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. 2021 Feb 19;79(4):464–469. doi: 10.1016/j.mjafi.2020.10.014

Anxiety, depression and harmful use of alcohol in severe chronic plaque psoriasis: A cross-sectional study

Avijit Mathur a, Shekhar Neema b,∗, Rajesh Sahu c, S Radhakrishnan d
PMCID: PMC10334124  PMID: 37441302

Abstract

Background

Psoriasis is a common, chronic T cell–mediated disease characterised by erythematous, scaly plaques. Psoriasis is associated with depression, anxiety, poor quality of life, harmful use of alcohol and suicidal ideation. We performed this study to find out prevalence of psychological morbidity in our patients with severe psoriasis and to know clinical variables associated with higher risk of psychological morbidity.

Method

This study is a cross-sectional, observational study conducted in a dermatology outpatient department (OPD) of a tertiary care centre. Study population included patients with severe psoriasis area severity index (PASI>10). Clinical and epidemiological data, Patient health questionnaire-9, Generalised anxiety disorder-7, Dermatology life quality index (DLQI) and Alcohol Use Disorders Identification Test questionnaires were recorded. Data were analysed using SPSS, version 24. Chi-square test and Spearman's rank correlation test (ρ) were performed, and p value of <0.05 was considered statistically significant.

Result

A total of 140 patients were included in the study and consisted of 67 men and 73 women. The median age was 44 years, median duration of disease was 10 years and median PASI was 13.6. Scoring revealed moderate-to-severe depression in 69 (49.3%) patients, moderate-to-severe anxiety in 40 (28.6%), severe impairment in quality of life in 98 (70%), harmful use of alcohol in 23 (16.4%) and suicidal ideation in 11 (7.8%) patients. Young age, recent onset, higher PASI and facial involvement show significant association with depression, anxiety and poor quality of life.

Conclusion

Screening for psychological morbidity should be performed in patients with severe psoriasis especially younger patients with recent onset disease. Higher DLQI points to concomitant psychological morbidity and it should be performed in all the patients.

Keywords: Psoriasis, Depression, Anxiety, PHQ-9, DLQI, GAD-7

Introduction

Psoriasis is a common, chronic T cell–mediated disorder; affecting 0.4–2% of general population.1 It is caused by complex interplay between genetics and environmental factors. Infection, drugs, smoking, alcohol, psychological and physical stressors are known triggers for psoriasis. It is increasingly being recognised that psoriasis is not just a skin disease but is associated with other comorbidities such as arthritis, metabolic syndrome, diabetes mellitus, hypertension, obesity, coronary artery disease (CAD), inflammatory bowel disease and depression.2 Visible skin disease such as psoriasis are associated with stigma and sense of shame and anger. The prevalence of depression in psoriasis varies from 8 to 62% in various studies.3 Alcohol-related problems are seen in almost 30% patients. Other psychiatric illnesses are also more common in patients with psoriasis. Unrecognised psychiatric symptoms are associated with poor quality of life (QoL).4 The exact pathophysiology of depression is not clear and results from interplay of genetic and environmental factors. The depression in psoriasis is partly attributed to proinflammatory state rather than social impact of disease only. This proinflammatory state results in dysfunction of neurotransmitters (mainly serotonin) responsible for depression. Cytokines such as IFN-α, interleukin 6 (IL-6), IL-1β and TNF α are elevated in depression and alters serotonin metabolism.5 IL-17 and TNFα are increased in psoriasis and may act as a biological link between psoriasis and depression. They also lead to increase in corticotrophin releasing hormone, adrenocorticotrophic hormone and cortisol, which are associated with a stress response and negative mood symptoms. Etanercept monotherapy has resulted in improvement of depression; etanercept and adalimumab improved comorbid depression and psoriasis.6,7

It is important to screen patients with psoriasis for psychiatric morbidity to improve compliance and to prevent unavoidable suffering; however, the screening of patients with psoriasis for psychiatric symptoms remains inadequate.8 Because it may not be possible to screen all patients of psoriasis in a busy dermatology OPD, we conducted this study to find out undiagnosed prevalence and clinical correlates of psychiatric morbidity that may help us in screening high-risk patients.

Material and methods

This study was cross-sectional, descriptive in nature and conducted in the dermatology OPD of a tertiary care centre between June 2019–December 2019. Institutional ethical committee clearance was obtained. Patient consent for inclusion in study was also obtained. Patients older than 18 years with severe chronic plaque psoriasis and willing to be part of study were included. Patients with diagnosed psychiatric illness and other skin disorders were excluded from the study. Convenience sampling method was used. Sample size was calculated to be 138 based on a similar study which used PHQ-9 as screening method, with prevalence of depression as 9.9%, α error of 0.05 and power of 90%.9

Assessment

Psoriasis area severity index (PASI) is an objective, validated, scoring system for assessment of psoriasis severity. PASI is calculated using body surface area involvement, erythema, induration and scaling of plaques. Severe psoriasis was defined as PASI score > 10 and formed the subject of the study. Basic epidemiological and clinical parameters such as age, sex, education and marital status, disease duration and severity and presence of comorbidities were recorded in proforma.

Patient health questionnaire-9 (PHQ-9) is a validated 9-item questionnaire used for screening of depression. Every item is scored from 0 (not at all) to 3 (nearly every day); score from 0 to 4 is considered normal, 5 to 9 is mild, 10 to 14 is moderate, 15 to 19 is moderately severe and 20 to 27 is considered severe depression.10 Generalised anxiety disorder-7 (GAD-7) is a 7-item questionnaire used for screening of anxiety. Every item is scored from 0 (not at all) to 3 (nearly every day); score from 0 to 4 is considered normal, 5 to 9 is mild, 10 to 14 is moderate and more than 15 is considered severe anxiety.11 Alcohol Use Disorders Identification Test (AUDIT) is a 10-item validated questionnaire for detecting harmful use of alcohol. Every item is scored from 0 to 4 and score more than 8 is considered as harmful use of alcohol.12 Dermatology life quality index (DLQI) is a validated 10-item questionnaire used to measure the impact of dermatological diseases on QoL. Every item is scored from 0 to 3 and scores are interpreted as follows: 0 to 1 is no effect on QoL, 2 to 5 is small effect, 6 to 10 is moderate effect, 11 to 20 is very large effect and more than 20 is having extremely large effect on patient's life.13 The validated Hindi version of PHQ-9, GAD-7, AUDIT and DLQI were used.14, 15, 16, 17, 18 Patient who could not understand written Hindi filled proforma in presence of one of the investigators and a translator.

Data were coded and analysed using SPSS, version 24. All continuous variables were expressed as mean ± standard deviation (SD) or median± SD depending on skewness of the data. Univariate analysis using chi-square test was carried out to evaluate the association between categorical variables and outcomes. A p value of <0.05 was considered statistically significant. Spearman's rank correlation test (ρ) was carried out to find out strength of association between variables. ρ value of 0–0.2, 0.2–0.4, 0.4–0.6, 0.6–0.8, 0.8–1 was considered as no correlation, weak, moderate, strong and very strong correlation respectively.

Results

A total of 148 patients were assessed for inclusion in the study during study period. Eight patients did not meet inclusion criteria (2 – prior psychiatric disease, 2 – unwilling, 4 – concomitant skin disease). A total of 140 patients were included in the study and consisted of 67 (47.85%) men and 73 (52.14%) women. The median age of the patients was 44 years (20–72 years), median duration of disease was 10 years (0.25–40 years) with a median PASI of 13.6 (10.2–39.6). Of 140 patients, 128 (91.4%) were married and 12 (9.6%) were unmarried; 76 (54.3%) patients studied less than 10th class, 32 (22.9%) between 10 and 12 class and 32 (22.9%) were graduates. Scalp involvement was the most common regional involvement and was seen in 130 (92.9%) patients; other regional involvement seen were nail involvement in 66 (47.1%) patients, facial involvement in 18 (12.9%), genitalia involvement in 20 (14.3%) and palmoplantar involvement in 4 (2.9%) patients. Comorbidities seen in patients were type 2 diabetes in 20 (14.28%) patients, hypertension in 16 (11.4%) patients, CAD in 9 (6.4%) patients and arthritis in 12 (8.5%) patients.

PHQ-9 scores revealed no depression in 30 (21.4%) patients, mild depression in 41(29.3%), moderate in 36 (25.7%), moderate-to-severe in 26 (18.6%) and severe in 7 (5%) patients. GAD-7 score was normal in 46 (32.9%), mild in 54 (38.6%), moderate in 28 (20%) and severe in 12 (8.6%) patients. The DLQI score showed no effect on QoL in 2 (1.4%) patients, small effect on QoL in 40 (28.5%), moderate effect in 32 (22.85%), very large effect in 49 (35%) and extremely large effect in 17 (12.14%) patients. The relationship between PHQ-9, GAD-7 and DLQI is demonstrated in chart 1. Harmful use of alcohol was seen in 23 (16.4%) patients. The effect of variables on PHQ-9, GAD-7 and DLQI is demonstrated in Table 1.

Chart 1.

Chart 1

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Relationship between PHQ-9, GAD-7 and DLQI. PHQ-9, Patient health questionnaire-9; GAD-7, Generalised anxiety disorder-7.

Table 1.

Association of variables with PHQ-9, GAD-7 and DLQI.

Variable PHQ-9 GAD-7 DLQI
Age 0.0001 0.003 0.0001
Sex 0.770 0.317 0.355
Marriage 0.188 0.089 0.035
Education 0.678 0.139 0.196
Duration 0.009 0.04 0.017
PASI 0.0001 0.002 0.0001
Arthritis 0.544 0.075 0.240
Nail 0.527 0.517 0.032
Scalp 0.627 0.416 0.119
Face 0.042 0.045 0.039
Genitalia 0.195 0.685 0.023
Alcohol 0.567 0.196 0.84
PHQ-9 0.0001 0.0001
GAD-7 0.0001 0.004
DLQI 0.0001 0.004
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∗Chi-square test was used. First column shows variables; and second, third and fourth columns show p value. DLQI, Dermatology life quality index; PHQ-9, Patient health questionnaire-9; GAD-7, Generalised anxiety disorder-7. Letters in bold suggests statistical significance (P value < 0.05).

On assessing the correlations between various indices used, we found PHQ-9 showed strong correlation to GAD-7 and moderate correlation to DLQI. PHQ-9, GAD-7 and DLQI show negative correlation to age and duration of disease. Patients with more severe involvement (higher PASI) had higher PHQ-9, GAD-7 and DLQI score with highly significant p value of 0.0001, 0.002 and 0.0001, respectively. Patients with facial involvement also had higher PHQ-9, GAD-7 and DLQI score with significant p value of 0.042, 0.045 and 0.039, respectively. The ρ values and correlations of other clinical variables have been mentioned in Table 2. Suicidal ideation was noted in 11 (7.8%) patients.

Table 2.

Correlation between variables and PHQ-9, GAD-7 and DLQI.

Variables Age Duration PASI PHQ-9 GAD-7 DLQI
PHQ-9 −0.427 −0.345 0.051 1 0.615 0.401
GAD-7 −0.241 −0.189 0.073 0.615 1 0.321
DLQI −0.447 −0.413 0.078 0.401 0.321 1
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∗Spearman correlation test was used; column 1 shows variables; and other columns show correlation coefficient (ρ). PASI, psoriasis area severity index; DLQI, Dermatology life quality index; PHQ-9, Patient health questionnaire-9; GAD-7, Generalised anxiety disorder-7. Letters in bold suggests statistical significance (P value < 0.05).

Discussion

Psoriasis results in significant impact on psychological health of the patients. The visibility of psoriatic lesions leads to feeling of self-consciousness, attempts to hide psoriasis lesions, avoiding public places, embarrassment with partner and thus negatively impact QoL. Psychological stress is known to aggravate psoriasis, and patients with depression have poor adherence to treatment that perpetuate this cycle. Addressing these issues is an important aspect of holistic care of patients with psoriasis. A multicentric European study on psychological burden of skin diseases consisting of 3635 patients and 1359 controls concluded that clinical depression was seen in 10.3% patients (odd's ratio (OR) 2.4; 95% CI: 1.67–3.47) and anxiety was seen in 17.2% patients (OR: 2.18; 95% CI: 1.68–2.82).19 A metanalysis published in 2014 concluded that patients with psoriasis are one and half times more likely to suffer from depression (OR: 1.57; 95% CI: 1.40–1.76) than the general population. Hazard ratio of depression was more in severe psoriasis (HR: 1.72; 95% CI: 1.57–1.88) as compared with mild psoriasis in a population-based cohort study (hazard ratio (HR): 1.38; 95% confidence interval (CI): 1.35–1.40).3 Our study consisted of patients with severe psoriasis and showed no or mild depression in 71 patients (50.7%) and moderate-to-severe depression in 69 (49.3%) patients which is lower than cross-sectional study conducted in which authors used PHQ-9 to measure depression and showed that 71 (78.9%) patients had depression. It is possibly because we did not include mild depression in calculation.20 The prevalence in our study is higher than other studies possibly because we included only patients with severe psoriasis in our study. The prevalence may also vary depends on the screening tool used for depression. There is no perfect screening tool, we used PHQ-9 because it is simple to perform and discriminate between patients with or without depression adequately.21 In our study, we found that patients of younger age, less duration of disease, higher PASI and facial involvement is statistically significant associated with higher risk of depression. A previous study showed similar findings with higher risk of depression associated with younger age, head involvement and severe disease. This study also showed association of depression with severe impairment of QoL (OR: 7.16; 2.7,18.98).22 In our study also, PHQ-9 positively correlated with DLQI. Age and longer duration of disease leads to better coping skills and less psychological problems. Many studies have reported that psychological symptoms are a function of perception of stigmatization rather than disease severity.23

Anxiety is a state of worry and unease. In a population-based cohort study of psoriasis, the HR for anxiety was 1.31 (95% CI: 1.29–1.34) as compared with general population.24 In a systematic review, prevalence of anxiety was seen in 20–50% in various studies using Hamilton anxiety and depression scale.25 In our study, GAD-7 questionnaire was used in which the score cut off value of 10 is a reasonable cut off for identifying cases of generalised anxiety disorder. In our study, no to mild anxiety (score 0–10) was seen in 100 (71.4%) patients and moderate-to-severe anxiety (score >10) in 40 (28.6%) patients. Positive correlation was seen in our study between anxiety with depression and poor QoL.

Psoriasis has a negative impact on health-related quality of life (HRQoL). The factors resulting in poor QoL may be chronic and recurrent nature of disease, unexpected outbreaks and hopelessness in cure. Various tools used for measurement of QoL are psoriasis-specific, skin-specific and generic. DLQI measures HRQoL in patients with skin disease. It has 10 items covering symptoms and feelings, daily activities, leisure, work and school, personal relationships and treatment. DLQI more than 10 is considered a severe impairment in QoL. In our study, DLQI more than 10 was seen in 98 (70%) patients. A study by Nyunt et al26 showed 58.5% patients with severe psoriasis had DLQI more than 10. In a previous study, poor QoL in patients has been associated with disease severity, nail involvement, education, marital and employment status and involvement of exposed areas. Poor QoL was also associated with depression and anxiety. In our study, DLQI also showed positive correlation with PHQ-9 and GAD-7. Younger age, disease duration, higher PASI and facial, genital and nail involvement have statistically significant association with higher DLQI. Marital status, educational status, sex and presence of comorbidities did not show statistically significant association with poor QoL in our study. A study by Gelfand et al27 had similar findings with body surface area involvement, young age and female patients showing strong association with decrease in QoL. Genital involvement in psoriasis is associated with poor sexual satisfaction and impaired QoL. In our study, genital psoriasis was associated with higher DLQI score and poor QoL, as DLQI consists of various subscores and questions 8 and 9 deals with personal relationship. This subscore of DLQI is good screening tool for impaired sexual satisfaction and should prompt detailed enquiry.28

Alcohol consumption is associated with higher incidence and more severe psoriasis. It also hampers treatment as concomitant use of hepatotoxic drugs such as methotrexate and acitretin can compound hepatic problems. Alcohol use is also associated with poor adherence to treatment regimes. A previous study showed that 17–30% patients with psoriasis have alcohol-related problems and patients with alcohol-related problems had more depression and anxiety.29 In our study, 23 (16.4%) patients had AUDIT score more than 8 indicating harmful use of alcohol. All the patients with harmful use of alcohol were men in our study. We could not find any significant association of harmful use of alcohol with depression, anxiety or poor QoL in our study. Harmful use of alcohol is common and should be specifically screened in men suffering from severe psoriasis as other screening tools such as DLQI does not show any clear association with harmful use of alcohol.

A cross-sectional multicentric study concluded that suicidal ideation is higher in patients with psoriasis as compared with the general population (odds ratio: 1.94; 95% CI: 1.33–2.82).30 A multinational study found that 11.5% patients had suicidal ideation linked to psoriasis. In our study, 11 (7.8%) patients had suicidal ideation.

Conclusion

Depression, anxiety and harmful use of alcohol are common in patients with severe psoriasis. Screening for psychological morbidity in patients with severe psoriasis should be done routinely as a part of holistic care. Younger patients, recent onset disease, severe disease and facial involvement are more prone to develop psychological morbidity and should be screened. In busy OPD, DLQI is a good screening tool as higher scores correlate with depression and anxiety. It also correlates well with sexual problems arising out of disease. AUDIT should be performed in all patients with severe psoriasis as other instruments or clinical indicators do not identify harmful use of alcohol.

Limitations

Limitations of the study were convenience method of sampling, cross-sectional nature and recruitment of patients from single tertiary care centre. This may limit generalisability of our findings.

Disclosure of competing interest

The authors have none to declare.

Footnotes

Appendix A

Supplementary data to this article can be found online at https://doi.org/10.1016/j.mjafi.2020.10.014.

Appendix A. Supplementary data

The following is/are the Supplementary data to this article:

Multimedia component 1
mmc1.pdf (177.1KB, pdf)
Multimedia component 2
mmc2.pdf (98.7KB, pdf)
Multimedia component 3
mmc3.pdf (149.9KB, pdf)

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Associated Data

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Supplementary Materials

Multimedia component 1
mmc1.pdf (177.1KB, pdf)
Multimedia component 2
mmc2.pdf (98.7KB, pdf)
Multimedia component 3
mmc3.pdf (149.9KB, pdf)

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