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Salari N, Heidarian P, Hosseinian-Far A, Babajani F, Mohammadi M. Global Prevalence of Anxiety, Depression, and Stress Among Patients with Skin Diseases: A Systematic Review and Meta-analysis. JOURNAL OF PREVENTION (2022) 2024; 45:611-649. [PMID: 38822990 DOI: 10.1007/s10935-024-00784-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/13/2024] [Indexed: 06/03/2024]
Abstract
The changes in human lifestyle over the past few decades have impacted the prevalence of skin diseases within different societies. Skin diseases may result in various physical and mental disorders. The most common mental disorders observed among the patients are stress, anxiety, and depression. This study aims to investigate the global prevalence of anxiety, depression, and stress in patients with skin diseases. In this Systematic Review and Meta-Analysis study, the PubMed, Scopus, Science Direct, Embase, Web of science, and Google Scholar repositories were searched without a lower time limit. Heterogeneity among the identified studies was examined using the I2 index, and accordingly random effects model was adopted for analysis. Data analysis was conducted within the Comprehensive Meta-Analysis software (v. 2). In total, 113 studies were included for the final analysis. The overall pooled prevalence of stress, depression, and anxiety in skin disease patients was found to be 39.4%, 27.2% and 28.8%, respectively. Among patients with psoriasis, acne, vitiligo or atopic dermatitis diseases, the highest number of patients suffering from stress was related to patients with acne (75.7%). The highest prevalence of depression, and anxiety was reported in patients with vitiligo (38.3%) and acne (36.5%), respectively. Considering the high prevalence of mental disorders among patients with skin diseases and recognising the impacts of mental health challenges on patients' well-being, the findings of this study provide valuable insights for identifying specific populations that require targeted interventions for the diagnosis, treatment, and prevention of mental illnesses. Accordingly, healthcare policymakers should incorporate psychological treatment and support measures as integral components of comprehensive care strategies for patients with skin diseases.
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Affiliation(s)
- Nader Salari
- Department of Biostatistics, School of Health, Kermanshah University of Medical Sciences, Kermanshah, Iran
- Sleep Disorders Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Pegah Heidarian
- Student Research Committee, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Amin Hosseinian-Far
- Department of Business Analytics & Systems, University of Hertfordshire, Hatfield, AL10 9EU, UK
| | - Fateme Babajani
- Department of Clinical Psychology, Faculty of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Masoud Mohammadi
- Research Center for Non-Communicable Diseases, Jahrom University of Medical Sciences, Jahrom, Iran.
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Depression among people with chronic skin disease at Boru Meda Hospital in Northeast Ethiopia. PLoS One 2023; 18:e0282022. [PMID: 36827301 PMCID: PMC9955985 DOI: 10.1371/journal.pone.0282022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 02/06/2023] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND The comorbidity of depression with chronic skin disease negatively affects the quality of life and disease prognosis, creating an immense burden on patients, families, and the wider community. However, there are limited studies conducted on the prevalence of depression and associated factors among people with chronic skin disease in Ethiopia. OBJECTIVE This study aimed to assess the prevalence and associated factors of depression among people with chronic skin disease at Boru Meda Hospital, Northeast Ethiopia. METHODS An institutional-based cross-sectional study was carried out from March 10- April 18, 2021, among a total of 381 people with chronic skin disease. The Patient Health Questioner-9 was used to assess depression. A logistic regression analysis model with an adjusted odds ratio was used to assess the strength of associations between the outcome and predictor variables. P-value < 0.05 was considered statistically significant. RESULT The magnitude of depression among people with chronic skin disease was 23.6% (95%Cl: 19.8%, 28.6%). We identified significantly increased odds of depression among participants with rural residence (AOR = 3.45, 95% CI: 1.64, 7.28), duration of illness above 5 years (AOR = 3.59, 95% CI: 1.31, 9.85), comorbid medical illness AOR = 2.51, 95% CI: 1.06, 5.98), family history of mental illness (AOR = 3.39, 95% CI: 1.11, 10.41), non-adherence to chronic skin disease medications (AOR = 3.53, 95% CI: 1.20, 10.41), low self-image (AOR = 4.69, 95% CI: 2.25, 9.77), and perceived stigma (AOR = 4.61, 95% CI: 2.14, 9.92). CONCLUSION Depression was common among patients with chronic skin diseases. This study has indicated a need for proper screening of depression in the current medical treatment of patients with chronic skin disease in Boru Meda Hospital, Northeast Ethiopia.
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Geetha AA, Abdul Latheef EN, Sukumarakurup S, Devi K, Jafferany M. Psychiatric morbidity, stress and quality of life among geriatric dermatology patients: Therapeutic considerations from an Indian perspective. Dermatol Ther 2021; 34:e15018. [PMID: 34076335 DOI: 10.1111/dth.15018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 02/23/2021] [Accepted: 05/31/2021] [Indexed: 12/24/2022]
Abstract
We aimed to determine the prevalence of psychiatric morbidities, stress and quality of life, the pattern of skin diseases and associated psychosocial factors in geriatric population. Patients aged 60 years and older were recruited. Demographics and dermatological history and findings were collected using a preset Proforma. Geriatric depression scale (GDS), hospital anxiety and depression scale (HADS), perceived stress scale (PSS), and dermatology life quality index (DLQI) were instituted in all the patients. A total of 310 patients were included in the study, 173 males and 137 females. Infectious diseases (39.6%), papulosquamous diseases (17.1%), and eczema (15.5%) were common disorders. 45.5% were depressed and 43.2% had anxiety (hospital anxiety and depression scale). 55.8% had depression (geriatric depression rating scale), 20.3% had high stress and 11% had extremely large effect on DLQI. Divorced/widowed patients experienced more depression (p = 0.037) and had more impairment in quality of life (p = 0.05). Patients living in three generation family experienced more impairment in quality of life (p = 0.000). Our study demonstrated high prevalence of psychiatric morbidities in geriatric dermatology patients. It implies the need of special care with more attention to psychiatric co morbidities. The role of psychiatry-dermatology liaison clinic may benefit these patients.
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Affiliation(s)
| | | | | | | | - Mohammad Jafferany
- Department of Psychiatry, Central Michigan University, Saginaw, Michigan, USA
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Ducoulombier V, Chiquet R, Graf S, Leroy B, Bouquet G, Verdun S, Martellier F, Versavel A, Kone A, Lacroix K, Duthoit D, Lenglet Q, Devaux A, Jeanson R, Lefebvre A, Coviaux B, Calais G, Grimbert A, Ledein M, Moukagni M, Pascart T, Houvenagel E. Usefulness of a Visual Analog Scale for Measuring Anxiety in Hospitalized Patients Experiencing Pain: A Multicenter Cross-Sectional Study. Pain Manag Nurs 2020; 21:572-578. [PMID: 32362472 DOI: 10.1016/j.pmn.2020.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 01/08/2020] [Accepted: 03/11/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Anxiety is common in hospitalized patients and can worsen pain or lead to unsuccessful pain relief. AIMS The purpose of this study was to evaluate the usefulness of measuring anxiety with a visual analog scale (VAS) in the hospitalized patient experiencing pain. DESIGN We conducted a multiple-center cross-sectional study. PARTICIPANTS/SUBJECTS Adult inpatients experiencing moderate to severe pain defined by a pain VAS score ≥40 of 100 were included. METHODS Pain and anxiety data were collected using the following instruments: pain VAS, anxiety VAS, State Anxiety Scale of the Spielberger State-Trait Anxiety Inventory (STAI-YA) and Anxiety Subscale of the Hospital Anxiety and Depression Scale (HAD-A). RESULTS Data were collected from 394 patients. Of those patients, 43.6% (171 of 392) and 36.6% (143 of 391) had significant anxiety according to STAI-Ya and HAD-A, respectively. Correlation was good between anxiety-VAS and STAI-YA (ρ = 0.67 [95% confidence interval 0.61-0.72]) and moderate between anxiety VAS and HAD-D (ρ = 0.48 [0.39-0.56]). The main factor predictive of situational anxiety was history of anxiety-depression symptoms (odds ratio = 2.95 [1.93-4.56]). For anxiety VAS score ≥ 40 of 100, the sensitivity for detecting anxiety was 81% with 70% specificity. CONCLUSION This study confirmed the high prevalence of anxiety among inpatients experiencing pain, demonstrated the capacity of a VAS to assess this anxiety, determined an anxiety VAS cutoff level to screen for significant anxiety, and identified risk factors of anxiety in this population. Anxiety VAS has been found to be an easy-to-use method familiar to caregivers, with all the advantages needed for an effective screening instrument. An anxiety VAS score ≥40 of 100 would thus warrant particular attention to adapt care to the patient's anxiety-related pain and initiate specific therapeutic interventions.
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Affiliation(s)
- Vincent Ducoulombier
- Department of Rheumatology, Saint-Philibert Catholic Hospital, University of Lille, Lomme, France.
| | - Roman Chiquet
- Pain Center, Saint-Vincent Catholic Hospital, University of Lille, Lille, France
| | - Sahara Graf
- Lille Catholic hospitals, Biostatistics Department-Delegation for Clinical Research and Innovation, Lille Catholic University, Lille, France
| | - Bernard Leroy
- Pain Center, Roubaix Hospital Center, Roubaix, France
| | - Guillaume Bouquet
- Department of Palliative Care, Tourcoing Hospital Center, Tourcoing, France
| | - Stéphane Verdun
- Lille Catholic hospitals, Biostatistics Department-Delegation for Clinical Research and Innovation, Lille Catholic University, Lille, France
| | - Fabienne Martellier
- Pain Center, Saint-Vincent Catholic Hospital, University of Lille, Lille, France
| | - Adeline Versavel
- Pain Center, Saint-Vincent Catholic Hospital, University of Lille, Lille, France
| | - Alexandre Kone
- Department of Anesthésia, Sainte-Marie Catholic Hospital, University of Lille, Cambrai, France
| | - Karine Lacroix
- Department of Pharmacy, Sainte-Marie Catholic Hospital, University of Lille, Cambrai, France
| | - Didier Duthoit
- Public Mental Health Institution of Lille Metropole, Saint-André-lez-Lille, France
| | - Quentin Lenglet
- Public Mental Health Institution of Lille Metropole, Saint-André-lez-Lille, France
| | - Amelie Devaux
- Public Mental Health Institution of Lille Agglomeration, Armentières, France
| | - Robert Jeanson
- Public Mental Health Institution of Lille Agglomeration, Armentières, France
| | - Antoine Lefebvre
- Department of Pharmacy, Saint-Philibert Catholic Hospital, University of Lille, Lomme, France
| | - Benoit Coviaux
- Department of Psychiatry, Saint-Vincent Catholic Hospital, University of Lille, Lille, France
| | - Gauthier Calais
- Department of Neurology, Saint-Vincent Catholic Hospital, University of Lille, Lille, France
| | - Adeline Grimbert
- Geriatrics Unit, Saint-Vincent Catholic Hospital, University of Lille, Lille, France
| | - Marie Ledein
- Department of Intensive Care, Saint-Philibert Catholic Hospital, University of Lille, Lomme, France
| | - Marie Moukagni
- Pediatrics Department, Saint-Vincent Catholic Hospital, University of Lille, Lille, France
| | - Tristan Pascart
- Department of Rheumatology, Saint-Philibert Catholic Hospital, University of Lille, Lomme, France
| | - Eric Houvenagel
- Department of Rheumatology, Saint-Philibert Catholic Hospital, University of Lille, Lomme, France
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Tian Z, Huang Y, Yue T, Zhou J, Tao L, Han L, Yan K, Huang Q, Zhang Z, Shao C. A Chinese cross-sectional study on depression and anxiety symptoms in patients with psoriasis vulgaris. PSYCHOL HEALTH MED 2018; 24:269-280. [PMID: 30293440 DOI: 10.1080/13548506.2018.1529323] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Previous studies have reported a higher incidence of depression and anxiety in psoriasis patients compared to the general population, which has important implications for assessment and treatment. In this study, we determined the frequency of depression and anxiety in Chinese patients with psoriasis and its relationship with disease severity and other demographic variables. The study included 208 Chinese patients with psoriasis vulgaris. The Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder scale (GAD-7) were used to screen for depression and anxiety. The Psoriasis Area and Severity Index (PASI) was used to assess the severity of psoriasis. Of the 208 patients included in the study, 29 patients (13.9%) were positive for moderate-to-severe depression (PHQ-9 ≥ 10) and 22 patients (10.6%) were positive for anxiety (GAD-7 ≥ 10) symptoms. Both positive stress reactors who perceived stress as an exacerbating factor of psoriasis and moderate-to-severe psoriasis were found to be positive predictors for the presence of moderate-to-severe depression or anxiety symptoms while longer duration and late onset age played a protective role. In the sample of Chinese patients with psoriasis there was a clinically significant prevalence of depression and anxiety. Our study suggests that Chinese psoriasis patients should be screened for psychiatric comorbidities.
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Affiliation(s)
- Zhen Tian
- a Department of Dermatology,Huashan Hospital , Shanghai Medical College of Fudan University , Shanghai , China
| | - Yike Huang
- a Department of Dermatology,Huashan Hospital , Shanghai Medical College of Fudan University , Shanghai , China
| | - Tao Yue
- b Department of Rheumatology , Shanghai Guanghua Integrative Medicine Hospital , Shanghai , China
| | - Jiaqing Zhou
- a Department of Dermatology,Huashan Hospital , Shanghai Medical College of Fudan University , Shanghai , China
| | - Lu Tao
- a Department of Dermatology,Huashan Hospital , Shanghai Medical College of Fudan University , Shanghai , China
| | - Ling Han
- a Department of Dermatology,Huashan Hospital , Shanghai Medical College of Fudan University , Shanghai , China
| | - Kexiang Yan
- a Department of Dermatology,Huashan Hospital , Shanghai Medical College of Fudan University , Shanghai , China
| | - Qiong Huang
- a Department of Dermatology,Huashan Hospital , Shanghai Medical College of Fudan University , Shanghai , China
| | - Zhenghua Zhang
- a Department of Dermatology,Huashan Hospital , Shanghai Medical College of Fudan University , Shanghai , China
| | - Chunhong Shao
- c Department of Psychiatry,Huashan Hospital , Shanghai Medical College of Fudan University , Shanghai , China
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Dixon LJ, Witcraft SM, Perry MM. How Does Anxiety Affect Adults with Skin Disease? Examining the Indirect Effect of Anxiety Symptoms on Impairment Through Anxiety Sensitivity. COGNITIVE THERAPY AND RESEARCH 2018. [DOI: 10.1007/s10608-018-9942-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Yanzón de la Torre A, Oliva N, Echevarrieta PL, Pérez BG, Caporusso GB, Titaro AJ, Todaro Kicyla A, Cuatz M, Locatelli M, Nelson LM, Mac Mullen M, Baldessarini RJ, Daray FM. Major depression in hospitalized Argentine general medical patients: Prevalence and risk factors. J Affect Disord 2016; 197:36-42. [PMID: 26967917 DOI: 10.1016/j.jad.2016.02.066] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2015] [Revised: 02/23/2016] [Accepted: 02/28/2016] [Indexed: 01/07/2023]
Abstract
BACKGROUND Depression is not uncommon among medically hospitalized patients, though reported prevalence has varied widely, often in samples involving elderly patients with particular illnesses. Accordingly, we evaluated risk of major depression in three metropolitan general hospitals in Buenos Aires, in subjects with a range of medical disorders and ages, comparing several standard screening methods to expert clinical examinations. METHODS Consecutively hospitalized general medical patients were evaluated over a six-months. Excluded were subjects under age 18 and those unable to participate in assessments because of illness, medication, sensory or speech impairment, or lack of language fluency, or scored <25 on the Mini Mental State Examination (MMSE). Consenting participants were examined for DSM-IV-TR major depression by psychiatrists guided by MINI examinations, compared with other standard screening methods. Risk factors were assessed by preliminary bivariate analyses followed by multivariate logistic regression modeling. RESULTS Overall prevalence of major depression in 257 subjects was 27% by psychiatric examination. The rate was most similar (25%) with the Hospital Anxiety & Depression Scale (HADS), and much higher with the Beck Depression Inventory-II (BDI, 44%) and Patient Health Questionnaire (PHQ, 56%). Factors associated independently with depression by multivariate modeling included: prior psychotropic-drug treatment, female sex, more children, and heavy smoking. Depression was associated most with neoplastic, urological, and infectious disorders, least with pulmonary, neurological, and hematologic conditions. LIMITATIONS Modest numbers limited power to test for associations of depression with specific medical conditions. CONCLUSIONS Major depression was identified in over one-quarter of Argentine, general medical inpatients, with marked differences among screening methods. Several risk factors were identified. The findings encourage assertive identification of depression in hospitalized medical patients using valid, reliable, and cost-effective means of improving their care.
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Affiliation(s)
| | - Nicolás Oliva
- Hospital General de Agudos Bernardino Rivadavia, CABA, Argentina
| | | | - Bibiana G Pérez
- Hospital Municipal Bernardo A. Houssay, Vicente López, Buenos Aires, Argentina
| | | | - Anabella J Titaro
- Hospital Interzonal De Agudos Eva Perón, San Martín, Buenos Aires, Argentina
| | | | - Mariana Cuatz
- Instituto de Farmacología, Facultad de Medicina, Universidad de Buenos Aires, Argentina
| | | | - Lucila M Nelson
- Hospital General de Agudos Bernardino Rivadavia, CABA, Argentina
| | - Mercedes Mac Mullen
- Instituto de Farmacología, Facultad de Medicina, Universidad de Buenos Aires, Argentina
| | - Ross J Baldessarini
- International Consortium for Mood & Psychotic Disorders Research, McLean Hospital, Harvard Medical School, Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Federico M Daray
- Instituto de Farmacología, Facultad de Medicina, Universidad de Buenos Aires, Argentina; Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Buenos Aires, Argentina.
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Dixon LJ, Lee AA, Viana AG, McCowan NK, Brodell RT, Tull MT. Anxiety Sensitivity in Dermatological Patients. PSYCHOSOMATICS 2016; 57:498-504. [PMID: 27137710 DOI: 10.1016/j.psym.2016.03.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 03/01/2016] [Accepted: 03/03/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Anxiety symptoms commonly occur in dermatological patients and can affect the severity of dermatological symptoms. Anxiety sensitivity (AS), defined as the fear of anxiety symptoms, is a well-supported cognitive vulnerability factor that may be particularly significant in these patients. OBJECTIVE This study compared the severity of AS between patients with psychodermatological (e.g., psoriasis) and nonpsychodermatological disorders (e.g., skin cancer). It was predicted that individuals with psychodermatological disorders would evidence significantly greater AS compared to individuals with nonpsychodermatological disorders. METHOD Adults presenting to outpatient dermatology clinics with psychodermatological (n = 63) and nonpsychodermatological (n = 52) conditions completed self-report questionnaires assessing sociodemographic characteristics, general anxiety, and AS. RESULTS Individuals with psychodermatological conditions reported significantly greater AS compared to individuals with nonpsychodermatological conditions (p < 0.05). Social concerns of AS emerged as the only significant factor that differentiated these categories of dermatological diseases, odds ratio = 1.13, 95% CI: 1.02-1.24, after adjusting for general anxiety. CONCLUSIONS These findings contribute to an advancing area of research linking AS and physical health problems. The results suggest that adjunctive cognitive-behavioral treatments targeting AS reductions could help patients with psychodermatological conditions.
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Affiliation(s)
- Laura J Dixon
- Department of Psychiatry and Human Behavior, University of Mississippi Medical Center, Jackson, MS.
| | - Aaron A Lee
- Department of Psychology, University of Wyoming, Laramie, WY
| | - Andres G Viana
- Department of Psychology, University of Houston, Houston, TX
| | - Nancye K McCowan
- Department of Dermatology, University of Mississippi Medical Center, Jackson, MS
| | - Robert T Brodell
- Department of Dermatology, University of Mississippi Medical Center, Jackson, MS
| | - Matthew T Tull
- Department of Psychiatry and Human Behavior, University of Mississippi Medical Center, Jackson, MS
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Lakshmy S, Balasundaram S, Sarkar S, Audhya M, Subramaniam E. A Cross-sectional Study of Prevalence and Implications of Depression and Anxiety in Psoriasis. Indian J Psychol Med 2015; 37:434-40. [PMID: 26702177 PMCID: PMC4676211 DOI: 10.4103/0253-7176.168587] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Physical and mental comorbidity is common and has significant implications for overall health outcomes. Psoriasis, a psychocutaneous disorder, is a classic example of mental-physical comorbidity. AIMS In view of the impact of socio-cultural influences on mind-body interactions and the paucity of Indian research pertaining to psychiatric morbidity in psoriatic patients, this study was undertaken to measure the prevalence of anxiety and depression in patients with psoriasis, and to correlate these with severity of psoriasis and quality of life. MATERIALS AND METHODS This cross-sectional study was conducted on 90 consecutive patients of psoriasis, over a period of 12 months, in a tertiary care centre. The Psoriasis Area and Severity Index was used to assess severity of psoriasis. PHQ-9, GAD-7 and the Perceived Stress Scale were used to screen for depression, anxiety and perceived stress respectively. The WHOQOL-BREF was used to determine the quality of life. STATISTICS ANALYSIS All analysis was performed using Microsoft Excel software and Statistical Package for Social Sciences. RESULTS A total of 71 (78.9%) subjects had depression and 69 (76.7%) had anxiety. Fifty one patients had significant stress. A significant positive correlation was established between psoriasis variables (severity and duration of psoriasis) and psychological variables (depression, anxiety and stress). Severity of psoriasis had a significant negative correlation with social relationships and environmental domains of WHOQOL. Quality of life was significantly worse in patients with psoriasis with comorbid anxiety/depression. CONCLUSION Patients with psoriasis have a clinically significant prevalence of depression, anxiety and perceived stress. This study highlights the complex relationship between psoriasis, psychiatric comorbidity and quality of life and the need to simultaneously consider dermatological and psychological factors.
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Affiliation(s)
- Sreelatha Lakshmy
- Department of Psychiatry, Mahatma Gandhi Medical College and Research Institute, Puducherry, India
| | - Sivaprakash Balasundaram
- Department of Psychiatry, Mahatma Gandhi Medical College and Research Institute, Puducherry, India
| | - Sukanto Sarkar
- Department of Psychiatry, Mahatma Gandhi Medical College and Research Institute, Puducherry, India
| | - Moutusi Audhya
- Department of Dermatology, Mahatma Gandhi Medical College and Research Institute, Puducherry, India
| | - Eswaran Subramaniam
- Department of Psychiatry, Mahatma Gandhi Medical College and Research Institute, Puducherry, India
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