Psychological Morbidity Among Dermatological Patients in a Rural Setting.

BACKGROUND: Dermatological conditions have an impact on psychology of the patients. There is a dearth of studies regarding this field in Rural population of India. AIMS AND
OBJECTIVES: The primary objective of this study is to evaluate the psychiatric morbidity in patients affected with Dermatological condition in a rural population and secondary objective is to assess the morbidity in dimensions of Depression Severity and the quality of life in the Emotional Sphere, Physical Symptoms, Psychosocial Functioning. SUBJECTS AND METHODS: Seventy three rural patients were included in the study. PHQ9 and SKINDEX-29 was used to assess the psychiatric morbidity and quality of life. Statistical analysis was done using SPSS V 20. Chi-square test was used as a test of significance.
RESULTS: Significance has been found for duration of suffering from a dermatological condition and quality of life (p=0.03). Correlation has also been established between dermatological diagnosis with depression severity (p=0.004) or quality of life (p=0.004). In the sub scales of SKINDEX it was noted that overall dysfunction was notably more marked in Emotional Sphere and Psychosocial Functions than the Physical symptoms. Eczema was the most affected diagnosis in Skindex indicating a poor quality of life followed by psoriasis, Acne vulgaris and Seborrhoeic Dermatitis however, It was found that the majorly affected condition in depression severity was Psoriasis followed by Eczema, Acne Vulgaris and Seborrhoeic Dermatitis.
CONCLUSION: There seems to be an increased morbidity among the rural population in depression severity and that of quality of life in terms of emotional sphere and psychosocial functioning.

What was known?

It is known that there exists an association between psychiatric and dermatological illness and most studies have established this in urban population.

Introduction

Psychodermatology or psychocutaneous medicine, is the result of the merging of two major medical specialties: Psychiatry and dermatology.[1] Dermatologist should be aware of the relationship between dermatology and psychiatry and consider the constant interaction between psychological and biological aspects of diseases.[2] In 1857, the English dermatologist and surgeon William James Erasmus Wilson wrote the book “Diseases of the Skin,” in which he describes the first the so-called “skin neurosis,” addressing topics such as delusions of parasitosis, alopecia areata, pruritus, and hypopigmented lesions.[3] Hence, it can be noted that the relationship has been long well-established.

Among rural population lack of awareness of dermatological problems leads to stigma and poor quality of life. Dermatologic problems account for 15–20% of visits to family practices.[45] With advances in generic and specific instruments measuring the quality of life, there is now a greater appreciation of how skin diseases affect children and adults.[67] The field of psychodermatology developed as a result of increased interest and understanding of the relationship between skin disease and various psychological factors.[8]

Patients with body dysmorphic disorder, acne, psoriasis, and particularly men and women with facial conditions are more likely to have reactive depression and be at risk of suicide.[91011] In a study conducted by Korabel et al.,[12] the incidence of psychiatric disorders among dermatological patients is estimated at about 30–60%.

Dermatologists have stressed the need for psychiatric consultation, in general, and psychological factors may be of particular concern in chronic intractable dermatologic conditions, such as eczema, prurigo, and psoriasis.[1314] Regardless of psychiatric morbidity, skin diseases can greatly affect patient's quality of life.[15] The drugs used in the treatment of dermatological diseases such as steroids and retinoids may lead to psychiatric symptoms.[16]

With this background, this study has been designed specifically to assess depression which is most prevalent and to assess the quality of life in patients with dermatological disorders among the rural population in the catchment area of Bhaskar General Hospital, Rangareddy District of Telangana.

Aims

To assess the severity of depression,

To assess the degree of emotional disturbance and quality of life among the patients with dermatological disorders.

Subjects and Methods

This study was conducted in the Department of Dermatology in Bhaskar Medical College and General Hospital. This is a cross-sectional study conducted from June 2014 to August 2014.

The study sample initially considered was 100 patients, and the reason for considering only a fixed number of patients was the permission granted by Skindex-29 scale authorities only for 100 individuals. Patients were selected by using stratified sampling, in which every twentieth patient attending the out-patient department (OPD) was considered. All of them were hailing from a rural background, and we considered only those patients who did not suffer from any major stressful life events in the past 2 months. Patients below 15 years of age were not considered for the study.

The final study sample included only the patients with more common diagnosis among the study population that is, the dermatological conditions present in more than three patients were considered and the rest were excluded from the study, making a final study sample of 73 patients.

Informed consent was taken from the patients, and two questionnaires, Patient Health Questionnaire-9 (PHQ-9) and Skindex-29 were administered. PHQ is a 9 item questionnaire (under public domain) and is sensitive in picking up depression in the patient. The PHQ-9 was the first self-report questionnaire that efficiently establishes Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria based psychiatric diagnoses.[17]

Skindex-29 is a 30-item questionnaire developed by Chren et al.,[18] to assess the quality of life under three domains-emotional sphere, physical symptoms, and psychosocial functioning. This was validated in a study by Abeni et al.[19] Chi-square test was used to assess the significance of the groups with Skindex-29 and PHQ-9 scores. SPSS version 16 (IBM corporation) was used for statistical analysis. The study was approved by the Local Ethical Committee of Bhaskar Medical College and General Hospital in 2012 with order number BMC/EC/3/021.

Results

In our study, among the dermatological conditions, acne vulgaris (17.8%) was the most common diagnosis, followed by eczema (15%) and psoriasis (15%) [Table 1].

Table 1

Dermatological diagnosis

The most common diagnosis among males was psoriasis and among the females, eczema and acne were common [Table 2].

Table 2

Distribution of dermatological diagnosis among males and females

Depending on the duration of the skin disease, the patients were divided in to three categories. Most of the patients (46.6%) were in the category of 1–5 years duration [Table 3].

Table 3

Duration of the dermatological disease in study population

On assessing the severity of depression using PHQ-9, most of the patients had mild depression, (31.5%) followed by moderately severe depression (28.8%) [Table 4].

Table 4

Severity of depression on PHQ-9 scale

On assessing the depression severity among various dermatological diseases, most of the patients with psoriasis had moderately severe and severe depression. In patients with eczema, many had moderately severe depression. Among those who were diagnosed with acne, most of them had mild depression [Table 5 and Figure 1].

Table 5

Distribution of severity of depression in dermatological conditions

Figure 1

Patient Health Questionnaire-9 depression severity

On assessing the relation between duration of the disease and total Skindex-29 score, most of the patients with duration <1-year, were mildly affected (n = 17). Those with duration of the disease between 1 and 5 years, most were moderately affected and among those who have the disease for more than 5 years, many were moderately and severely affected [Table 6].

Table 6

Quality of life (Skindex-29) score distribution according to duration of skin disease

Among the patients with eczema, the quality of life of most of the patients was severely affected, indicating a poor quality of life. Most of them with Psoriasis also scored high in the Skindex-29 score and were moderately and severely affected. The majority with Acne were mild and moderately affected [Table 7 and Figure 2].

Table 7

Quality of life (Skindex-29) in various dermatological conditions

Figure 2

Skindex-29 total score

On assessing of components of quality of life index (Skindex-29) in our sample it was observed that overall dysfunction was notably more marked in emotional sphere and psychosocial functions than the physical symptoms [Table 8 and Figures 3–5].

Table 8

Quality of life in various domains of Skindex-29

Figure 3

Skindex-29 emotional sphere (10-item)

Figure 5

Skindex-29 psychosocial functioning (12-item)

Skindex-29 physical symptoms (7-item)

Discussion

Individuals with chronic skin diseases may suffer from psychiatric disorders in particular the mood disorders; this would have further impact on the quality of life of the patient. Although studies aimed at estimating the extent of their symptoms have been conducted in advanced societies, the quality of life for patients with skin disease in developing countries continued to be a major problem because related issues have not been adequately addressed.[20]

This study is an attempt to strengthen the concept of psychocutaneous disorders and to evaluate the effect of skin disease on the quality of life of the patients. In our study, the most common diagnosis was acne, followed by eczema and psoriasis. This finding is similar to the finding in a study conducted in a medical college setting in north India by Agarwal et al.,[21] in which eczema and acne were the most common non-infective skin diseases.

In the study population, during the study period, relatively more females (n = 40) attended the OPD than males (n = 33). A similar pattern female to male proportion was found in the study by Kuruvilla et al.,[22] in South India. The more male patient proportion was found in the study conducted by Kar et al.[23] in a Tertiary Care Centre.

Although the majority of the study population had depressive symptoms (89%), most of them had mild depressive symptoms (31.5%). Kim et al.,[24] in his study found that nearly 62.5% of the patients with skin diseases had clinical depression. This difference in the findings could be due to the varying sociodemographic profile of the study population.

On assessing the severity of depression, we found that the severity of depression was more among the patients with eczema and psoriasis than those with acne and other diseases. Our findings were in accordance with the study conducted by Gupta and Gupta[25] in which the score of depression was more in patients with psoriasis than those with acne.

In the majority of the patients with eczema and psoriasis, the quality of life was more affected than those patients with acne. But previous studies conducted by Berg and Lindberg[26] and Aksoy et al.[27] reported that the quality of life of patients with hand eczema was similar to that of patients with acne. This difference in finding could be because of difference in the lesions of eczema considered. In our study, we considered patients with all types of eczema.

On assessing the various domains of quality of life in Skindex-29, we found that the individuals were more affected in the emotional sphere when compared to the psycho-social functioning and physical symptoms. Abolfotouh et al.,[28] in a study also reported that the emotional domain was more affected, which is similar to the current study finding. Among the other two domains, physical symptoms were more affected than functioning which was different from our study finding.

Conclusion

From this study, we can conclude that the duration of dermatological disease had a positive correlation to the quality of life of a patient that is, the longer a patient suffered from a dermatological condition, the poorer the quality of life. It was also observed that having a dermatological disease had a positive correlation for both decreased quality of life and having depression of some severity.

Eczema was the most affected diagnosis in Skindex-29 indicating a poor quality of life followed by psoriasis, acne vulgaris, and seborrheic dermatitis. However, it was found that the depression severity was more in patients suffering from psoriasis followed by eczema, acne vulgaris, and seborrheic dermatitis. In Skindex-29 subscales, the overall dysfunction in the quality of life was notably more marked in the emotional sphere and psychosocial functions than the physical symptoms.

In our experience, a dermatologist who has a good knowledge and awareness of psychiatric diseases can utilize the services of a psychiatrist. This liaison can go a long way in providing a holistic care for the patients.

Limitations

Only the dermatological conditions with more than 3 patients were considered in the study

Patients with age group <15 years of age were not considered

Since the study was focused only on rural population, the findings cannot be generalized

Sociodemographic details of the patients such as age group and literacy were not considered

Co morbid medical conditions such as diabetes and hypertension were not considered.

What is new?

It is now known that the association of psychiatric and dermatologic illness does exist and also is significant among rural population in terms of quality of life.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.