Introduction
Psoriasis is a chronic inflammatory, and non-contagious skin disease that may involve the entire system of a person [1]. According to the report of the World Health Organization (WHO), the prevalence of psoriasis in countries ranges from 0.09% to 11.43%, and affects at least approximately 100 million people around the world [2]. In Iranian population, the prevalence has been reported to be 1–2.5% [3]. This disease may occur at any age and in both sexes [1, 4]. The etiology of psoriasis is not completely understood [5]. Psoriasis as an immune-mediated inflammatory dermatosis, being widely considered an autoimmune disease in recent years [6]. It seems that different factors, both genetic and environmental, play a role in this disease [7]. The physical and psychological effects of psoriasis might affect all aspects of the patient's life [8], such as the social, personal and sexual attitudes of patients [9]. According to some research, it was associated with poor quality of life [10–12].
The visibility of lesions in patients and the insufficient understanding of skin conditions in the general public might lead to some problems for psoriasis patients. These patients might suffer from stigma in their daily life, which might have adverse effects on their mental health, quality of life, and treatment responses [13]. Also, false beliefs and social justice might lead to social isolation and loneliness [14].
Psychiatric comorbidities are one of important issues in psoriasis patients. These patients might have a high prevalence of many mental disorders [15, 16]. Some believe that there might be an overlapping biological mechanism in psoriasis and psychiatric conditions, such as depression [17–19]. The evidence of a review about an association between inflammation and mood disorders showed their strong association [20].
According to the recent review article, symptoms of depression were 1.5 times more likely in psoriasis patients than in people without psoriasis, also suicidal ideation (12.7%) and anxiety symptoms (20–50%) were higher in these patients [21].
Objective
Regarding the prevalence of psoriasis in Iran, its effects on the patient’s quality of life, and no recent study in our country, we have decided to survey psoriasis patients referred to the dermatology clinic to describe the prevalence of depression and anxiety among them.
Material and methods
Study design
The present study was a cross-sectional study on patients with psoriasis referred to the dermatology clinic in 2021. This study was carried out based on the Helsinki declaration. The inclusion criteria were: psoriasis, age above 18-yo, negative history for psychiatric disorders before suffering from psoriasis, and not using psychotropic drugs. The participants completed four questionnaires.
Demographic questionnaire
This questionnaire included age, gender, marital status, education, medical history and comorbidities such as: high blood pressure, diabetes, heart disease, heart attack, asthma, chronic obstructive pulmonary disease (COPD), stroke, kidney disease, and cancer, and type of treatments for psoriasis (oral/injection/phototherapy).
Severity of psoriasis
Severity of psoriasis was determined by the psoriasis area screening index (PASI) so that PASI above 12 is severe, PASI 7-12 is moderate and PASI less than 7 is considered mild [22].
Beck Depression Inventory (BDI-II)
The Beck Depression Inventory (BDI-II) is a 21-item inventory measuring depression. Items are scored from 0 (not bothered at all) to 3 (severely bothered). The total score is between 0 and 63, with higher scores indicating greater depression severity (no depression: 0–13, mild 14–19, moderate: 20–28, and severe ≥ 29). The internal consistency of BDI-II was reported to be 0.9 [23]. The internal consistency and test-retest reliability of the Persian version of the scale were 0.87 and 0.74, respectively [24].
Beck Anxiety Inventory (BAI)
The Beck Anxiety Inventory (BAI) [25] is a 21-item inventory measuring distress associated with common symptoms of anxiety. Items are scored from 0 (not bothered at all) to 3 (severely bothered), with higher scores indicating greater anxiety severity (no anxiety: 0–7, mild: 8–15, moderate 16–25, and severe anxiety: ≥ 26). The BAI is a reliable and valid scale to measure [26, 27]. The validity and reliability of the Persian version of the scale were good. Its internal consistency was reported to be 0.92 [28].
Psoriasis Area Severity Index (PASI)
The PASI was used to evaluate the severity of psoriasis and was performed by a dermatologist. The intensity of erythema, induration, and desquamation is scored on a 5-point scale (0: no involvement, 1: slight, 2: moderate, 3: severe, 4: very severe). The degree of involvement for the four anatomical regions is scored between 0 and 6 (1: 1–9%, 2: 10–29%, 3: 30–49%, 4: 50–69%, 5: 70–89% and 6: 90–100%). The total PASI score is between zero and 72. The severity rate includes: more than 12: severe, 7–12: moderate, and less than 7: mild psoriasis [29]. This scale was indicated as a reliable tool to measure psoriasis severity (intraclass correlation coefficients (ICC) = 0.729) [30]. The ICC of the Persian version of the scale was 0.88 [31]. In addition, the type of treatments used for the patients was determined by a dermatologist.
Statistical analysis
The sample size was calculated based on the study by Soliman [32]. Mean, standard deviation, frequency, and percentage were used to describe the data. Also, to analyze the research, c2, ordinal regression, and Spearman correlation were used. The data were analyzed by IBM SPSS Statistics version 28, and the significance level was considered to be 0.05.
Results
Demographic characteristics and clinical data of psoriasis patients are reported in table 1. Table 2 shows the frequency of the severity of depression and anxiety in participants. The frequency of depression among patients with psoriasis according to demographic and clinical data is indicated in table 3. The frequency of anxiety among patients with psoriasis according to demographic and clinical data is shown in table 4. None of the variables had a significant association with anxiety. The effect of independent variables on the severity of depression of patients by ordinal regression is reported in table 5.
Table 6 shows the effect of independent variables on the severity of anxiety of the patients by ordinal regression.
Discussion
Psoriasis is a chronic skin disease affecting psychosomatic aspects. This disease has a hereditary background, but psychological factors play a major role in the clinical manifestations of this disease [33].
In a study in Iran, the frequency of depression and anxiety in patients with psoriasis was reported at 69.9% and 20.5%, respectively [34], which showed a higher prevalence than our results. In another study, in India, the frequency of depression and anxiety in psoriatic patients was significantly higher (approximately 80% for both) [35]. However, in another study, the results were completely different, and a lower prevalence of depressive (8.5%) and anxiety symptoms (16.9%) was reported [11]. Consistent with the results of our study, in a systematic review in 2019, the prevalence of depression and anxiety was 9–22%, and 15–30% respectively in patients with psoriatic arthritis [36].
A considerable point was that in our study, like in several studies [11, 34, 36, 37], the prevalence of anxiety in these patients was more than in depression. According to a systematic review, the prevalence of anxiety in psoriasis patients was reported as 7–48% [38]. Findings of clinical observations indicated that skin patients might face psychological problems from the moment the disease is diagnosed. They have to accept the disease and manage treatment, which might cause emotional pressure. Loss of health and physical attractiveness can severely disrupt the feelings about self and interpersonal relationships [39]. Other factors, like persistency and recurrence of the disease and the poor therapeutic efficacy can contribute to the negative emotions in these patients [40].
According to our results, the rate of depression and anxiety was higher in older patients than younger, although this difference was not significant. It was consistent with the result of the study by Lakshmy et al. [35]. However, in another study, the risk of depression was higher in younger patients with psoriasis [41].
Based on the present study, depression in males and anxiety in females was higher, but there was no significant difference between anxiety and depression in terms of gender. Unlike our study, in some studies, higher frequency depression and anxiety were reported in women [42–44]. Gender differences in behavior and the risk of mental disorders can be influenced by environmental factors, including gender stereotypes in different cultures [45].
While, in our study, patients with severe psoriasis had a higher rate of depression and anxiety than those with mild disease, this difference was not statistically significant. Unlike our study, in several studies [17, 35, 46, 47], this difference was significant, and severe psoriasis was associated with a higher risk of depression and anxiety compared to mild. In the study by Tee et al., although patients with moderate or severe psoriasis had a higher risk of depression, consistent with our study, there was no association between anxiety and the severity of psoriasis [37].
In the present study, there was no relationship between comorbidities and anxiety, but patients with a medical history had a significantly higher rate of depression. In the study by Bakar et al., psoriasis patients with comorbidities were prone to depression and anxiety symptoms [11]. Based on a systematic review, there was a mutual relationship between depression and metabolic syndrome. Unhealthy behaviors, like poor diet, and a sedentary lifestyle, and increased fat tissue by releasing hormones during depression might exacerbate metabolic syndrome, and obesity and social stigma can lead to depression [48]. According to our findings, the frequency of depression and anxiety in people receiving injection treatment was higher then these being on combination treatment, oral and phototherapy, although this difference was not significant. In contrast, in another study, biologic drugs, which are used by injection to treat psoriasis, reduced the risk of depressive symptoms [49].
Moreover, there was a significant relationship between the severity of depression and anxiety in the present study. However, no relationship was found between the severity of psoriasis, and anxiety and depression. Psoriatic patients referring to dermatology clinics have worries about the such as duration of the disease and treatment results leading to more anxiety and depression symptoms. Increasing anxiety and depression prevent adherence to the treatment in patients, leading to vicious cycle. In other words, when the patient stops treatment for the disease, depression and anxiety might worsen if the disease is not treated.
Study limitations: One of the limitations of this study was the lack of a control group to compare the findings. Also, comorbidities as a confounding factor, might increase the risk of depression or anxiety in the patients. This study was a cross-sectional study, so to obtain more accurate results, a longitudinal study in several dermatology centers should be conducted. Also, it suggests to investigate the relationship with other factors, such as quality of life with anxiety and depression in psoriasis patients.
Conclusions
According to our results, about half of the patients had moderate psoriasis. Prevalence of anxiety was higher than that of depression and most of patients had mild anxiety. The frequency of depression was significantly higher in people with comorbidities. However, no relationship was found between anxiety and demographic characteristics. There was no association between depression and anxiety with the severity of psoriasis and type of treatment for psoriasis, but the severity of anxiety increased with the severity of depression, thus clinical interventions, screening for concomitant mental illnesses and psychotherapy in patients with psorisis should be considered.
Acknowledgments
The authors wish to thank the staffs for their excellent assistance in gathering the patient data.
Funding
No external funding.
Ethical approval
The project was approved by the ethics committee in the research of the Guilan University of Medical Sciences (Ethical Code: IR.GUMS.REC.1399.571) and carried out based on the Helsinki declaration.
Written informed consent was obtained from all subjects before conducting the study.
Conflict interest
The authors declare no conflict of interest.
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