Anxiety and depression levels in psoriatic patients in Almaty, Kazakhstan

Introduction

Psoriasis is a chronic, immune-mediated disorder resulting from a polygenic predisposition and environmental triggers such as trauma, infections, medications, and psychological stress [1]. Mental health comorbidities are more significant in psoriatic patients than those without psoriasis or other skin diseases [2]. Studies show that 10% to 62% of psoriatic patients are diagnosed with depression [3]. Many patients report moderate to severe anxiety, depression, and anger during the disease flares and remission. The diagnosis of psoriasis can result in significant psychological sequelae [4].
Combined anxiety and depression in psoriatic patients are associated with significant impairment of social, marital status, and occupational life, higher suicidal risk, lower adherence to treatment, and inadequate treatment response [4, 5]. Depression among psoriatics may be associated with increased alcohol intake and contribute to the increased frequency of cardiovascular disease [6]. Control of psoriasis symptoms is associated with improved psychological conditions [6, 7]. Management of psychological comorbidity may improve the patient’s quality of life and the disease course [1].
There are contradicting data on the correlation between psoriasis severity and the level of patient anxiety and depression. Some reports do not show a significant association between them [8, 9], but many confirm the higher levels of depression and anxiety in patients suffering from severe forms of psoriasis [5, 10, 11].
The prevalence of psoriasis in Kazakhstan was high (8% prevalence rate), and there were no up-to-date data on the issue [12]. Individual attitudes to skin diseases vary among countries and cultures [13].

Objective

This study aimed to determine the prevalence and severity of anxiety and depression in psoriatic patients in Almaty, Kazakhstan. Other objectives included associating the patients’ sociodemographic and clinical characteristics with depression and anxiety.

Material and methods

This prospective cross-sectional study was conducted at Kazakh's Scientific Center of Dermatology and Infectious Disease and Almaty Venereology Dispenser. The patients were categorized by origin: from Almaty or other Kazakhstan's cities. The recruitment period was from 1^st Sept 2020, to 1^st July 2021. In this study, we used a convenience sampling method.
The inclusion criteria were as follows:
– The diagnosis of psoriasis with different severity and clinical manifestations regardless of whether it has been treated or not;
– Patient age > 16 years (because the disease has a peak of onset between 16 and 22 years [6], and patients of these ages can fill out the questionnaires themselves);
– The diagnosis of psoriasis for at least 6 months (The time required to develop anxiety after a physical illness [14]);
– The signing of an informed consent form.
Patients unable to understand or answer the questions due to a language barrier or cognitive issues were excluded. The patients below 16 years old with less than 6 months of psoriasis duration were excluded.

Sample size

In 2018–2019, the prevalence of psoriasis in Kazakhstan was 8.0% [12], and in 2019, the Almaty population amounted to 1,854,800 (both sexes) [15]. With a 5% margin of error and a 95% confidence level, the Raosoft sample size calculator showed a sample size of 114 patients.

Research tools

Measurement of disease severity
In 1978, the PASI score was created by Fredriksson and Pettersson to determine the effects of retinoids on chronic plaque-type psoriasis [16]. PASI has gained worldwide use in quantifying the severity of the disease according to the extent affected and clinical parameters [17]. The PASI is a quantitative rating score to measure plaque characteristics (erythema, desquamation, and skin induration or thickness) ranging from 1 to 4, and the affected area percentage ranges from 1 to 6. The PASI score reaches 0 to 72, with higher scores indicating more severe disorders [1, 18]. In this study, psoriasis with a PASI > 10 has a mild severity grade, a PASI of 10 to 20 indicates moderate severity, and a PASI of 20 or above indicates severe cases.
>The hospital anxiety and depression scale (HADS)
We used the Hospital Anxiety and Depression Scale (HADS) by Zigmond and Snaith [19] to identify and quantify the depression and anxiety levels. HADS is a self-rated 14-item scale, 7 for anxiety and 7 for depression subscales. A grading of 0–7 non-case, 8–10 mild case, 11–15 moderate, and 16 or above severe cases [20].
The Hamilton Anxiety and Depression Rating Scale
In this study, the severity of depressive and anxiety symptoms was additionally assessed using the Hamilton Depression Rating Scale (HDRS) [21] and the Hamilton Anxiety Rating Scale (HARS) [22], respectively. The HDRS is a 17-item clinician-rated instrument widely used to evaluate depressive symptom severity. Scores 0 to 7 indicate a normal condition, 8 to 13 – mild depression, 14 to 18 – moderate depression, 19 to 22 – severe depression, and > 23 – very severe depression. The HARS is a 14-item clinician-rated scale for measuring the severity of anxiety symptoms. The symptom severity level is rated from 0 to 4. Scores < 17 indicate mild anxiety, 18 to 24 – mild to moderate anxiety, 25 to 30 – moderate to severe anxiety, and > 30 – severe anxiety [23].
Sociodemographic questionnaire
In this study, we used an original sociodemographic questionnaire that included sociodemographic characteristics of the participants (sex, age, age of onset, weight, place of residence, marital status, education status, employment status, smoking or drinking alcohol), the duration of psoriasis cases, the existence of pain in joints, the interval between attacks, the nail changes, the pruritus level, comorbidities, etc. For assessing the pruritus level, we used the verbal rating scale (VRS) and divided the itching level into four categories: none = 0, mild = 1, moderate = 2, and severe = 3 [24, 25].

Data processing and statistical analysis methods

Qualitative variables were presented by frequency and percentages; quantitative variables were represented by median, mean, and standard deviation. Differences between two or more groups of categorical variables were tested by the χ² test and Fisher’s exact test, as appropriate. To compare the severity of anxiety and depression among females and males, as the variables were not distributed normally, we compared the median of these variables using the Mann-Whitney U test. Bivariate relationships between quantitative variables were examined using Spearman’s coefficient correlation. Statistical significance was defined by a p-value < 0.05. Data were processed using the Excel program and IBM SPSS Statistics version 26.

Results

The study involved 114 patients, including 41 (36%) women and 73 (64%) men. Among them, 54 (47.4%) participants had anxiety, and 53 (46.5%) had depression.
There was anxiety in 61% of females and 39.7% of males and depression in 58.5% of females and 39.7% of males. The anxiety level was significantly sex-related (p = 0.029), but the depression level did not differ significantly (p = 0.053) (table 1).
The mean and median of the severity of anxiety amounted to 17.0 and 14.0 among females and 14.0 and 8.0 among males, respectively. The mean and median of the severity of depression amounted to 14.0 and 12.0 among females and 10.0 and 7.0 among males. As seen in figure 1 A, the median of anxiety in both sexes was 11.0 (grand median). The median of the female group (14.0) was higher than the grand median, but the median of the male group (8.0) was lower than the grand median. So, the severity level of anxiety was higher in females than males, but these differences were not statistically significant (p = 0.060).
As shown in figure 1 B, the grand median for depression was 8.0, while the median in females was 12.0, and in males 7.0. This indicated a higher depression among females than males (p = 0.036).
In the age category below 25 years, 23.3% of patients experienced no anxiety compared to 20.0% in the group aged 26 to 35. The anxious people share was 9.3% in the group below 25 years and 35.2% in the next age group. Those differences were statistically significant (p = 0.037) (table 2).
Psoriasis vulgaris was present among 74.0% of patients, guttate form in 9.3%, erythrodermic in 7.4%, pustular in 5.6%, and the palmoplantar form was present among 3.7% of patients. Most psoriatic patients with erythrodermic and pustular form experienced anxiety (62.5% and 66.7%, respectively). Depression was also more prevalent among erythrodermic and pustular forms than in guttate and vulgaris forms of psoriasis (20.0% and 48.8%, respectively). However, there was no statistically significant difference in the prevalence of anxiety (p = 0.623) and depression (p = 0.565) among different clinical forms of psoriasis.
13.50% of females and 47.80% of males were smokers (p < 0.001). Alcohol abuse was registered in 11.10% of females and 25.40% of males, but the differences were not statistically significant (p = 0.080).
Anxiety was registered in 66.7% of patients with a drinking history vs. 42.7% with no drinking history. Only 33.3% with a drinking history experienced no anxiety compared to 57.3% of patients without a drinking history (table 2). Those differences were statistically significant (p = 0.050).
Severe depression was registered in 12.5% of patients with low education levels and not in patients with high education levels. No depression was reported in 64.9% of patients with high education levels and 47.9% with middle education levels. Those differences were statistically significant (p = 0.002). According to table 2, depression was not registered in 60.7% of patients with high education levels vs. only 1.6% of patients with low education levels. The differences were statistically significant (p = 0.01).
All patients had itching (no one was in the 0 category of the itching levels). Most patients (47.5% of females and 62.5% of males) had moderate pruritus. Mild pruritus was present in 30.0% of females and 27.8% of males, and severe pruritus – in 9.7% of males and 22.5% of female patients.
According to table 3, severe depression was reported in 56.3% of patients with severe pruritus and 21.4% with mild pruritus. In comparison, 18.8% of patients with severe pruritus and 60.7% with mild pruritus had no depression. Those differences were statistically significant (p = 0.025).
No patients with severe pruritus were “normal” on the Hamilton anxiety scale. Severe anxiety was registered in 9.4% of patients with mild, 12.5% with moderate, and 31.3% with severe pruritus (p = 0.014).
Severe depression was registered in 66.7% of patients with diabetes mellitus (DM) vs. only 16.4% of patients with no comorbidities. 61.2% of patients with no comorbidities had no depression, while all patients with DM reported some level of depression. Those differences were statistically significant (p = 0.025). No patients with DM had mild or moderate anxiety, while 33.3% reported severe anxiety. Most patients with no comorbidities (67.6%) had mild anxiety, while only 7.0% reported severe anxiety. Those differences were also statistically significant (p = 0.002) (table 3).
Severe anxiety was reported in 17.8% of patients living in Almaty vs. no patients from other cities of Kazakhstan. Moderate to severe anxiety was registered in 28.6% of patients living in other cities vs. 7.8% of patients living in Almaty. Those differences were statistically significant (p = 0.029) (table 3).
The statistical analysis revealed a correlation between PASI and anxiety (p = 0.005). Depression and PASI had no statistically significant correlation (p = 0.763) (table 4).
In this study, we analyzed a correlation between HADS and Hamilton scales. We found no statistically significant correlation between HADS A and Hamilton A (p = 0.167) but a positive correlation between HADS D and Hamilton D (p < 0.001).

Discussion

In this study, the prevalence of depression (46.5%) and anxiety (47.4%) among psoriatic patients in Kazakhstan were extremely higher than in the country’s general population (4.4% and 3.3%, respectively [26]). Our finding is even higher than in the general population of conflict-affected areas [27]. In a similar study in Brazil with 281 participants, Pollo et al. reported anxiety and depression in 36.0% and 19.0% of psoriatic patients, respectively [9]. In a multicentre study in 13 European countries, anxiety and depression were registered in 22.7% and 13.8% of psoriatic patients [28]. The studies mentioned above revealed a very low prevalence of anxiety and depression in psoriatic patients compared to our results. The differences might be due to different sample sizes. Another reason could be the different prevalence of psoriasis in different geographical regions of Brazil (1.10% to 1.51%) [19] in comparison to Kazakhstan (8.0%) [12].
It is thought that the high prevalence of a disease in society can increase public awareness. Also, this chronic, lifelong, and exfoliating disease has a greater impact on the mental state of patients and their families. In a study by Lakshmy et al. in India involving 90 participants, 78.9% had depression, and 76.7% had anxiety [29]. The authors used GAD-7 to assess anxiety and PHQ-9 for depression. That study reported a higher prevalence of anxiety and depression among psoriatic patients. The difference could be due to another sample population and study tools.
In this study, the mean anxiety and depression scored 7.45 ±4.47 and 7.12 ±3.79, respectively. The Hamilton scales showed mean anxiety and depression of 14.95 ±12.89 and 11.19 ±9.59, respectively. In a study by Pompili et al., the mean and standard deviation of anxiety and depression were 12.7 ±9.1 and 13.4 ±8.6, respectively. Pompili et al. also used the Hamilton Anxiety and Depression Rating Scales (HARS and HDRSA) [23]. They reported lower anxiety but higher depression compared to our results. Other studies found a high level of anxiety among psoriatic patients – 9.87 ±4.56 [18] and 9.7 ±4.7 [30], which is closer to our results.
In a multinational study in different European countries, Lesner et al. found that anxiety and depression were low among psoriatic patients in Denmark (anxiety: 5.0 ±4.4 and depression: 3.2 ±3.2) and were high among the patients from Italy (anxiety: 10.6 ±3.9 and depression: 9.6 ±4.4) [10]. The mean anxiety in this study was close to France, Poland, and the UK and lower than in Italy, Belgium, and Germany. However, the results differ more from Denmark, Hungary, Netherlands, Norway, Russia, Spain, and Turkey. In contrast to Lesner et al., the mean depression in this study was higher than in all other countries except Italy.
According to PASI at data collection, this study mainly included in-patients with severe disease (40.4%). Mean PASI scores were 21.43 ±15.91, ranging from 2.1 to 70.0. Kouris et al. found a mean PASI score of 12.29 ±4.25, ranging from 3 to 23. In that study, the patients attended an outpatient skin clinic in Athens, Greece [18]. Differences in disease severity in these studies may be due to differences in the study population.
Although the severity of psoriasis positively correlated with the severity of anxiety, the c2 test showed no association between the disease severity and the level of depression and anxiety. In agreement with our findings, Cohen et al. found no association between disease severity and depression [31].
In the present study, females had higher anxiety and depression than males. Obsessive habits were more common in males (smoking – significantly more, drinking – non-significantly more). We found that males had significantly more psoriatic nail changes than females. This difference could be due to the severity of the disease in males in contrast to females. Females had mild and moderate disease more often, while males had more severe cases. This aligns with the findings of Solmaz et al., Napolitano et al., and Hägg et al. [32–34].
According to the World Health Organization, anxiety disorders and depression are more common among females globally [26]. The same was true among psoriatic patients in this study, where depression was more common in females. Although this difference was not statistically significant, females experienced statistically significantly higher anxiety than males. Similar results were reported in some other studies [8, 11, 16, 30, 33, 35]. Also, we found no statistically significant difference in the prevalence of anxiety and depression among different clinical forms of psoriasis.
Psoriasis vulgaris prevailed in our study (70.2%). Ayala reported the prevalence of this form in 80.0% of patients [17], Tribó et al. – 62.0% of patients [36], Griffiths et al. in 90.0% of patients [6].
This study found a positive correlation between HADS D and Hamilton D scales (p < 0.001). This positive correlation means that the higher the HADS D, the higher the Hamilton D, and vice versa. However, no correlation was found regarding anxiety. This could be due to the difference between the questionnaires’ purpose and the scales’ nature (Hamilton scales are the observer rating scales, and HADS are self-rating scales) [37].
Our cross-sectional study could not determine causalities despite many variables and avoid all possible biases and confounding. Selection bias associated with recruiting mainly in-patients could influence disease severity or duration proportions. To avoid selection bias, we tried to involve outpatients as well. To avoid possible recall bias when completing the questionnaires, we asked the participants to focus on recalling their last 2 weeks’ experiences. Another limitation of our cross-sectional study was the absence of a control group. Therefore, we could not compare our findings with the same variables among the general population without psoriasis. Instead, we compared and contrasted our results with various international studies.
This study’s advantages were that most of our patients were admitted to the hospital, and we could obtain accurate and precise information about them. Also, we used the same international and validated questionnaires as in many previous studies. Before starting the study, we checked them for external validity through a validation process.

Conclusions

The most prevalent clinical form of psoriasis is psoriasis vulgaris. Anxiety and depression are highly prevalent among psoriatic patients. The disease severity positively correlates with the severity of anxiety but not with depression. The level of disease severity does not correlate with the level of anxiety and depression. Anxiety and depression are more common among females who experience more severe depression than males. Nail changes and smoking are more common among male patients. Age distribution has differences between males and females. Anxiety is more common in the age ranges of 26–35 years and 46–55 years. Severe anxiety is more common among patients with up to 10 years of disease duration. Severe anxiety is common among patients living in Almaty compared to other cities. Psoriatic patients with comorbidities are more likely to have depression. All patients with low levels of education had some level of depression. Most patients with high education levels were normal, and none had severe depression. Higher pruritus levels are associated with higher anxiety and depression, so we recommend treating pruritus promptly with appropriate antipruritic drugs.
Based on this study, we recommend using the HADS questionnaire when seeing inpatients and outpatients with psoriasis, especially females. Patients with signs of anxiety or depression should be referred to a psychologist.
This research had no control group to compare the prevalence of depression and anxiety among psoriatic patients and healthy populations. Therefore, further studies in this context but with control groups or population-based studies are required to determine the effect of psoriasis on mental health.

Funding

No external funding.

Ethical approval

Ethical approval was obtained from Kazakh's Scientific Center of Dermatology and Infectious Disease and Almaty Venereology Dispenser Ethical Committee (code IRB-277).

Conflict of interest

The authors declare no conflict of interest.

References