Indian Journal of Dermatology
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ORIGINAL ARTICLE
Year : 2006  |  Volume : 51  |  Issue : 1  |  Page : 18-22
Psychiatric morbidity in dermatology patients: Frequency and results of consultations


Department of Dermatology, Inonu University Medical Facultly, Malatya, Turkey

Correspondence Address:
Muammer Seyhan
Bilkent-1, E-4, Blok, No. 59 06530 Bilkent, Ankara
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5154.25181

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  Abstract 

BACKGROUND: Dermatological patients quite commonly depict psychiatric morbidity. PURPOSES: To study the psychiatric morbidity among skin patients of our clinic. METHODS: In the present study, the patients who were treated in the Dermatology Clinic of Inonu University Medical Faculty were evaluated retrospectively. The age, gender, marital status, habits, dermatological and systemic diseases, previously used drugs, current therapy and psychiatric diagnosis of each patient were recorded. FINDINGS: Of 636 patients involved in the study, 15.3% had psychopathological problems, which were depression (32.0%), adjustment difficulty (15.5%), anxiety (13.4%), psychosomatic disorders (10.3%), obsessive-compulsive disorder and conversion (5.1%), dysthymic disorder (4.1%), attention deficit and hyperactivity disorder (2.1%), panic attack (1.0%), premenstrual syndrome, schizophrenia, somatization disorder, insomnia, alcohol dependency, bipolar affective disorder, mental retardation, agoraphobia, social phobia and dementia. The dermatological diseases defined for the patients with psychopathology diagnosis were chronic urticaria (25.8%); psoriasis (15.5%); alopecia areata, totalis and iniversalis (11.3%); acute urticaria, neurodermatitis and Behcet's disease (5.1%); atopic dermatitis and drug eruptions (4.1%); pemphigus (3.1%); angioedema, contact dermatitis and generalized pruritus (2.1%); folliculitis and the others (1.0%). CONCLUSIONS: Psychiatric morbidity has an affect on the course of dermatological diseases. When required, psychiatric consultation should be sought by dermatology clinics and patients should be followed with the cooperation of dermatologists and psychiatrists. LIMITATION: The indoor-based study had not included any control group and any domicillary patient.


Keywords: Psychiatric morbidity, Skin diseases


How to cite this article:
Seyhan M, Aki T, Karincaoglu Y, Ozcan H. Psychiatric morbidity in dermatology patients: Frequency and results of consultations. Indian J Dermatol 2006;51:18-22

How to cite this URL:
Seyhan M, Aki T, Karincaoglu Y, Ozcan H. Psychiatric morbidity in dermatology patients: Frequency and results of consultations. Indian J Dermatol [serial online] 2006 [cited 2019 Oct 17];51:18-22. Available from: http://www.e-ijd.org/text.asp?2006/51/1/18/25181



  Introduction Top


Psychopathological disorders are highly prevalent among dermatology patients.[1],[2] The relationship between dermatological diseases and psychiatric morbidity can be established as follows: 1) The appearance of skin lesions and the chronic progression of the disease may frequently affect the quality of social and work life of patients, thus, psychiatric morbidity may arise as a complication, 2) less frequently, these skin diseases may result from primary psychological diseases cuh as obsessive compulsive and delusional disorders, 3) both the skin findings and psychiatric complaints may develop secondary to a disease such as systemic lupus erythematosus, 4) some drugs, such as corticosteroids, used in dermatological treatment may trigger psychiatric symptoms, or lithium and some antipsychotic drugs may cause dermatological diseases. [3],[4],[5]

The prevalence of psychiatric diseases in the patients presenting to dermatology clinics has been reported as 25-43%.[3],[6],[7] Stress may aggravate the cutaneous disease in 40-100% of patients.[5] In general, patients prefer the treatment of their dermatological diseases rather than psychiatric disorders and seek dermatologic consultation. Consequently, dermatologists often see patients who also have psychiatric conditions.[6] The most efficient treatment of dermatological diseases is achieved with combined evaluation of emotional factors.[4],[5]

The aim of the present study was to investigate the psychiatric morbidity, consultation rate and results in patients in our clinic.


  Materials and Methods Top


The study involved the patients hospitalized in Dermatology Clinic of Inonu University. Psychiatric morbidity, consultation rate and results were investigated retrospectively. Their age, gender, marital status, habits, dermatological and systemic diseases, previous drug use, the treatment modality applied after diagnosis, psychiatric diagnosis and recommended psychiatric therapy were recorded. The duration of dermatological diseases were also determined. The patients who had personal and/or family history of psychiatric disorders and/or previous suicide attempt were also recorded.


  Results Top


Of 636 patients, 104 (16.4%) had psychiatric consulations and in 97 of them a psychopathology had been diagnosed. The patients with a psychopathology constituted 15.3% of all the patients and 93.3% of those who received a psychiatric consultation. Of the patients who had a diagnosis of psychopathology, 62 patients (63.9%) were female and 35 patients (36.1%) were male. The age range was 7 to 66 years (mean age: 35.98 15.34). The mean age of the female patients was 37.86 17.44, while the mean age of the males was 34.92 14.68. Two patients (2.1%) were children. Fifty-eight patients (59.8%) were married; 32 patients (33.0%) single; and 5 patients (5.2%) were widow/widower or divorced. When in patient treatments of the patients were evaluated, 11 patients (11.3%) were hospitalized twice before; 6 patients (6.2%) three times; 1 patient (1%) four times, 2 patients (2.1%), five times; and the remaining 77 patients (79.4%) were adulted for the first time. Seven patients who had been hospitalized for a total of three times had received a psychiatric evaluation during their second or the third hospitalizations. Of the three patients with a history of suicidal attempts, two patients had been hospitalized five times and one patient was hospitalized four times. The sociodemographic features of the patients have been presented in [Table - 1]. The occupational distribution of the patients with psychomorbidity was as follows: housewife: 47 patients (48.5%); student: 18 patients (18.6%) [Table - 2]. The most prevalent pathology was depression (31 patients 32.0%), followed by adaptation problem in 15 patients (15.5%), anxiety in 13 patients (13.4%) and psychosomatic disorder(s) in 10 patients (10.3%). The relatively less prevalent psychopathologies were obessive disorders, conversion, dysthymic disorder, attention deficit and hyperactivity. The distribution of these findings has been listed in [Table - 3]. The most prevalent dermatological diagnosis of the patients with psychatric morbidity was chronic urticaria (25 patients, 25.8%). The other dermatological diagnoses were psoriasis in 15 patients (15.5%) and alopecia in 11 patients (11.3%) [Table - 4]. The rates of psyhopathologies accompanying the most prevalent dermatological diseases have been presented in [Table - 5].


  Discussion Top


The association of psychiatric disorders and dermatological anomalies has long been known.[2],[8] Dermatological diseases have an affect on the daily life, self-confidence and self-respect. In fact, they may lead to questioins on self-image; thus, creating a problem of identity.[8],[9] Dermatologists have observed their patients to be relatively more concerned and worried about the diseases that are related to their physical appearance,[9] as a result of which dermatology patients may be aflicted with disorders such as anxiety, depression and other psychosocial problems.[1]

Woodruff et al[6] have reported a prevalence of 30-40% for the psychiatric problems among the dermatology patients attendins their clinic. On the other hand, Picardi et al[3] have reported 25.2% psychiatric morbidity rate in dermatology patients. In general evaluation of the epidemiological studies, the prevalence of psychiatric morbidity was, found to be 25-43% in outpatient dermatology patients.[1],[6] Among our patients who had been observed in our clinic within a period of 3 years, 16.4% had received psychiatric consultation and among them 93.3% had received a diagnosis of a psychiatric disorder. The psychiatric morbidity rate among those who had been hospitalized was 15.3%. Psychiatric consultation was sought when the psychopathologies had been thought to be probable etiological factor or aggravating factor and when marked psychopathologies were observed. Thus, the consultation offers of our clinic were selective and did not involve all the patient groups. In the study of Aslan et al,[10] in which psychiatric consultation rates during one year were evaluated, dermatology clinic was determined as the one that sought consultations from the psychiatry clinic most frequently with a rate of 25%. The psychiatric consultation order rate by the dermatology clinic was 16%, which was nearly same with that of our study. Despite the lack of a study about the interclinical consultation rates in our hospital, to expression of the consultant physicians of psychiatry clinic, dermatology has been the most frequently consulting clinic to date. In another study from our country, Aktan et al[11] have found 33.4% prevalence of psychiatric disorders accompanying dermatological diseases, which is nearly twice as much as the rate found in our study.

In the study of Woodruff et al,[6] the mean age of female patients was 46.8 years and of male patients, 41.9 years (mean age of all patients: 44.88 years). However, in our study mean age of females was 37.8 years and 35.0 for males, with a general mean of 36.0 years. The prevalence of psychiatric morbidity is higher in female patients and widows, particularly those with eczema, psoriasis, pruritis, urticaria, acne and alopecia with widespread lesions.[2],[6] Picardi et al[3] have found higher psychiatric morbidity rates in females, widows and widowers. There were, however, no differences associated with age and educational level of the patients.[3] In our study, the number of female patients was significantly higher and psychiatric morbidity was more prevalent in married patients. The prevalance of psychiatric morbidity was higher among housewives, students, retired, unemployed and teachers, respectively.

Picardi et al[1] have given a questionnaire to 1389 patients of the dermatology outpatient clinic and ound a psychiatric morbidity rate of 20.6%. The patient group with the higher rate of psychiatric morbidity has been the females with hand and foot lesions. Similarly, in our patient group, various psychopathologies, primarily depression, was detected in female patients, 67.7% of whom were housewives and 40% of these patients had lesions at visible parts of their bodies. In another study, Pulimood et al[12] have found higher rate of psychiatric morbidity in the patients who had received therapy for at least six months, especially steroid therapy.[12] In the present study, the morbidity rate in the patients with dermatological problems of longer than one year was 27.8% while it was 72.2% in those with problems of less than one year. The lower rate of psychiatric morbidity in patients with long-standing disease may be accounted for by patients' eventual psychological adjustment to the disease.

Depression (34%) was the most prevalent finding in the study of Pulimood et al.[12] Chronic urticaria, exfoiliative dermatitis and sexually transmitted diseases were the diseases that led to psychiatric disorders most. In study of Aslan et al[10] among psychological problems associated with physical disorders, depression was the most prevalent and adjustment disorder were the second most prevalent. Woodrufft et al[6] have reported mild to moderate depression (28%), mild anxiety (25%) and severe depression (14%). In their patient group, they have reported patients with a history of psychiatric disorders (40%), patients with a familial history (29%) and patients with an additional systemic disease (29%).[6] Parallel to the results of Pulimood et al , Woodruff et al and Aslan et al ,[10] out results were depression (32.0%), adjustment disorder (15.5%) and anxiety (13.4%). The distribution of psychiatric morbidity in various dermatological disease groups in this study were psychosomatic disorders (25%) and depression (18.8%) in urticaria group; adjustment disorder (40%) and depression (30%) in the patients with psoriasis; and anxiety (36.4%) and adjustment difficulty (18.2%) in the patients with alopecia.

When dismorphic diseases such as acne and psoriasis lead to lesions, particularly of face, the prevalence of depression and suicide attempts have been relatively higher in both genders.[3],[13],[14],[15] In the study of Akay et al[16] from Turkey, depression rate was 58% in the patients with psoriasis, 53% in the patients with lichen planus, while it was 20% in the control group. The rate in psoriasis group was significantly higher compared to that of the control group. Thus, PASI score was parallel to depression score.[16] The dermatological diseases accompanied by psychopathologies were, in the order of prevalence, chronic urticaria, psoriasis and alopecia areata. Chronic and debilitating dermatological diseases like psoriasis may lead to suicide associated with depression.[3],[15] Particularly female patients with dermatological problems on the face and males with dermatological scars have been reported to have higher suicidal tendency. Therefore, young patients with scarring acne who use isotretinoin and the patients with prevalent dermatological diseases such as atopic dermatitis should undergo comprehensive psychiatric evaluation.[13] In our study, three patients with widespread psoriasis had a history of suicide attempt. One of these patients was a female with inverse psoriasis with genital area involvement and was not supported by her spouse. Two other male patients had often been hospitalized with erythroderma and their family and work lives were affected. The study involved patients with dermatological problems requiring hospitalization; thus, there was no patient with acne.

The drugs used in the treatment of dermatological diseases such as steroid and retinoid may lead to psychiatric symptoms.[5] In this study, 31.0% of the patients had used steroids, which may have facilitated the development of psychopathologies. Thus, the patients with psychopathologies requiring steroid treatment should be closely observed. In a questionnaire on 100 patients with eczema, psoriasis and acne, 40% of the patients have reported experiencing difficulties in their social life; 75% in their work life and 80% of the patients have expressed embarrassment.[9] Accordingly, the patients with dermatological diseases and their family should be educated and there must be a well-established patient-doctor relationship. Individual or group therapies should be performed and internet sites and associations should be set up for patients.[3],[9],[17] We think that the communication between the patient groups in our country should be systematically provided. Informing the parents of pediatric patients and providing psychatric consultations are recommended. This recommendation is also valid for the spouses of married patients. In our study, the parents of pediatric patients had also been consulted. Particularly psoriatic and alopecic children are the patients most in need of specially designed psychiatric help.

The recognition of psychiatric disorders by a dermatologist is not adequate in itself. The cooperation of the dermatologist and a psychiatrist in order to increase the life quality of the patients is of utmost importance. A dermatologist's lack of knowledge on the psychiatric morbidity rates in dermatological diseases may delay the diagnosis of psychiatric condition and hinder the treatment. Dermatologists should be more wary and sensitive about the possible psychiatric morbidity in their patients. We think that when the problems noticed by dermatologists are definitely diagnosed, patients can be properly informed and referred to psychiatrists and patients can be followed through the cooperation of dermatologists and psychiatrists.



 
  References Top

1.Picardi A, Daimano A, Renzi C. Increased psychiatric morbidity in female outpatients with skin lesions on visible parts of the body. Acta Derm Venereol 2001;81:410-4.  Back to cited text no. 1    
2.Humphreys F, Humphreys MS, Psychiatric morbidity and skin disease: what dermatologists think they see. Br J Dermatol 1998;139:679-81.  Back to cited text no. 2    
3.Picardi A, Abeni D, Melchi CF, Psychiatric morbidity in dermatological out patients: an issue to be recognized. Br J of Dermatology 2000;143:983-91.  Back to cited text no. 3    
4.Gupta MA, Gupta AK. Pyschodermatology: an update. J Am Acad Dermatol 1996;34(6):1030-46.  Back to cited text no. 4    
5.Koo J, Lee CS. Psycotropic agents. In: Wolverton SE, eds Compherensive Dermatologic Drug Therapy. 1th ed. Philadelphia: WB. Saunders Company, 2001:402-422.  Back to cited text no. 5    
6.Woodruff PWR, Higgins EM, Vivier AW. Psychiatric illness in patients referred to a dermatology-psychiatry clinic. Gen Hosp Psychiatry. 1997; 19(1):29-35.  Back to cited text no. 6    
7.Picardi A, Abeni D, Renzi C, Braga M, Melchi CF, Pasquini P. Treatment outcome and incidence of psychiatric disorders in dermatological out-patients. J Europ Acad Dermatol Venereol 2003;17(2):155-9.  Back to cited text no. 7    
8.Sampogna F, Picardi A, Chren MM, Melchi F, Pasquini P, Masini C, Abeni D. Association between poorer quality of life and psychiatric morbidity in patients with different dermatological conditions. Psycho Med 2004;66:620-4.  Back to cited text no. 8    
9.Ginsburg JH. The psychosomatic impact of skin disease. Dermatologic clinics 1996;14(3):473-84.  Back to cited text no. 9    
10.Aslan S, Candansayar S, Cosar B. Bir universite hastanesinde bir yil stiresince gerveklestirilen psikiyatri konsultasyon hizmetlerinin degerlen-dirilmesi. Yeni Symposium 2003; 41(1): 31-8.  Back to cited text no. 10    
11.Aktan S, Ozmen E, Sanli B. Psychiatric disorders in patients attending a dermatology outpatient clinic. Dermatology 1998;197(3):230-4.  Back to cited text no. 11    
12.Pulimood S, Rajagopalan B, Rajagopalan M, Jacob M, John JK. Psychiatric morbidity among dermatology inpatients. Natl Med J India 1996; 9(5): 208-10.  Back to cited text no. 12    
13.Cotteril JA, Cunliffe WJ. Suicide in dermatological patients. Br. Dermatol 1997;137(2):246-50.  Back to cited text no. 13    
14.Yazici K, Baz K, Yazici AE, Kokturk A, Tot S, Demirseren D, Buturak V. Disease-specific quality of life is associated with anxiety and depression in patients with acne. JEADV (J Eur Acad Dermatol Venercol) 2004;18(4):435-9.  Back to cited text no. 14    
15.Barankin B, DeKoven J. Psychosocial effect of common skin diseases. Csan Fam Physician 2002;48:712-6.  Back to cited text no. 15    
16.Akay A, Pekcanlar A, Bozdag KE, Altintas L, Kraman A. Assesment of depression in subject with psoriasis vulgaris and lichen planus. J Eur Acad Dermatol Venereol. 2002;16(4):347-52.  Back to cited text no. 16    
17.Koo J, Lebwohl A. Psychodermatology: The mind and skin connection. American Family Physician 2001;64(11):1873-8.  Back to cited text no. 17    


    Tables

[Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5]

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   Abstract
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