Original Article

Psychiatric problems in psoriasis: A descriptive case series study

Introduction

The skin serves as a bridge between the internal and external environments, making it a key area for studying the mind-body connection. Stress can significantly impact the skin, with physical and psychosocial factors playing a role in the development of skin diseases. Research dating back to 1946 has focused on the relationship between psychological stress and conditions like psoriasis.¹ Psoriasis is considered a skin disease influenced by psychosocial factors, with stress playing a role in exacerbating symptoms.² The connection between psoriasis and psychological stress involves various pathways in the body, including the nervous system, hormonal systems, and immune responses.^3,4 Despite ongoing research, the exact mechanisms are still being investigated. Individuals with psoriasis often experience high rates of mental health disorders, with studies showing a significant prevalence of psychiatric comorbidities among patients. Psoriasis is more strongly linked to psychiatric conditions compared to other skin diseases, and patients may exhibit psychological symptoms that are not proportional to their skin condition. These patients also report a decrease in quality of life similar to those with serious medical conditions like cancer or cardiovascular diseases.⁵ Understanding the relationship between psychiatric comorbidities and psoriasis can provide valuable insights into both conditions and their treatments.⁶

Skin conditions are a significant contributor to the overall burden of nonfatal diseases, with psoriasis being a prominent dermatological disorder linked to emotional distress.⁷ Research indicates that individuals with psoriasis are at a higher risk of experiencing psychiatric comorbidities and thoughts of suicide compared to those with other skin conditions like melanoma and allergies.^8,9 Additionally, the quality of life for individuals with psoriasis is often comparable to that of individuals with serious medical conditions such as cardiovascular disease or cancer.¹⁰ Psoriasis patients commonly report feelings of stigma, depression, and anxiety, with sexual dysfunction being more prevalent in those with severe symptoms.¹¹ Furthermore, alcoholism is more common among individuals with psoriasis compared to the general population. Studies have also shown a connection between psoriatic arthritis, depression, and suicidal tendencies.¹² Regarding the results of various studies on the relation between psoriasis and psychiatric disorders, further research is needed to explore these connections and develop comprehensive approaches to managing these patients. Therefore, in this study, we aimed to explore the relationship between psychiatric problems in psoriasis Azerbaijan’s patients in northwest of Iran.

Materials and Methods

The present study was cross-sectional descriptive research. All patients with a definitive diagnosis of psoriasis entered the study by consensus and consecutive methods with informed consent. These patients were referred to the dermatology clinic of Sina Hospital in Tabriz for 12 months, from December 1, 2017, to December 1, 2018. The previous studies indicate that 50 patients with psoriasis were evaluated for anxiety disorders as the minimum sample size.

Existence of physical illnesses or joint symptoms, consciousness disorder, history of psychiatric hospitalization or background of taking antipsychotic drugs, being over 60 years and having substance abuse were our exclusion criteria.

Tool introduction

The Persian version of the DASS-21 questionnaire was used to evaluate the presence of anxiety disorders and depression. DASS-21 scale can recognize and screen anxiety, depression, and stress symptoms. The questions are in the form of 21 questions with four options, completed in the form of self-assessment. The range of responses differs from “never” to “always.”

Lovibond and Lovibond wrote the 21-item DASS after inventing 42 questions. In a sample of 1771 participants, Crawford and Henry reported its validity and reliability as 95% depression, 90% anxiety, 0.93 stress, and 97% total scores. In addition, Asghari has reported that the validity and reliability of the Persian version in Iran are favorable.^13,14

The initial history and exclusion of patients with exclusion scales were presented, such as the history of antipsychotic and intermediate drug use (in cases of the wide distribution of data with a standard deviation greater than average).

Statistical analysis

Despite descriptive statistics, data analysis was used to investigate the relationship between anxiety disorder and the mentioned parameters according to the needs and conditions of t-tests for independent statistical groups such as Mann-Whitney U test, Pearson or Spearman correlation, chi-square, or Fisher’s exact test. In addition, a logistic regression test was used to investigate the effect of confounding variables if necessary. Kolmogorov-Smirnov test or Shapiro test was used to investigate Quantitative data distribution. Statistically, the results were significant if they had P< 0.05.

Results

Fifty-four patients were studied according to the inclusion and exclusion criteria. Twenty-eight patients (51.9%) were female, and 26 (48.1%) were male. The average age was 41.76 ± 16.17 years, ranging from seven to 81 years (42.57 ± 15.78 for males, and 41.03 ± 16.51 for females). The type of psoriasis in patients was mostly plaque type (n = 47;87%) and two patients had generalized postural type (3.7%). In terms of the distribution of affected areas in skin, more than two areas were involved (29.6%) in most of the patients, and four different areas were involved in seven patients (13%). Patients were treated with narrowband ultraviolet B (NBUVB), psoralen ultraviolet A (PUVA), methotrexate (MTX), cyclosporin, Neotigason, and adalimumab and the most common was with Neotigason with 26.1% (Table 1).

Twenty-seven patients (50%) did not have a serious psychiatric disorder in examinations. The most common disorder among people with psychological disorders (50%) was generalized anxiety disorder (GAD). It was seen in 13 patients (24.1%). The lowest cases were cluster A personality, paranoia, obsessive-compulsive disorder (OCD), and cyclothymia (Table 2).

According to the results, the rate of GAD in female patients was higher than in males. Statistically, there was no significant difference between the types of psychiatric disorders in psoriasis patients by gender (P = 0.515) (Table 3).

Psoriasis patients with social phobia and paranoia had a higher average of psychological examination results by age. Statistically, there was not a significant difference between the age of patients and the type of disorder (P = 0.506). Approximately half of the patients had a university degree and were psychologically normal and patients with GAD according to the examination of results based on level of education (Table 4).

The Psoriasis Area and Severity Index (PASI) was 12 ± 13 among psoriasis patients without psychological disorders. The highest PASI score was related to the patient with cluster A personality (PASI = 41). The lowest PASI rate was related to patients with OCD and NOS anxiety. There was also a significant difference in the analysis of the PASI index among psoriasis patients with the results of various psychological examinations (P = 0.020) (Table 5).

Based on the duration of illness to referral and the results of psychological examinations in patients with psoriasis, the average years of infection in patients without psychological disorders was 14 ± 22 years. The longest duration of illness was seen in patients with paranoia among patients with psychological disorders (35 years). The shortest duration was related to the psoriasis patient with cyclothymia (Table 6). There was no significant difference between patients with the results of different psychological examinations (P = 0.471) in the analysis of the disease duration among patients with psoriasis.

Discussion

The results of this study provide valuable insights into the relationship between psoriasis and psychiatric disorders among a cohort of 54 patients who met the inclusion and exclusion criteria. The demographic characteristics of the study population revealed an even gender distribution, with a slightly higher proportion of female patients. The average age of the patients was in the fourth decade of life, with a wide range spanning from childhood to older adulthood. The majority of patients had plaque-type psoriasis, consistent with the most common form of the disease. In terms of psychiatric comorbidities, half of the patients did not have a serious psychiatric disorder, while the other half exhibited various psychological disorders. GAD emerged as the most prevalent psychiatric disorder among those with psychological issues, affecting nearly a quarter of the patients. Interestingly, no significant gender differences were observed in the types of psychiatric disorders present in psoriasis patients, highlighting the importance of considering mental health aspects across all patient populations. The analysis also revealed interesting trends related to age, education level, and disease severity among psoriasis patients with psychiatric comorbidities. Patients with social phobia and paranoia tended to have higher average psychological examination results at older ages, suggesting a potential impact of age on the manifestation of certain psychiatric disorders in psoriasis patients. Additionally, approximately half of the patients with a university degree were psychologically normal, indicating a potential association between education level and mental health outcomes in this population. Furthermore, the study found significant differences in the PASI scores among patients with different psychiatric disorders, with the highest score observed in patients with cluster A personality. This highlights the potential influence of specific psychiatric conditions on disease severity in psoriasis patients. However, no significant differences were noted in disease duration based on the results of various psychological examinations, suggesting that disease duration may not be strongly associated with specific psychiatric disorders in this study. According to a systematic evaluation of eighty-two observational studies, the frequency and incidence of depression varied greatly, primarily because of study design heterogeneity. However, among individuals (whether healthy controls or those with other chronic conditions) with psoriasis compared to those without, depression was substantially more common.¹⁵ In a cross-sectional investigation of 118 psoriasis patients from South Korea, the prevalence of depression was 74.6%. While in a large retrospective cohort analysis of 169 909 people with psoriasis in Taiwan it was 0.2%. Despite being low, the Taiwanese study’s stated prevalence was much greater than the 0.13% observed for non-psoriatic controls who were age and sex-matched.^16,17 Two of the nine studies that used the Hospital Anxiety and Depression Scale (HADS) to describe depression outcomes compared their findings to a control group.^18,19 Patients with psoriasis had a considerably higher mean score in both studies. When the nine-item Patient Health Questionnaire (PHQ-9) was used to gauge the degree of depression, similar findings were noted.²⁰ The most widely used instruments for assessing depression burden in the studies that made up this review were the Beck Depression Inventory (BDI), HADS, and PHQ, which are also frequently used in clinical settings.^21,22 Female sex and more severe psoriasis were risk factors linked to depression in psoriasis patients. In every study that reported data on the prevalence of depression in psoriasis by gender, with the exception of one, women with the condition reported a higher overall prevalence of depression than male patients. Still, males with psoriasis had higher prevalence than their non-psoriatic counterparts in studies comparing psoriasis patients of both sexes against a control group of patients without psoriasis. This indicates that depression is more common in psoriasis sufferers of all genders, while there may be a higher risk for females. Suicidal thoughts and attempts were more common in patients with psoriasis than in those without, although the frequency varied greatly. Patients with psoriasis are substantially more likely than those without psoriasis to experience suicidal ideation, according to all but one study comparing the prevalence of suicidal ideation in psoriasis with controls. Patients with other dermatological conditions were employed as a reference group in the one study²³ that did not detect an elevated incidence of present suicidal thoughts in patients with psoriasis, suggesting that the comparison with psoriasis was not entirely reliable. These findings imply that psoriasis sufferers tend to have suicide thoughts more frequently than the overall population. Patients with psoriasis had a considerably higher risk of suicide than those without the condition when compared to controls. There are numerous more emotional, psychological, and physical comorbidities linked to depression in psoriasis. These include obesity,¹⁸ cardiovascular comorbidity,^23,24 sleep issues,²⁵ and type D personality^21,26 (propensity for negative affect such as concern, anger, and melancholy associated with social restraint, shyness, and lack of self-assurance²²). Sleep issues,²⁵ subjective well-being,²⁷ and sexual dysfunction were linked to comorbid depression in psoriasis.^25,28 The results of this mentioned systematic review indicate a possible correlation between depression and a lower quality of life in psoriasis patients.¹⁵ Depression was found to be substantially correlated with poorer levels of body satisfaction and self-esteem, according to one study.²⁹ Another study discovered that psoriasis patients’ physical condition, as determined by the 12-item Short Form, may be adversely affected by the existence and severity of depression.¹⁸ The results indicate that depression has a negative impact on physical health, which further decreases quality of life. A recent systematic review and meta-analysis also report that patients with psoriasis or psoriatic arthritis have a higher risk of depression when compared to non-psoriasis controls.³⁰ The burden of psoriasis has been disregarded or undervalued by medical professionals. A greater understanding of the correlation between psoriasis patients and depression would allow for improved care and management that includes psychosocial therapies to lessen depressive symptoms and overall patient burden. Several evidence gaps about the prevalence of depression in psoriasis patients have been found by this research. Numerous investigations were carried out mostly in Europe and Asia, indicating regional differences in the understanding and treatment of psoriasis’s psychological effects. Evidence from patients in these regions is also underrepresented, with only one study undertaken in each of the Americas (the United States and Canada) and Africa (Egypt). As a result, the data from patients in these areas is not as strong.¹⁵ Only one of these studies reported incidence by age and sex, and none of them evaluated the incidence of suicidal ideation/suicide attempts based on the severity of psoriasis. The variability in depression assessments, cutoff points, and data collection techniques (such as patient surveys, administrative claims databases, and health records) among research is one of the review’s limitations. Second, there were insufficient data on depression based on the severity of the illness and the psoriasis subtype. The psoriasis severity assessment measure and cutoff point were not disclosed in numerous trials. Lastly, factors that might influence the association between psoriasis and depression were not always taken into account when estimating the frequency and incidence of depression. Many studies presented adjusted data, although it was frequently unclear which factors were included in various regression models.

The current study has some limitations. The study sample size of 54 patients may not be representative of the broader population of individuals with psoriasis and psychiatric disorders. A larger sample size would provide more robust and generalizable results. Moreover, the study did not consider potential confounding variables such as socioeconomic status, family history of psychiatric disorders, or access to mental health care, which could impact the relationship between psoriasis and psychiatric comorbidities. Future research should aim to include a larger and more diverse sample of patients with psoriasis to enhance the generalizability of the findings. For this purpose, longitudinal studies could be conducted to explore the causal relationship between psoriasis and psychiatric disorders, as well as the impact of different treatment modalities on mental health outcomes. Investigating the role of potential confounding factors such as socioeconomic status, family history, and access to mental health care in the association between psoriasis and psychiatric disorders would provide a more comprehensive understanding of this relationship.

Conclusion

Overall, these findings showed that the most common psychiatric disorder observed was GAD. Gender differences were noted, with a higher prevalence of GAD in female psoriasis patients. The analysis also revealed that patients with social phobia and paranoia tended to have higher average psychological examination results by age. underscore the complex interplay between psoriasis and psychiatric comorbidities, emphasizing the need for comprehensive assessment and management strategies that address both physical and mental health aspects in patients with psoriasis. These findings highlight the complex interplay between psoriasis and psychiatric comorbidities, emphasizing the importance of considering both physical and mental health aspects in the management of patients with psoriasis. Further research with larger sample sizes and consideration of confounding variables is warranted to better understand this relationship and optimize patient care.

Acknowledgments

The authors would like to appreciate all patients who participated in this study.

Competing Interests

The authors declare that they have no competing interests.

Data Availability Statement

All data generated or analysed during this study are included in this article. Further inquiries can be directed to the corresponding author.

Ethical Approval

This study was evaluated and approved by the ethics committee of Tabriz University of Medical Sciences (IR.TBZMED.REC.1396.838). All cases were interested in participating study and had signed informed consent.

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