AHMAD ALABDULKAREEM AND NICOLA RALPH
Skin conditions are a significant cause of disease burden globally. Psoriasis has been previously described as a model dermatologic psychosomatic disorder; it is a chronic inflammatory skin disease with a well-documented impact on patients’ psychological wellbeing and results in higher levels of psychopathology when compared to other dermatologic conditions. Due to the paucity of data, there is a need to assess psychological wellbeing in Irish patients with psoriasis. The aim of this paper was to measure the prevalence of anxiety and depression among Irish patients with psoriasis, to correlate psychological morbidity with impact on quality of life, and with disease severity. This study was a cross-sectional study conducted at a tertiary referral hospital in Dublin using the Hospital Anxiety and Depression Scale (HADS) and Dermatology Life Quality Index (DLQI) questionnaires. Disease severity was assessed using Psoriasis Area Severity Index (PASI) scores. In total, 72 patients participated in this study, 38 males and 34 females. Psoriasis worsened quality of life in 79.2% of patients, 45.8% of patients (34.8-57.2%, Cl 95%) were anxious, 20.8% (13-31.57%, Cl 95%) were depressed, and 15.3% (8.8-25.3%, Cl 95%) had comorbid anxiety and depression. Psychological morbidities were strongly correlated with a worse quality of life and were more likely in female and younger patients and in patients on topical treatments. Disease severity was correlated with a worse quality of life but was not associated with psychological morbidities. Overall, there is a considerable need to routinely assess psychological wellbeing in all patients with psoriasis in Ireland. This will allow for comprehensive management and better overall health outcomes.
Globally, skin diseases are ranked as the fourth leading cause of non-fatal disease burden expressed as years lost due to disability1. The contribution of mental health to physical disease burden has been stressed by the World Health Organization as they stated ”there is no health without mental health”2. This is particularly relevant to dermatology where it has been reported that as much as 60% of patients with skin diseases may show evidence of significant mental distress3. Psoriasis has been previously described as a model dermatologic psychosomatic disease where psychological comorbidities are well-documented and are uniformly higher when compared to patients with other forms of skin disease4, 5.
Psoriasis is an immune modulated chronic inflammatory skin condition characterized by thickened, red, scaly lesions affecting 1-3% of the population in Ireland6. Psychodermatological research investigating the complex interplay between the skin and the mind in patients with psoriasis established a bidirectional relationship between the two. Psychological distress triggers disease flares, and worsening psoriasis further distresses patients7, 8. Therefore, the National Institute for Health and Care Excellence recommends routinely assessing psychological well-being in people with chronic skin diseases including psoriasis9.
In view of the paucity of data investigating the extent of the psychological impact of psoriasis on Irish patients, this study was undertaken with aims to measure the prevalence of anxiety and depression among Irish patients, to assess any potential correlations with disease impact on quality of life, and to correlate psychological morbidity with disease severity.
Materials and methods
This study was an observational cross-sectional study conducted at the department of dermatology of a tertiary referral hospital in Dublin. Adult psoriasis patients over the age of 17 attending the department’s general clinics, systemic clinics, dermatology day-centre, and phototherapy units between February and April 2018 were invited to participate. All diagnoses were made by consultant dermatologists and for the purpose of this study their management plan was recorded as either topical, phototherapy, or systemic treatment. Patients with comorbid skin conditions, established psychiatric diagnoses, and patients attending the department’s psychologist-led psychodermatology clinic were excluded. All participants were explained the purpose of this study and informed consent was obtained. This study was approved by the institutional ethics committee.
The Hospital Anxiety and Depression Scale (HADS) questionnaire was used to assess psychological well-being10. The HADS is a screening tool, which has high levels of psychometric validity and reliability, developed to assess the levels of anxiety and depression in patients. It has 14 items; 7 identifying anxiety and 7 for depression. According to the patient’s answer, each item is scored from 0-3 giving a maximum score of 21 for either anxiety or depression. A score of 8/21 has been used as a cutoff point for both anxiety and depression11.
The Dermatology Life Quality Index (DLQI) was used to examine perceived disease severity and disease impact on quality of life. The DLQI has ten questions covering symptoms, embarrassment, self-care, limitations of everyday activities, impact on intimate relationships, and effect of treatment on lifestyle. Each question is scored from 0-3 giving a maximum score of 30 where quality of life is maximally affected12.
Psoriasis Area Severity Index (PASI) scores were documented to objectively account for disease severity. PASI is calculated by assessing the area of skin involved and the severity of disease pathology. Scores range from 0 (no active disease) to 72 (most severe form of psoriasis). A PASI score of more than 10 is considered to be severe psoriasis.
All data obtained was analyzed using Microsoft Excel 2013 software and OpenEpi. Tests used were ANOVA, Student’s t-test, and Pearson’s correlation coefficient. Prevalence rates were reported as percentages.
- Cohort characteristics:
Seventy two psoriasis patients with a mean age of 44.3 years (range, 17-77 years) participated in this study. Thirty eight males (52.8%) and thirty four females (47.2%) were included, of which 31 (43%) were being managed with phototherapy, 23 (32%) were on systemic drugs, and 18 (25%) were on topical agents.
Table 1. Distribution of variables (gender, age, and treatment) among study participants (n=72) and their corresponding rates of psychopathology and mean quality of life (DLQI) scores.
- Psychopathology and impact on quality of life:
Overall rates of psychopathology observed among study participants show that 45.8% of patients scored above the clinical cut-off for anxiety, 20.8% for depression, and 15.3% from both anxiety and depression.
Table 2. Overall rates of psychopathology – defined as a cutoff score of 8/21 or more on the relevant HADS section-among study participants, n=72.
Overall, the mean DLQI score reported was 7.2 (standard deviation, 6.8). Based on DLQI scores, 57 patients (79.2%) stated their quality of life is impaired by their psoriasis. In 23 patients (31.9%), the detrimental effect of psoriasis was not pronounced whereas for the other 34 patients (47.2%) their quality of life was either largely or extremely affected by their disease.
- Influence of demographic variables on psychopathology and quality of life:
Female participants scored more highly in terms of anxiety (47% vs. 44.7, p=0.78) and depression (23.5% vs. 18.4%, p=0.44) and reported a worse mean DLQI quality of life score (8.26 vs. 6.31, p=0.23) when compared to male patients [Table 1]. These findings, however, did not reach statistical significance.
While age did not correlate directly with either total HADS anxiety or depression scores, patients aged 30 and younger had slightly higher rates of anxiety (56.25% vs 42.9%, p=0.28) and depression (25% vs 19.6%, p=0.58) when compared to older patients. Similarly, the younger cohort of patients were more likely to have their quality of life negatively impacted by psoriasis (DLQI score 9 vs. 6.7, p=0.27) [Table 1]. Nevertheless, these differences were not of statistical significance.
Patients’ age was negatively correlated with their perceived disease severity and its impact on their quality of life as measured by DLQI scores, r= -0.2, p=0.08, which approached the level of statistical significance.
Table 3. Correlation study (r coefficient and p value) between quality of life (DLQI) scores and other study variables.
- Association of quality of life with psychological morbidity:
Mean DLQI scores in patients with scores above the clinical cut-off for anxiety on the HADS (mean DLQI = 9, range 0-29) was significantly higher than the mean DLQI scores of patients without (mean DLQI = 5, range 0-24), p=0.02. Likewise, patients above the clinical cut-off for depression on the HADS had higher mean DLQI scores (DLQI = 12, range 0-23) when compared to patients who were not (DLQI = 6, range 0-29), p=0.01. DLQI scores were strongly correlated with both HADS depression scores (r=0.4, p=0.000) and HADS anxiety scores, (r=0.3 p=0.01) [Table 3].
- Associations between disease severity, quality of life, and psychological morbidity:
Overall, mean PASI score among study participants was 4.64 (standard deviation, 4.27) and there was no correlation between PASI scores with neither HADS anxiety nor depression scores. However, PASI scores were strongly correlated with DLQI scores (r=0.4, p=0.002) [Table 3].
As demonstrated in [Table 1], patients with relatively less severe form of the disease managed with topical treatments were much more likely to score above the clinical cut-off for anxiety (66.7%) compared to patients treated with more advanced treatment modalities like phototherapy (45.2%, p=0.06) and systemic agents (30.4%, p=0.000).
Patients managed with systemic agents were also least likely to score above the clinical cut-off for depression (17.4%), however the differences in depression rates when compared to patients on topical treatments (22.2%) or phototherapy (22.5%) were not statistically significant, p=0.5.
Similarly, Patients on systemic agents had the lowest mean DLQI score of 4.52 compared to 9.65 for phototherapy patients and 6.56 in patients on topical treatments, with the differences among the three groups being statistically significant, p=0.018 [Table 1].
This study found that about one in every two Irish patients with psoriasis suffers from anxiety, significantly higher than the European reference values for anxiety among the general public of 14%13. Similarly, about every fifth patient with psoriasis is clinically depressed when compared to only 7% of the population13. A review estimated that about half of all patients with clinical depression suffer from other comorbid mental disorders most commonly anxiety, about 3-4% of the population, which is considerably less than the prevalence rate of 15.3% among Irish patients with psoriasis observed in this study14. These high rates have significant relevance to routine clinical practice given the prevalence of psoriasis in Ireland8.
While it is difficult to interpret previous published research due to the varying inclusion criteria of patients, psychopathology scales used, lack of control groups and dependency on population reference values, a 4994-participant study investigated the prevalence of anxiety and depression among patients with skin diseases across 13 European countries, not including Ireland. It reported an anxiety prevalence rate of 17.2% overall and 22.7% among patients with psoriasis and a depression rate of 10.1% overall and 13.8% in psoriasis patients15. These rates are in accordance with several other studies from different countries that estimated anxiety rates to be between 12%-30% and depression rates of 10-24% among their participants9, 16-19. Despite the partial overlap between those findings and the rates reported in this study, psychological distress among Irish patients appear to be higher. Other studies, however, have reported far higher rates of anxiety and depression of up to 50-80% among their study participants20, 21. While the tertiary population of patients included in this study may –to an extent- explain the higher prevalence of psychological comorbidities, the cross-sectional nature of this study combined with the chronic natural history of psoriasis suggest these findings may be an underestimation.
In this study, higher prevalence of psychopathology has been observed among female participants and in younger patients. Furthermore, there was a negative correlation between age and quality of life scores. While this correlation was only nearing statistical significance (r=-0.2, p=0.08), it highlighted that the younger patient, the more likely they are to suffer a worse quality of life as a result of their psoriasis. The limited number of patients and the slight difference in anxiety and depression rates observed in between the demographic variables of gender and age may have reduced the statistical significance. Nevertheless, these findings are consistent with the majority of published research, which have found that the greater importance placed by young people on their appearances possibly influenced the greater psychological distress caused by their psoriasis 22,23. Therefore, gender and age may both have an influential role in predicting the susceptibility of patients with psoriasis to psychological distress.
The bidirectional relationship between the skin and the mind creates a vicious cycle whereby disease flares and psychological distress are closely intertwined. The associations observed in this study between patients’ subjective perception of disease impact on their quality of life and their psychological wellbeing provide further evidence. While this study did not interview patients and explore their attitudes toward their disease or their coping mechanisms as part of assessing their mental wellbeing, it showed that screening patients for anxiety and depression provides a tool that may help recognize patients whose quality of life is more severely affected as a result of their psoriasis.
Disease severity as measured objectively by area of skin involved and the extent of skin pathology (PASI) was significantly associated with a worse quality of life, however, there was no associations with psychological morbidity. This is consistent with available evidence and it could be due to patients presenting only with a localized yet highly exposed or sensitive area of skin involved, and hence PASI scores would be inappropriately low despite the stigmatizing aesthetic nuisance patients would have among other symptoms24, 25. PASI scores also do not take into account nail involvement which has been associated with more severe forms of the disease and correlated with higher levels of psychological distress26.
In terms of treatments, patients are usually initially managed with topical treatments especially if their disease is localized, hence it may be argued that patients on topical agents are likely the least experienced with disease presentation and have relatively less severe pathology. If lesions become unresponsive and refractory, more advanced treatment modalities include phototherapy or systemic and other biologic therapies are utilized. In this study, a markedly higher rate of anxiety has been observed among patients on topical treatments with about two thirds of patients being above the clinical cutoff for anxiety on the HADS tool when compared to 30.4% of patients managed with systemic drugs. While the same trend has also been seen with depression rates, the differences were not as statistically significant. Similarly, patients on systemic therapy had the lowest mean DLQI score of 4.52 which differed significantly from the mean DLQI scores of 9.65 for patients managed with phototherapy and 6.56 for patients on topical treatments. These findings have been previously highlighted in a study where Spanish patients on systemic drugs had better psychological wellbeing and quality of life compared to patients on topical treatments27. Therefore, higher levels of psychological distress and a worse quality of life may be attributed to the novelty of disease pathology among patients on topical treatments and their possible lack of practical experience with disease flares. This is in contrast to patients on more advanced treatment modalities, who may have possibly developed a degree of acceptance of their disease. Moreover, the nature of the treatments, their efficacies, and their varying delivery methods which affect the amount of time and effort patients’ spend interacting with their disease may all be compounding factors; multiple daily applications of topical agents are often needed compared to a few weeks of phototherapy, or only weekly/biweekly administration of systemic drugs. Overall, there appears to be a role for an early intervention of a psychological nature; a low intensity, brief, psychoeducational intervention offered to everyone upon diagnosis with escalation plans available if needs be. For this to be realized and for patients’ health outcomes to be improved, regular input from clinical psychology through specialist psychodermatology clinics should be incorporated within the standard practice of dermatology.
This study gave an insight as to the extent of the co-occurrence of psychological morbidity and psoriasis among Irish patients and assessed the negative impact this had on quality of life. The sample size was however limited and the cross-sectional nature of this study did not allow for assessing the therapeutic benefits of treatments and their potential effects on mental health. Length-time bias was not a concern given to the natural history of psoriasis however larger scale and longitudinal, qualitative research with patients to assess how psychopathology and attitudes towards disease, can change over time is necessary to better assess the magnitude of psychological comorbidities and how to best manage patients holistically.
Psoriasis is a chronic inflammatory skin condition with significant impact on psychological wellbeing that often goes under-recognized and unassessed. Patients with psoriasis suffering from anxiety and depression have evidently worse quality of life when compared to patients with better mental wellbeing. This study shows that Irish patients also suffer from relatively higher levels of psychological distress when compared to patients elsewhere in Europe. Similarly, female and younger patients appear to be more susceptible to mental distress. Severity of disease pathology was not correlated with psychological morbidities further highlighting the underpinning issues of personal attitudes, coping mechanisms and stigmatization. This study supports available evidence investigating the complex interplay between psoriasis and mental wellbeing, and by extension, quality of life. While the concept of psychodermatology is still evolving, there is a need to incorporate its principles within routine clinical practice.
Ahmad AlAbdulkareem, Royal College of Surgeons in Ireland. Email: firstname.lastname@example.org
Dr Nicola Ralph, Consultant Dermatologist, Mater Misericordiae University Hospital.
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