Anxiety, depression, and suicidal ideation in patients with chronic dermatoses

INTRODUCTION

The skin is the largest organ of our body. Being visible to everyone, a healthy, youthful skin is a source of great pride. However, when affected by a disease, the same skin becomes a great cause of anxiety. Dermatologic disorders, apart from their own morbidity, are always accompanied by psychological stress due to prevalent social stigmas. The affected individual becomes so preoccupied with the disease that he or she may isolate themselves from friends, colleagues, social gatherings, etc., for hiding the disease. Anxiety, irritation, and body dysmorphic disorder become a constant accompaniment, especially in chronic skin ailments. Students lose their interest in their studies, employees in their work, and housewives in their daily activities, due to constant negative thoughts lurking in their minds.

CHRONIC SKIN DISORDERS AND MENTAL HEALTH

All over the globe, chronic skin diseases constitute a major portion of total outpatients. These cutaneous disorders were the fourth leading cause of non-fatal disease burden according to the Global Burden of Disease Study.^[1] Chronic skin disorders, running for years to decades, are linked to considerable psychological distress and psychiatric comorbidity. This further magnifies the quantum of disability in such patients.^[2] Way back in the year 1983, Hughes et al.^[3] studied 196 consecutive dermatologic outpatients and 40 consecutive dermatologic admissions. They applied the general health questionnaire (GHQ) of Goldberg^[4] (1972) and Wakefield Self-Assessment (WSA) Depression scale of Snaith et al.^[5] They were astonished to find that 30% of outpatients and 60% of inpatients obtained a significantly higher GHQ score. Further among these high scores’ patients, 50% in each category also had a high WSA score. Their patients chiefly comprised acne, psoriasis, eczema, and alopecia, most of whom had extensive lesions on exposed parts of the body. This underlines a high prevalence of psychiatric disorders both in dermatologic outpatients and inpatients when compared with the general population or other inpatients, respectively.

Dalgard et al.^[6] conducted an international, multicentral, observational, and cross-sectional study involving the dermatologic outpatients of 13 European countries. Among 3635 patients and 1359 controls, they recorded a significantly higher prevalence of depression (10.1% vs. 4.3%), anxiety disorder (17.2% vs. 11.1%), and suicidal ideation (12.7% vs. 8.3%) when they compared the patients with the controls [Table 1]. Earlier several workers (Cvetkovski et al.,^[7] 2006; Dalgard et al.,^[8] 2008; Onderdijk et al.,^[9] 2013) recorded an increased risk of depression in atopic dermatitis, eczema, acne, and hidradenitis suppurativa.

Psoriasis, which affects 2–4% of the world population and requires long-term treatment that extends to decades, poses another significant psychological challenge. Exacerbations of the disease are well known to be influenced by stressful events. Singh et al.^[10] did a meta-analysis in 18 studies comprising 1,767,583 participants, of whom 330,207 had psoriasis. All aspects of suicidality – ideation, attempts, and completion – were significantly higher in psoriasis patients when compared with the general population. Further, the more the severity of psoriasis, the higher the chances of such an event. Another grim finding of the study revealed that the younger psoriasis patients are especially at a higher risk for suicidal ideation, suicide attempts, and suicide completion. Nicholas and Gooderham^[11] similarly found the relative risk of self-harm in psoriasis patients when compared with healthy controls, which they attributed to biological changes as well as a negative effect of self-image and quality of life.

In comparison to all dermatological conditions (nonmelanoma skin cancers, dermatitis, skin infections, acne, nevi, atopic dermatitis, benign skin tumors, hand eczemas, and psoriasis), Dalgard et al. found psoriasis to have significantly higher suicidal ideation. Liang et al.^[12] believed that psoriasis is an independent risk factor for suicidality. This appears to have been compounded due to the use of certain biologics which themselves have potential adverse psychiatric effects but this is a controversial opinion.^[13]

Allergic disorders such as atopic dermatitis and chronic urticaria similarly affect the psyche of the affected individuals. Atopic dermatitis is known to affect up to 13% of school-going children and 7% of adults.^[14,15] It is another chronic skin ailment accompanied with extreme itching. A depressive state of mind, anxiety disorders, and sleep disturbance are the usual accompaniments in these patients which interfere with their day-to-day activities.^[16] Zachariae et al.^[17] postulated that itch-related sleep impairment causes substantial psychological stress and somatic symptoms, whose severity is directly proportional to the severity of the itch. Pompili et al.^[18] did a systematic review of reports of suicidal ideation, attempts, and suicides among subjects diagnosed with atopic dermatitis and compared to healthy controls or people with other illnesses. They recorded that the mean rate of suicide ideation in atopic dermatitis was 1.84-fold higher, suicide attempts 2.814-fold higher, and significantly more suicidal acts when compared with healthy controls or people with other illnesses. Timonen et al.^[19] in an analysis of 1585 Finnish suicide victims from 1988 to 2000 recorded that 71.8% of atopic dermatitis died from January to June, while 28.2% died from July to December. They concluded that the exacerbation of atopic dermatitis during the spring season increases the risk of suicide from January to June. Kimata^[20] (2006) studied atopic dermatitis aged between 15 and 49 years. He found that the prevalence of suicide ideation in mild disease was 0.21%, 6% in moderate disease while 19.6% in severe atopic dermatitis. The corresponding figure in the healthy controls was 0.08%.

Vitiligo is another significant chronic idiopathic multifactorial disease of melanocyte involving a sizable number of populations. In India, where closed society of villages considers it as a curse/taboo. It causes untold anxiety and hopelessness in the affected individuals. Often, these patients refrain from going to their native places fearing that their discovery of vitiligo will affect the life of their family including the marriage of their children. Hamidizadeh et al.^[21] studied 100 vitiligo patients and recorded that the triad of hopelessness, anxiety, and depression was directly proportional to the duration of the disease. The long-term treatment, lack of consistent effective therapy, and high financial burden compound the stress. The quality of life of such patients is affected by stigma,^[22] lack of self-esteem,^[23] and obstacles in getting job or marriage.^[24] Thus, it is imperative for the treating dermatologist to keep in mind, the psychiatric status of such patients while undertaking the physical treatment. Counseling should be an important part of vitiligo therapy for improving the self-esteem and the quality of life, which may, in turn, have a positive influence on the outcome of the therapy.^[25]

CONCLUSION

Chronic skin disorders, by virtue of their tortuous course of remissions and exacerbations, grossly affect the psychological state of the patient. The cosmetic aspect of the illness creates a further deterioration in the fragile balance of the mental equilibrium. Thus, the quality of life of the affected individual suffers a dual setback of pathological and psychological illness. This myriad of symptoms needs to be simultaneously dealt with along with the management of the primary cutaneous disorder. A swift and targeted management for the skin disease along with effective counseling and therapy sessions can greatly reduce the psychiatric morbidity and mortality.