Psychosomatic Medicine 66:620-624 (2004)
© 2004 American Psychosomatic Society
Association Between Poorer Quality of Life and Psychiatric Morbidity in Patients With Different Dermatological Conditions
Francesca Sampogna, BD, MPH,
Angelo Picardi, MD,
Mary-Margaret Chren, MD,
C. Franco Melchi, MD,
Paolo Pasquini, MD, MPH,
Cinzia Masini, MD and
Damiano Abeni, MD, MPH
From the Dermatological Institute IDI-IRCCS, Rome, Italy (F.S., A.P., C.F.M., P.P., C.M., D.A.); and the Departments of Dermatology, University of California at San Francisco and the HSR&D Research Enhancement Award Program, San Francisco Veterans Affairs Medical Center, San Francisco, CA (M.-M.C.).
Address correspondence and reprint requests to Damiano Abeni, Dermatological Institute IDI-IRCCS, Via dei Monti di Creta, 104 – 00167 Rome, Italy. E-mail: d.abeni{at}idi.it
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ABSTRACT
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OBJECTIVE: To determine the relationship between skin-related quality of life and psychiatric morbidity in patients with different skin conditions.
METHODS: We recruited all adults attending the outpatient clinics of the Dermatological Institute IDI-IRCCS, Rome, Italy, during 14 predetermined days. Eligible patients, who gave their informed consent, completed the Skindex-29 and the 12-item General Health Questionnaire (GHQ-12). We used a stringent cut-off threshold (
5 on the GHQ-12) for identification of psychiatric morbidity. Skindex-29 scale scores were computed separately for GHQ noncases and GHQ cases.
RESULTS: A total of 2,136 patients were included in the analysis. For all skin conditions, GHQ cases had substantially poorer score in all 3 domains of quality of life, Symptoms, Emotions, and Functioning. Most differences remained significant after adjusting for clinical severity, age, sex, and education in multiple regression models. These differences were not as marked in the Symptoms scale for some conditions known to be nearly asymptomatic (eg, alopecia, vitiligo, nevi), suggesting that, although patients with psychiatric morbidity might be more burdened by their symptoms, nevertheless they do not perceive nonexistent symptoms.
CONCLUSION: In most skin conditions we considered, psychiatric morbidity was strongly associated with poorer quality of life. Although the cross-sectional nature of our study does not allow identification of the direction of this association, care for the psychological condition of patients might have an impact on their quality of life.
Key Words: quality of life, • psychiatric morbidity, • dermatology, • Skindex-29, • GHQ-12.
Abbreviations: GHQ-12 = 12-item General Health Questionnaire.
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INTRODUCTION
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Many studies pointed out complex, mutual relationships between psyche and skin. There is extensive literature on the relationship between emotional stress and skin diseases (1). Furthermore, dermatologists commonly think that psychiatric disorders are frequent in their patients (2), and several studies confirm this opinion (3–7). In addition to any causal mechanism linking psychiatric morbidity and dermatological diseases, it is important to consider the consequences of the interrelation between these two conditions. For example, psychiatric morbidity is associated with increased subjective perception of pruritus (8), is higher among patients whose skin condition does not improve with treatment (9), and may affect treatment adherence (10).
Regardless of psychiatric morbidity, skin diseases can greatly affect patients’ quality of life (11). For example, eczema and psoriasis have been found to have an impact on quality of life comparable to that of cardiovascular diseases (12). Until now, studies on the association between psychiatric morbidity and quality of life have been focused on a specific disease, or on a small group of diseases (8, 13–15), and no single study has described and compared the effect of psychological distress on the burden of a wide variety of skin conditions with different severity levels.
The aim of this study was to investigate whether patients with psychiatric morbidity had greater impairment in skin-related quality of life than patients without psychiatric morbidity. We speculated that the relationship between psychiatric morbidity and quality of life would be stronger in patients with chronic skin diseases that can affect appearance and cause substantial subjective symptoms (eg, psoriasis, acne) than in generally asymptomatic disorders affecting appearance (eg, vitiligo, alopecia) or in conditions that are mostly asymptomatic and have a modest impact on appearance (eg, nevi).
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METHODS
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Setting and Study Population
Patients aged 18 or more, attending the outpatient clinics of IDI-IRCCS (Rome, Italy) on 14 predetermined days, who gave their informed consent, were asked to complete the questionnaires while waiting, and to return them during the visit. At the end of the visit, the physician recorded the diagnosis and rated the severity of the skin condition on a 5-point scale, which was already used in previous studies (16).
The study was approved by the Institutional Ethical Committee.
Assessment Instruments
General Health Questionnaire (GHQ-12)
The GHQ-12 is a self-administered questionnaire consisting of 12 items, designed to measure psychological distress and to detect current nonpsychotic psychiatric disorders (17), usually depressive or anxiety disorders. The reliability and validity of the Italian version has been documented in many types of patients, including those with dermatological conditions (18,19). Answers are given on a 4-point scale: for instance, the answers to the item "in the last weeks, did you feel under strain?" are "no," "no more than usual," "more than usual," and "much more than usual." The GHQ-12 was scored with the binary method (0–0-1–1). For instance, to receive a score of 1 on the previously described item, a subject should answer "more than usual" or "much more than usual." In this way, each subject obtained a score from 0 to 12: patients scoring 5 or more were operationally defined "GHQ cases," ie, as having significant psychiatric morbidity. Such a stringent criterion for psychiatric morbidity has been shown to optimize specificity and positive predictive value, while retaining an acceptable sensitivity (18).
Skindex-29
Skindex-29 is a reliable and valid self-administered instrument designed for measuring health-related quality of life in dermatology (16). It consists of 29 items, loading on three scales to measure the effects of skin conditions on symptoms, emotional state, and social functioning. The questions refer to the previous 4-week period, and scores are given on a 5-point scale, from "never" to "all the time." Higher scores indicate poorer quality of life. We administered the validated Italian version (20).
Statistical Analysis
For different skin conditions, we computed median Skindex-29 scale scores for patients with and without psychiatric disorders as determined using the GHQ-12. The same analysis was performed separately for two levels of clinical severity, derived from the global physician assessment: "mild," including "very mild," and "mild" cases, and "moderate-to-severe," including "moderate," "severe," and "most severe" cases.
The Mann-Whitney nonparametric test for two independent samples was used to compare scores of patients with or without psychiatric morbidity in each diagnostic category. To convey the magnitude of the difference in Skindex-29 scale scores for a given condition relative to the other conditions, we computed the effect size for each diagnostic category (21,22). For eight prevalent and clinically relevant skin conditions, three multiple linear regression models (ie, one for each Skindex-29 scale) were fitted to the data, to determine whether Skindex-29 scores were related to the presence of psychiatric morbidity after adjusting for other relevant independent variables (ie, clinical severity, age, sex, and education). In each model, one Skindex-29 scale was entered as dependent variable, and the main independent variable was the presence or absence of psychiatric morbidity. The resulting regression coefficients represent the estimated change in Skindex-29 scores in the presence of psychiatric morbidity.
All analyses were run under SPSS, version 9.0 for Windows.
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RESULTS
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The original study population has been described in detail in previous papers (6,20). Of 4,268 patients, 3,125 returned questionnaires, of which 267 were blank, so the response rate was 67%. For the purpose of this report, we did not include in the analysis patients with nondermatological conditions, patients coming for a follow-up visit although no longer suffering from a skin disease, and patients with multiple diagnoses. Hence, the sample of this study consisted of 2,136 patients with complete information on both GHQ-12 and Skindex-29.
There was no difference in gender, marital status, geographical area of residence, or severity of the skin condition between subjects who completed the study instruments and those who either declined to participate, or did not return completed questionnaires. However, study participants were more educated (senior high school diploma or university degree 71% vs. 51%) and younger (less than 40 years of age 61% vs. 38%) (p < .001 in both cases).
Overall, 41% of the patients were males, 39% were less than 30 years old, and 25% were more than 50 years old. Dermatologists rated the clinical severity as "moderate-to-severe" for 46% of patients. Patients with psychiatric morbidity (n = 494, 23%) were similar in age but more likely to be women than those without psychiatric morbidity (71% compared with 59%).
Table 1 reports the Skindex-29 median scale scores for all conditions observed, separately for patients with or without psychiatric morbidity, and the effect sizes. Median Skindex-29 scores were generally higher among patients with psychiatric morbidity. A notable exception was observed in pigmentary changes for all scales, and for nevi, alopecia, and vitiligo for the Symptoms scale, with effect sizes very low, or even negative. The most striking differences were observed in the social functioning scale where, for example, lichen planus, nail disorders, balanitis, and connective tissue diseases showed effect sizes of 1.6 to 2.2. For the emotions scale, balanitis, connective tissue diseases, and lichen planus had effect sizes greater than 1.4.
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TABLE 1. Median Scores Observed for General Health Questionnaire (GHQ) Noncases and Cases in the Three Scales of Skindex-29 for Different Skin Conditions
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The same pattern was observed in the subgroups of patients with either "mild" or "moderate-to-severe" clinical severity. Consistent with the observation on the unstratified data for the Symptoms scale, the differences in quality of life according to psychiatric status were negligible or absent in the nearly asymptomatic diseases such as alopecia, nevi, and vitiligo (Figure 1).
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Figure 1. Median scores of Symptoms scale of Skindex-29 for GHQ noncases and cases in mild and moderate-to-severe forms of disease, according to the physician’s rating of severity. Lines in the graphs are only meant to connect points referring to the same disease and do not have any intrinsic statistical or mathematical meaning. Alopecia, nevi, and vitiligo are mostly asymptomatic skin conditions.
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Table 2 displays the unstandardized regression coefficients resulting from the multiple linear regression models. The mean Skindex-29 differences between patients with and without psychiatric morbidity were significant after adjusting for age, gender, clinical severity, and education, for most conditions. As in the univariate analysis, no significant differences were observed in the Symptoms scale for alopecia, nevi, and vitiligo. For all skin conditions, in the social functioning scale, mean scores were substantially and significantly different between patients with and those without psychiatric disorders.
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TABLE 2. Unstandardized Regression Coefficients, for the Presence of Psychiatric Morbidity in Multiple Linear Regression Models of Skindex Subscales Scoresa
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DISCUSSION
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In this study on dermatological patients, we observed a strong association between psychiatric morbidity and poorer quality of life, both measured using standard self-administered questionnaires of established validity and reliability. This association was consistent in a wide variety of skin conditions, representing a broad range of quality-of-life involvement, and different clinical severity levels. The association between psychiatric morbidity and poorer quality of life did not depend on the severity of the skin condition. These results are of particular interest as they represent typical problems encountered by dermatologists in their daily ambulatory practices.
The magnitude of the differences in quality of life between patients with and those without psychiatric disorders was often striking, and was observed in all three domains of quality of life. Differences in the Symptoms subscale are particularly interesting. A previous study (8) in patients with psoriasis, atopic dermatitis, and chronic urticaria reported that more depressed patients experienced more pruritus. In our study, we observed an association between psychiatric morbidity and perceived impact of symptoms considered in the Skindex-29 Symptoms scale (eg, pruritus, burning, bleeding, pain, stinging, irritation). It is interesting to note that these differences were not observed in patients with some generally asymptomatic conditions such as nevi, vitiligo, and alopecia. This lends additional confidence in our findings and suggests that patients with psychiatric morbidity might be more burdened by symptoms, but they do not perceive "inappropriate," nonexistent symptoms.
Because we mainly relied on patient-rated measures, the issue of reporting bias should be taken into account. It is possible that patients might have thought that the clinician who was about to see them would have access to the questionnaire results, and thus they may have tended to present themselves as more symptomatic and distressed in an attempt to engage the interest and sympathy of the clinician, a form of reporting bias (23). However, a differential bias was not likely, because all patients had been instructed to return both the GHQ-12 and the Skindex-29 to the dermatologist, so there is no reason to believe that the results of only one questionnaire have been affected.
Given the cross-sectional design of our study, it is not possible to draw a conclusion about the direction (or bidirectionality) of the association between poor quality of life and psychiatric morbidity. Regardless, given the consistency and strength of the association in several skin conditions of different severity, the association may be important clinically. Patients with concurrent psychiatric disorders may need particular attention, given the increased burden of disease on their life. A mutual, respectful collaboration between dermatologists and mental health professionals might be of help for many patients (24). There are studies documenting that not only emotional distress, but also skin lesions themselves can be ameliorated by psychotherapeutic interventions (25,26). The role of psychiatric interventions on dermatological patients should be evaluated further to determine their effect on quality of life related to these common conditions.
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ACKNOWLEDGMENTS
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The study was partially supported by the Italian Ministry of Health, Rome, Italy, grants ICS-120.4/RF98.7 and RC2002-7.1. Dr. Chren is supported by grants: US Department of Veterans Affairs (HSR&D IIR 97010–2) and National Institute of Arthritis, Musculoskeletal and Skin Disease, National Institutes of Health (#K02 AR 02203–01).
The authors thank Mr. Simone Bolli, Ms. Solenn de Tanouarn, and Ms. Valentina Salvatori, who assisted in the data collection and performed the data entry, as well as the administrative employees and dermatologists of IDI-IRCCS whose collaboration made the study possible.
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ABSTRACT
INTRODUCTION
