|Year : 2017 | Volume
| Issue : 1 | Page : 18-23
Psychiatric morbidity in psoriasis: A case-control study
Sunil Goyal, Rohith R Pisharody, Shubhranshu Nath
Department of Psychiatry, INHS Asvini, Mumbai, Maharashtra, India
|Date of Web Publication||17-Aug-2017|
Surg Cdr Rohith R Pisharody
Department of Psychiatry, INHS Asvini, Mumbai - 400 005, Maharashtra
Source of Support: None, Conflict of Interest: None
Objective: Psoriasis is a chronic, relapsing and disfiguring dermatological disorder with a significant effect on occupational, social, and other areas of functioning. Psychological stress has been known to have a significant role in the onset and exacerbation of this illness. To study the prevalence of psychiatric morbidity in psoriasis and the influence of specified demographic, psychological, social and illness-related variables. Methods: The study was carried out at a tertiary care hospital in a large urban setup. In this case–control study, 100 cases of psoriasis were studied in comparison with healthy controls who were matched for sociodemographic profile. The participants were given a sociodemographic questionnaire, clinical profile sheet, and psoriasis area and severity index (PASI). General Health Questionnaire-12 (GHQ-12) was used to screen for psychological distress, and subsequently, Hospital Anxiety and Depression Scale for screening for depression and anxiety and World Health Organization Quality of Life-BREF scale for assessing the quality of life (QOL) were administered. The results obtained were analyzed for evaluating the psychiatric morbidity and its various correlates. Appropriate statistical analysis was done using SPSS 21. Results: Using GHQ-12 cutoff score (≥3) for psychological distress, the overall prevalence of psychological distress was significantly more in cases of in comparison to healthy controls with an odds ratio of 8.54 (95% confidence interval 3.16–23.07, P < 0.0001). Statistical analysis showed a statistically significant correlation of educational status with QOL and severity of skin lesions (PASI) with anxiety level. Severe skin lesions, more so on visible body parts were associated more commonly with psychological distress. Conclusions: All patients of psoriasis should be educated about the nature of the illness and screened for psychological distress. Dermatologists and family members should be educated to recognize the symptoms early and encouraged to seek the help of psychiatrist.
Keywords: Psoriasis, psychiatric area and severity index, psychiatric morbidity
|How to cite this article:|
Goyal S, Pisharody RR, Nath S. Psychiatric morbidity in psoriasis: A case-control study. J Mar Med Soc 2017;19:18-23
| Introduction|| |
Physical appearance has always been a matter of concern to human beings. A healthy skin is essential to the external appearance of an individual. However, if any illness causes the normal appearance of the skin to change, it causes distress to the individual. The role an individual's skin plays throughout their life in their social connectedness is well known. Not only does it influence one's self-image and esteem but it also responds to emotional stimuli.
Psoriasis is a chronic, disfiguring, noncontagious inflammatory skin disease prevalent in 0.6%–4.8% of general population. Psoriasis is often accompanied by pain and itching resulting in significant psychological impairment; reported to be ranging from 21% to 43%,, experiences of stigmatization , and poorer perception of health-related quality of life (QOL). This is likely to have an effect on day-to-day activities, social interactions, occupational, and sexual functioning, often independent of extent, and severity of skin lesions.,, The coping skills of psoriasis patients is often overwhelmed. In one study, 9.7% of patients revealed a death-wish and 5.5% suicidal ideas. Psoriasis patients also suffer from added financial problems due to workplace absence to add to the cost of treatment. Several factors, including genetics, race, geographical variation, injury, infection, smoking, alcohol, diet and psychological issues, particularly emotional stress, play a role in either causing or aggravating psoriasis. These are likely to affect the treatment outcome.,
Doctors, even dermatologists, often do not understand the degree of psychological disability and even when they do, fewer than 33% receive mental health care, affecting the eventual outcome of the skin disease. General QOL improves significantly following treatment of psoriasis. The effects of the illness on the psyche were also noted with a clinical change of the primary illness, psoriasis. The above highlight the need for understanding the various demographic, psychological, social and illness-related causes of psychiatric morbidity in cases of psoriasis. Understanding these would help in improving the overall outcome in the patient's life.
Although there is extensive Western literature available on the subject, due to the different psychosocial situation of the third world countries vis-à-vis that of the industrialized world and due to paucity of research on this issue in India , as compared to the West, a need was felt for the index study.
| Methods|| |
To estimate the psychiatric morbidity in patients of psoriasis, we studied the prevalence of psychiatric diseases in patients suffering from psoriasis and the level and nature of functional impairment in psoriasis. We also set out to study the demographic, psychological, social and illness-related facets associated with psychiatric morbidity and finally correlated the psychiatric area and severity index (PASI) scale with psychiatric morbidity.
A case–control study was conducted at a tertiary care general hospital wherein the study group was formed by 100 patients suffering from psoriasis both inpatients and outpatients attending the dermatology outpatients department (OPD) of the general hospital in a large urban setup. All new and old cases of psoriasis either inpatients or outdoor patients were included irrespective of their gender, socioeconomic status, religion, educational qualifications, occupation, native place, and geographical location of residence. All cases were included irrespective of the duration of illness or treatment, and the diagnosis was confirmed by a dermatologist through clinical examination. Exclusion criteria included patients of psoriasis aged <10 years of age, those with the previous history of any diagnosed mental illness, and those suffering from any other major physical illness or disability which could lead to confounding effect on the study or hamper the patient's ability to cooperate in the study. The confidence interval (CI) being 95% and the power of the study at 80%, a sample size of 48/arm was required given the odds ratio (OR) in a previous study 3.3 of detecting psychological distress among chronic dermatological conditions.
The healthy control group was selected from the patients' attendants who did not have any significant physical or mental illness, matched for various demographic variables. All participants with the previous history of any diagnosed mental illness were excluded from the study.
Both groups were informed about the purpose of the study and confidentiality was assured. All the subjects cooperated adequately, and consent was obtained. Both groups were subjected to detailed interview covering sociodemographic information, previous psychiatric and medical history, recent symptoms, and general medical status. The study group suffering from psoriasis, meeting the inclusion criteria, was administered clinical profile sheet specially designed for our study to get relevant clinical details of psoriasis. The severity and the extent of skin lesions of psoriasis were assessed by PASI scale. General Health Questionnaire-12 (GHQ-12) scale was administered to all the individuals in the study and healthy control group. All the subjects who scored ≥3 on GHQ-12 scale were given Hospital Anxiety and Depression Scale (HADS) and World Health Organization Quality of Life-BREF scale (WHOQOL-BREF). All the above patients were interviewed in detail for determining whether a psychiatric diagnosis as per the International Classification of Disease - Tenth Revision (ICD-10) existed or not 6. The results obtained were analyzed statistically to assess the correlation of anxiety and depressive symptoms with various demographic and disease-related variables and the effect on QOL.
The assessment was done using GHQ-12 which gives an indication of psychological distress, PASI scale  indicating the severity of the skin condition, HADS  a standardized tool to screen for depression and anxiety and the WHOQOL-BREF scale, a time-tested QOL assessment tool. Patients were also subjected to clinical psychiatric examination. Only those participants who scored ≥3 on GHQ-12 scale were administered HADS and WHOQOL-BREF. SPSS 21 (IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.) was used for statistical analysis, and the independent t-test was used to confirm the homogeneity of the different two study groups. OR was calculated to find out level of significance of the observations.
| Results|| |
The psoriasis patients group (n = 100) and healthy control group (n = 100) were comparable on sociodemographic variables [Table 1]. The groups were delineated into two subgroups on the basis of GHQ-12 responses; GHQ negative (GHQ score <3, suggesting the absence of psychological disturbance) and GHQ Positive (GHQ score ≥3, suggesting the presence of psychological disturbances, as per the normative data available for GHQ ). It was found that 31% of psoriatic cases had psychiatric disturbances in comparison to 5% of the healthy control. This was significant with an OR of 8.54 (95% CI 3.16–23.07, P < 0.0001) [Figure 1]. On comparing the severity of anxiety and depressive scores between cases of psoriasis and controls with a GHQ score ≥3, it was noted that several of the cases had scored above 8 while most of the controls had a score of <7. This difference was however not statistically significant (P = 0.31, P = 0.59) [Table 2].
|Figure 1: Correlation of General Health Questionnaire score between psoriasis cases and healthy control.|
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|Table 1: Demographic comparison of psoriasis and healthy control groups (Original)|
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|Table 2: Correlation of severity of anxiety, depression and QoL scores in Psoriasis cases and healthy control with GHQ score ≥3 (Original)|
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On the assessment of QOL, all the healthy controls scored above 80 while 9 of the psoriasis cases scored below 80 indicating the perceived impairment of QOL by the cases. This however did not correlate to statistical significance probably due to the small sample size amongst healthy control with high GHQ scores (P = 0.31) [Table 2]. The severity of skin lesion assessed by PASI (a cutoff of 2 was taken to indicate severity as per normative data available for the scale ) was not statistically significantly (P = 0.17) correlated with GHQ score. However, a trend was noted in this study in that patients with higher PASI score were more likely to have psychopathology (56%) and patients with lower PASI score have less psychopathology (25%) [Table 3]. This study found statistically significant association between educational status and QOL in Psoriasis cases with GHQ score ≥3. It is observed in the study that the less educated patient experiences poorer QOL (19.3% to 9.6%) (OR = 6.80, 95% CI 1.23–37.50, P = 0.03).
|Table 3: Correlation of GHQ score with severity (PASI) of skin lesion in cases of Psoriasis (n=100) (Original)|
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We found statistically significant (P = 0.03) association between severity of skin lesions (PASI score) and anxiety score. Thus, 55% of the 31 cases of psoriasis with a GHQ score ≥3 who had a PASI score more than 2 (a score which indicates at least a moderate to severe psoriasis), scored 8 or more in the anxiety scale [Figure 2]. The study found no statistically significant (P = 0.06) association between visibility of skin lesions and anxiety, depression, and QOL scores in psoriasis cases with GHQ score ≥3. However, a trend toward higher depression score (19% vs. 12.9%) and poorer QOL perception (42% vs. 22.5%) in patients with more exposed skin lesion when compared to those with unexposed skin lesion was evident [Table 4]. The study found that no subjects from healthy control group with GHQ score ≥3 were found to fulfill clinical criteria of psychiatry disease according to ICD-10. However, 10 patients out of 31 cases of psoriasis who reported psychological distress fulfilled clinical criteria of psychiatric illness [Figure 3].
|Figure 2: Correlation between severity of skin lesions (psoriasis area and severity index) with anxiety scores in cases of psoriasis with General Health Questionnaire score ≥3 (n = 31).|
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|Figure 3: Distribution of psychiatric diseases according to International Classification of Disease- Tenth Revision among the subjects scoring ≥3 General Health Questionnaire-12 scale.|
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|Table 4: Correlation between visibility of skin lesion and anxiety, depression and QoL scores in cases of Psoriasis with GHQ score ≥3 (n=31) (Original)|
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| Discussion|| |
In this study, the administration of GHQ-12 to all the persons, whether cases of psoriasis or healthy control, led to generation of two subgroups, i.e., those with GHQ score <3 suggesting the absence of psychological disturbance and other subgroup with GHQ score ≥3, suggesting the presence of psychological disturbance (the cutoff of 3 was chosen as given in the normative data of the GHQ-12 version ). A significantly greater number of psoriasis cases had psychological disturbance in comparison to healthy controls (31% vs. 5%) with an OR of 8.54 implying that psoriasis cases experienced more psychological stress in comparison to general population. Similar results were found in one of the largest studies on the subject in a large population-based cohort study from Pennsylvania  which found a 30%–40% increased the risk of a serious mental health disorder in patients with psoriasis vis-à-vis the control group. An Indian study by Lakshmy et al., in fact found the correlation of psychological distress to be about 80% in cases of psoriasis.
In our study, further evaluation with HADS and WHO QOL-BREF was limited to cases and control with GHQ score ≥3. The severity of anxiety and depressive symptoms experienced by Psoriasis patients with GHQ score ≥3 was more in comparison to the controls with GHQ score ≥3. This implied that there is more psychological distress in cases of psoriasis in comparison to control group. The healthy control group with GHQ score ≥3 enjoys a better QOL in comparison to psoriasis patients with GHQ score ≥3. Lakshmy et al. found that the QOL was significantly worse in patients with psoriasis with comorbid psychological distress. The lower scores on QOL scale by cases of psoriasis may be due to their perceived social stigma, lack of social support, and disturbed activities of daily living due to skin lesions.
In the present study, even though there was no statistically significant association between educational status and anxiety score or depressive score in psoriasis cases with GHQ score ≥3, analysis revealed higher anxiety and depression levels in the more educated patients. This may be because they have more concern about their external physical appearance and it could also pertain to the fact that they have more knowledge about the chronic and relapsing nature of the illness.
This study did not reveal statistically significant association of severity of psoriasis skin lesion (PASI score) and GHQ score. However, there was a trend of higher percentage of patients with more severe skin lesions scoring ≥3 on GHQ Scale. The low sample size was probably the cause of the statistical insignificance. Another study done in Himachal Pradesh, India  showed a significant increase in psychiatric morbidity with an increase in PASI scores. Anxiety levels appeared to be higher in the age group 20–50 years, probably because they are yet to become habituated to the disease (though the association between age and anxiety score was not statistically significant). This study revealed statistically significant association between educational status and QOL in cases of psoriasis with GHQ score ≥3. Thus, less educated patients experience impairment of QOL which can be attributed to lack of social supports, difficulty in carrying out his job due to associated disability and stigma attached to illness being misconstrued as a contagious disease in the surrounding social network. This finding appears to be somewhat contradictory, but then mood related factors constitute only a subpart of the QOL-BREF scale. This study also revealed statistically significant association between severity of skin lesions (PASI score) and anxiety score. This can be because the extent of lesion in body and associated erythema, scaling and infiltration cause heightened concern in a patient about their physical appearance and disability which might lead to social embarrassment. There was also concern about the outcome of illness, use of more toxic drugs and hospital admissions in the course of illness. We did not demonstrate statistically significant association of severity of skin lesions (PASI score) with depression score or QOL score in psoriasis cases with GHQ score ≥3, even though a trend was evident of more depression and poorer QOL in cases with more severe skin lesions. In the present study, the cases with more visible skin lesions in the exposed areas had more depressive symptoms and a poorer QOL when compared to the cases with lesions predominantly in the nonvisible, unexposed areas of the body. Detailed clinical interview of cases of psoriasis and healthy control group with GHQ score ≥3 revealed that no subject of control group had a syndromal psychiatric diagnosis as per ICD-10 criteria. However, 10 out of 31 cases of psoriasis fulfilled clinical criteria of psychiatric illness. These cases were subsequently followed up in psychiatry OPD and offered appropriate treatment.
| Conclusions|| |
The prevalence of psychological distress among the patients of psoriasis was found to be 31%, which was significantly more in comparison to healthy controls. Cases of psoriasis with GHQ ≥3 scored lower on QOL scale signifying the effect of psychological distress on the QOL. It was also noted that a higher number of patients with more severe skin lesions scored ≥3 on GHQ indicating the correlation between the severity of psoriasis and the psychological distress caused. There was also statistically significant association between educational status and QOL in cases of psoriasis in that the less educated experienced poorer QOL. There was statistically significant positive correlation between the level of anxiety and the severity of skin lesions in cases of psoriasis. Cases of psoriasis with visible skin lesions in exposed parts of the body experienced more depressive symptoms and poorer QOL in comparison to those cases with lesions in the unexposed body parts.
Based on the findings of our study, we would recommend that education about the nature of the illness, prognosis, and impact on social and occupational sphere must be offered to all cases of psoriasis and this would help in mitigating any associated psychological distress. All patients of psoriasis should be screened for psychological distress using simple instruments such as GHQ-12 and HADS. In view of the significant proportion of patients of psoriasis having psychological disturbance, dermatologists, and family members should be educated to recognize psychological symptoms early and seek the help of Psychiatrist. Those having significant anxiety or depression may be referred to a psychiatry center after obtaining consent of the patient. If found clinically depressed or anxious, they should be offered treatment.
Limitations of the study
The sample size was relatively small and therefore statistically significant association between the psychological distress and various illness-related variables could not be established. Any other ongoing stressor along with psoriasis could have been a confounding factor. The study was conducted in tertiary care urban center, and therefore, the results may not be generalized to the whole population.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4]