Assessment of depression and suicidal risk in patients with psoriasis: A hospital-based cross sectional study

Pranjal Dey; Rezib Uz Zaman; Jyoti Nath

doi:10.4103/jms.jms_88_20

ORIGINAL ARTICLE

Year : 2022 | Volume : 36 | Issue : 3 | Page : 124-128

Assessment of depression and suicidal risk in patients with psoriasis: A hospital-based cross sectional study

Pranjal Dey¹, Rezib Uz Zaman², Jyoti Nath³
¹ Department of Psychiatry, Central Institute of Psychiatry, Ranchi, Jharkhand, India
² Department of Psychiatry, Silchar Medical College and Hospital, Silchar, Assam, India
³ Department of Dermatology, Gauhati Medical College and Hospital, Guwahati, Assam, India

Date of Submission	06-Sep-2020
Date of Decision	12-Oct-2020
Date of Acceptance	14-Dec-2020
Date of Web Publication	25-Feb-2023

Correspondence Address:
Dr. Pranjal Dey
Department of Psychiatry, Central Institute of Psychiatry, Ranchi - 834 006, Jharkhand
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jms.jms_88_20

Abstract

Background: Psoriasis is one of the common psychosomatic illnesses which have impairment of physical, psychological, social functioning of an individual. This impairment may lead to psychiatric morbidities such as anxiety disorders and depressive disorder which increase the suicidal risk in these patients. The present hospital-based comparative study was carried out to evaluate the depression and suicidal risk in patients with psoriasis and to compare them with healthy control.
Methods: This was a hospital-based cross-sectional study. Fifty patients with psoriasis were enrolled for the study after their informed consent with purposive sampling method from the department of dermatology in a tertiary care hospital in the northeastern part of India and compared them with those of the control group. The severity of psoriasis was assessed using the Psoriasis Area and Severity Index scale. The same patients were evaluated by the International Classification of Mental and Behavioral Disorders tenth revision research criteria along with the Hamilton Rating Scale for Depression and suicidal risk assessment form to diagnose and grade depression and assess for suicidal risk. Data were analyzed in SPSS version 16.0.
Results: The incidence of depression was significantly higher in the psoriasis patient group (44%) in comparison to the control group. Among them, 50% of the depressed patients had mild depression and 31.9% of the patients had very severe depression with death wish with suicidal ideation. Furthermore, 4.6% of the depressed patients have a high risk of suicide.
Conclusions: These findings indicate the need of early recognition of depression and suicidal risk among these patients and their early intervention will improve the primary disease process and will prevent a devastating outcome like suicide.

Keywords: Depression, psoriasis, suicidal risk

How to cite this article:
Dey P, Zaman RU, Nath J. Assessment of depression and suicidal risk in patients with psoriasis: A hospital-based cross sectional study. J Med Soc 2022;36:124-8

How to cite this URL:
Dey P, Zaman RU, Nath J. Assessment of depression and suicidal risk in patients with psoriasis: A hospital-based cross sectional study. J Med Soc [serial online] 2022 [cited 2023 Apr 1];36:124-8. Available from: https://www.jmedsoc.org/text.asp?2022/36/3/124/370596

Introduction

The concept of mind - body relationship is from ancient times. Galen validated emotion is important in pathogenesis of disease. The word psychosomatic medicine dates back to the early nineteenth century and it means “a physical disease that is thought to be caused or made worse by mental factors.”^[1],[2] Among different psychosomatic illnesses, dermatological illness is very frequent.^[2],[3] Previous studies have reported that 30% of outpatients and 60% of inpatients of the dermatology department obtained high scores in the thirty-item General Health Questionnaire and half of the high scorers in each group scored high in the Wakefield Self-Assessment Depression Scale.^[4],[5]

Psoriasis is one of the most common dermatological illnesses affecting 1%–2% of general population.^[2] Patients with psoriasis have impairment of physical, psychological, vocational, social functioning. These result from the disease-related stress, its cosmetic disfigurement, and social stigma.^[1],[6],[7] This, in turn, led to psychiatric morbidities such as anxiety disorders, depressive disorder, and substance use disorder.^[8],[9] A comparative study revealed psychiatric comorbidity in vitiligo and psoriasis patients to be 33.63% and 24.7%, respectively.^[10]

A large percentage of patients with psoriasis have death wish and active suicidal ideation.^[11] Previous literature addressed the psychological and emotional aspect of psoriasis, which showed that psoriasis was associated with a variety of psychological problems such as poor self-esteem, sexual dysfunction, anxiety depression, and suicidal ideation.^[12]

Thus, keeping in mind the extensive negative impact of various comorbid psychiatric issues in patients with psoriasis and lack of similar research work particularly in the northeastern part of India, an endeavor has been made to estimate the prevalence of depression and suicidal risk in patients with psoriasis from this particular geographical location attending a tertiary care hospital.

Methods

This was a hospital-based cross-sectional study. The sample was drawn with purposive sampling method from the outpatient department (OPD) and patients admitted in the dermatology department of a tertiary care teaching hospital situated in the northeastern part of India from July 2005 to June 2006.

Mode of selection of cases

Sampling procedure

After informed consent, fifty psoriasis patients of age group 15–60 years of both sexes were included. Patients with present or past history of any major physical or dermatological illness were excluded. Patients with present psychiatric disorder other than depression and past history of any psychiatric disorder were excluded. Suicidal risk is often associated with many psychiatric disorders such as schizophrenia, bipolar mood disorder, and anxiety disorder, hence excluded. Again, persons with past history of any psychiatric disorder including depression are more prone to suicidal risk and subsequent episode of depression which might be not related to psoriasis, hence excluded. Pregnant and lactating women and patients on systemic steroid and substance dependence were excluded.^[13]

Operational procedure

Diagnosed cases of psoriasis were selected from dermatology outdoor and indoor with purposive sampling method as per inclusion and exclusion criteria. Prior approval from the institutional ethical review board was taken. After obtaining informed consent, the Psoriasis Area and Severity Index (PASI) scale was applied under the guidance of dermatologists and documented.^[14] In selected cases after mental status examination, the International Classification of Mental and Behavioral Disorders tenth revision (ICD-10) research criteria along with the 21-item Hamilton Rating Scale for Depression (HAM-D) were applied to diagnose the presence of depression with different grading.^[15],[16] Furthermore, a suicidal risk assessment form was applied to assess the risk of suicide.^[17]

Mode of selection of controls

The control group comprised fifty attendants of patients attending dermatology OPD and indoor without any dermatological illness with the same exclusion criteria. They were demographically matched with the study group. Controls were subjected to the same tools except PASI.

Description of tools:

Specially designed proforma was used to record the sociodemographic data, present, family, medical, and drug history, and also physical examination as designed by the researchers
Depression was diagnosed and assessed by the ICD-10 research criteria^[15]
Twenty-one-item HAM-D was applied to assess the severity of depression. Items are scored between 0 and 4 points. A score of <7 has no depression, 8–13 mild depression, 14–18 moderate depression, 19–22 severe depression, and >23 has very severe depression^[16]
Suicidal risk assessment form was adapted from the Beck Suicidal Intent Scale. This is a 15-item scale with a score of 0–2 for each item. Risk is graded as low (0–10), medium (11–20), and high (21–30)^[17]
PASI scale was used to assess the skin area involved and severity of psoriasis. The area covered is for the head, trunk, upper limb, and lower limb corresponding to 10%, 20%, 30%, and 40% of the total body area, respectively. The severity assessment is done along a 0–4 scale (0 – no lesion to 4 – severest possible lesion) for the three target symptoms of erythema, induration, and desquamation. The total PASI score ranging from 0 to 72 is obtained by adding the values of the sum of severity ratings for the three target symptoms multiplied with the numerical value of the areas involved and with various percentages of the four body areas.^[14]

Analysis of data

Data were tabulated showing sociodemographic distribution between depressed and nondepressed patients. On parametric test, “Chi-square test” or “Fisher's exact t-test” was administered to compare between the groups.” To assess the relationship between severities of psoriasis with severity of depression linear regression model was used. All analysis was performed using Microsoft Excel software and Statistical Package for the Social Sciences (SPSS Inc. Released 2007. SPSS for Windows, Version 16.0. Chicago, SPSS Inc). P < 0.05 was taken as statistically significant in all aspects.

Results

In our study, 44% of the patients with psoriasis were depressed, whereas only 4% in the control group were depressed [Table 1]. Majority of the males in the study group showed depression. Depression was significantly prominent among the patients in illiterate and in those who studied up to high school level. Also similar significant finding was for Daily wage earner and cultivator who comprised 50% of all depressed study population [Table 2]. As per the HAM-D scale, 50% of the depressed patients had mild depression and 31.9% of the patients have very severe depression with death wish and suicidal ideation, which was significantly more than the control group with P = 0.000 [Table 3]. Our study showed that 18.2% and 4.6% of the depressed patients had medium and high suicidal risks, respectively, which was also statistically significant, with P = 0.000 [Table 4]. The study showed that 7.98% of the patients with a PASI score of <10 and all the patients with a PASI score of >21 had very severe depression with death wish and suicidal ideation [Table 5].

Table 1: Assessment of depression using the Hamilton Rating Scale for Depression scale in the study and control groups

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Table 2: Association of depression with different sociodemographic variables

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Table 3: Distribution of depression according to severity using the Hamilton Rating Scale for Depression in the study and control groups

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Table 4: Assessment of suicidal risk in the study and control groups using suicidal risk assessment form

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Table 5: Severity of depression in different scores of the Psoriasis Area and Severity Index

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Discussion

The frequency of depression found in our study in cases of psoriasis was 44%, and in the control group, the frequency of depression was only 4%. The higher rate of depression in psoriasis was similar to previous studies which reported to be approximately 50%.^[18],[19] The reasons for a higher rate of depression in psoriasis could be impairment in vocational, social function; this disability resulted from disease-related stress, cosmetic disfigurement, and social stigma.^[20],[21] In the control group, this represents the prevalence of depression in general population.^[22] Out of the fifty patients with psoriasis, majority of the depressed patients were in the age below 45 years which goes in concordance with an earlier study finding where men <40 years of age were reported to have depressive symptoms in psoriasis.^[10],[23] This is because psoriasis is more common in the second to fourth decades of life which represent our study population.^[2],[3] Our study comprises mostly male patients. This might be the cause of a higher incidence of depression in male patients. We also found that depression had an inverse relationship with the number of years of education means lesser was the years of education more was the prevalence of depression in this study population. Similar findings were in previous study.^[23] Furthermore, we have found that 100% of the daily wage earners were depressed. The reason might be due to the need to earn for the family on the one side and physical disability to work along with cosmetic disfigurement on the other side.

According to the Hamilton Psychiatric Rating scale of depression, 50% of the depressed people had mild depression and 31.9% have very severe depression with death wish and suicidal ideation. Again, 18.2% and 4.6% of the depressed patients had medium-to-high suicidal risk as on applying suicidal risk assessment form on those study population. These findings were similar to previous studies, which showed that 7.2% of the patients with psoriasis had suicidality.^{[11],[12],[21]} We found a significant correlation between severity of psoriasis and severity of depression which was in accordance with other studies.^[18] We divided the PASI score into four groups, and 38 patients out of 50 had a PASI score of 0–10, of which 28.7% had mild depression and 7.9% had very severe depression with death wish and suicidal ideation. On the other hand, all the five patients (100%) having a higher PASI score (>21) had very severe depression with suicidal ideation. This goes in concordance with the previous study as mentioned above.^[20] A total of 7.9% of the patients with a PASI score of <10 had death wish and suicidal ideation. They had involvement of palms and soles, which might have hampered their work abilities; hence, a significant correlation between occupation and depression was found.

The limitations of the study were the small sample size and patients were evaluated once only. Larger sample size and further evaluation would have been helpful to elicit the presence of depression and suicidal risk in the course of illness.

Conclusions

Our findings revealed the need for psychiatry consultation, especially in psoriasis patients with high disease activity and disability. A multidisciplinary approach with the treatment of depression may overall improve the disease outcome in these patients. Furthermore, early assessment and intervention in suicide risk may prevent a devastating outcome in patients with psoriasis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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