European Journal of Cardiovascular Medicine

Recently, the interrelationship of psychiatry and dermatology has gained immense attention in the field of Medicine. Dermatological conditions usually extend beyond the physical manifestations which usually intertwin with psychiatric and psychosocial factors and which further present unique challenges for both clinicians and subjects.1

In the past era, dermatological conditions encountered high social criticism which led to stigmatization by subjects themselves and others that further took a toll on their mental health. Subjects that have psychiatric conditions such as catatonia, schizophrenia, and depression usually find it as challenging to maintain self-care owing to lack of contact with reality, loss of interest, and reduced energy. Further, these subjects can develop different dermatological conditions. Also, psychotropic drugs can lead to dermatological side effects including acne, and in a few cases, metabolic side-effects which can expose subjects to different dermatological disorders.2

Co-occurrence of various psychiatric and dermatological conditions can be seen in different ways ranging from exacerbation of psychiatric symptoms owing to skin disorders to development of skin manifestations secondary to psychiatric conditions or from treatment of psychiatric conditions. Also, the psychosocial effect of various dermatological conditions such as eczema, psoriasis, and acne usually extends beyond physical symptoms causing impaired quality of life, social stigma, and emotional distress.3

Despite the growing identification of this vital dermatologic-psychiatric interrelationship, the data is scarce for comprehensive studies on assessing the clinical picture, prevalence, and treatment outcomes of subjects with psychiatric comorbidities. Understanding the complex interrelationship of dermatological and psychiatric disorders is vital in providing appropriate care and in the improvement of management outcomes in these subjects.4 The present study aimed to assess the psychiatric comorbidity in subjects from the dermatology department in the Indian context.

The present prospective cross-sectional observational study was aimed to assess the psychiatric comorbidity in subjects from the Psychiatry Department in the Indian context. Verbal and written informed consent were taken from all the subjects before participation.

The study included subjects who were diagnosed with any dermatological disorder, aged 18 to 60 years, had disease for a minimum of 4 weeks of duration, and subjects willing to participate in the study. The exclusion criteria for the study were subjects with pemphigus, toxic epidermal necrolysis, and erythroderma-like debilitating and serious diseases. Particularly, 14 subjects were in the exclusion criteria and were excluded.     

The present study included 846 subjects that had various dermatological conditions. After inclusion, detailed history was recorded for all the subjects including detailed sociodemographic data. After a comprehensive assessment, subjects were sent to the Outpatient Department of Psychiatry for their screening of stress, anxiety, and depression using the DASS-21 scale.5

Statistical analysis of the gathered data was done using SPSS (Statistical Package for the Social Sciences) software version 24.0 (IBM Corp., Armonk. NY, USA) for assessment of descriptive measures, Student t-test, ANOVA (analysis of variance), and Chi-square test. The results were expressed as mean and standard deviation and frequency and percentages. The p-value of <0.05 was considered.

The present prospective cross-sectional observational study was aimed to assess the psychiatric comorbidity in subjects from the dermatology department in the Indian context. The present study assessed 846 subjects having dermatology disorders and presented to the Institute within the defined study period. In all the included subjects, sociodemographic data were gathered along with a comprehensive dermatological assessment. The mean age of the study subjects was 52.0±24.24 years. The majority of study subjects were in the age range of 18-30 years with 38% (n=316) subjects followed by 31-40 years with 31.7% (n=264) subjects, 15.4% (n=128) subjects in 41-50 years, and least 14.9% (n=124) subjects in 51-60 years. There were 57.7% (n=480) males and 42.3% (n=352) females in the study. The majority of subjects were from rural residences with 63.9% (n=532) subjects followed by 11.1% (n=92) subjects from semi-urban, and 25% (n=208) subjects from urban residences. There were 68.2% (n=568) married, 27.4% (n=228) unmarried, and 4.3% (n=36) widower subjects. There were 31.2% (n=260) subjects from joint and 68.8% (n=576) subjects were from nuclear family. There were 15.86% (n=132), 25.96% (n=216), 56.73% (n=472), and 1.4% (n=12) subjects from upper lower, lower middle, upper middle, and upper class respectively (Table 1).

On assessing the clinical profile of the study subjects, the duration of illness was 4 weeks and 6 months in 69.2% (n=576) subjects, 6 months in 20.2% (n=168) subjects, 1-5 years in 5.8% (n=48), and >5 years in 4.8% (n=40) subjects respectively. The most common presenting complaint was itching in 60.09% (n=500) subjects followed by discoloration in 28.84% (n=240) subjects, rashes in 21.15% (n=176), scales in 9.13% (n=76), wheals and nodules in 8.17% (n=68), hair loss and pustules in 6.73% (n=56), erosions in 5.76% (n=48), comedons in 4.8% (n=40), papules in 4.32% (n=36), and fluid-filled lesions in 3.36% (n=28) study subjects respectively (Table 2).

The study results showed that for the prevalence of stress, anxiety, and depression in study subjects using DASS-21, stress was seen in 13.95% (n=116) subjects with a mean stress score of6.7±6.6. Mild, moderate, and severe stress was seen in 31.03% (n=36), 51.72% (n=60), and 17.24% (n=20) subjects respectively. Anxiety was seen in 30.76% (n=256) subjects with a mean anxiety score of 6.15±6.6. Mild, moderate, severe, and extreme anxiety was seen in 26.56% (n=68). 34.37% (n=88), 12.5% (n=32), and 26.56% (n=68) subjects respectively. Depression was seen in 23.5% (n=196) subjects with a mean depression score of 5.72±6.5. Mild, moderate, severe, and extremely severe depression was seen in 42.8% (n=84), 34.69% (n=68), 20.4% (n=40), and 2.04% (n=4) subjects respectively (Table 3).   

It was seen that for the correlation of sociodemographic data with stress, anxiety, and depression in study subjects, a statistically significant correlation was seen in family type to anxiety and depression with p=0.03 and 0.02 respectively. A significant association was also seen between socioeconomic status and depression with p=0.04. Gender also depicted a significant association with stress and anxiety with p=0.01 and 0.04 and illness duration to depression with 0.007 (Table 4).

Table 1: Demographic data of study participants

Table 2: Clinical profile of study participants

Table 3: Prevalence of stress, anxiety, and depression in study subjects using DASS-21

Table 4: Correlation of sociodemographic data with stress, anxiety, and depression in study subjects

The present study assessed 846 subjects having dermatology disorders and presented to the Institute within the defined study period. In all the included subjects, sociodemographic data were gathered along with a comprehensive dermatological assessment. The mean age of the study subjects was 52.0±24.24 years. The majority of study subjects were in the age range of 18-30 years with 38% (n=316) subjects followed by 31-40 years with 31.7% (n=264) subjects, 15.4% (n=128) subjects in 41-50 years, and least 14.9% (n=124) subjects in 51-60 years. There were 57.7% (n=480) males and 42.3% (n=352) females in the study. The majority of subjects were from rural residences with 63.9% (n=532) subjects followed by 11.1% (n=92) subjects from semi-urban, and 25% (n=208) subjects from urban residences. There were 68.2% (n=568) married, 27.4% (n=228) unmarried, and 4.3% (n=36) widower subjects. There were 31.2% (n=260) subjects from joint and 68.8% (n=576) subjects were from nuclear family. There were 15.86% (n=132), 25.96% (n=216), 56.73% (n=472), and 1.4% (n=12) subjects from upper lower, lower middle, upper middle, and upper class respectively. These data were comparable to the previous studies of Halvorsen JA et al6 in 2014 and Dalgard FJ et al7 in 2015 where authors assessed subjects with dermatological and psychiatric disorders in their studies as in the present study.

Concerning the assessment of the clinical profile of the study subjects, the duration of illness was 4 weeks and 6 months in 69.2% (n=576) subjects, 6 months in 20.2% (n=168) subjects, 1-5 years in 5.8% (n=48), and >5 years in 4.8% (n=40) subjects respectively. The most common presenting complaint was itching in 60.09% (n=500) subjects followed by discoloration in 28.84% (n=240) subjects, rashes in 21.15% (n=176), scales in 9.13% (n=76), wheals and nodules in 8.17% (n=68), hair loss and pustules in 6.73% (n=56), erosions in 5.76% (n=48), comedons in 4.8% (n=40), papules in 4.32% (n=36), and fluid-filled lesions in 3.36% (n=28) study subjects respectively. These results were consistent with the findings of  Carniciu S et al8 in 2023 and Shenoi SD et al9 in 2020 where the clinical profile of dermatological and psychiatric disorder subjects comparable to the present study was also reported by the authors in their respective studies.

It was seen that for the prevalence of stress, anxiety, and depression in study subjects using DASS-21, stress was seen in 13.95% (n=116) subjects with a mean stress score of6.7±6.6. Mild, moderate, and severe stress was seen in 31.03% (n=36), 51.72% (n=60), and 17.24% (n=20) subjects respectively. Anxiety was seen in 30.76% (n=256) subjects with a mean anxiety score of 6.15±6.6. Mild, moderate, severe, and extreme anxiety was seen in 26.56% (n=68). 34.37% (n=88), 12.5% (n=32), and 26.56% (n=68) subjects respectively. Depression was seen in 23.5% (n=196) subjects with a mean depression score of 5.72±6.5. Mild, moderate, severe, and extremely severe depression was seen in 42.8% (n=84), 34.69% (n=68), 20.4% (n=40), and 2.04% (n=4) subjects respectively. These findings were in agreement with the results of Raikhy S et al10 in 2017 and Bewley A et al11 in 2011 where the prevalence of stress, anxiety, and depression in dermatologic subjects reported by the authors in their studies was comparable to the results of the present study.   

The study results also showed that for the correlation of sociodemographic data with stress, anxiety, and depression in study subjects, a statistically significant correlation was seen in family type to anxiety and depression with p=0.03 and 0.02 respectively. A significant association was also seen between socioeconomic status and depression with p=0.04. Gender also depicted a significant association with stress and anxiety with p=0.01 and 0.04 and illness duration to depression with 0.007. These results were in line with the findings of Ray A et al12 in 2011 and Karia SB et al13 in 2015 where the correlation of sociodemographic data with stress, anxiety, and depression in subjects with dermatological diseases was comparable to the present study was also reported by the authors in their respective studies.

The present study, considering its limitations, concludes that there is an underestimation of the necessity for the adoption of the biopsychosocial approach for the treatment of dermatological disorders which focuses on the vital role of routine screening in psychiatric comorbidities and the need for integrated care models that involve interrelationship of mental health professionals and dermatologists.

1.       Bennis I, De Brouwere V, Belrhiti Z, Sahibi H, Boelaert M. Psychosocial burden of localized cutaneous Leishmaniasis:  a scoping review. BMC Public Health.  2018;18:358.

2.       Nuwangi H, Agampodi TC, Price HP, Shepherd T, Weer-akoon KG, Agampodi SB. The stigma associated with cutaneous and mucocutaneous leishmaniasis: A systematic review. PLoS Negl Trop Dis. 2023;17:e0011818.

3.       Gieler U, Gieler T, Peters EMJ, Linder D. Skin and Psycho-somatics - Psychodermatology today. J Dtsch Dermatol Ges. 2020;18:1280-98.

4.       Marsh K.  Treating a Patient Skin Deep: A Qualitative Study with Dermatologists on the Integration of Psychology in Dermatology (Doctoral dissertation, Adler University). ProQuest [Internet].  Proquest.com.  2022

5.       Lovibond SH, Lovibond PF. Depression anxiety stress scales. Psychological Assessment. 1995. APA Psyc Tests.

6.       Halvorsen JA, Lien L, Dalgard F, Bjertness E, Stern RS. Suicidal ideation, mental health problems, and social function in adolescents with eczema: a population-based study. J Invest Dermatol. 2014;134:1847-54.

7.       Dalgard FJ, Gieler U, Tomas-Aragones L, Lien L, Poot F, Jemec GBE, et al. The psychological burden of skin diseases: a cross-sectional multicenter study among dermato-logical out-patients in 13 European countries. J Invest Dermatol.  2015;135:984-91.

8.       Carniciu S, Hafi B, Gkini MA, Tzellos T, Jafferany M, Sta-mu‐O’Brien C. Secondary psychiatric disorders and the skin. Dermatological Reviews. 2023;4:162-71.

9.       Shenoi SD, Soman S, Munoli R, Prabhu S. Update on Pharmacotherapy in Psychodermatological Disorders. Indian Dermatol Online J.  2020;11:307-18.

10.    Raikhy S, Gautam S, Kanodia S. Pattern and prevalence of psychiatric disorders among patients attending dermatology OPD.  Asian J Psychiatr.  2017;1:85-8.

11.    Bewley A, Page B. Maximizing patient adherence for optimal outcomes in psoriasis. J Eur Acad Dermatol Venereol. 2011;25:9-14.

12.    Ray A, Pal MK, Ghosh M, Sanyal D. Psychodermatological disorders: an assessment of psychiatric morbidity. Int Med J. 2011;18:300–4.

Karia SB, De Sousa A, Shah N, Sonavane S, Bharati A. Psychiatric morbidity and quality of life in skin diseases: a comparison of alopecia areata and psoriasis. Ind Psychiatry J. 2015;24:125–8