Quality of life, anxiety and depressive symptoms in patients with psoriasis: A case-control study
Introduction
Psoriasis is a chronic inflammatory skin disease whose lifetime prevalence varies from 0.91% in the USA to 8.5% in Norway [1]. Psoriasis and psychiatric disorders (especially depression, anxiety or alcohol-related disorders) often co-occur; moreover, psychological stress can induce exacerbation of psoriasis [[2], [3], [4], [5], [6], [7], [8]]. This comorbidity is associated with poorer quality of life (QoL) [6] and with increased mortality due to suicide [4,7], alcohol-related causes [9] and cardiovascular diseases, especially among those with depression [10,11].
Psoriasis seems to have a multifactorial aetiology [12] and it can be considered as a psychosomatic disorder [13,14], because biological, enviromental and psychosocial factors are intertwined. In fact, the variations in the prevalence of psoriasis worldwide may reflect differences in genetic and enviromental factors [15]. One of these environmental factors is the exposition to sun hours and the climate characteristics. A region, Andalusia characterized by hot and dry climate has a prevalence of psoriasis of 2.1%, and the whole country of Spain of 2.3% [16]. Firstly, there are several biological factors associated with psoriasis or its exacerbations, such as genetics [12,17], tobacco smoking, alcohol consumption, drug use and higher body mass index, whereas healthy diet seems to have a protective role [18]. Secondly, psoriasis has an important psychosocial dimension [4,7,8], since subjects with psoriasis have higher prevalence of psychiatric disorders [[2], [3], [4], [5], [6], [7], [8]] and stressful life events may act as risk factors for psoriasis [18]. Compared to psoriasis-free controls, patients with psoriasis are more likely to have depression, anxiety, alexithymia and suicidal ideation [4,7,8]. In particular, patients with psoriasis are one and a half to two times more likely to have depression [3,19] and four times more likely to use antidepressants [20]. Similarly, anxiety symptoms have been found almost three times more frequently in patients with psoriasis compared with subjects without psoriasis [4]. Furthermore, among subjects with psoriasis, the lifetime prevalence of suicide attempts is 37%, significantly higher than those without psoriasis [7]. Unlike other skin diseases, only psoriasis shows a significant association with suicidal ideation [4]. Finally, psoriasis is linked to poorer QoL [8,[20], [21], [22], [23], [24], [25]], especially in women with genital lesions [8,24].
Despite such evidence concerning the psychosomatic nature of psoriasis [13,14], the interplay between the different factors leading to a low QoL has not been properly described and the research on this topic is still scarce. The underlying relationship is likely to be bidirectional, given that a greater severity of psoriatic symptoms leads to an increase in the level of depressive symptoms [20] or social anxiety among patients with pre-adult onset psoriasis [26], and psoriasis is an independent predictor of any kind of depressiveness [27]. In addition, there is evidence that biological treatment of psoriasis can improve mental symptoms [28] and viceversa [29]. Stress could be a mediator in a circular process between biological and psychosocial factors. It has been described as an independent risk factor for both mental disorders and psoriasis, probably owing to shared risk factors such as inflammatory mechanisms, pruritus, specific genital locations, stigmatization, social isolation or history of traumatic experiences in childhood [14].
The aim of the present study was two-fold. First, to compare QoL (using mental and psychical global measures separately), anxiety and depressive symptoms, alcohol consumption, smoking and other correlates between patients with psoriasis and controls matched by sex, age and residence or job location, in a region (Andalusia) with a lower prevalence of psoriasis. Second, to identify features of psoriasis associated with lower levels of QoL, controlling for demographic factors as well as depression and anxiety scores.
Section snippets
Method
The sample of this case-control study included 210 subjects: 70 with moderate-severe psoriasis and 140 controls without psoriasis. Each case was matched by sex, age and residence or job location (neighbors or workmates) with two controls. The investigation was carried out in accordance with the Helsinki Declaration of 1975, as revised in 2013. The research protocol was approved by the local Institutional Review Board. Both patients and control subjects gave written informed consent.
The
Comparison between cases and controls
Altogether, among cases and controls, the proportion of men was 41% and of women 59%. There were no significant differences in age (cases 48.9 ± 17.1 vs. controls 49.2 ± 16.3; Student t = 0.09; df = 208; p = .93), marital status (married, 69% vs. 65%; χ2 = 0.39; df = 1; p = .61) or educational level (university degree 26% vs. 31%; χ2 = 0.73; df = 1; p = .39).
Subjects with psoriasis, as opposed to controls, showed significantly lower levels in all SF-36 subscales and in both physical and mental
Discussion
This study shows that patients with psoriasis differed from subjects without psoriasis in terms of familiy history of psoriasis, current HADS depression score and proportion of subjects with alcohol consumption higher than 20 gr/day. Current HADS anxiety score was significantly higher in the bivariate analysis but disappeared in the multivariate analysis. Moreover, patients had lower levels of QoL (particularly in its mental component).
Among subjects with psoriasis, multivariate analysis showed
Acknowledgements
The authors would like to gratefully acknowledge the collaboration of all participants (patients and non-patients) in this study, and the help of Jean L. Sanders in editing the manuscript.
Declaration of Competing Interest
The authors declare that they have no conflict of interest.
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Current address: Dermatology Service, HLA Inmaculada Hospital, Granada, Spain.