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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 16  |  Issue : 3  |  Page : 275-280

Psychiatric disorders among psoriatic patients attending Assiut University Hospital


1 Department of Psychiatry, Faculty of Medicine, Assiut University, Assiut, Egypt
2 Department of Dermatology, Venereology and Andrology, Faculty of Medicine, Assiut University, Assiut, Egypt

Date of Submission10-Aug-2018
Date of Acceptance04-Feb-2019
Date of Web Publication15-Apr-2019

Correspondence Address:
Hisham Diab Gaber
Department of Dermatology, Venereology and Andrology, Faculty of Medicine, Assiut University, Assiut 17515
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AZMJ.AZMJ_80_18

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  Abstract 


Background Psoriasis is an immune-mediated genetically determined common dermatological disorder. Psoriasis has the potential for significant psychological and social morbidity. Depression and anxiety are the most common psychiatric disorders that are associated with psoriasis.
Objective The aim was to evaluate some of the psychiatric disorders especially depression and anxiety among psoriatic patients attending Assiut University Hospital.
Patients and methods This was a cross-sectional study. The sample consisted of 100 psoriatic patients that met the inclusion criteria. All eligible patients were subjected to the following tools: Beck depression inventory, Zung self-rating anxiety scale, psoriasis disability index, and short form-36 quality of life questionnaire.
Results The overall prevalence of depression was 76% among psoriatic patients; 60% of the patients presented with moderate and severe depression and the overall prevalence of anxiety was 79% among psoriatic patients; 66% of the patients presented with marked to severe and most extreme anxiety. There was a significant negative correlation between depression/anxiety and quality of life. There was a significant positive correlation between depression/anxiety and duration of psoriasis. Female sex and long duration of the disease were found to be risk factors for the occurrence of depression and anxiety among psoriatic patients.
Conclusion Depression and anxiety are significantly high among psoriatic patients.

Keywords: anxiety, depression, psoriasis, short form-36


How to cite this article:
Hassan WA, Abdel-Rahman AA, Gaber HD, Hassan KM. Psychiatric disorders among psoriatic patients attending Assiut University Hospital. Al-Azhar Assiut Med J 2018;16:275-80

How to cite this URL:
Hassan WA, Abdel-Rahman AA, Gaber HD, Hassan KM. Psychiatric disorders among psoriatic patients attending Assiut University Hospital. Al-Azhar Assiut Med J [serial online] 2018 [cited 2020 Jul 15];16:275-80. Available from: http://www.azmj.eg.net/text.asp?2018/16/3/275/255862




  Introduction Top


Psoriasis is an immune-mediated genetically determined common dermatological disorder which affects the skin, nails, and joints and has various systemic associations. There is evidence that the disease is associated with a high impact on the health-related quality of life (QOL) and considerable cost [1].

Psoriasis is a persistent, disfiguring, and stigmatizing disease [2] affecting ∼2–3% of the general population [3]. The two age peaks of onset were considered for the disease; the early age of onset is between 16 and 22 years, and the latent age of onset is between 57 and 60 years [4].

Psoriasis makes stress itself, and in turn, stress can worsen psoriasis. However, most psoriatic patients who reported episodes of psoriasis precipitated by stress describe disease-related stress, resulting from the cosmetic disfigurement and social stigma of psoriasis [5].

Psoriasis is associated with a variety of psychological problems. Psoriasis impairs one’s ability in everyday activities requiring the use of hands, walking, sitting, and standing for long periods of time, occupational performance, sexual activities, and sleep. So, considering the psychosocial aspects of the disease is very important in psoriatic patients [5]. In a systematic review it is recorded that the prevalence of depression in psoriatic patients ranged from 9 to 62%, while the prevalence of anxiety ranged from 11 to 43% [6]. On the other hand, psychological stress can induce resistance to regular psoriatic treatment and causes psoriasis to appear worse. In this view, psoriasis is an inflammatory disease with expensive and long-term therapies, and as mentioned before, psychological stress can exacerbate the disease. Therefore, recognition and treatment of psychosocial problems can decrease health-care costs and shorten the therapeutic period [7].

The aim of the study was to evaluate some of the psychiatric disorders especially depression and anxiety among psoriatic patients attending Assiut University Hospital (AUH).


  Patients and methods Top


Patients

This study is a cross-sectional study which included 100 psoriatic patients (65 men and 35 women) who attended the Dermatology Department (Ultra-Violet Unit and Out-Patient Clinics) of AUH from 1 July 2016 to 31 May 2017.

Psoriatic patients had been chosen from both sexes, their ages were from 18 to 65 years, had greater than 10% body surface area involvement, as determined by a dermatology physician using the psoriasis area severity index [8].

Methodology

All eligible patients were subjected to the following tools:
  1. Beck depression inventory (BDI) [9], Arabic version: This inventory was used for measuring depression. It consists of 21 groups of statements on a four-point scale with the subject selecting the one that best matches the patient’s current state. Each statement group corresponding to a specific behavioral manifestation response is scored as 0–3, corresponding to no, mild, moderate, or severe depressive symptomatology in the response. The score range varies from 0 to 63, where higher scores indicate greater depression severity. Scores in the range of 0–13 indicate no or minimal depression; 14–19, mild depression; 20–28, moderate depression; and 29–63, severe depression.
  2. Zung self-rating anxiety scale [10],[11]: This scale was used for measuring anxiety. It is a 20-statement self-rated scale for the assessment of anxiety in adults. Each one is a positive or negative statement that relates to some of the symptoms of anxiety. The patients are expected to answer these questions on their own by selecting any one of the following four answers: a little of the time − some of the time − a good part of the time − most of the time. The rating scale is scored from 1 to 4 points. Most answers go in the order of 1 (a little of the time) to 4 (most of the time). However, questions 5, 9, 13, 17, and 19 are scored in the opposite order, since they represent positive/non-anxiety statements. Scores below 45–normal range anxiety; 45–59–mild to moderate anxiety; 60–74–marked to severe anxiety; 75 and over − most extreme anxiety.
  3. Psoriasis disability index (PDI) [12]: The PDI is a widely used instrument to measure the impact of psoriasis on patients [12]. It is self-explanatory and can be handed to the patient who is asked to fill it in without the need for a detailed explanation. The PDI can be analyzed under five headings as follows: daily activities: questions 1, 2, 3, 4, and 5; work or school: questions 6, 7, and 8; personal relationship: questions 9 and 10; leisure: questions 11, 12, 13, and 14; and treatment: question 15.
    • The scoring of each question is answered in a series of four answers; not at all (scores 0), a little (scores 1), a lot (scores 2), and very much (scores 3).
    • The PDI is calculated by summing the score of each of the 15 questions resulting in a maximum of 45 and a minimum of 0. The higher the score, the more QOL is impaired and can also be expressed as a percentage of the maximum possible score of 45.
  4. Short form-36 quality of life questionnaire (SF-36) [13]: the SF-36 was designed as a generic indicator of health status for use in population surveys and evaluative the studies of health policy. It can also be used in conjunction with disease-specific measures as an outcome measure in clinical practice and research. As a generic instrument, the SF-36 was designed to be applicable to a wide range of types and severity of conditions. It is a useful instrument for monitoring patients with multiple conditions, for comparing the health status of patients with different conditions, and for comparing patients with the general population.


The SF-36 includes 36 items, in a Likert-type or forced-choice format, intended to measure the following eight dimensions; scores for each domain range from 0 to 100, with high scores indicating a better status [14].

Statistical analysis

Data entry and data analysis were done using the Statistical Package for the Social Sciences (SPSS, version 19; IBM SPSS; SPSS Inc., NY, USA). Data were presented as a number, percentage, mean, and SD. Mann–Whitney test was used to compare the quantitative variables between two groups and Kruskal–Wallis test for more than two groups in case of nonparametric data. Spearman’s correlation was done to measure the correlation between quantitative variables. Multiple logistic regression is used to model nominal outcome variables, in which the log odds of the outcomes are modeled as a linear combination of the predictor variables. The P value is considered statistically significant when P is less than 0.05.

Odds ratio is a way to quantify how strongly the presence or absence of property A is associated with the presence or absence of property B in a given population.

Ethical considerations

The protocol and study design of this thesis were approved by the ethics committee in the Faculty of Medicine, Assiut University. An informed consent was obtained from all the participants.


  Results Top


One hundred psoriatic patients were recruited for the study, with the mean age of 42.10±13.86 years, 65% were men, whereas 35% were women. The mean of depression among the psoriatic patients was significantly higher among divorced and widowed compared with single and married patients. The mean duration of psoriasis was 8.02±5.11 years. Of the patients, 64% had a disease duration of less than 10 years while 36% of the patients had a disease duration of equal to or more than 10 years ([Table 1]).
Table 1 Demographic characteristics of the studied sample

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The mean score of BDI in the studied sample was 24.55±10.27 (9.0–43.0) with 60% of the patients presented with moderate and severe depression, whereas 24% show no depression ([Table 2]).
Table 2 Frequency of severity of depression in the studied sample according to Beck depression inventory

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The mean score of Zung anxiety scale in the studied sample was 60.70±14.10 (34.0–85.0) with 66% of the patients presented with marked to severe and most extreme anxiety level, whereas 21% show no anxiety ([Table 3]).
Table 3 Frequency of severity of anxiety in the studied sample according to Zung anxiety scale

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There was a statistically significant positive correlation between BDI, Zung anxiety scale, and PDI in the studied sample ([Table 4]). Also, we found a statistically significant positive correlation between the duration of psoriasis and BDI, Zung anxiety scale, and PDI (i.e. there was a higher cumulative probability for psoriatic patients with longer duration of psoriasis to have depression, anxiety, and higher disability) ([Table 5]).
Table 4 Correlations among Beck depression inventory, Zung anxiety scale, and psoriasis disability index in the studied sample

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Table 5 Correlation between duration of psoriasis and Beck depression inventory, Zung anxiety scale, and psoriasis disability index in the studied sample

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This study showed a statistically significant negative correlation between Zung anxiety scale, BDI, and all subscales of SF-36 (quality of life questionnaire) ([Table 6]). The logistic regression model of developing depression and anxiety was significantly higher among the female sex (odds ratio: 4.31 and 2.25, respectively) ([Table 7] and [Table 8]).
Table 6 Correlation between short form-36 subscales scores and Beck depression inventory, Zung anxiety scale, and psoriasis disability index in the studied sample

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Table 7 The risk factors for depression in the studied sample

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Table 8 Risk factors for anxiety (Zung) in the studied sample

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  Discussion Top


Psoriasis affects patients socially, emotionally, and professionally [15]. The prevalence of mental disorders was four times higher in patients with psoriasis than in patients with other skin diseases [16]. With respect to marital state, the mean of depression among psoriatic patients was significantly higher among divorced and widowed compared with single and married patients. These findings are in partial agreement with one study (studied the prevalence of depression in 1407 Black women recruited through the National Black Women’s Health Project) in USA which illustrated that single and divorced women show significantly higher levels of depression compared with women who were married [17]. It is possible that the huge burden of physical illness in the absence of a supportive partner, together with the social burden in our community, contributes toward the higher mean of depression among the divorced and the widowed.

The duration of illness in psoriatic patients in this study ranges from 1 to 22 years, with a mean of 8.02±5.11 years, which is in agreement with another study that was conducted in Egypt that showed the duration of illness in psoriatic patients to range from 1 to 28 years, with a mean of 9.3±7.97 years [18].

In the present study, we found an overall prevalence of depression of 76% in patients with psoriasis, of which 60% had moderate and severe depression that would require psychiatric intervention. In a similar study, the BDI was 67% in psoriatic patients [5]. When the BDI scores were assessed on the basis of mild, moderate, and severe depression, we found that 16% of the patients with psoriasis had scores corresponding to mild depression, 18% to moderate depression, and 42% to severe depression. This is in agreement with another study which was carried out in Egypt where it revealed that 16.7% of the patients with psoriasis had scores corresponding to mild depression, 16.7% to moderate depression, and 43.3% to severe depression [19]. Other study carried out on 100 psoriatic patients revealed that 40% psoriatic patients had severe depression on BDI, 19% had moderate depression, and 19% had mild depression. Depression was absent in 22% [7].

Moreover, in a pilot study on psychiatric morbidity of psoriasis, it was described that 90% of psoriatic patients had some depression. It revealed that 68% of the psoriatic patients had mild depression, 18% had moderate depression, 4% had severe depression, and 10% had minimal or no depression [20].

Compared with other studies carried out on 50 psoriatic patients in Turkey, it did not agree with our results and found that the majority of the patients had scores corresponding to moderate depression (32%) whereas 26% corresponded to severe depression [21]. The difference between the two studies may be interpreted by the different social, educational, and economic factors in addition to the different medical care and the early diagnosis of depression due to the good screening and effective referral system.

In a previous study on the epidemiology of depressive disorders among patients attending the outpatient clinics of AUHs out of the 2304 studied individuals 202 (8.8%) patients were reported to have depressive disorders [22], while in the present study we found the overall prevalence of depression was 76% in psoriatic patients, of which 42% had severe depression that would require psychiatric intervention. That result confirms the high prevalence of depression in psoriatic patients.

The overall prevalence of anxiety disorders among psoriatic patients in this study was 79%. The prevalence of moderate to severe anxiety levels and marked extreme anxiety requiring psychiatric intervention was 66% (15% of psoriatic patients had marked extreme anxiety, 51% moderate to severe anxiety, and 13% minimal to moderate anxiety). This is in partial agreement with the findings of another study which revealed that 45% of psoriatic patients had severe anxiety, 25% moderate anxiety, and 16% had mild anxiety. Anxiety was absent in 14% of cases [7].

Moreover, Akay et al. [20] found that 52% psoriatic patients had mild anxiety, 36% had mild to moderate anxiety, and 12% had moderate to severe anxiety.

The high prevalence of anxiety can be explained by the fact that patients attending the dermatology clinic have significant apprehension about the illness, duration, outcome of treatment, fear of investigations, and anxiety concerning the financial aspects of treatment.

In the present study, there was positive correlation between the duration of psoriasis and the depression score, anxiety score. The findings of the present study agreed with a similar one which revealed that there was a positive correlation between the total duration of psoriasis and the total depression score (r=0.382, P=0.000), anxiety score (r=0.309, P=0.000). The predictive relationship between the duration of psoriasis and the absolute scores of depression and anxiety was statistically significant (P=0.000 and 0.007 in arrangement). Consequently, there is a higher cumulative probability for patients with longer duration of psoriasis to have a severe grade of depression/anxiety [22].

There is convincing evidence that depression and anxiety play an important role in the QOL in psoriatic patients. This study found that there is a statistically significant negative correlation between BDI, Zung anxiety scale, and QOL scale in all its subscales (SF-36). This means that the increase in the severity of depression and anxiety is associated with a decrease in QOL. These findings were consistent with the study carried out on 50 Egyptian psoriatic patients using rating scales for psychopathological health status and QOL scale and found that there is a strong association between psychiatric morbidity and poorer QOL in psoriasis [23].


  Conclusion Top


Psoriasis is a disease with major QOL impairment. There was a significant negative correlation between depression/anxiety and QOL in psoriatic patients. Detection and solving of psychiatric problems may help psoriatic patients in improving their QOL and may improve the treatment effect.

Acknowledgements

Assuit Dermatology Department Conference and Workshop on 18 March 2018, in Assuit and Hurgada.

The article had been read and approved by all authors.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]



 

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