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ORIGINAL ARTICLE
Year : 2018  |  Volume : 63  |  Issue : 4  |  Page : 281-284
Vitiligo and psychiatric morbidity: A profile from a vitiligo clinic of a rural-based tertiary care center of eastern India


1 Department of Dermatology, B. S Medical College, Bankura, India
2 Department of Dermatology, Burdwan Medical College, Bardhaman, India
3 Department of Psychiatry, MMC, Midnapore, West Bengal, India

Date of Web Publication9-Jul-2018

Correspondence Address:
Dr. Tanusree Sarkar
Department of Dermatology, Burdwan Medical College, Barsul, Bardhaman - 713 124, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijd.IJD_142_18

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   Abstract 


Background: Vitiligo is an idiopathic acquired progressive de/hypopigmentary disorder of skin and mucosae. In Indian skin depigmentaion is very much obvious and can cause psychological distress, low self esteem and social stigmatization. Aims: The primary objective of this study was to evaluate the psychiatric morbidity in vitiligo patients and secondary objective was to assess the morbidity in all eight dimensions of psychosocial and physical aspects, i.e. cognitive, social, discomfort, limitations, depression, fear, embarrassment and anger. Materials and Methods: An institution based case-control study with sixty-one patients of vitiligo and equal number of healthy age and sex matched controls was undertaken. The self-reporting questionnaire-24 (SRQ-24) and skindex (A 61-item survey questionnaire) were used to assess the psychiatric morbidity in both the groups. Results: The SRQ-assessed psychiatric morbidity in the study group was 63.93%, compared with 24.59% in the control group (P<0.0001). Acral vitiligo had maximum association with psychiatric morbidity (86.67%) followed by vitiligo vulgaris (68%), mucosal vitiligo (62.5%) and others. According to the skindex, the most common psychiatric morbidity in vitiligo patients was depression (62.29%) followed by embarrassment (55.73%), social problem (54.09%), cognitive impairment (50.81%), physical limitation (47.54%), discomfort (40.98%), anger (36.06%) and fear (24.59%). The difference in Skindex scoring that marked the psychiatric morbidity among the case and control groups was statistically significant for depression, discomfort, social problem, cognitive impairment, embarrassment (P<0.0001) and physical limitation (P=0.0044). Conclusion: Vitiligo has a high degree of psychiatric morbidity.


Keywords: Psychiatric morbidity, skindex, self-reporting questionnaire-24, vitiligo


How to cite this article:
Sarkar S, Sarkar T, Sarkar A, Das S. Vitiligo and psychiatric morbidity: A profile from a vitiligo clinic of a rural-based tertiary care center of eastern India. Indian J Dermatol 2018;63:281-4

How to cite this URL:
Sarkar S, Sarkar T, Sarkar A, Das S. Vitiligo and psychiatric morbidity: A profile from a vitiligo clinic of a rural-based tertiary care center of eastern India. Indian J Dermatol [serial online] 2018 [cited 2018 Sep 22];63:281-4. Available from: http://www.e-ijd.org/text.asp?2018/63/4/281/236216

What was known?
Vitiligo is associated with psychological upset.



   Introduction Top


Vitiligo is an idiopathic, acquired, chronic dermatological disorder characterized by hypopigmentation or depigmentation of skin and mucosae. Skin being the outermost covering of the body and being exposed to environment, its appearance greatly influences body image and self-esteem.[1],[2] It affects 1%–2% of the world population.[3] There is a possibility of development of vitiligo due to increased psychological stress that increases the level of neuroendocrine hormones which activate the immune system and increase the level of neuropeptides subsequently. These pathophysiological the changes may be the triggering or precipitating factors for the pathogenesis of vitiligo. The sense of being stigmatized or being different from others is a common reaction and may affect an individual's interpersonal and social behavior. The chronic nature and unpredictable course of the disease along with lack of uniform effective therapy can be a cause of stress, anxiety, depression, and frustration. It influences the way we are perceived by others and can affect the social and marital life. The disease may provoke negative emotions such as shame or embarrassment, anxiety, lack of confidence, and even psychiatric diseases such as depression. About 75% of vitiligo patients have psychological disorder.[4] Papadopoulos et al.[5] have shown that counseling can help improve body image, self-esteem, and quality of life (QoL) of patients with vitiligo. At the present scenario, the field of psychodermatology has been more enriched as a result of our increased interest and understanding of the relationship between skin diseases and various psychological factors.[6]

Depending on data available from different research work and focused discussion with patients and with clinicians who care for patients with skin diseases, Chren et al. constructed a conceptual framework for the subjective effects of skin disease on patients' quality of life (QoL) [Figure 1]. These effects have two major domains: Psychosocial and physical. Within these domains, they identified five dimensions: Psychosocial effects that were cognitive, social or emotional and physical effects that were related to physical discomfort or limitations in physical functions. Within the emotional dimension, they included the sub-dimensions of depression, fear, embarrassment and anger.[7] There are a lot of studies assessing the QoL in vitiligo patients in India and abroad. However, there is a paucity of studies comparing the prevalence and degree of impairment in QoL in patients who are suffering from vitiligo and in otherwise healthy individuals attending the dermatology outpatient department.
Figure 1: Conceptual framework for the effects of skin disease on patients' quality of life. This hypothesis was based on literature review and directed interviews with the patients with skin disease and clinicians who care for them. The constructs included in Skindex are marked with red color

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The present study was undertaken to assess and analyze the psychiatric morbidity among treatment-seeking patients of vitiligo with that of patients with other skin disorders and to evaluate the morbidity in all eight dimensions of psychosocial and physical aspects, i.e., cognitive, social, discomfort, limitations, depression, fear, embarrassment, and anger in a rural-based tertiary care center.


   Methodology Top


An institution-based case–control study was undertaken in a tertiary care hospital of eastern India from January to December 2016, with 61 cases of vitiligo and a similar number of age- (±2 years) and sex-matched controls from other patients and from healthy accompanying persons.

Inclusion criteria

  1. Vitiligo patients diagnosed by a consultant dermatologist
  2. Patient's age >18 year
  3. Both sexes
  4. Patients willing to provide informed consent
  5. Age and sex matched controls
  6. Must understand, read, and write Bengali.


Exclusion criteria

  1. The patient should not have any other comorbid general medical illness other than minor skin ailment
  2. In the patient group, any history of psychiatric illness before the onset of vitiligo
  3. Patients who are were unwilling to participate in the study
  4. The control group should be free from vitiligo.


A detailed history and physical examination of each participant were undertaken. The self-reporting questionnaire-24[8] (SRQ-24, a psychitric screener) and Skindex [7] (a 61-item self-administered survey questionnaire to assess the QoL of patients of dermatological disorder on the aforementioned eight scales) were used as study tools. Data were collected in a predesigned case datasheet and were analyzed with MedCalc software version 10.2.0.0” by Acacialaan 22, B-8400, Ostend, Belgium. Chi-squared test or Fisher's exact test or Monte–Carlo approximation was applied as a statistical tool.


   Results Top


Over a period of 1 year, 61 patients of vitiligo and similar number of age- (±2 years) and sex-matched healthy controls were included in the study from the patients attending the dermatology outpatient department of a rural-based tertiary care institute of West Bengal, India.

The age of the vitiligo patients ranged from 20 year to 68 year with a mean of 43.8±12.48 years. In the control group, age ranged from 22 year to 70 year with a mean of 44.01±11.85. In both the groups, 31 (50.82%) patients were male and 30 (49.18%) were female. Most patients suffered from vitiligo vulgaris (40.98%), followed by acral type (24.59%), focal (16.39%), mucosal (13.12%), segmental (3.28%), and universal type (1.64%). Psychiatric screener (SRQ-24) was positive in 39 (63.93%) patients, while in the control group, it was positive in 15 (24.59%) patients; this difference was statistically significant (P

<0.0001). It was observed that patients with acral vitiligo had the highest percentage of psychiatric screener (SRQ-24) positivity (86.67%), followed by vitiligo vulgaris (68%), mucosal vitiligo (62.5%), and segmental vitiligo (50%); lowest psychiatric screener positivity was noted in focal vitiligo (30%) [Figure 2]. According to Skindex, the most common psychiatric morbidity noted among the vitiligo patients was depression (62.29%), followed by embarrassment (55.73%), social problem (54.09%), cognitive impairment (50.81%), physical limitation (47.54%), discomfort (40.98%), anger (36.06%), and fear (24.59%) [Figure 3]. In the control group, psychiatric morbidity observed was physical limitation (22.95%), followed by anger (21.31%), fear (11.47%), cognitive impairment (11.47%), embarrassment (11.47%), depression (6.65%), discomfort (3.27%), and social problem (1.63%). Excepting anger and fear, the observed differences were statistically significant [Table 1].
Figure 2: Psychiatric screener positivity

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Figure 3: Psychiatric morbidity among the vitiligo patients

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Table 1: Comparison of different psychiatric morbidities among the vitiligo patients and the controls

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   Discussion Top


Vitiligo is considered as a cosmetic problem. It affects an individual's emotional and psychological well-being,[8] having major consequences on patient's life.[9] The relationship between skin and brain is based on both being originated from the same ectodermal structure and being under influence of the same hormones and neurotransmitters.[1] Psychodermatology makes up a common area of interest based on the mutual relationship and interaction between psychiatry and dermatology.[10] In this study, we used SRQ-24 for screening purpose. This questionnaire is comparable to General Health Questionnaire (GHQ) 12 or 28 for assessing the psychiatric morbidity.[11] GHQ is commonly used by different studies to assess the dermatology quality life index, but this scale is unable to detect psychotic phenomena.[12] For measuring QoL in vitiligo patients, we used Skindex-61 questionnaire. This scale used eight dimensions for assessing QoL in a patient with dermatologic disorder.

The results of the present study showed that the mean age of vitiligo patients was 43.8 years and the mean age of control group was 44.01 years. This confirms that both the groups were age matched as the difference in mean age was negligible. The SRQ-assessed psychiatric morbidity was 63.93% in vitiligo patients in our study, which was higher than that in GHQ-assessed study done by Mattoo et al.[13] (25%). Sharma et al.[14] showed that GHQ assessed psychiatric morbidity in psoriasis and vitiligo patients were 53.3% and 16.2% respectively. However, few studies have found lower prevalence of psychological morbidity of 31%, 24%, 42%, and 10% using different assessment tools such as Structured Clinical Interview for Diagnostic and Statistical Manual-IV Axis I Disorders (SCID-1) and psychiatric assessment schedule.[15],[16],[17],[18] Higher prevalence of psychiatric morbidity (79.2%) was found in a study done by Ramakrishna and Rajni using the Rosenberg self-esteem scale and Hamilton depression rating scale.[19] The use of different diagnostic tools may be the cause of the differences in the prevalence of psychiatric morbidity in different studies.

Skindex [7] was used to assess aforementioned eight subdomains of psychiatric disorder in our study. Skindex values of all dimensions are higher in vitiligo patients than in control group, but it is not significant for anger, and fear and significant for depression, discomfort, social, cognitive impairment, embarrassment and physical limitation. This result was highly predictable that psychiatric screener positivity detected by SRQ had poor Skindex value. Most of the studies conducted to assess the QoL of vitiligo patients mainly focused on depression, but few studies at the same time also considered poor self-esteem, anxiety, and social problem. In our study, depression (62.29%) was also the major psychiatric disorder in vitiligo patients. The presence of depression in vitiligo patients in our study was comparable with the study done by Sangma et al.[20] (59%), Ramakrishna and Rajni [19] (56.6%), and Balaban et al.[15] (33.33%). Among vitiligo patients, Mattoo et al. depicted adjustment disorder (56%), depressive episode (22%), and dysthymia (9%);[13] Karia et al. reported depression (20%) followed by anxiety (8%);[21] Potter et al. found 40% cases to be depressive and had low self-esteem;[22] and Sharma et al. found depression (10%) and anxiety (3.3%).[14]

The prevalence of psychiatric illness was high in vitiligo group compared with that in the control group according to SRQ-24 screener. This difference was also statistically significant (P<0.0001). Among different types of vitiligo, acrofacial vitiligo was associated with maximum psychiatric comorbidity (86.67%), followed by vitiligo vulgaris, mucosal, segmental, focal, and universal vitiligo.


   Conclusion Top


The present study showed higher degree of psychological comorbidity and major impairment in QoL associated with vitiligo, and the extent of this comorbidity is even greater than hitherto thought of. This study had addressed different factors that could influence the prevalence of psychiatric morbidity in this disorder. Taking care of these psychiatric morbidity along with specific vitiligo therapy may bring a favorable outcome.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Koblenzer CS. Psychosomatic concepts in dermatology. A dermatologist-psychoanalyst's viewpoint. Arch Dermatol 1983;119:501-12.  Back to cited text no. 1
    
2.
Gupta MA, Voorhees JJ. Psychosomatic dermatology. Is it relevant? Arch Dermatol 1990;126:90-3.  Back to cited text no. 2
    
3.
Agrawal D, Sahani MH, Gupta S, Begum R. Vitiligo etiopathogenesis and therapy – A review. J Maharaja Sayajirao Univ Baroda 2001;48:97-106.  Back to cited text no. 3
    
4.
Salzer BA, Schallreuter KU. Investigation of the personality structure in patients with vitiligo and a possible association with impaired catecholamine metabolism. Dermatology 1995;190:109-15.  Back to cited text no. 4
    
5.
Papadopoulos L, Bor R, Legg C. Coping with the disfiguring effects of vitiligo: A preliminary investigation into the effects of cognitive-behavioural therapy. Br J Med Psychol 1999;72 (Pt 3):385-96.  Back to cited text no. 5
    
6.
Barankin B, DeKoven J. Psychosocial effect of common skin diseases. Can Fam Physician 2002;48:712-6.  Back to cited text no. 6
    
7.
Chren MM, Lasek RJ, Quinn LM, Mostow EN, Zyzanski SJ. Skindex, a quality-of-life measure for patients with skin disease: Reliability, validity, and responsiveness. J Invest Dermatol 1996;107:707-13.  Back to cited text no. 7
    
8.
Ongenae K, Beelaert L, van Geel N, Naeyaert JM. Psychosocial effects of vitiligo. J Eur Acad Dermatol Venereol 2006;20:1-8.  Back to cited text no. 8
    
9.
Firooz A, Bouzari N, Fallah N, Ghazisaidi B, Firoozabadi MR, Dowlati Y, et al. What patients with vitiligo believe about their condition. Int J Dermatol 2004;43:811-4.  Back to cited text no. 9
    
10.
Mercan S, Kivanç Altunay I. Psychodermatology: A collaboration between psychiatry and dermatology. Turk Psikiyatri Derg 2006;17:305-13.  Back to cited text no. 10
    
11.
Araya R, Wynn R, Lewis G. Comparison of two self administered psychiatric questionnaires (GHQ-12 and SRQ-20) in primary care in Chile. Soc Psychiatry Psychiatr Epidemiol 1992;27:168-73.  Back to cited text no. 11
    
12.
Chowdhury AN, Bramha A, Sanyal D. The validation of the Bengali version of self reporting questionnaire. Indian J Clin Psychol 2003;30:56-61.  Back to cited text no. 12
    
13.
Mattoo SK, Handa S, Kaur I, Gupta N, Malhotra R. Psychiatric morbidity in vitiligo: Prevalence and correlates in India. J Eur Acad Dermatol Venereol 2002;16:573-8.  Back to cited text no. 13
    
14.
Sharma N, Koranne RV, Singh RK. Psychiatric morbidity in psoriasis and vitiligo: A comparative study. J Dermatol 2001;28:419-23.  Back to cited text no. 14
    
15.
Balaban ÖD, Atagün Mİ, Özgüven HD, Özsan HH. Psychiatric morbidity in patients with vitiligo. J Psychiatry Neurol Sci 2011;24:306-13.  Back to cited text no. 15
    
16.
Rashid HA, Mullick SI, Jaigirdar QH, Ali R, Nirola DK, Salam MA, et al. Psychiatric morbidity in psoriasis and vitiligo in two tertiary hospitals in Bangladesh. Bangabandhu Sheikh Mujib Med Univ J 2011;4:88-93.  Back to cited text no. 16
    
17.
Ahmed I, Ahmed S, Nasreen S. Frequency and pattern of psychiatric disorders in patients with vitiligo. J Ayub Med Coll Abbottabad 2007;19:19-21.  Back to cited text no. 17
    
18.
Esfandiar Pour I, Afshar Zadeh P. Frequency of depression in patients suffering from vitiligo. Iran J Dermatol 2003;6:13-8.  Back to cited text no. 18
    
19.
Ramakrishna P, Rajni T. Psychiatric morbidity and quality of life in vitiligo patients. Indian J Psychol Med 2014;36:302-3.  Back to cited text no. 19
[PUBMED]  [Full text]  
20.
Sangma LN, Nath J, Bhagabati D. Quality of life and psychological morbidity in vitiligo patients: A study in a teaching hospital from North-East India. Indian J Dermatol 2015;60:142-6.  Back to cited text no. 20
[PUBMED]  [Full text]  
21.
Kaira S, Sonsa AD, Shah N, Sonavane S, Bharti A. Psychological morbidity in vitiligo- A case control study. Pigmentary disorder 2015;2:170.  Back to cited text no. 21
    
22.
Porter J, Beuf AH, Nordlund JJ, Lerner AB. Psychological reaction to chronic skin disorders: A study of patients with vitiligo. Gen Hosp Psychiatry 1979;1:73-7.  Back to cited text no. 22
    

What is new?

  • Vitiligo patients are subjected to different psychosocial and physical co-morbidity.
  • Depression, embarrassment, social problem, cognitive impairment, and discomfort are the predominant psychological co-morbidities.


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1]



 

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