to “all the time.” Higher scores indicate poorer quality of life. We adminis-
tered the validated Italian version (20).
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.
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
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.
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,”
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)
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
TABLE 1. Median Scores Observed for General Health Questionnaire (GHQ) Noncases and Cases in the Three Scales of Skindex-29 for
Different Skin Conditions
N Symptoms scale Emotions scale Social functioning scale
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.
Alopecia, nevi, pigmentary changes, and vitiligo are mostly asymptomatic skin conditions.
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.
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
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.
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)
1. Picardi A, Abeni D. Stressful life events and skin diseases: disentangling
evidence from myth. Psychother Psychosom 2001;70:118–36.
2. Gieler U, Niemeier V, Kupfer J, Brosig B, Schill WB. Psychosomatics
dermatology in Germany: a survey of 69 dermatologic clinics [in Ger-
man, abstract in English]. Hautarzt 2001;52:104–10.
3. Hughes JE, Barraclough BM, Hamblin LG, White JE. Psychiatric symp-
toms in dermatology patients. Br J Psychiatry 1983;143:51–4.
4. Wessely SC, Lewis GH. The classification of psychiatric morbidity in
attenders at a dermatology clinic. Br J Psychiatry 1989;155:686–91.
5. Aktan S, Ozmen E, Sanli B. Psychiatric disorders in patients attending a
dermatology outpatient clinic. Dermatology 1998;197:230–34.
6. Picardi A, Abeni D, Melchi CF, Puddu P, Pasquini P. Psychiatric mor-
bidity in dermatological outpatients: an issue to be recognized. Br J
7. Picardi A, Abeni D, Renzi C, Braga M, Puddu P, Pasquini P. Increased
psychiatric morbidity in female outpatients with skin lesions on visible
parts of the body. Acta Derm Venereol 2001;81:410–4.
8. Gupta MA, Gupta AK, Schork NJ, Ellis CN. Depression modulates
pruritus perception: a study of pruritus in psoriasis, atopic dermatitis, and
chronic idiopathic urticaria. Psychosom Med 1994;56:36–40.
9. Picardi A, Abeni D, Renzi C, Braga M, Melchi CF, Pasquini P. Treatment
outcome and incidence of psychiatric disorders in dermatological outpa-
tients. J Eur Acad Dermatol Venereol 2003;17:155–9.
10. Renzi C, Picardi A, Abeni D, Agostini E, Baliva G, Pasquini P, Puddu
P, Braga M. Association of dissatisfaction with care and psychiatric
morbidity with poor treatment compliance. Arch Dermatol 2002;138:
11. Finlay AY. Quality of life assessments in dermatology. Semin Cutan Med
12. Sprangers MA, de Regt EB, Andries F, van Agt HM, Bijl RV, de Boer
JB, Foets M, Hoeymans N, Jacobs AE, Kempen GI, Miedema HS, Tijhuis
MA, de Haes HC. Which chronic conditions are associated with better or
poorer quality of life? J Clin Epidemiol 2000;53:895–907.
13. Gupta MA, Gupta AK. Depression and suicidal ideation in dermatology
patients with acne, alopecia areata, atopic dermatitis and psoriasis. Br J
14. Kent G, Al’Abadie M. Psychologic effects of vitiligo: a critical incident
analysis. J Am Acad Dermatol 1996;35:895–8.
15. van der Meeren HL, van der Schaar WW, van der Hurk CM. The
psychological impact of severe acne. Cutis 1985;36:84–6.
16. Chren MM, Lasek RJ, Flocke SA, Zyzanski SJ. Improved discriminative
and evaluative capability of a refined version of Skindex, a quality-of-life
instrument for patients with skin diseases. Arch Dermatol 1997;133:
17. Goldberg DP. The detection of psychiatric illness by questionnaire.
London: Oxford University Press; 1972.
18. Piccinelli M, Bisoffi G, Bon MG, Cunico L, Tansella M. Validity and
test-retest reliability of the Italian version of the 12-item General Health
Questionnaire in general practice: a comparison between three scoring
methods. Compr Psychiatry 1993;34:198–205.
19. Picardi A, Abeni D, Pasquini P. Assessing psychological distress in
patients with skin diseases: reliability, validity and factor structure of the
GHQ-12. J Eur Acad Dermatol Venereol 2001;15:410–7.
20. Abeni D, Picardi A, Pasquini P, Melchi CF, Chren MM. Further evidence
of the validity and reliability of the Skindex-29: an Italian study on 2242
dermatological outpatients. Dermatology 2002;204:43–9.
21. Hedges L, Olkin I. Estimation of a single effect size: parametric and
nonparametric methods. In: Statistical methods for meta-analysis. San
Diego, CA: Academic Press; 1985. p. 76–106.
22. Cohen J. Statistical power analysis for the behavioral sciences. Hillsdale,
NJ: Lawrence Erlbaum Associates Publishers; 1988.
23. Streiner DL, Norman GR. Health measurement scales: a guide to their
development and use. New York: Oxford University Press; 1995.
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.
POOR QOL AND PSYCHIATRIC MORBIDITY
623Psychosomatic Medicine 66:620–624 (2004)
24. Woodruff PW, Higgins EM, du Vivier AW, Wessely S. Psychiatric
illness in patients referred to a dermatology-psychiatry clinic. Gen Hosp
25. Papadopoulos L, Bor R, Legg C. Coping with the disfiguring effects of
vitiligo: a preliminary investigation into the effects of cognitive-
behavioral therapy. Br J Med Psychol 1999;72:385–96.
26. Kabat-Zinn J, Wheeler E, Light T, Skillings A, Scharf MJ, Cropley
TG, Hosmer D, Bernhard JD. Influence of a mindfulness meditation-
based stress reduction intervention on rates of skin clearing in patients
with moderate to severe psoriasis undergoing phototherapy
(UVB) and photochemotherapy (PUVA). Psychosom Med 1998;60:
F. SAMPOGNA et al.
624 Psychosomatic Medicine 66:620–624 (2004)