6)

 

DISCUSSION

The present study assessed the prevalence of psychiatric morbidity in psoriasis patients of a Tertiary Care Hospital of Ahmednagar in Maharashtra, India. We also studied the impact of sociodemographic and clinical variables on psychiatric morbidity. Chronic and severe skin disorders are usually associated with psychiatric comorbidity. Psoriasis is one of the most common skin disorders. The chronic nature of the disease has a prominent negative influence on psychological and social well-being of the patient. Psychological distress has a significant and adverse effect on long term outcome in patients with psoriasis.¹⁰

Prevalence of psychiatric morbidity in patients of psoriasis : Our study found an overall prevalence of psychiatric morbidities of 48% (n=24) in patients of psoriasis. 8 patients (16%) were having diagnosis of Anxiety NOS, 10% were having Depressive episode -mild. other comorbid Psychiatric diagnosis were generalised anxiety disorder(n=12, 6%), Depressive episode - moderate (n=4,8%), Dysthymia (n=2, 4%) and Alcohol dependence (n=2, 4%). Gaikwad et al in a study of 43 psoriasis patients found psychiatric comorbidity in Sixty-seven percentage of the patients.¹¹ In another study psychiatric morbidity was studied in 103 psoriasis patients, using the general health questionnaire (GHQ). They found psychiatric morbidity in 24.7% of the patients. The psychiatric diagnoses as per ICD-10 were adjustment disorder (62%), depressive episode (29%) and dysthymia (4%).¹² Zachariae and colleagues reported that patients with psoriasis have 40–90% more psychological morbidity than the general population.¹³ Various studies have reported a prevalence of depression from 28% to 67% in patients with psoriasis..^14-17 In our study 10% were having Mild Depressive episode, 8% moderate Depressive episode and 4% were having Dysthymia. Heterogeneity in the assessment tools used across various studies to determine psychiatric morbidity could explain these variations, to some extent. In our study 16% patients were having diagnosis of Anxiety NOS and 6% had generalised anxiety disorder as per ICD-10. Similar findings were reported by other studies. ^18,19 This high prevalence of anxiety can be due to higher apprehension about the illness, duration and outcome of treatment in patients of psoriasis. Also fear of investigations and worry concerning the financial aspects of treatment leads to anxiety.

Substance abuse : Some reports suggest that there is a higher prevalence of alcohol abuse and cigarette smoking in patients with psoriasis. In one study, there was an 4%prevalence of alcohol dependence.^20,21 There is an increased incidence of alcohol abuse in patients with psoriasis and alcohol abuse is related to a higher incidence and greater severity of psoriasis. Alcohol related disorders, such as alcoholic liver cirrhosis, may also exacerbate psoriasis or prevent the expected response to given therapy.²²

Correlation between sociodemographic variables and Comorbid Psychiatric diagnosis in patients of psoriasis : Sociodemographic variables have consistently shown the least impact on psychiatric morbidity in patients with psoriasis.^18,23 We found a statistically significant association was found between age (p value: 0.001), marital status (p value: 0.011) and comorbid psychiatric diagnosis in patients of psoriasis. No significant association was found between other sociodemographic variables and comorbid psychiatric diagnosis. In this study, younger patients found to have more psychiatric morbidity. However, Sampogna et al²⁴ observed that psychological distress was higher in older patients with psoriasis.

Correlation between clinical variables and Comorbid Psychiatric diagnosis in patients of psoriasis :

Age of onset of psoriasis: In general, about 40% of patients have the onset of psoriasis before the age of 30 years. This early onset can have severe effects on an individual’s psychological health.²⁵ In our study, early onset (≤ 35 years) of psoriasis was significantly associated with comorbid psychiatric diagnosis in patients. This finding is in accordance with a study by Youn et al,²⁶ that revealed psoriasis with an onset prior to age 40 to be associated with more psychological stress compared with later onset. Gupta et al found patients with early onset (younger than 40 years) presenting with greater psychopathology, probably as a result of greater genetic susceptibility and experiencing more severe and recurrent psoriasis.²⁷ Ginsburg and Link suggested that older age at onset of psoriasis was associated with lower psychosocial morbidity. Patients who were older at the time of onset of their psoriasis reported being less sensitive to others’ opinions, had a lesser tendency to anticipate rejection in social situations, were less secretive and had fewer feelings of guilt and shame in relationship to their psoriasis.²⁵ However, Kossakowska et al. found that adjusting to psoriasis later in life may be more difficult than in earlier years when a patient is young and has a lot of time to deal with negative emotions, especially anger.²⁸

Severity of illness: Various studies have shown a significant association between illness severity and duration of psoriasis and psychiatric morbidity.^{17, 29-31} The psychiatric morbidity found to be increasing with severity of psoriasis. Similarly, the severity of anxiety -depression was more in patients with longer duration of illness. Our study also showed that patients with higher PASI scores are likely to have a psychiatric morbidity. However, Fortune et al found that the psychiatric morbidity is not determined by the severity of psoriasis.³²

Duration of illness: Fried et al. and Esposito et al. found a meaningful association between the severity of anxiety -depression and psoriasis illness duration. Our study showed no significant association between duration of psoriasis and psychiatric morbidity.^33,34

 

CONCLUSION

This study shows significant impact of psoriasis on patients social life which leads to various psychiatric co-morbidities. Psychological distress has a significant and negative effect on long term management outcome in patients with psoriasis. Hence in a patient with moderate to severe disease, dermatologist should vigilant about symptoms suggestive of psychological disturbances and refer the suspected patients to Psychiatrists for detailed evaluation and necessary early intervention.

 

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