Psychiatric comorbidity in patients with Psoriasis: a cross sectional study from North India

doi:10.21203/rs.3.rs-4999262/v1

Background: Psoriasis is a psychocutaneous disorder whose prognosis is affected by psychological factors. Despite the psychological impact of the disease only 33% of the sufferers receive mental healthcare. The current study was planned to estimate the prevalence and factors affecting psychiatric co-morbidities among psoriasis patients in a tertiary care hospital.

Materials and methods: 288 consecutive patients diagnosed with psoriasis of the age 18 and above were inducted in the study. Patient were included after signing informed consent. Patient particulars were noted in the sociodemographic profile sheet and clinical profile sheet designed for the study. Diagnosis of psychiatric disorders was made according to ICD-10. If the patients are found to have anxiety or depressive disorders, the severity of the same was assessed by using appropriate scales.

Result: Anxiety was reported in 66 (22.9%) patients. Mild depression found in 23 (8.0%) patients, moderate depression occurred in 25 (8.7%) patients, and severe depression recorded in 23 (8.0%) patients. Psychiatric comorbidity was present in 74.3%, with maximum patients being diagnosed with anxiety disorder unspecified. The association between psychiatric comorbidity and higher educational level, living in joint families, in urban areas and lower middle socioeconomic status was statistically significant.

Conclusion: Our study showed the psychiatric burden to be significant in patients with psoriasis. It represents an unmet need with treatment of psychiatric comorbidity leading to improved quality of life.

Psoriasis

Psychiatric comorbidity

anxiety

depression

Psoriasis is a psychocutaneous disorder with multiple factors involved in its induction and exacerbation.¹

Indian studies have shown the incidence of psoriasis in between 0.8 to 5.6%.² While the disease’s progress is affected by psychological factors, the illness in itself affects the psyche of the person especially due to its chronic nature and visible deformity which negatively affecting the quality of life.^3,4,5

The relationship between psoriasis and mental illness, as well as any possible underlying pathophysiologic causes for this relationship have a biological basis also with inflammatory pathways being implicated.⁶

Studies have shown a strong association between depressive symptoms, suicidal ideation, and psoriasis.⁷ Kumar et al. reported psychiatric morbidity in psoriasis patients to the tune of 52% having light anxiety, 36% having mild to moderate anxiety, and 12% having moderate to severe anxiety.⁸ In a cross-sectional study, by Lakshmy et al. reported prevalence of 78.9% for depression and 76.7% for anxiety.⁹ Another study confirmed the increased number of psychiatric diagnoses in patients with psoriasis, with 38.5% having had a lifetime psychiatric disorder diagnosis compared with 16.7% of patients with other conditions.¹⁰

Despite the psychological impact of the disease only 33% of the sufferers receive mental healthcare.¹¹ With a dearth of studies from India, the current study was planned to estimate the prevalence and factors affecting psychiatric co-morbidities among psoriasis patients in a tertiary care hospital.

The cross sectional analytical study was carried out in the Department of Psychiatry. Patients was recruited from Dermatology outpatient department (OPD) and inpatient department (IPD). 288 consecutive patients diagnosed with psoriasis of the age 18 and above were inducted in the study. Patient with history of traumatic brain injury (significant head injury) / any organic disease-causing Psychiatric co-morbidity in past/ present, patients already diagnosed with psychiatric illness before being diagnosed with psoriasis and those unwilling or unable to give consent were excluded from the study. All eligible patients signed informed consent before participating in the study. Before starting the study was approved from the institute ethics committee (IEC).

Patient particulars were noted in the sociodemographic profile sheet and clinical profile sheet designed for the study. Diagnosis of psychiatric disorders was made according to ICD-10. If the patients are found to have anxiety or depressive disorders, the severity of the same was assessed by using appropriate scales such as: Hamilton Depression Rating Scale (HAM- D), or Hamilton Anxiety Rating Scale (HAM-A). Medical comorbidities of the patients were assessed from history, examination and medical records and was confirmed by a medicine specialist as well.

Statistical analysis

Descriptive data on socio demographic and clinical variables were analyzed by using percentage, mean and standard deviation. The differences in the distribution of categorical and continuous variables was compared by using chi2test and by unpaired t test respectively.2-tailed value of < 0.05 was taken as statistically significant. Data was analyzed using statistical software SPSS info version 27.0.

A total of 288 patients were evaluated. Majority of patients belong to the age group of 36-60 years (58%) while the rest of patients belong to the age group of 18-35 years (42%). Majority of the patients was male (53.1%) followed by females (46.9%).

Sociodemographic profile of patients were as given in table 1.

Table 1: Sociodemographic profile

Sociodemographic Profile of patients recruited
Category	Number	Percent
Marital status
Unmarried	71	24.7
Married	190	66.0
Divorced	27	9.4
Education status
No formal Education	50	17.4
Up to 12th Standard	132	45.8
Graduation	89	30.9
Postgraduation	17	5.9
Occupation
Unemployed	106	36.8
Employed	182	63.2
Residence
Rural	183	63.5
Urban	105	36.5
Family structure
Nuclear	109	37.8
Extended/Joint	179	62.2
Socioeconomic status according to Modified Kuppuswamy scale
Upper	10	3.5
Upper middle	61	21.2
Lower middle	84	29.2
Upper lower	61	21.2
Lower	72	25.0
Clinical profile Disease duration
<2 years	44	15.3
2-5 Years	100	34.7
6-10 Years	92	31.9
>10 Years	52	18.1

Psychiatric comorbidity:

Anxiety was reported in 66 (22.9%) patients. Mild anxiety found in 27 (9.4%) patients (HAM-A score <17), mild to moderate anxiety found in 24 (8.3%) patients, and moderate to severe anxiety found in 15 (5.2%) patients as shown in figure number 1.

Mild to severe depression was reported in 71 (24.7%) patients. Mild depression found in 23 (8.0%) patients, moderate depression occurred in 25 (8.7%) patients, and severe depression recorded in 23 (8.0%) patients.

Mild to moderate (9.6%) and moderate to severe (9.6%) anxiety tends to occurred in advanced age at a higher rate as compared to the age group of 18-35 years, however, the difference was not statistically significant (p value= 0.428) which is shown in figure number 2.

Severe depression tends to occurred in age group of 30-60 years (11.1%) at a higher rate as compared to the age group of 18-35 years (5.2%), however, the difference was not statistically significant (p value= 0.129) as shown in figure number 3.

Mild to moderate (9.6%) and moderate to severe (5.4%) anxiety tends to occurred in female at a higher rate as compared to the males, however, the difference was not statistically significant.

Severe depression tends to occurred in females (7.4%) at a higher rate as compared to the males (3.3%), however, the difference was not statistically significant.

Diagnosis according to ICD 10

Table 2: Prevalence of Psychiatric comorbidity

Neuropsychiatry symptoms	Number	Percent
Nil psychiatry	74	25.7
Adjustment disorder	35	12.2
Anxiety disorder unspecified	56	19.4
Mixed anxiety and depression	40	13.9
Mild to Moderate Depressive episode	44	15.3
Severe Depressive episode	25	8.7
Nonorganic insomnia	14	4.9
Total	288	100.0

Psychiatric comorbidity was present in 74.3%, with maximum patients being diagnosed with anxiety disorder unspecified.

The association between education level and psychiatric diagnosis was statistically significant. (p value: 0.001). Patients having psoriasis who were diagnosed with psychiatric illnesses resided significantly more in rural areas (p value:0.001).

Those living in joint families had significantly more psychiatric illnesses than nuclear family. (p value: 0.001). Psychiatric diagnosis were significantly more in patients belonging to lower middle socioeconomic status. (p value: 0.001)

Table 3: Association between sociodemographic factors and psychiatric comorbidity

Sociodemographic factor

Nil Psychiatry

Psychiatric comorbidity

P value

Education

No formal Education

Up to 12th Standard

Graduation

Post graduation

5

45

20

4

45

87

69

13

0.001*

Occupation

Unemployed

Employed

23

51

83

131

0.707

Residence

Rural

Urban

37

146

68

0.001*

Marital status

Unmarried

Married

Divorced

19

47

8

52

143

19

0.434

Family structure

Nuclear

Joint

26

48

83

131

0.001*

Socioeconomic status

Upper

Upper middle

Lower middle

Upper lower

Lower

4

27

16

9

18

6

34

68

52

54

0.001*

Psoriasis is a chronic inflammatory disease of the skin and joints which imposes a unique burden notably in terms of poor body image and social perception, due to the condition’s increased frequency and visible skin discoloration.¹²

Psoriasis patients experience stress associated to their illness, cosmetic deformities, and social stigma, which impairs their physical, psychological, vocational, and social functioning. This leads to psychological disorders including depression and anxiety as well as other associated comorbidities.¹³

This study exemplifies the need of consultation liaison between dermatologists, psychiatrists, and psychologists for comprehensive care and treatment of patients with psoriasis.

Age

Majority of the patients was male (53.1%) followed by females (46.9%) in our study which is comparable to other studies like Sarkar et al., Mohapatra et al. and Kumar et al.^2,3,8 This may be due to females being less treatment seeker than men.

In the study by Kumar et al. majority of the population in the study group were married (n = 70, 77.8%) which is corroborated with the findings of present study.⁸

A majority of study population was from rural areas (63.5%) which is in contrast to the study by Kumar et al. which showed most of patients were from an urban background (62.2%) as well as the observations reported by the Lakshmy et al.^8,9 Patients with lower educational attainment and a rural background may have fewer coping mechanisms and, as a result, greater mental health problems.

Socioeconomic status indicates that most of patients belong to lower middle class (29.2%) which was in contrast to that of study by Kumar et al. where majority of patients belonged to the upper lower socioeconomic class (n = 47, 52.2%).⁸ This can be attributed to our hospital being a state level hospital and majority of the population in the state being rural.

In present study, anxiety was reported in 22.9% patients and mild to severe depression was reported in 24.7% patients. Mattoo et al., assessed psychiatric morbidity among psoriasis out-patients using GHQ and psychiatric morbidity was reported in 24.3% of cases which is corroborated with the present study.¹³ In the study by Sarkar et al., the psychiatric morbidity was assessed by SRQ and found to be 62.5%.³ According to a systemic review by Gosh et al., patients with psoriasis showed prevalence of depression varying from 8.5–89.1% and reported that both depressive and anxiety condition tends to occur together in individuals with psoriasis which support finings of present study.¹⁴ The combined prevalence of mild, moderate, and severe depression in the Mohapatra et al. research was 44.4%.²

Present study was limited by the small sample size, due to which results of present study could not be generalized for a larger cohort. It was a single centric study and results may not be applicable for larger demographics. A further multicentric study with ample sample is required to validate the results of present study.

Current study elucidates the need of management of psychiatric manifestations in patients with psoriasis for comprehensive care and better quality of life for the patients.

1. Funding: none

2. Conflicts of interest/Competing interests :The authors declare no competing interests.

3. Ethics approval: study approved by Institutional ethics committee of Indira Gandhi Medical College, Shimla, Himachal Pradesh.

4. Consent to participate: Written consents taken from all participants.

5. Written Consent for publication: Consent has been taken from the institute and all authors for publication

6. Availability of data and material: Data can be made available on request.

7. Code availability: NA

8. Authors Contributions:

K.S. , D.D.S, S.L, G.S were contributed to the conception and design of work

K.S. was involved in acquisition, analysis, or interpretation of data, drafting the work,

S.J. , S.L. revised the work,

S.J, K.S. wrote the main manuscript text, prepared the figures and text

All authors reviewed the manuscript.

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No competing interests reported.

Psychiatric comorbidity in patients with Psoriasis: a cross sectional study from North India

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Abstract

Figures

Introduction

Material and methods

Statistical analysis

Results

Discussion

Declarations

References

Additional Declarations

Status:

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