BASIC/CLINICAL SCIENCE

The Prevalence of Anxiety and Depression in Arab Dermatology Patients Mohammed A. AlShahwan Background: Psychiatric disorders are common among patients with physical illnesses. Objectives: To estimate the prevalence of anxiety and depression in Arab dermatology patients and to study its association with the patients’ characteristics. Materials and Methods: A cross-sectional study was carried out on 875 patients attending the Dermatology Clinic at King Khalid University Hospital in Riyadh, Saudi Arabia. Each patient was asked to complete the Hospital Anxiety and Depression Scale and the demographic-clinical questionnaire. Results: The frequency of anxiety and depression in Arab dermatology patients was 29% for anxiety and 14% for depression. These frequencies were not related to sociodemographic and clinical variables (p . .05), except skin disease type (p , .05). Patients suffering from hair loss had the highest anxiety and depression scores (OR 1.725 [95% CI 1.247–2.386] and OR 1.686 [95% CI 1.101– 2.581], respectively). On the other hand, patients suffering from psoriasis had the highest depression scores (OR 2.909 [95% CI 1.611– 5.254]). Conclusion: Anxiety and depression are frequent among Arab dermatology patients. Contexte: Les troubles psychiatriques sont fre´quents chez les patients atteints de maladies physiques. Objectifs: L’e´tude visait a` estimer la pre´valence de l’anxie´te´ et de la de´pression chez les patients arabes traite´s en dermatologie, et a` examiner l’association de ces troubles avec les caracte´ristiques des patients. Mate´riel et me´thode: Une e´tude transversale a e´te´ mene´e chez 875 patients traite´s au service de dermatologie, a` l’hoˆpital universitaire King Khalid, a` Riyad, en Arabie saoudite. On a demande´ a` chacun des patients de coter les e´nonce´s figurant sur l’e´chelle Hospital Anxiety and Depression Scale et de remplir un questionnaire sur des donne´es de´mographiques et cliniques. Re´sultats: La fre´quence de l’anxie´te´ s’e´levait a` 29% et celle de la de´pression, a` 14% chez les patients arabes traite´s en dermatologie. Ces pourcentages n’e´taient pas lie´s a` des variables sociode´mographiques ou cliniques (p . .05), sauf dans les cas de maladie de la peau (p , .05). Les patients souffrant d’une chute des cheveux ont obtenu les re´sultats les plus e´leve´s en ce qui concerne l’anxie´te´ et la de´pression (risque relatif approche´ [RRA]:1.725 [IC a` 95%: 1.247–2.386] et RRA: 1.686 [IC a` 95%: 1.101–2.581], respectivement), et ceux atteints de psoriasis ont obtenu les re´sultats les plus e´leve´s en ce qui concerne la de´pression (RRA: 2.909 [IC a` 95%: 1.611–5.254]). Conclusion: L’anxie´te´ et la de´pression sont des troubles fre´quents, observe´s chez les patients arabes traite´s en dermatologie.

T HAS BEEN WELL ESTABLISHED that psychiatric disorders are quite common among patients with physical illnesses.1 Comorbid psychiatric disorders also affect the outcome of the medical disorder and the health care costs of

I

From the Department of Dermatology, College of Medicine, King Khalid University Hospital and King Saud University. Riyadh, Saudi Arabia. Address reprint requests to: Mohammed A. AlShahwan, MD, Department of Dermatology, College of Medicine, King Khalid University Hospital and King Saud University, Riyadh, Saudi Arabia; e-mail: Dr_m_alshahwan@ yahoo.com.

DOI 10.2310/7750.2014.14110 # 2014 Canadian Dermatology Association

medical patients.2 Some of the principal reasons for the nonrecognition of mental disorders are the high probability of these patients reporting only somatic symptoms during consultation and the doctor’s difficulty in recognizing these symptoms as evidence of mental disorders.3 In the Arab world, the prevalence of mental health disorders has increased over the past several decades.4 A systematic review on anxiety disorders showed different rates of anxiety disorders among some Arab populations: 28.2% in Jordan, 16% in Saudi Arabia, 16.7% in Lebanon, and 10% in the United Arab Emirates.5 Researchers of community medicine in the Arab world have found variable rates of depression, ranging from 12 to 32%.6

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All studies from Arab countries that evaluate the presence of mental illness in dermatology patients focus on certain populations having a particular disease. On the other hand, quality of life studies on dermatology patients in the Arab world grossly assess the psychological distress of these patients without specifically looking for a certain mental illness. Therefore, we could not find a study that evaluated the presence of anxiety and depression in Arab general dermatology patients and analyzed the associated risk factors. The objective of this study was to estimate the prevalence of anxiety and depression in Arab dermatology outpatients at King Khalid University Hospital in Riyadh, Saudi Arabia, and to study the association between their prevalence and the different sociodemographic and clinical characteristics of these patients.

diseases, and severity of diseases). The local ethical committee approved the study, and all analyses were performed with SPSS 21 for Windows (IBM Corp., Armonk, NY). All p values less than .05 were considered to be statistically significant. The results of the categorical variables were described as frequencies. Univariate analyses of the categorical variables were conducted using the chi-square test. Categorical variables with a p value less than .1 in the univariate analysis were submitted to a multivariate logistic regression analysis. Odds ratios (ORs) and their 95% confidence intervals (CIs) were then calculated.

Results Sample Characteristics

Materials and Methods A cross-sectional study was carried out on patients attending the Dermatology Outpatient Clinic at King Khalid University Hospital from June to October 2013. Questionnaires were distributed to 1,000 patients after exclusion based on the following factors: not younger than 18 years and not having any disease that could interfere with cognition. Both the Hospital Anxiety and Depression Scale (HADS) and the demographic-clinical questionnaire were used for each patient. The HADS is a reliable screening instrument for clinically significant anxiety and depression and has been found to be a valid measure of the severity of such disorders. It has been used in analyses of dermatology outpatients and general practice settings and found to have good sensitivity and specificity for the diagnosis of depression and anxiety.7 The HADS consists of 14 items, with 7 depression-related items and 7 anxiety-related items. Higher scores on each section reflect higher levels of depression or anxiety, respectively. The 14 items are answered on a 4-point scale, where 0 represents the absence of the problem and 3 represents an extreme problem. The original procedure used by Zigmond and Snaith divides scores as normal (0–7 of 21), borderline abnormal (8–10 of 21), and abnormal (11–21 of 21). Therefore, to include only definitely abnormal cases, participants were grouped as normal (0–10) and abnormal (11–21) with a cutoff of 10.8 The demographic-clinical questionnaire was composed of four questions on demographic data (age, sex, marital status, and employment) and four questions on clinical data (number of diseases, types of diseases, duration of 298

As stated earlier, the questionnaire was distributed to 1,000 patients, 875 of whom completed it. Of these, 661 (75.5%) were women, and 454 (51.9%) were between 25 and 44 years of age. Regarding marital status, 422 (48.2%) were married and 402 (45.9%) were single. In terms of occupation, 300 (34.3%) were unemployed (including housewives) and 299 (34.2%) were employed. A total of 656 (75%) patients had one dermatologic disease, 478 (54.6%) had a moderate dermatologic disease, and 623 (71.2%) patients had a disease that had lasted between 1 and 10 years (Table 1). The prevalence rates of the specific dermatologic conditions in the sample were as follows: acne (32.2%), hair loss (26.3%), hyperpigmentation (20%), skin infection (14.2%), eczema (12.1%), unpleasant scarring (9.1%), psoriasis (8.1%), vitiligo (7.4%), and skin cancer (1.1%) (see Table 1). Univariate Analyses According to the HADS, 253 patients (29%) demonstrated anxiety, particularly female patients (33.6%), unemployed patients (33%), patients with severe disease (44.6%), patients suffering multiple dermatomes (46.6%), and patients diagnosed with hair loss (37%) or skin cancer (60%). On the other hand, the HADS indicated that 122 patients (14%) were suffering from depression, particularly older patients (57.2%), female patients (15.6%), divorced or separated patients (23.6%), unemployed patients (22%), patients with severe disease (22.9%), and patients diagnosed with acne (10.7%), hair loss (18.2%), psoriasis (29%), and unpleasant scars (8.7%) (Table 2 and Table 3).

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Table 1. Sociodemographic Characteristics and Health Status of the Study Population (N 5 875) Characteristic Age (yr) 18–24 25–44 45–64 $ 65 Gender Male Female Social status Single Married Separated/divorced Occupation Student Employee Unemployed Number of diseases 1 2 3 or more Type of disease Acne Psoriasis Eczema Vitiligo Hyperpigmentation Hair loss Skin infection Skin cancer Unpleasant scarring Severity of disease Mild Moderate Severe Duration of disease (yr) #1 1–5 6–10 $ 10

hair loss (OR 1.686 [95% CI 1.101–2.581]) and psoriasis (OR 2.909 [95% CI 1.611–5.254]) (Table 4).

n (%)

Discussion 298 454 116 7

(34.1) (51.9) (13.3) (0.8)

214 (24.5) 661 (75.5) 422 (48.2) 402 (46) 51 (5.8) 276 (31.5) 299 (34.2) 300 (34.3) 656 (75.0) 176 (20.1) 43 (4.9) 282 69 106 64 173 226 127 10 92

(32.2) (8.1) (12.1) (7.4) (20.0) (26.3) (14.2) (1.1) (9.1)

222 (25.4) 478 (54.6) 175 (20.0) 77 323 300 175

(8.8) (36.9) (34.3) (20.2)

Multivariate Regression Analyses The multivariate analyses found a significant association between high anxiety scores on the HADS and skin conditions such as hair loss (OR 1.725 [95% CI 1.247– 2.386]) and skin cancer (OR 4.008 [95% CI 1.113–14.430]). In addition, there was a significant association between high depression scores on the HADS and skin conditions such as

It has been well established that psychiatric disorders are quite common among patients with physical illnesses.1 The main psychiatric disorders that appear in dermatology patients are anxiety, depression (mood disorders), and body dysmorphic disorder. Psychiatric problems may play a role in the occurrence or relapse of dermatologic disorders; however, it is possible that psychiatric morbidity is secondary to dermatologic disorders as a result of their chronic course, effect on body image, and stigmatic characteristics.3 The proportion of mood disorders in dermatology patients varies according to the location or setting of the study (ambulatory versus inpatients), diagnosis of patients, and tool used to assess the mental illness.9–15 Hughes and colleagues reported that 30% of dermatology outpatients and 60% of dermatology inpatients suffered from a psychiatric disorder.16 Recently, Ludwig and colleagues found that in a public health outpatients’ service of a dermatology clinic, the frequency of anxiety was 40.3% and the frequency of depression was 43.7%.17 In the Arab world, Al-Huzali and colleagues reported that 40% of acne patients suffer from depression regardless of its severity.18 AlGhamdi reported that more than half of vitiligo patients describe themselves as either being anxious or depressed.19 In our study, the frequency of mood disorders in Arab dermatology outpatients was 29% for anxiety and 14% for depression. When faced with a disfiguring disease, women may respond differently to men, and in most studies, the former were found to experience greater interference in their relationships with men and other women and with their sex life, reporting more subjective stress and worry. Zachariae and colleagues found that female patients had greater impairment of disease-related quality of life and more psychological symptoms than male patients.20 Similarly, Al-Hoqail found that skin disease caused a higher quality of life impairment in Saudi female patients than in male patients.21 Similarly, the Arab female patients in our study had higher anxiety and depression scores on the crude analysis that did not persist in the results of the multivariate analysis. Zachariae and colleagues reported that age was inversely related to both disease-related quality of life and psychological symptoms, even when controlling for the remaining demographic and disease-related factors.20 In our study,

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Table 2. Association between Positive HADS-Anxiety (HADS-A $ 10) and Sociodemographic/Clinical Characteristics Characteristic Age (yr) 18–24 25–44 45–64 $ 65 Gender Male Female Social status Single Married Separated/divorced Occupation status Student Employee Unemployed Number of diseases 1 2 3 or more Type of disease Acne Psoriasis Eczema Vitiligo Hyperpigmentation Hair loss Skin infection Skin cancer Unpleasant scarring Severity of disease Mild Moderate Severe Duration of disease (yr) #1 1–5 6–10 $ 10

HADS-A Negative 215 311 91 5

.195

183 (85.5) 439 (66.4)

31 (14.5) 222 (33.6)

.000

298 (70.6) 293 (72.8) 31 (67)

124 (29.4) 109 (27.2) 20 (33)

.191

196 (71) 225 (75.2) 201 (67)

74 (24.8) 99 (33)

.084

483 (73.6) 116 (65.9) 23 (53.4)

173 (26.4) 60 (34.1) 20 (46.6)

.004

(69.8) (69.5) (75.4) (73.4) (72.2) (62.8) (69.2) (40) (66.3)

187 (84.2) 338 (70.7) 97 (55.4) 55 236 217 11

(71.4) (73) (72.3) (65.1)

older patients had higher depression scores, but the influence of age on depression scores did not continue after the regression analysis. Depression was found to be more common among widowers, divorced or separated patients, and unemployed patients, thereby indicating the greater need to screen for depression in subsets of these patients.3 A recent study from Saudi Arabia found that depression was more prevalent among single female vitiligo patients.22 In our study, we found that separated/divorced and 300

83 143 25 2

p Value

(27.9) (31.5) (21.6) (28.6)

197 48 80 47 125 142 88 4 61

(72.1) (68.5) (78.4) (71.4)

HADS-A Positive

80 (29)

85 21 26 17 48 84 39 6 31

(30.2) (30.5) (24.6) (26.6) (27.8) (37.2) (30.8) (60) (33.7)

.317 .433 .172 .393 .391 .001 .350 .039 .171

35 (15.8) 140 (29.3) 78 (44.6)

.000

22 87 83 61

(28.6) (27) (27.7) (34.9)

.278

unemployed patients had higher depression scores on the crude analysis, although this association did not persist after the multivariate analysis. Hughes and colleagues reported that patients with chronic, extensive, and easily visible conditions (e.g., acne, psoriasis, and eczema) obtained higher scores on the psychological measures than patients with small localized lesions, whether benign or malignant, and those who had no visible lesions.16 In the present study, patients suffering

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Anxiety and Depression in Dermatology Patients

Table 3. Association between Positive HADS-Depression (HADS-D $ 10) and Sociodemographic/Clinical Characteristics Characteristic Age (yr) 18–24 25–44 45–64 $ 65 Gender Male Female Social status Single Married Separated/divorced Occupation status Student Employee Unemployed Number of diseases 1 2 3 or more Type of disease Acne Psoriasis Eczema Vitiligo Hyperpigmentation Hair loss Skin infection Skin cancer Unpleasant scarring Severity of disease Mild Moderate Severe Duration of disease (yr) #1 1–5 6–10 $ 10

HADS-D Negative 270 385 95 3

(90.6) (84.8) (81.8) (42.8)

.000

195 (91.1) 558 (84.4)

19 (8.9) 103 (15.6)

.014

376 (89) 338 (84) 39 (76.4)

46 (11) 64 (16) 12 (23.6)

.014

252 (91.3) 267 (89.2) 234 (78)

24 (8.7) 32 (10.8) 66 (22)

.000

567 (86.4) 150 (85.2) 36 (83.7)

89 (13.6) 26 (14.8) 7 (16.3)

.830

252 49 92 55 151 185 109 9 84

30 20 14 9 22 41 18 1 8

(89.3) (71) (86.7) (85.9) (87.2) (81.8) (85.8) (90) (91.3)

Anxiety related Hair loss Skin cancer Depression related Psoriasis Hair loss

28 69 21 4

p Value

(9.4) (15.2) (18.2) (57.2)

(10.7) (29) .001 (13.3) (14.1) (12.8) (18.2) (14.2) (10) (8.7)

.031 .478 .548 .351 .024 .513 .583 .079

206 (92.7) 412 (86.1) 135 (77.1)

16 (7.3) 66 (13.9) 40 (22.9)

.000

65 281 261 146

12 42 39 29

.650

(84.4) (86.9) (87) (83.4)

Table 4. Results of the Multivariate Logistic Regression of the Studied Variables that Were Significant in the Univariate Analysis Variable

HADS-D Positive

OR (95% CI) 1.725 (1.247–2.386) 4.008 (1.113–14.430) 2.909 (1.611–5.254) 1.686 (1.101–2.581)

(15.6) (13.1) (13) (16.6)

from moderate and severe diseases were more anxious and depressed in comparison with patients suffering from mild diseases. It was not possible to find other articles that addressed the relationship between psychological distress and the number of skin diseases. Nevertheless, our study findings suggest that patients suffering from more than one skin disease are more anxious and depressed compared to patients suffering from one disease, although this difference did not persist in the results of the multivariate analysis.

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Schmitt and colleagues found that the perception of hair loss may lead to feelings of loss of health and of senility, generating significant psychological stress.23 Their data showed a significant association between complaints of hair loss and symptoms of depression, principally with respect to patients in the third and fourth decades of life. A recent study from Tunisia showed that younger patients, unmarried patients, and patients with a severe form of alopecia areata had higher psychological distress and lower quality of life.24 Although, in our study, there was a significant association between hair loss and symptoms of depression and anxiety in Arab patients, this study does not permit causal relationships to be established between complaints of hair loss and the presence of symptoms of depression and anxiety. In a recent systematic review, it was found that approximately 30% of all patients diagnosed with melanoma reported levels of psychological distress equivalent to those identified in patients with breast and colon cancer.25 The relationship between psychological aspects and the course and recurrence of cancer has often been investigated, although the results are inconclusive.26 Our study found that patients suffering from skin cancer were more anxious, but owing to the small number of sample patients suffering from this disease, we were unable to draw a conclusion from this observation. The psychological impact of psoriasis on patients’ lives has been well documented.27 A recent meta-analysis showed that psoriatic patients are at least one and a half times more likely to manifest signs of clinical depression compared to their healthy peers. It also found that more than one-quarter of psoriatic patients show symptoms of depression and approximately one-tenth have signs of clinical depression.28 Al-Mutairi and colleagues found that 36% of psoriasis patients from Kuwait suffer from affective disorders.29 In our study; there was a significant association between psoriasis and high depression scores in Arab patients. Our study has a number of limitations, including its cross-sectional nature and the lack of a control group. The inclusion of dermatology outpatients only in the study made the generalization of the results to all dermatology patients questionable because the psychological profile of dermatology inpatients might differ. In addition, the psychometric assessment of patients with multiple dermatologic conditions carries its own inherent difficulties.

Conclusion This study shows that the frequency of mood disorders in Arab dermatology patients was 29% for anxiety and 14% for 302

depression. These frequencies were not related to sociodemographic and clinical variables except skin disease type. We also found that Arab dermatology patients suffering from hair loss had higher anxiety and depression scores. On the other hand, patients suffering from psoriasis only had higher depression scores. This fact emphasizes the importance of a multidisciplinary approach to treating dermatology outpatients due to high comorbidity with psychiatric disorders.

Acknowledgments The author would like to thank Dr. Ashry Gad Mohammed for providing the statistical analysis and reviewing the manuscript and Professor Marwan Alkhawaja for reviewing the manuscript. Financial disclosure of author and reviewers: None reported.

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The Prevalence of Anxiety and Depression in Arab Dermatology Patients.

Psychiatric disorders are common among patients with physical illnesses...
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