A study on prevalence of depression in patients of vitiligo in tertiary care centre in South India

INTRODUCTION

Skin has a special place in psychiatry with its responsiveness to emotional stimuli and by providing self-esteem the skin plays an important role in socialization process which continues from childhood to adulthood.¹

The physical or perceived disfigurement can become a source of significant distress with a considerable impact on an individual’s psychological, social and physical well-being. Dermatological conditions are responsible for a significant source of social stigmatization in many human societies and culture, contributing to development of depression and anxiety.²

The relationship between dermatology and psychiatry is very strong because skin and brain exists more than a fact have same ectodermal origin and are affected by same hormones and neurotransmitters.² The incidence between dermatology and psychiatry is estimated to be about 30 to 60%.³

Psychiatry is more focused on “internal” visible disease and Dermatology is more focused on “external” visible disease.

It has been estimated that the effective management of atleast some patients attending the skin department depends to some extent upon the recognition of emotional factors.⁴

Vitiligo considered just a cosmetic problem, affects a person’s emotional and psychological wellbeing having major consequences on patient’s life.⁵

Most of the patients of vitiligo report embarrassment and low self-esteem leading to emotional stress and social isolation, particularly if the disease develops on exposed areas of the body. Although not fatal, it may considerably influence patient’s health related quality of life and psychological wellbeing.⁶

Objectives

The objectives of the present study were to compare the frequency and the level of depression in patients of vitiligo with that of matched control population and to analyze and compare the level of depression with the clinico-demographic pattern of vitiligo.

METHODS

This is cross sectional study, descriptive, case control, hospital based study conducted in the Dermatology and Venereology outpatient department of Basaweshwar hospital and MR Medical College in Gulbarga.

Clinically diagnosed vitiligo patients in the age group of 30 to 50 years willing to take part in the study were included. Exact study period is from June 2018 to June 2019. Of these, males were 44 and females were 56. Patients with personal and familial mental illness, substance abuse and other obvious causes of depression were excluded.

Detailed demographic variables, age of onset, duration and course of disease, family and treatment history were recorded. Clinical examination in respect to skin type, type of vitiligo, site of involvement, extent and percentage of involvement was done.

English language versions of Hamilton Depression Rating Scale (HAMD) 17 questionnaire were translated into local languages like Kannada and Hindi by translators knowing the respective language.

Patients were given the HAMD 17 questionnaire after the informed consent.⁷ HAMD 17 is used to find out the level of depression in vitiligo patients.

RESULTS

Total 100 patients were included in this study. Age group was 30 to 50 years. Males were 44 and females were 56. Mean age is 42 years. Of these, 25 (25%) patients did not show any signs of depression, 45 (45%) patients showed mild depression, 20 (20%) patients showed moderate depression and 10 (10%) patients showed severe depression on a 17 point scale.

DISCUSSION

The link between mind and skin has long been recognized. The skin has been described as the mirror of the mind, and so it is not surprising that the interface between dermatology and psychiatry (“psychocutaneous medicine’ or ‘psychodermatology’) is emerging as a specific sub-specialty of dermatology. Psychodermatology is an increasingly recognized and important branch of dermatology.

It encompasses disease that involves the complex interaction between the brain, the cutaneous nerves, the cutaneous immune system and the skin. Patients with psychocutaneous disease are often variably managed as dermatologists struggle.

Most patients with psychocutaneous disease are reluctant to attend purely psychiatric clinics. For these reasons, over the last few decades, the sub-specialty of psychodermatology has emerged to address the clinical–academic needs of this group of patients. Skin–psyche interactions may be any of the following as primarily cutaneous disorders that can be substantially influenced by psychological factors, e.g., psoriasis, primary psychiatric disease presenting to dermatology health care professionals, e.g., delusional infestation, body dysmorphic disorder, psychiatric illness developing as a result of skin disease, e.g., depression, anxiety or both and co‐morbidity of skin disease with another psychiatric disorder e.g., alcoholism.⁸

Although vitiligo being a mental and psychological hamper to patient’s wellbeing, concerns and worries of the patient’s family members about the condition also add to the mental trauma experienced by the patient.⁸

Psychological stress is an integral cause of skin disease either as an initiating or an exacerbating factor leading to increased disease morbidity. It is therefore essential that the skin condition is treated concomitantly with the psychological co‐morbidities. Part of the ‘appropriate treatment’ of concomitant psychiatric or psychological disease is the assessment of risk and suicidality that should be in one’s mind for every dermatology consultation. Treating the skin disease without treating the psychiatric or psychological disease makes no sense and yet a lot of training in dermatology makes little reference to the treatment of psychological disease.⁸

There is an increasing recognition that it is not just the life of the patient affected by a skin disease, but also the lives of family, partners, carers and loved ones who are often affected by the patient’s journey through treatment. Assessing the impact of disease on partners and family is crucial to the well‐being of the patient.⁸

The word ‘stigma’ referred originally to a mark or brand on Greek slaves, distinguishing them from those who were free. The term describes the situation of an individual who is disqualified from full social acceptance. The stigmatized individual is normal until abnormalized by societal views. These events may occur early, for example in those afflicted by congenital skin problems, or later in individuals with an acquired visible difference. But stigma is not just confined to the alterations in the visible body. Stigmatization may be an issue following individual behaviours and social factors such as substance abuse and unemployment. Or stigmatization may be associated with psychiatric disease. In addition there are the population prejudices of ethnicity and religion.⁹ This stigma can cause depression in such individuals and affect the quality of life in such patients.

The measurement of stigma in dermatology and psychiatry has tended to rely on general measures of mental health with depression and anxiety scores, but also with psychometric measures of self‐esteem such as the Rosenberg self‐esteem scale. This has been used to assess stigmatization in psoriasis and eczema as well as mental illness. Furthermore the stigma scale for mental illness, developed to examine discrimination, disclosure and potential positive reactions to mental illness, demonstrated that stigma scale scores were negatively correlated with global self-esteem. Interventions in dermatological stigmata are concentrated on firstly the reduction in visibility, and secondly psychological based approaches to forestall stigmatization.⁹

Earlier study as concluded by Al-Harbi who published in Skin Med 2013 edition, depression was about 59.7% in men and 40.3% in women in total of 308 patients.¹⁰

A study done by Sangma et al showed major impairments in quality of life and higher prevalence of depression in patients with vitiligo. They used Dermatology Life Quality Index and HAMD questionnaire and found out that 59% suffered from depression.¹¹

The clinician should screen the patient for depression and suicidal ideations using cost effective self-report tools.

If screening positive, the patient should be offered consultation with a psychiatrist. The clinician should also make sure to evaluate progress on follow up note visits.

CONCLUSION

Vitiligo is a secondary psychocutaneous disorder which definitely has psychiatric co morbidity in the form of depression. Psychiatrist opinion and counselling is very much important apart from specific treatment.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the institutional ethics committee

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