Psychiatric disorders in patients attending a dermatology outpatient clinic

Quality of life and mental health status in patients with lichen planopilaris based on Dermatology Life Quality Index and General Health Questionnaire-28 questionnaires

Background

Lichen planopilaris (LPP) is a relatively uncommon inflammatory skin condition that causes permanent hair loss. Irreversible hair loss can have a significant psychosocial and psychological impact on patients’ lives. Limited studies have assessed the psychological status of patients suffering from LPP, and to our knowledge, none have evaluated patients with LPP as a separate group in this regard.

Objective

This study aimed to assess the quality of life (QoL) and general health of patients with LPP using the Dermatology Life Quality Index (DLQI) questionnaire and General Health Questionnaire-28 (GHQ-28), respectively.

Methods

Our study employed a cross-sectional design. In total, 41 patients with LPP attending the follow-up skin clinic at the Razi Hospital in Tehran, Iran were asked to complete the DLQI and GHQ-28. Furthermore, selected demographic information was obtained from patients to evaluate their association with general health and QoL.

Results

Forty-one patients (14 men and 27 women) with a mean age of 44.02 ± 10.8 years completed both questionnaires. QoL was affected moderately to extremely in 70.7% of patients. Also, 26 patients (63.4%) were at risk for psychological disorders. Lower QoL was reported by patients age <45 years (p < .05). Both QoL and general health had a negative relation with the disease activity index (p < .05), but were not affected by sex, marital status, education level, treatment type, presence of mucous lesions, and disease duration.

Conclusion

LPP significantly affects patients’ QoL and general health. Dermatologists should address these issues in patients with LPP alongside treating physical symptoms.

Anxiety sensitivity and social anxiety in adults with psychodermatological symptoms

Many dermatology patients experience social anxiety symptoms; however, few studies have investigated vulnerabilities contributing to this distress. Anxiety sensitivity (AS), or the fear of the consequences of anxiety, warrants consideration given its association with social anxiety and dermatological symptoms, respectively. The purpose of this investigation was to investigate the role of AS in social anxiety symptoms in two samples of adults with psychodermatological conditions. AS social, but not physical or cognitive, concerns were hypothesized to demonstrate unique associations with social anxiety symptoms after controlling for relevant variables. Participants completed self-report measures online (Study 1) or in-person (Study 2). Study 1 included 164 participants with active skin conditions (M_age = 31.88; 69.5% female; 83.5% White), and Study 2 included 63 dermatology outpatients (M_age = 51.49; 70.7% female; 65% White). Results revealed AS social concerns was a unique factor contributing to social anxiety symptoms in both samples. This study demonstrates replication, and the findings suggest heightened concerns about the negative consequences related to visible skin conditions may worsen social anxiety symptoms in individuals with psychodermatological conditions. Despite limitations, this study informs the conceptualization of co-occurring psychological and dermatological conditions and highlights the need to evaluate the efficacy of brief AS interventions among patients with psychodermatological conditions.

The Brazilian version of Skindex-16 is a valid and reliable instrument to assess the health-related quality of life of patients with skin diseases

INTRODUCTION

The aim of this study was to assess the psychometric properties of the Brazilian version of Skindex-16 in patients with various skin diseases.

METHODS

Dermatologic assessments were performed for the diagnosis and classification of the severity of skin conditions. The clinical feasibility of Skindex-16 was assessed based on the time required to complete the questionnaire and the number of unanswered items. The participants (n = 110) answered the Hospital Anxiety and Depression Scale (HADS), the Dermatology Life Quality Index (DLQI) and the Skindex-16 (Portuguese/Brazil version) questionnaires. Convergent validity was assessed based on the correlation of the Skindex-16 with the DLQI and HADS subscales. Known-groups validity was assessed based on the comparison of the mild, moderate and severe disease groups using the Kruskal-Wallis test. Internal consistency was assessed using Cronbach's alpha and test-retest reproducibility using the intraclass correlation coefficient (ICC) obtained with 29 participants who answered the Skindex-16 a second time 3 to 10 days after the first assessment.

RESULTS

The mean time to answer the questionnaire was 2 min 41 sec. Cronbach's alpha scores were 0.867, 0.930 and 0.888 for the Skindex-16 domains symptoms, emotions and functioning, respectively. The ICCs were 0.947, 0.860 and 0.843 for the Skindex-16 domains symptoms, emotions and functioning, respectively. All three Skindex-16 scales exhibited strong correlations with DLQI. Moderate correlations were found between HADS subscales and the Skindex-16 emotions domain. Known-groups validity showed differences in all three Skindex-16 domains between the mild and moderate skin disease groups (emotions: p < 0.001; symptoms: p = 0.049; functioning: p < 0.001) and between the mild and severe skin disease groups (emotions: p = 0.002; symptoms: p = 0.001; functioning: p = 0.002).

CONCLUSION

The Portuguese/Brazil version of Skindex-16 is a valid and reliable instrument to assess the quality of life of patients with skin diseases.

NK1R/5-HT1AR interaction is related to the regulation of melanogenesis

Substance P (SP) is a candidate mediator along the brain-skin axis and can mimic the effects of stress to regulate melanogenesis. Previously, we and others have found that the regulation of SP for pigmentary function was mediated by neurokinin 1 receptor (NK1R). Emerging evidence has accumulated that psychologic stress can induce dysfunction in the cutaneous serotonin 5-hydroxytryptamine (5-HT)-5-HT1A/1B receptor system, thereby resulting in skin hypopigmentation. Moreover, NK1R and 5-HTR (except 5-HT3) belong to GPCR. The present study aimed at assessing the possible existence of NK1R-5-HTR interactions and related melanogenic functions. Western blot and PCR detection revealed that SP reduced expression of 5-HT1A receptor via the NK1 receptor. Biochemical analyses showed that NK1R and 5-HT1AR could colocalize and interact in a cell and in the skin. When the N terminus of the NK1R protein was removed NK1R surface targeting was prevented, the interaction between NK1R-5-HT1AR decreased, and the depigmentation caused by SP and WAY100635 could be rescued. Importantly, pharmaceutical coadministration of NK1R agonist (SP) and 5-HT1A antagonist (WAY100635) enhanced the NK1-5-HT1A receptor coimmunoprecipitation along with the depigmentary response. SP and WAY100635 cooperation elicited activation of a signaling cascade (the extracellular, regulated protein kinase p-JNK signaling pathway) and inhibition of p70S6K1 phosphorylation and greatly reduced melanin production in vitro and in vivo in mice and zebrafish. Moreover, the SP-induced depigmentation response did not be occur in 5-htr1aa^+/- zebrafish embryos. Taken together, the results of our systemic study increases our knowledge of the roles of NK1R and 5-HT1AR in melanogenesis and provides possible, novel therapeutic strategies for treatment of skin hypo/hyperpigmentation.-Wu, H., Zhao, Y., Huang, Q., Cai, M., Pan, Q., Fu, M., An, X., Xia, Z., Liu, M., Jin, Y., He, L., Shang, J. NK1R/5-HT1AR interaction is related to the regulation of melanogenesis.

Pattern and prevalence of psychiatric disorders among patients attending dermatology OPD

BACKGROUND

Consideration of psychiatric and psychosocial factors is important for the management and prevention of dermatologic disorders. Dermatology patients suffer commonly from psychiatric comorbidity.

AIM

To study pattern and prevalence of psychiatric disorders among patient attending dermatology OPD.

METHODS

The study was carried out in Psychiatry department of NIMS Medical College, Jaipur, Rajasthan, a north State of India. The sample was taken from Dermatology department of Medical College. All the participants were diagnosed/confirmed cases of skin diseases. Socio-demographic data was collected. Patients scoring more than 12 on GHQ were examined for presence of psychiatric illness. Clinical interview & Mental Status Examination (MSE) of these patients was carried out to ascertain diagnosis according to ICD-10.

FINDINGS

As per ICD-10 diagnosis 34.2% of total sample were diagnosed with definite Psychiatric comorbidity. Maximum number of cases were of Depression 36.32% (N=146) followed by Anxiety disorder 18.41% (74) and 7.96% (N=32) with Somatoform disorder. Obsessive compulsive disorder was diagnosed in 6.47% (N=26) followed by Adjustment disorder 4.98% (N=20) and Alcohol dependence syndrome 4.98% (N=20). Minimum number of cases belonged to Schizophrenia 2.99% (N=12) and Bipolar Affective Disorder 2.99% (N=12). No diagnosis was found in 14.93% (N=60).

CONCLUSION

Significant psychiatric comorbidity exists in patients of dermatology. Biopsychosocial approach to patients with skin disease should be sought by liaison between psychiatrist and dermatologist.

Evaluation of fatigue and its correlation with quality of life index, anxiety symptoms, depression and activity of disease in patients with psoriatic arthritis

Background

Psoriatic arthritis is associated with psychosocial morbidity and decrease in quality of life. Psychiatric comorbidity also plays an important role in the impairment of quality of life and onset of fatigue.

Objectives

This study aimed to assess the prevalence of fatigue in psoriatic arthritis patients and to correlate it to quality of life indexes, functional capacity, anxiety, depression and disease activity.

Patients and methods

This cross-sectional study was performed on outpatients with psoriatic arthritis. Functional Assessment of Chronic Illness Therapy – Fatigue (FACIT-F; version 4) was used to measure fatigue; 36-Item Short Form Health Survey (SF-36) and Psoriasis Disability Index (PDI) to measure quality of life; Health Assessment Questionnaire (HAQ) to assess functional capacity; Hospital Anxiety and Depression (HAD) scale to measure anxiety and depression symptoms; Psoriasis Area and Severity Index (PASI), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and Clinical Disease Activity Index (CDAI) to evaluate clinical activity.

Results

In all, 101 patients with mean age of 50.77 years were included. The mean PDI score was 8.01; PASI score, 9.88; BASDAI score, 3.59; HAQ score, 0.85; HAD – Anxiety (HAD A) score, 7.39; HAD Depression (HAD D) score, 5.93; FACIT–Fatigue Scale (FACIT-FS) score, 38.3 and CDAI score, 2.65. FACIT-FS was statistically associated with PASI (r_s −0.345, p<0.001), PDI (r_s −0.299, p<0.002), HAQ (r_s −0.460, p<0.001), HAD A (r_s −0.306, p=0.002) and HAD D (r_s −0.339, p<0.001). The correlations with CDAI and BASDAI were not confirmed. There was statistically significant correlation with all of the domains of SF-36 and FACIT-F (version 4).

Conclusion

Prevalence of fatigue was moderate to intense in <25% of patients with psoriatic arthritis. Fatigue seems to be more related to the emotional and social aspects of the disease than to joint inflammatory aspects, confirming that the disease’s visibility is the most disturbing aspect for the patient and that “skin pain” is more intense than the joint pain.

[Dermatological diseases and their importance for psychiatry]

The relationship between skin and psychiatric disorders is not an uncommon occurrence in the clinical practice; however, there are only a few systematic studies and in addition knowledge about the neurobiological and immunological mechanisms is lacking. Impairments and disorders of the skin are often an (early) sign of a psychiatric disorder. In the sense of true psychosomatics, psychiatrists should also be aware of this relationship as far as possible. This review article focuses on the most important dermatological diagnoses in relation to the respective psychiatric comorbidities and presents the most important aspects of epidemiology, symptomatology, pathophysiology and treatment options.

A systematic review of patient-reported outcomes in patients with cutaneous lupus erythematosus

Cutaneous lupus erythematosus (CLE) is a chronic dermatological autoimmune disease marked by photosensitive lesions that can lead to hyperpigmentation changes, scarring and hair loss. Health-related quality of life (HRQoL) in patients with CLE is severely impaired. Given the heterogeneous nature of CLE, health perceptions of patients can differ significantly from those of clinicians. It is important to use subjective measures, such as patient-reported outcomes (PROs), to capture HRQoL data in patients with CLE. We conducted a systematic review of published PRO instruments used in measuring HRQoL in patients with CLE. Also, we examined the disease burden on HRQoL in patients with CLE. To identify studies, PubMed/MEDLINE, Web of Science and CINAHL were searched using 'CLE/cutaneous lupus erythematosus' in combination with PRO-related keywords such as 'quality of life', 'self-report' and 'instrument'. English-language articles published between 2003 and 2014 were identified. A total of 482 citations were identified in the initial search. Eleven studies met our inclusion criteria, and five PRO instruments were found to be used: Skindex (versions 16 and 29), Dermatology Life Quality Index, 36-Item Short-Form Health Survey, and visual analogue scales for pain and pruritus. Patients with CLE reported having poor quality of life and experienced symptoms ranging from pain, pruritus and fatigue to photosensitivity. There is a limited number of studies examining PRO in patients with CLE. While our findings suggest that quality of life in patients with CLE is poor, further studies are needed to understand better the impact of CLE from patients' perspectives.

Body Image Satisfaction and Anxiety of a Turkish Sample of University Students with Skin Diseases

The aim of this study was to evaluate perception of body image and anxiety of 221 university students presenting to the dermatology outpatient clinic with a skin disease and 205 students without skin disease. Analysis of anxiety and body image scores yielded differences by sex and age in both groups. The group with skin disease had lower scores on body image. Acne vulgaris seems to be the most disturbing among the skin diseases, and this was more prominent in younger patients.

Association between skin conditions and depressive disorders in community-dwelling older adults

BACKGROUND

Depression is frequently observed in dermatologic patients. However, the association between depressive disorders and skin conditions has rarely been explored through population-based studies, especially within older-adult populations.

OBJECTIVE

To test this association in a representative sample of an older-adult population.

METHODS

Data came from the Survey on the Health of the Elderly (Enquête sur la Santé des Aìnés [ESA]), a longitudinal survey conducted in Quebec among 2,811 older adults. Cross-lagged panel models were used to simultaneously examine cross-sectional and longitudinal relationships between the presence of skin conditions and depressive disorders.

RESULTS

The prevalence of skin conditions was 13%, and the prevalence of depressive disorders among participants presenting with skin conditions was 11%. Our results indicated significant cross-sectional correlation (ζ  =  0.20) between skin conditions and depressive disorders, but no longitudinal association was observed.

CONCLUSION

Our results reinforce the hypothesis that skin conditions and depressive disorders are concurrently associated in older adults. However, no evidence of the predictive effect of skin problems on depression (and vice versa) was found in our community sample. Despite the deleterious effect of the coexistence of these problems in older adults, studies are lacking. This article highlights the importance of this issue and emphasizes the need for further research on this topic.

Illness acceptance degree versus intensity of psychopathological symptoms in patients with psoriasis

Introduction

Chronic inflammatory skin diseases such as psoriasis have undoubtedly a negative impact on the patients’ quality of life. Many of them may face various limitations in their psychosocial lives because of symptoms indicating the presence of psychopathological phenomena. Mental disorders in patients with skin diseases occur much more frequently than in the general population. Studies show that a considerable percentage (30-60%) of dermatological patients suffers from mental disorders (depressive and anxiety disorders being the most common). A person's attitude towards illness, its acceptance, and also the recognition of its limitations may be of a great importance in the process of the disease control.

Aim

To evaluate of the relationship between the illness acceptance degree, and the presence and intensity of psychopathological symptoms in patients with psoriasis.

Material and methods

The research was conducted on a group of 54 people (23 men and 31 women), who were treated for psoriasis in the Department of Dermatology and Venereology, Medical University of Lodz and in the Department of Dermatology, Pediatric Dermatology and Oncology, Medical University of Lodz. The following research methods were used: a questionnaire prepared for the purpose of the research, Acceptance of Illness Scale (AIS) and Symptom Checklist (SCL-90).

Results

It was found that there was a relationship between the skin illness acceptance degree and intensity of psychopathological symptoms in patients with psoriasis (negative correlations).

Conclusions

The higher the degree of illness acceptance is, the better mental condition of patients with psoriasis is. The intensity of psychopathological symptoms is also affected by the duration of illness, other people's attitude to the skin disease, age and education level of the patients examined.

Psychological Stress and the Cutaneous Immune Response: Roles of the HPA Axis and the Sympathetic Nervous System in Atopic Dermatitis and Psoriasis

Psychological stress, an evolutionary adaptation to the fight-or-flight response, triggers a number of physiological responses that can be deleterious under some circumstances. Stress signals activate the hypothalamus-pituitary-adrenal (HPA) axis and the sympathetic nervous system. Elements derived from those systems (e.g., cortisol, catecholamines and neuropeptides) can impact the immune system and possible disease states. Skin provides a first line of defense against many environmental insults. A number of investigations have indicated that the skin is especially sensitive to psychological stress, and experimental evidence shows that the cutaneous innate and adaptive immune systems are affected by stressors. For example, psychological stress has been shown to reduce recovery time of the stratum corneum barrier after its removal (innate immunity) and alters antigen presentation by epidermal Langerhans cells (adaptive immunity). Moreover, psychological stress may trigger or exacerbate immune mediated dermatological disorders. Understanding how the activity of the psyche-nervous -immune system axis impinges on skin diseases may facilitate coordinated treatment strategies between dermatologists and psychiatrists. Herein, we will review the roles of the HPA axis and the sympathetic nervous system on the cutaneous immune response. We will selectively highlight how the interplay between psychological stress and the immune system affects atopic dermatitis and psoriasis.

Psychosomatic services for melanoma patients in tertiary care

BACKGROUND

Individuals diagnosed with malignant melanoma face significant practical and psychological challenges, including existential fears and pain and discomfort associated with treatment. To enhance psychological adjustment, patients receive psychosomatic-psychotherapeutic consultation-liaison services (CLS) within the general medical hospital. However, little is known about the use of these services in routine clinical care.

METHODS

This study includes all patients referred to the CLS of a large German tertiary care hospital between 2005 and 2008 (n=3658). Data were recorded using the CL-BaDo form - a multicenter documentation form for the assessment of clinical characteristics of patients and CLS delivery. Descriptive and inferential statistics were employed to compare patients with melanomas and patients with other dermatological diseases.

RESULTS

Dermatologists requested CLS more often for other dermatology patients than for patients with melanoma. These two groups also differed in the reasons for referral: patients with melanoma were referred more often for acute coping issues; other dermatology patients were referred more often for unexplained physical symptoms. Additionally, the latter group was diagnosed with more and different mental and behavioral disorders. Patients with melanomas received more psychotherapeutic interventions while admitted to hospital but fewer recommendations for further psychosocial treatment after their hospital stay.

CONCLUSION

These findings highlight the need for professional psychosocial support in individuals diagnosed with melanoma - especially when first diagnosed or experiencing a recurrence. Dermatologists play a crucial role in identifying their patients' needs and in navigating them toward available support services.

Mental health in patients with pemphigus: an issue to worth consideration

Background:

There exists a high prevalence of psychiatric disorders in dermatological patients. Although, investigators have evaluated psychiatric aspects of the patients suffering from skin diseases; there are rare studies concerning mental health in pemphigus patients. The objective of this study was to evaluate mental health status and quality of life of newly diagnosed pemphigus patients.

Materials and Methods:

Between April 2007 and June 2008, all newly diagnosed pemphigus patients attending the outpatient clinic of a dermatological hospital were given a questionnaire comprising the GHQ-28 and DLQI to fill out.

Results:

Of 283 patients, 212 complete forms were returned. The bimodal score of GHQ ranged from 0 to 26 (Mean = 9.4) and the Likert score of GHQ ranged from 6 to 68 (Mean = 31.9). The DLQI score ranged between 0 and 30 (Mean of 13.8). A total of 157 patients (73.7%) were yielded to be possible cases of mental disorder considering GHQ-28 bimodal scores. Significant correlation was detected between the DLQI score and bimodal and Likert scoring of GHQ-28.

Conclusion:

Our study has depicted high prevalence of psychiatric comorbidity in pemphigus patients. It underlines the fact that physicians, who are in-charge of care for these patients, are in an exceptional position to distinguish the psychiatric comorbidity and to take appropriate measures.

Quality of life in dermatomyositis

BACKGROUND

Quality of life (QoL) for patients with inflammatory skin disease can be significant, but has been evaluated in just one study in dermatomyositis (DM).

OBJECTIVE

We sought to examine the relationship between the Cutaneous Dermatomyositis Area (CDASI) and Severity Index, a DM-specific cutaneous severity instrument, and various QoL study instruments and to determine the impact of DM on QoL.

METHODS

Skin-specific QoL instruments, the Skindex and the Dermatology Life Quality Index, and global medical QoL instruments, the Short Form 36 and the Health Assessment Questionnaire-Disability Index, were used. Pruritus was evaluated by a visual analog scale and a 0-to-10 scale in DM and cutaneous lupus erythematosus (CLE) populations, respectively.

RESULTS

There was a significant correlation between the CDASI and all skin-specific QoL scores (lowest P = .0377). Using the Short Form 36, DM population was found to have significantly worse QoL scores than the general population with the exception of bodily pain (all subscore P values < .01). Furthermore, DM had a significantly lower vitality score, representing energy level, compared with CLE, hypertension, diabetes, and recent myocardial infarction scores (lowest P = .003). There was a significantly lower mental health score, representing overall mood, to all compared diseases except CLE and clinical depression (P values < .01 when significant). We found that DM produces more pruritus than CLE (P < .0001).

LIMITATIONS

A larger patient population needs to be studied to further assess QoL in patients with DM.

CONCLUSION

We conclude that DM has a large impact on QoL, even when compared with other diseases, and that DM skin disease activity correlates with a poorer QoL.

Psychological distress and coping strategies in patients attending a dermatology outpatient clinic

BACKGROUND

  Psychological distress is frequent among dermatological patients. The development of a positive attitude toward diagnosis and treatment is thought to be critical for successful coping and mental health outcomes.

OBJECTIVE

  The aim of this study was to assess the coping strategies and the psychological distress, due to anxiety and depression, in an unselected sample of dermatological patients.

METHODS

  Self-administered questionnaires (HADS, COPE) were given to 603 dermatological patients.

RESULTS

  Out of 567 participants, 149 (26.2%) scored positive for Anxiety, and 52 (9.2%) scored positive for Depression. Multivariate analysis, adjusting for gender, age, socio-economic status, and disease, showed that both Anxiety and Depression are associated with a less frequent use of Positive attitude coping.

CONCLUSION

  Our results reinforce the notion that while planning the treatment of dermatological patients, evaluating their mental health might help to provide optimal treatment. Since coping ability was found to be important for mental health status, policy implications could include emphasis on social programs to assist individuals to manage stress, as well as psychological support.

Development and preliminary validation of the PC-SAD5, a screener-derived short depression severity measure

BACKGROUND

The prevalence of depressive disorders is high among patients with skin disease. The PC-SAD is a 37-item self-administered depression screening questionnaire that has been validated in dermatological patients.

OBJECTIVE

The aim of this study was to develop and validate a brief depression severity instrument derived from the PC-SAD that can be used to assess severity and monitor ongoing clinical course.

METHODS

Two patient samples participated in the study: 72 adult dermatological inpatients and 73 adults attending six primary care practices. Psychiatric assessment included the Structured Clinical Interview for DSM-IV and an 18-item version of the PC-SAD; moreover, dermatological patients completed the Patient Health Questionnaire depression scale (PHQ-9), while primary care patients were administered the Montgomery-Asberg Depression Rating Scale (MADRS). A subset of five PC-SAD items showing the best psychometric properties were selected, and the reliability and validity of the resulting instrument (PC-SAD5) were examined.

RESULTS

The PC-SAD5 showed satisfactory internal consistency in both samples. There was a high correlation between PC-SAD5 and PHQ-9 and MADRS scores. Multiple regression analysis revealed a gradient of PC-SAD5 scores from patients with no mental disorder, those with milder forms of depression, to those with Major Depressive Disorder. Similar results were observed for the 18-item version of the PC-SAD.

CONCLUSION

The availability of valid and reliable continuous measures of depression severity derived from the PC-SAD extends its field of application from depression screening to use as a follow-up measure of depression severity in routine clinical practice. A validated very short instrument such as the PC-SAD5 may have substantial clinical value.

Quality of life in cutaneous lupus erythematosus

BACKGROUND

Little is known about quality of life in patients with cutaneous lupus erythematosus.

OBJECTIVE

We sought to determine how cutaneous lupus affects quality of life and which independent variables are associated with poor quality of life.

METHODS

A total of 157 patients with cutaneous lupus completed surveys related to quality of life, including the Skindex-29 and the Short Form-36.

RESULTS

Quality of life in cutaneous lupus is severely impaired, particularly with respect to emotional well-being. Patients with cutaneous lupus have worse quality of life than those with other common dermatologic conditions, such as acne, nonmelanoma skin cancer, and alopecia. With respect to mental health status, patients with cutaneous lupus have similar or worse scores than patients with hypertension, type 2 diabetes mellitus, recent myocardial infarction, and congestive heart failure. Factors related to poor quality of life include female gender, generalized disease, severe disease, distribution of lesions, and younger age.

LIMITATIONS

The study was done at a single referral-only center.

CONCLUSION

Patients with cutaneous lupus have very impaired quality of life, particularly from an emotional perspective.

Psychological distress and coping strategies in patients with psoriasis: the PSYCHAE Study

OBJECTIVE

Our objectives were to determine the prevalence of psychological distress in a large sample of Italian patients with psoriasis; to establish whether disease severity and psychological distress are associated; to identify the strategies employed to cope with psoriasis; to evaluate the coping strategies employed by dermatologists; and to identify potential predictors of psychological distress.

DESIGN

Cross-sectional.

SETTING

Thirty-nine Italian dermatology centres.

SUBJECTS

One thousand five hundred and eighty (1580) patients with psoriasis.

METHODS

Minor psychological distress was evaluated using the General Health Questionnaire-12 (GHQ-12) and major psychopathological distress using the Brief Symptom Inventory (BSI); coping strategies were evaluated using the Brief COPE questionnaire; disease severity was evaluated using the body surface area index.

RESULTS

Patients were aged 44 +/- 13 years (mean +/- SD) and were mainly men (57%). Minor psychological distress was present in 46% of patients and major psychopathological distress in 11% of them. Both minor (54% vs. 40%, P < 0.0001) and major (17% vs. 7%, P < 0.0001) distress were more frequent in women than in men. The psychological status of women was worse than that of men independently from the extension of psoriasis. There was no association between the presence of distress and the treatment prescribed by dermatologists. Planning and active coping were the strategies most commonly employed by patients to cope with psoriasis, but there were between-gender differences. Most dermatologists employed a 'problem-orientated' attitude in caring for patients.

CONCLUSIONS

(i) Psychological distress was relatively frequent in our patients with psoriasis; (ii) female gender was the most important predictive factor for psychological distress; (iii) there was no association between psoriasis severity and psychological distress; (iv) planning and active coping were the coping strategies most frequently employed by patients; and (v) most dermatologists employed a problem-orientated attitude in caring for patients.

Psychiatric morbidity and quality of life in patients with chronic idiopathic urticaria

BACKGROUND

Chronic idiopathic urticaria (CIU) is a frequently occurring disease that has a great impact on the health-related quality of life (HRQL) of patients and seems to be associated with a number of psychological factors.

OBJECTIVES

To determine the prevalence of psychiatric morbidity in patients with CIU and to determine HRQL of CIU patients compared with controls.

METHODS

A semistructured interview form, a generic form of the HRQL questionnaire (Medical Outcomes Study 36-Item Short-Form Health Survey [SF-36]), and the Structured Clinical Interview for DSM-IV Axis Disorders (SCID-I) were administered to CIU patients who presented to the Allergy Department of the University of Istanbul (from January 1 to April 30, 2005). Healthy subjects matched sociodemographically with the study group were used as the control group.

RESULTS

Eighty-four CIU patients and 75 controls were included in the study. The mean +/- SD age of the study participants was 36.83 +/- 10.26 years, and 84% were women. The mean +/- SD duration of the disease was 6.34 +/- 7.2 years, and symptoms were intermittent in 51%. The SCID-I revealed a psychiatric diagnosis in 60% of the patients. In terms of the distribution of psychiatric diagnoses, the most frequently occurring diagnosis was depressive disorders (40%). Most patients (81%) believed that their illnesses were due to stress. The subdomains on the SF-36 measurements were significantly lower than those of the control subjects (P < or = .005). The physical function, vitality, and mental health subdomains of the SF-36 in the patients with a psychiatric diagnosis were significantly lower (P < .05).

CONCLUSION

These findings suggested that psychiatric morbidity is high among ICU patients and is detrimental to their quality of life.

Psychological status of patients with chronic urticaria

Although chronic urticaria is the most common cutaneous disorder seen in our outpatient allergy clinics, to our knowledge, no study of psychiatric morbidity in allergy departments has been carried out in our country. For the present study, we used the Minnesota Multiphasic Personality Inventory (MMPI) to evaluate the personality traits and psychological status of patients with chronic idiopathic urticaria (CIU). Fifty-nine outpatients with CIU and 59 healthy control subjects were enrolled in the study. Patients were included if no specific cause for their urticaria could be identified by detailed history and appropriate investigations. Psychiatric evaluation for all patients and controls was conducted at the Department of Psychiatry by using MMPI. Analysis of the MMPI profile showed that the scores for hypochondriasis, depression, hysteria, psychopathic deviance, paranoia, psychasthenia, schizophrenia, and social introversion were higher in patients with CIU compared to the control group (P < 0.05). The mean score of hysteria was significantly higher in women. There were no significant correlations between the scores of MMPI and duration of the disease. These data indicate that our patients with CIU seem to have more depressive, hysteric, touchy and suspicious personality traits with hypochondriac tendencies and in more conflict with their social environment. Attitudes such as perfectionism, need for approval, external control and need to be loved were also characteristics of the patient group. We believe that psychological status should be considered for effective management of patients with CIU.

Integration of Multiple Criteria for Psychosomatic Assessment of Dermatological Patients

Psychological distress has been frequently reported in the setting of skin disorders. The Diagnostic Criteria for Psychosomatic Research (DCPR) have been found to yield valuable integrative information, in addition to DSM-IV nosology, in a variety of medical diseases. The aim of this study was to verify whether this integration could also be helpful in dermatology. A consecutive series of 539 inpatients with various skin conditions was evaluated by means of structured interviews for DSM-IV and DCPR diagnoses. The prevalence of DSM-IV conditions was 38% (mostly depressive disorders and anxiety disorders), whereas that of DCPR clusters (mostly demoralization and somatization secondary to psychopathology) was 48%. Overall, DCPR diagnoses were significantly more frequent than DSM-IV categories, regardless of the presence or absence of a psychiatric disorder. Psychological assessment of patients with skin diseases needs to incorporate both clinical (DSM-IV) and subclinical (DCPR) methods of classification. The health status of these patients can be improved if their psychological problems are appropriately assessed and recognized.

Effects of patient satisfaction with care on health-related quality of life: a prospective study

OBJECTIVES

To evaluate the effect of patient satisfaction on health-related quality of life among dermatological outpatients, independently of patients' sociodemographic, and clinical characteristics.

DESIGN

Prospective cohort study. Satisfaction was evaluated with a standardized questionnaire three days after the visit by telephone interview. Quality of life and psychiatric disorders were measured with validated instruments (Skindex-29 and Ghq-12) before the dermatological visit and after four weeks. At the four week interview also self-reported medication adherence was assessed.

SETTING

Outpatient clinics of a large dermatological hospital in Rome, Italy.

PATIENTS

A consecutive sample of 1389 outpatients was approached, and 52% agreed to participate. Inclusion criteria were met by 424 patients, and 396 (93%) of them completed the study.

MAIN OUTCOME MEASURES

Improvement in health related quality of life.

RESULTS

At multivariate analysis satisfied patients have approximately twice the odds for an improved quality of life on the emotions scale (OR = 1.99; 95%CI 1.1 to 3.7; P = 0.03) and on the functioning scale (OR = 2.2; 95%CI 1.1 to 4.7; P = 0.03). Patients with psychiatric disorders at baseline were less likely to have an improved quality of life on the functioning scale (OR = 0.3; 95%CI 0.2 to 0.8; P = 0.01).

CONCLUSIONS

This is the first prospective study showing that patient satisfaction and psychiatric disorders have a significant effect on quality of life improvement among dermatological patients, independently of patient characteristics. Particular attention should be devoted to improving physicians' interpersonal skills, the major component of patient satisfaction.

Depression in dermatological patients identified by the Mini International Neuropsychiatric Interview questionnaire

BACKGROUND

Early diagnosis and treatment of depression are of vital importance in dermatological patients.

OBJECTIVE

Our purpose was to evaluate the prevalence of depression among patients visiting a dermatology clinic in southern Israel.

METHODS

Patients who visited the dermatology clinic were interviewed using the Mini International Neuropsychiatric Interview screening tool.

RESULTS

The study included 384 patients. The screening questionnaire identified 37 patients (9.6%) with major depression, 3 patients (0.8%) with minor depression, and 74 patients (19.3%) with depressive symptoms. Higher prevalence of depression was found among widowers, among divorced or separated patients, and in unemployed patients. Depression was significantly associated with the perception of severity and suffering induced by the skin diseases.

LIMITATIONS

The study was conducted in a cross-sectional design. To confirm causality, a longitudinal study should be conducted.

CONCLUSION

Depression should be a consideration by dermatologists in the effective management of skin diseases.

Psychosomatic assessment of skin diseases in clinical practice

BACKGROUND

Psychiatric disorders are frequent in dermatology patients, and many studies pointed out complex, mutual relationships between psyche and skin. Our aim was to provide a systematic psychosocial evaluation of a large and heterogeneous population of patients with skin diseases, including assessments of quality of life, psychiatric status according to the DSM-IV and psychological conditions with psychosomatic relevance according to established criteria (Diagnostic Criteria for Psychosomatic Research, DCPR).

METHODS

We studied 545 dermatological inpatients aged 18-65 years, free from dementia and cognitive impairment. They completed the Skindex-29 and the 12-item General Health Questionnaire (GHQ-12) and were administered the SCID-I and the Structured Interview for Psychological Conditions of Psychosomatic Relevance by a trained mental health professional blinded to questionnaire scores.

RESULTS

Overall, 38% of patients received a DSM-IV diagnosis. The most common diagnoses were mood (20%) and anxiety disorders (16%); 48% of patients also received a DCPR diagnosis. The most common were demoralisation, irritable mood, type A behaviour and various forms of abnormal illness behaviour. Adjusting for gender, age, and education, the presence of DSM-IV or DCPR diagnoses was significantly associated with high scores on the GHQ-12 and on the Functioning and Emotions scales of the Skindex-29. Also, DCPR diagnoses were significantly associated with high scores on the Symptoms scale of the Skindex-29.

CONCLUSIONS

These findings highlight the high frequency of psychosocial problems in patients with skin disease and suggest that the joint use of DSM-IV and DCPR criteria may help identify those patients in whom psychiatric issues are worthy of increased clinical attention.

Screening for Depressive Disorders in Patients with Skin Diseases: A Comparison of Three Screeners

Despite being common, depression often goes undetected in patients with skin diseases. Our aim was to examine and compare the performance of three depression screeners. We studied dermatological inpatients aged 18-65 years. They completed the questionnaires Primary Care Screener for Affective Disorders (PC-SAD), Patient Health Questionnaire (PHQ) and General Health Questionnaire (GHQ-12) and were administered a standardized psychiatric interview (SCID-I) by a mental health professional, who was unaware of the questionnaire answers. The analysis was performed on 141 patients with complete data (79% of all eligible patients, 89% of all patients who agreed to participate). The prevalence of the main forms of depression, major depressive disorder and dysthymic disorder, was 8.4% and 6.3%, respectively. For major depressive disorder, the sensitivity and specificity of the questionnaires were as follows: PC-SAD, 73% and 88%; PHQ, 55% and 91%; GHQ-12, 73% and 78%. For dysthymic disorder, the sensitivity and specificity were as follows: PC-SAD, 56% and 95%; PHQ, 44% and 90%; GHQ-12, 56% and 76%. The small sample size suggests caution in drawing conclusions about the relative merits of these screeners. Although both the GHQ and the PHQ are short and easily hand scored, the first is a generic screener for psychiatric morbidity that is not specific for depression, while the second displayed modest sensitivity. The PC-SAD, with short average administration time, acceptable sensitivity and high specificity, might be particularly useful in settings where the technology for computer automated scoring is available. Although screening programmes might be useful, they should be supplemented by quality improvement programmes and by the development of consultation-liaison services.

Screening for psychiatric disorders in patients with skin diseases: a performance study of the 12-item General Health Questionnaire

OBJECTIVE

Although psychiatric disorders are frequent among dermatological patients, no study has formally assessed the performance of any psychiatric screening questionnaire in dermatological practice. This study tested the ability of the 12-item General Health Questionnaire (GHQ-12) to identify psychiatric morbidity in dermatological patients.

METHODS

A sample of 521 adult inpatients (81% of all eligible patients) completed the GHQ-12 and were administered the Structured Clinical Interview for DSM-IV Axis I disorders (SCID-I) by a trained mental health professional masked to GHQ-12 score.

RESULTS

The Receiver Operating Characteristic (ROC) analysis showed that GHQ-12 possesses substantial discriminatory ability (area under the curve=0.70). The best balance between sensitivity (68%) and specificity (64%) was found at the GHQ-12 cutoff score of 3/4. This threshold gave a likelihood ratio for a positive or negative result of 1.90 and 0.50, respectively.

CONCLUSION

The performance of GHQ-12 was reasonably good for a self-administered questionnaire requiring only a few minutes to be completed and scored. Its routine use might increase recognition of psychiatric disorders in dermatological patients and contribute to improve patients' outcome.

Association between poorer quality of life and psychiatric morbidity in patients with different dermatological conditions

OBJECTIVE

To determine the relationship between skin-related quality of life and psychiatric morbidity in patients with different skin conditions.

METHODS

We recruited all adults attending the outpatient clinics of the Dermatological Institute IDI-IRCCS, Rome, Italy, during 14 predetermined days. Eligible patients, who gave their informed consent, completed the Skindex-29 and the 12-item General Health Questionnaire (GHQ-12). We used a stringent cut-off threshold (> or =5 on the GHQ-12) for identification of psychiatric morbidity. Skindex-29 scale scores were computed separately for GHQ noncases and GHQ cases.

RESULTS

A total of 2,136 patients were included in the analysis. For all skin conditions, GHQ cases had substantially poorer score in all 3 domains of quality of life, Symptoms, Emotions, and Functioning. Most differences remained significant after adjusting for clinical severity, age, sex, and education in multiple regression models. These differences were not as marked in the Symptoms scale for some conditions known to be nearly asymptomatic (eg, alopecia, vitiligo, nevi), suggesting that, although patients with psychiatric morbidity might be more burdened by their symptoms, nevertheless they do not perceive nonexistent symptoms.

CONCLUSION

In most skin conditions we considered, psychiatric morbidity was strongly associated with poorer quality of life. Although the cross-sectional nature of our study does not allow identification of the direction of this association, care for the psychological condition of patients might have an impact on their quality of life.

The impact of skin diseases on patients: comparing dermatologists' opinions with research data collected on their patients

BACKGROUND

Research data suggest that the detection of psychiatric disorders by dermatologists is not completely satisfactory, and that patients and dermatologists often assess patients' quality of life differently. Given that expectations influence perception and cognitia, these discrepancies might at least in part descend from conceptual models of skin disease that are prevalent among dermatologists.

OBJECTIVES

We explored to what degree dermatologists' opinions about quality of life and prevalence of psychiatric disorders in several dermatological conditions corresponded to the actual data collected on their patients.

METHODS

All dermatologists working in a large institution were asked to express on a five-point scale their opinion about the quality of life and the prevalence of depressive and anxiety disorders in different skin conditions. Physicians' opinions were then compared with the results of a large research project on quality of life and psychological well-being in dermatological out-patients performed in their institution some months before.

RESULTS

Forty-six dermatologists (82%) agreed to participate and completed the research questionnaire. We observed a fairly good concordance between dermatologists' opinion about the impact of the various skin conditions on patients' lives and survey data on quality of life impairment. With regard to psychiatric morbidity, we found that dermatologists believe that psychiatric disorders are substantially less frequent than they actually are in many skin conditions.

CONCLUSIONS

The belief that psychiatric morbidity is rare in patients with certain skin conditions might hamper, at least in part, the recognition of psychiatric disorders in these patients. Dermatologists probably should be more alert to the question of psychiatric morbidity in their patients. Allocating more space to this issue in training programmes for dermatologists might favour a shift in their conceptual models of skin disease.

Treatment outcome and incidence of psychiatric disorders in dermatological out-patients

OBJECTIVE

Epidemiological studies have shown that the prevalence of psychiatric disorders among dermatological patients is high. We aimed at estimating the short-term incidence of psychiatric disorders among patients with skin disease.

METHODS

The 12-item General Health Questionnaire (GHQ-12) was used to identify subjects free from psychiatric morbidity at their first dermatological visit. The GHQ-12 was administered again after 1 month during a computer-assisted telephone interview.

RESULTS

A total of 277 subjects was included in the study. At the follow-up interview, 21 (7.6%) were found to have significant psychiatric morbidity. Only lack of improvement was associated with increased incidence of psychiatric morbidity (13.6%), with an odds ratio of 3.1 (95% confidence interval 1.2-7.8), after adjustment for gender, age, educational level and clinical severity.

CONCLUSIONS

Physicians should devote special attention to the risk of psychiatric complications in patients who have not improved with treatment.

Measuring Adjustment to Chronic Skin Disorders: Validation of a Self-Report Measure

This article describes the development of a questionnaire that assesses problems in adapting to chronic skin disorders, the Adjustment to Chronic Skin Diseases Questionnaire. Patients (N = 442) with different skin disorders completed the original item pool. Principal-components analysis suggested a 6-factor solution that was largely replicated with 2 additional samples of 192 patients with psoriasis or atopic dermatitis and 165 patients with atopic dermatitis. Four of the subscales showed very good internal consistencies, retest reliabilities, and sufficient correlations with expert ratings: Social Anxiety/Avoidance, Itch-Scratch Cycle, Helplessness, and Anxious-Depressive Mood. Two short additional subscales, Impact on Quality of Life and Deficit in Active Coping, showed moderate internal consistencies, but good retest reliabilities. Correlations of the subscales with measures of depression, anxiety, and coping, and meaningful differences between dermatological subgroups support their construct validity. A treatment study showed that changes in some of the subscales correlated with changes in the severity of the skin condition.

Self-reported dermatological problems and use of prescribed topical drugs correlate with decreased quality of life: an epidemiological survey

BACKGROUND

Skin problems are common in the population. Although a substantial fraction of the population suffers from skin conditions, we still have little information on how this affects the everyday life of the individuals concerned.

OBJECTIVES

To evaluate the impact of skin disease on health-related quality of life (HRQOL) measured with the Short Form-36 (SF-36), a multidimensional generic HRQOL instrument, from an epidemiological perspective. A further aim was to study differences in HRQOL by use of non-prescription and prescription dermatological drugs.

METHODS

The survey was carried out in the county of Uppland, Sweden in a random sample of 8000 individuals aged 20-84 years, of whom 5404 (68%) answered the questionnaire.

RESULTS

A large part of the population (20.5%) reported dermatological problems and/or use of topical dermatological drugs, with a higher frequency among women (23.3%) than men (17.3%). Persons reporting dermatological problems scored lower on all eight dimensions of the SF-36. This pattern, although weaker, persisted after adjusting for comorbid somatic as well as psychiatric diseases and complaints. Those using topical dermatological drugs on prescription generally scored lower than the other groups with skin problems: in particular, they evaluated personal health as poorer (general health perceptions), perceived more limitations in daily activities (role limitation because of emotional health problems) and felt more tired and worn out (vitality).

CONCLUSIONS

The study shows that skin disorders constitute a substantial problem in the population and cause a significant decrease in HRQOL. Furthermore, the results of this population survey point out the need for further population-based studies more specifically aimed at dermatological problems and HRQOL.

Assessing psychological distress in patients with skin diseases: reliability, validity and factor structure of the GHQ-12

OBJECTIVE

We studied reliability, validity and factor structure of the 12-item General Health Questionnaire (GHQ-12) in dermatological patients.

METHOD

Subjects attending a dermatological outpatient clinic were administered the GHQ-12 and the Skindex-29. A random subsample was mailed another copy of the questionnaires to be completed within 1 week.

RESULTS

A total of 2,579 subjects completed the GHQ-12. The internal consistency of the GHQ-12 was high (Cronbach's alpha = 0.88). Test-retest reliability on 137 subjects was also fairly satisfactory (intraclass correlation coefficient = 0.72), notwithstanding a re-test artefact probably related to reassurance from the physician. Evidence of construct validity was provided by the pattern of correlation between scores on the GHQ-12 and on the scales of Skindex-29, which were as hypothesized. Also, GHQ-12 scores of patients in different clinical groups varied as hypothesized, with patients affected by inflammatory skin diseases scoring significantly higher than patients with isolated skin lesions. We obtained both a two-factor and a three-factor solution: the latter seemed theoretically more appropriate, although the first may have practical advantages. A 'social dysfunction' factor emerged in both analyses, while the other items loaded on a 'general dysphoria' factor or on two separate factors interpreted as 'anxiety' and 'loss of self-esteem'.

CONCLUSIONS

The GHQ-12 is a reliable and valid instrument with a factor structure that is quite stable across different samples as well as across diverse cultures. Its brevity and easiness of completion make it a useful tool to assess psychological distress in dermatological patients.

Stressful life events and skin diseases: disentangling evidence from myth

The possibility of a causal influence of emotional stress, especially of stressful life events, on the course of various skin diseases has long been postulated. Clinical wisdom and experience, as well as many anecdotal observations and uncontrolled case series, support this opinion. We reviewed the available evidence on the role of stressful life events in triggering or exacerbating skin diseases. The role of stressful events in vitiligo, lichen planus, acne, pemphigus and seborrhoeic dermatitis was either controversial or insufficiently explored. The role of stressful events in psoriasis, alopecia areata, atopic dermatitis and urticaria was apparently clearer. However, only a few studies met acceptable methodological standards for stress measurement. Also, few studies considered common potential confounding factors (e.g. age, duration of illness, familial factors), and no study controlled adequately for the influence of other crucial factors (e.g. discontinuation of treatment, seasonal effects). Adding that the large majority of studies were retrospective, it seems wise to conclude that only preliminary evidence has been published so far on the role of stressful life events in bringing on or worsening any dermatological disease. Further research is mandatory, either in the form of prospective studies or, more feasibly, of well-designed case-control studies with adequate statistical power. Future studies should also pay more attention to protective as well as vulnerability factors in stressful events. Further, it would be important to investigate other sources of psychological stress, such as chronic stress and everyday stress. Measuring stress appraisal, although difficult, would also be important.

Psychiatric morbidity in dermatological outpatients: an issue to be recognized

BACKGROUND

There is a high prevalence of psychiatric disorders in dermatological outpatients.

OBJECTIVES

To estimate the magnitude of this problem and to identify a set of variables associated with the presence of psychiatric disorder.

METHODS

All adults attending the outpatient clinics of a dermatological hospital on predetermined days were given a questionnaire comprising the Skindex-29 and the 12-item General Health Questionnaire (GHQ-12).

RESULTS

In total, 4268 questionnaires were given at admission, and 3125 were returned. Of these, 546 were blank or incomplete, leaving 2579 respondents (response rate 60.4%). Using a stringent cut-off threshold (> or = 5) for psychiatric case identification with the GHQ-12, scored in the conventional way, the overall prevalence of psychiatric morbidity was 25.2% (95% confidence interval 23.6-27.0%). We found a higher prevalence of psychiatric disorders in women and in widows/widowers, controlling for age. Health-related quality of life was a much stronger predictor of psychiatric morbidity than physician-rated clinical severity. High prevalence rates (> 30%) were observed among patients with acne, pruritus, urticaria, alopecia and herpesvirus infections, and in subjects without objective signs of dermatological disease.

CONCLUSIONS

Our study has depicted the situation that is actually faced by dermatologists in their everyday practice, where they are in a unique position to recognize psychiatric morbidity and to take appropriate measures. The GHQ-12, being easy for patients to compile and for physicians or nurses to score, may be a practical tool to increase identification of patients with substantial psychological distress or formal psychiatric disorder in order to provide more comprehensive and appropriate intervention.