Gender differences in depression and anxiety among atopic dermatitis patients.

BACKGROUND: Dermatological patients invariably suffer one or the other psychological problems which may escalate to the extent of a mental disorder. One of the most common dermatological disorders is atopic dermatitis (AD), but the literature has limited data on gender differences for psychiatric morbidity in such patients. AIMS: To evaluate and compare gender differences in the prevalence of depression and anxiety in AD.
MATERIALS AND METHODS: This cross-sectional study with consecutive sampling was done in an outpatient clinic of Dermatology at a Tertiary Care Center. AD subjects giving informed consent were evaluated on a brief semi-structured performa for collecting demographic and clinical information. Primary Care Evaluation of Mental Disorders (PRIME-MD) was used to assess the presence of psychiatric symptoms in these patients. Descriptive analysis was done for the socio-demographic profile and independent sample t-test, Chi-square and Cramer's V test was carried out to find in-between group differences for males and females.
RESULTS: A total of 81 patients were included in the final analysis (males = 36, females = 45) with no significant difference in mean age between male and female subjects (36.14 ± 17.62 and 33.98 ± 14.49 years, respectively; P = 0.54). When including moderate to severe grade of depression or anxiety, the current study found prevalence rates of 15% and 12% respectively. Females had significantly more anxiety and depression scores than males (P = 0.04 and P = 0.03 respectively).
CONCLUSIONS: There is a female preponderance of depression and anxiety disorder in AD patients.

What was known?

High prevalence of psychiatric morbidity particularly depression and anxiety in patients suffering from atopic dermatitis

The relationship of psychological problems and atopic dermatitis is vice-versa with both increasing the propensity of occurrence of each other.

Introduction

Through the studies done so far, strong association is found between dermatological condition and psychological problems.[1] The incidence of psychiatric disorders among dermatological patients is approximately between 30% and 40%.[2] The presence of a concomitant psychiatric illness is predominantly observed in patients with various dermatological disorders like dermatitis, acne, pruritus, urticaria, alopecia, psoriasis or vitiligo,[3] of which atopic dermatitis (AD) is the most common skin disease observed in general practice. AD is a chronic inflammatory skin disease, characterized by pruritic and eczematous skin lesions with series of exacerbations and remissions. Common age of presentation is children and adolescence, but in one-third of cases it extends to adulthood.[4]

Various mechanisms have been proposed to understand this association both forming a vicious cycle.[5] Most frequent symptoms reported as a basis for distress are disfigurement and itching causing significant insomnia, and sleep deprivation leads to fatigue, mood lability, impaired functioning and suicide in few cases.[6] Furthermore, frequent bullying and embarrassment due to disfigurement leads to social stigma and social isolation. On the other hand, it has been also been appraised that stressful life events often exacerbates or precedes dermatitis.[7] Any stress causes stimulation of hypothalamic-pituitary-adrenal (HPA) axis and autonomic nervous system resulting in inducing helper T cells causing release of neuropeptides and hormones. These neuropeptides causes adrenergic and other neurotransmitters release causing vascular instability in dermatitis patients, indicating a link between neuroendocrine and immune system.[8] On the other hand, disfigurement caused due to dermatitis can lower patients self esteem, in turn increasing the propensity to anxiety and depression.[9] It has also been put forward that intense itching in dermatitis leads to sleep disturbances causing irritable behavior, decreased concentration, and decreased threshold of tolerance which on persisting for a protracted period can cause various psychiatric illness like depression, anxiety, attention-deficit hyperactivity disorder (ADHD) and autism.[10] There is tendency of presentation of somatic symptoms in patients with dermatological conditions in comparison to normal population.[11]

On exploring the personality of patients suffering from dermatitis, some traits commonly found are of feelings of insecurity, inferiority and inadequacy, tension, anxiety, depression, aggressiveness, dependence, sensitivity, emotional liability, hyperactivity, difficulty in expressing feelings, sexual conflicts, masochism, high intelligence level, shyness and being doubtful.[12] Therefore timely evaluation of patient's personality and sub-syndromal psychiatric symptoms (lack of self esteem/confidence, shame, stigma embarrassment, decrements in body image) can detect various psychological risk factors in the patient, which would help in early co-morbid psychiatric diagnosis and its proper management.

Through the current study, we aim to assess the relationship of AD and psychiatric illness (depression and anxiety), further strengthening the existing data particularly focusing upon gender differences among the patients.

Materials and Methods

This cross-sectional study with consecutive sampling was done in an outpatient clinic of Dermatology at a Tertiary Care Center spread over a period of 8 month. The diagnosis of AD was made by using Williams criteria.[13]

Subjects giving informed consent were evaluated on a brief semi-structured performa for collecting demographic and clinical information. Primary Care Evaluation of Mental Disorders (PRIME-MD) was used to assess the presence of psychiatric symptoms in these patients. All consecutive subjects not suffering from chronic illness other than skin disease, with no past history of psychiatric illness and no apparent life stress other than the skin disease were included. Subjects having skin disease other than AD were also excluded.

PRIME-MD was 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.[14] 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 second-stage process took an average of 5-6 minutes of clinician time in patients without a mental disorder diagnosis and 11-12 minutes 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, individual screening tools for each psychiatric illness were assessed for their validation.

Through various studies, Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder Questionnaire (GAD-7) have been validated to effectively assessing depression and anxiety disorders when applied alone instead of the whole PRIME-MD.[1516] In our study, we have used these two components of PRIME-MD, as these two psychiatric illnesses were commonly found concurrently with skin disorders.

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.

The data were analyzed using SPSS version 17.0. Descriptive analysis was done for socio-demographic profile. Independent sample t-test (for continuous variables) and Chi-square test (for categorical variables) were used to find difference between the patients and the care givers on different variables. Additionally Cramer's V test and phi test were used for 2 × 4 contingency tables. The level of statistical significance was kept at P < 0.05. The conditions of confidentiality as specified in the institutional ethical guidelines were strictly adhered to.

Results

A total of 81 patients were included in the final analysis (males = 36, females = 45). The socio-demographic profile of study subjects is given in Table 1. The mean age of the subjects was 34.94 ± 15.89 years (10-74). There was no significant difference in mean age between male and female subjects (36.14 ± 17.62 and 33.98 ± 14.49 years, respectively; P = 0.54). All the subjects belonged to the urban area and it was seen that more females were unemployed than males (P = 0.001).

Table 1

Socio-demographic and clinical parameters in the study population

About 57% of the patients were diagnosed as having clinically significant depression [Figure 1]. It included mild (31%), moderate (8%), moderately severe (5%) and severe (2%). Nearly 48% subjects were diagnosed with significant anxiety features [Figure 2]. It included mild (27%), moderate (4%) and severe (8%). Suicidal ideation was reported by 16% subjects. Among female subjects, 22.2% reported of a suicidal ideation while only 8.3% male subjects reported of any suicidal ideation.

Figure 1

Bar chart representing the severity of depression amongst the genders in the study population PHQ-9 = Patient health questionnaire

Figure 2

Bar chart representing the severity of anxiety amongst the genders in the study population GAD-7 = Generalized anxiety disorder scale

Females had significantly more anxiety and depression scores than males (P = 0.04 and P = 0.03 respectively), but had no difference in terms of suicidal ideation [Table 2]. But on comparison of individual severity scores of scales among the genders [Table 3], no difference was observed for anxiety among the groups (Cramer's V = 0.267; P = 0.12).

Table 2

Gender comparison for depression, anxiety and suicidal ideation among individuals with dermatitis (M=36, F=45)

Table 3

Gender comparison for severity of depression and anxiety

PHQ-9 and GAD-7 scores significantly correlated to each other (). Suicidal ideation was positively correlated to total PHQ-9 and GAD-7 scores (r = 0.42, P < 0.001; r = 0.37, P = 0.001 respectively). Age, education, occupation and duration of illness were not found to be correlated to depression, anxiety or suicidal ideation in the overall sample population. Among female subjects, age was found to be positively correlated to total GAD-7 scores (r = 0.45, P = 0.002) but not to total PHQ-9 (r = 0.28, P = 0.06) or suicidal ideation (r = 0.18, P = 0.22). Education, occupation and duration of illness were not found to be correlated to depression, anxiety or suicidal ideation in female subjects. Among male subjects, being employed was found to be positively correlated to total GAD-7 scores (r = 0.39, P = 0.01) and suicidal ideation (r = 0.33, P = 0.04) but not to total PHQ-9 scores (r = 0.17, P = 0.31). Age, education and duration of illness were not found to be correlated to depression, anxiety or suicidal ideation in male subjects.

Discussion

The current study confirmed the previous findings of significant association of AD with anxiety, depression and suicidal ideations.[5171819202122]

When including moderate to severe grade of depression or anxiety, the current study found prevalence rates of 15% and 12%, respectively. Other studies have reported similar rates of depression and anxiety in AD patients. Hordaland health study reported that 12.9% had current anxiety only, 4.2% current depression only, and 7.5% had comorbid anxiety/depression.[23] The lower prevalence of depression in this study could have been due to utilization of self-reported HADS while our study used clinician-administered PRIME-MD, which might have given a more accurate data. Another study in patients with occupational hand eczema reported that 20% had a positive anxiety score and 14% had a positive depression score.[24] The slight difference from our findings could be because we incorporated all cases of AD involving all body locations. Adolescents with AD are also reported to have high rates of lifetime rates of anxiety (9-32%) and depressive (12-24%) disorders.[25] Studies report that both trait anxiety (TA) and state anxiety (SA) are significantly higher in patients with AD with TA being significantly higher than SA.[2026]

In our study, women were found to be having significantly higher depressive and anxiety symptoms than males. Similar observations have been reported in other studies comparing anxiety symptoms or depressive symptoms.[2728] Young female patients with AD have been reported to be more distressed than older male patients.[29] Probably, these findings are due to the reason that women are more concerned regarding their physical appearance than men perceiving the skin disorder as a threat in turn leading to emotional disturbance. Researchers have also suggested other hypothesis to explain gender-specific association between atopy and depression implicating role of genetic abnormalities in serotonin metabolism, HPA-axis dysfunction, and histamine theory.[17] The study by Klokk et al. (2010) found depression to be more in men than women with AD, the opposite of Timonens hypothesis.[23]

More than half of the study group had secondary and higher secondary education indicating that higher the education there is more awareness and concern regarding physical appearance leading to medical consultation contrary to finding by Khan et al.[28] Slattery et al. (2011) found a substantial reduction in quality of life (QOL) in patients suffering from dermatitis. Factors liable for the same could be intense itching leading to disturbed sleep, fatigability, decreased concentration at work, social rejection thinking dermatitis as contagious and emotional disturbances.[25]

It was also noted that half of the patients were suffering from chronic illness (>6 months). Though there are no studies on association of chronic dermatitis with psychiatric morbidity, but one study mentions that persistent skin disease had higher psychiatric co-morbidity in comparison to intermittent and incident skin disease.[30] It could be due to the reason that chronic illness may act as a constant stressor generating higher mental morbidity.

Suicidal ideation was reported by significant proportion of subjects (16%) in our study similar to other studies.[19] The prevalence of suicidal ideation in patients with mild, moderate, and severe AD between the age of 15 and 49 years is reported to be 0.21%, 6%, and 19.6%, respectively.[31] Studies comparing various dermatological disorders report that depression is highest in AD as are suicidal ideation.[2829] A previous study reported rates of suicidal ideation to be 2.1% among AD patients but did not report on the severity of AD.[32] Studies support a strong correlation between severity of dermatitis symptoms and psychological burden which may increase the risk of suicidal ideas in AD patients.[193132] We found significant correlation of suicidal ideations to depressive as well as anxiety symptoms.

Our study also showed more of suicidal ideation in women in comparison to men though not significantly, which could be due to more propensities of women to be affected by stressor and psychological distress leading to pessimistic view regarding the future ending up in suicidal ideation/suicide. Other studies have also reported suicidal thoughts among female with skin problems to be more than male AD patients.[333]

While our study did not find any significant correlation between the duration of illness and presence of depression in subjects, other studies have reported the same.[2829]

The current study was limited in generalization due to its limited sample size, cross-sectional assessment, findings from a single tertiary care center and an absence of a control group. Associated risk factors which might have exacerbated the psychiatric condition were not evaluated like personality traits or any concomitant stressful life event. We didn’t assess the severity of dermatitis so, we were unable to compare association of severity of dermatitis with anxiety and depression.

The strength of our study was the through assessment of psychiatric and dermatological illness by specialists of the relevant field increasing the reliability of findings.

Conclusion

The present study confirmed the previous findings linking an association between dermatological condition and psychiatric illness. It can also be concluded that there is a need for thorough assessment of psychiatric illness in patients with dermatological conditions and also there is need to actively assess regarding any suicidal plans/ideations for improving the patient management and overall quality of life.

Female patients suffered from more anxiety and depression than males, which in light of the a female preponderance for AD,[34] making it utmost important to focus upon this population subgroup in the society.

What is new?

Female patients suffering from atopic dermatitis endure more anxiety and depressive symptoms than males

There is high prevalence of suicidal ideation (16%) among patients of atopic dermatitis.