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Association Between Poorer Quality of Life and Psychiatric ...

  1. 1. 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 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 (Ն5 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. GHQ-12 ϭ 12-item General Health Questionnaire. INTRODUCTION 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 psychi- atric 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, psy- chiatric morbidity is associated with increased subjective per- ception 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 psycho- logical distress on the burden of a wide variety of skin con- ditions 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 mor- bidity. 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 asymp- tomatic and have a modest impact on appearance (eg, nevi). METHODS 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 reli- ability 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” 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 Fran- cisco, CA (M.-M.C.). Address correspondence and reprint requests to Damiano Abeni, Derma- tological Institute IDI-IRCCS, Via dei Monti di Creta, 104 – 00167 Rome, Italy. E-mail: 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). DOI: 10.1097/01.psy.0000132869.96872.b2 620 Psychosomatic Medicine 66:620–624 (2004) 0033-3174/04/6604-0620 Copyright © 2004 by the American Psychosomatic Society
  2. 2. to “all the time.” Higher scores indicate poorer quality of life. We adminis- tered 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,” in- cluding “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 regres- sion 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 psychi- atric 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. RESULTS 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, pa- tients coming for a follow-up visit although no longer suffer- ing 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, geo- graphical 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 de- gree 71% vs. 51%) and younger (less than 40 years of age 61% vs. 38%) (p Ͻ .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 morbid- ity (n ϭ 494, 23%) were similar in age but more likely to be women than those without psychiatric morbidity (71% com- pared 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 Skin- dex-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. 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). Table 2 displays the unstandardized regression coefficients resulting from the multiple linear regression models. The mean Skindex-29 differences between patients with and with- out psychiatric morbidity were significant after adjusting for age, gender, clinical severity, and education, for most condi- tions. 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. DISCUSSION 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 as- sociation 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 psy- chiatric morbidity and poorer quality of life did not depend on the severity of the skin condition. These results are of partic- ular 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 mor- bidity 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 bur- dened 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 ques- tionnaire results, and thus they may have tended to present POOR QOL AND PSYCHIATRIC MORBIDITY 621Psychosomatic Medicine 66:620–624 (2004)
  3. 3. 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 question- naire have been affected. Given the cross-sectional design of our study, it is not possible to draw a conclusion about the direction (or bidirec- tionality) 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 dif- ferent severity, the association may be important clinically. Patients with concurrent psychiatric disorders may need par- ticular attention, given the increased burden of disease on their life. A mutual, respectful collaboration between dermatolo- gists 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 pa- tients should be evaluated further to determine their effect on quality of life related to these common conditions. 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. TABLE 1. Median Scores Observed for General Health Questionnaire (GHQ) Noncases and Cases in the Three Scales of Skindex-29 for Different Skin Conditions Diagnostic groupsa N Symptoms scale Emotions scale Social functioning scale GHQ noncases GHQ cases GHQ noncases GHQ cases Effect sizeb GHQ noncases GHQ cases Effect sizeb GHQ noncases GHQ cases Effect sizeb Acne 107 45 28.6 39.3** 0.61 37.5 50.0** 0.74 8.3 27.1** 0.87 Alopecia 82 42 3.6 3.6 0.12 20.0 38.8** 0.86 4.2 11.4** 0.64 Bacterial and parasitic diseases 19 7 39.3 53.6 0.12 27.5 50.0 0.57 20.8 50.0 0.79 Balanitis 12 4 14.3 46.4* 1.38 7.5 46.2** 1.87 10.4 41.7* 1.56 Benign skin neoplasms 143 31 7.1 17.8* 0.52 12.5 20.0** 0.87 0.0 4.2** 0.70 Connective diseases 13 4 14.3 39.3 1.14 22.5 46.2* 1.45 2.1 31.2** 1.57 Dermatitis 319 100 35.7 53.6** 0.63 20.0 45.0** 1.12 6.2 28.1** 0.99 Fungal diseases 68 14 17.8 23.2 0.24 18.8 33.8** 0.95 6.2 21.9** 1.09 Insect bites 24 11 35.7 57.1** 1.05 22.5 45.0** 1.08 7.3 33.3** 0.90 Lichen planus 15 3 21.4 46.4 0.89 27.5 67.5** 1.96 8.3 43.8** 2.20 Mixed low-prevalence skin diseasesc 31 11 7.1 57.1** 1.65 12.5 55.0** 1.68 2.1 41.2** 1.61 Nail disorders 27 5 10.7 32.1 0.69 12.5 40.0 1.16 4.2 45.8** 2.02 Nevi 209 44 3.6 3.6 0.12 10.0 13.8** 0.41 0.0 2.1** 0.73 Pigmentary changes 34 4 5.4 0.0 Ϫ0.42 17.5 16.2 Ϫ0.15 2.1 1.0 0.00 Pruritus 9 5 46.4 67.8 1.00 35.0 65.0 1.02 20.8 43.8* 1.10 Psoriasis 56 20 35.7 51.8 0.36 30.0 47.5** 0.76 14.6 27.1* 0.73 Scar 10 4 12.5 23.2 0.69 22.5 30.0 0.52 6.2 9.4 0.67 Solar keratosis/malignancies 63 8 14.3 28.6 0.42 12.5 17.5 0.70 0.0 4.2 0.81 Urticaria 17 9 39.3 50.0 0.54 20.0 25.0 0.64 14.6 33.3 0.86 Viral diseases 155 42 7.1 21.4** 0.77 12.5 25.0** 0.69 6.2 12.5** 0.71 Vitiligo 21 8 3.6 0.0 0.00 32.5 47.5 0.77 6.3 33.3 1.13 Unrecorded diagnosis 208 73 14.3 32.1** 0.67 17.5 35.0** 0.97 4.2 18.8** 1.00 * p Ͻ 0.05; ** p Յ 0.01, Mann-Whitney U-test for the difference between Skindex-29 scores in GHQ noncases and GHQ cases. a Alopecia, nevi, pigmentary changes, and vitiligo are mostly asymptomatic skin conditions. b Effect sizes are computed for each condition dividing the differences between GHQ cases and GHQ noncases mean Skindex-29 scores by the overall standard deviation of the Skindex-29 score for all cases with that condition (21). Suggested guidelines for interpreting effect sizes (22) are: Ͼ0.2–0.5, small effect size; Ͼ0.5–0.8, moderate effect size; Ͼ0.8, large effect size. c The “mixed low-prevalence skin diseases” group includes all infrequent conditions that could not be assigned to other groups (eg, bullous disorders, hyperhidrosis, leg ulcers, etc.). TABLE 2. Unstandardized Regression Coefficients, for the Presence of Psychiatric Morbidity in Multiple Linear Regression Models of Skindex Subscales Scoresa Diagnostic group Symptoms subscale score Emotions subscale score Social functioning subscale score Acne 11.6** 14.2** 18.5** Alopecia 0.4 13.1** 7.8** Benign skin neoplasms 10.2** 12.4** 6.8** Dermatitis 12.2** 21.8** 17.6** Nevi 1.4 3.9 4.2** Psoriasis 7.3 10.6* 11.7* Solar keratosis and malignancies 6.8 8.7 6.8* Vitiligo Ϫ0.08 21.5* 27.8** * p value Ͻ 0.05; ** p value Ͻ 0.01. a These coefficients indicate mean differences in Skindex-29 scores between patients with and without psychiatric morbidity. Models were adjusted for: clinical severity, age, sex, and educational level. F. SAMPOGNA et al. 622 Psychosomatic Medicine 66:620–624 (2004)
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