A Cross-sectional study of quality of life and psychiatric morbidity in patients with Acne Vulgaris

Journal:
July-December 2008 Volume 5(2)

Original Article

Author(s):
S. Srivastava, Manjeet S. Bhatia, P. Das, S.N. Bhattacharya
Page No:
86

ABSTRACT

Objective: The objectives of the study were: (i) To assess the psychiatric morbidity and quality of life of patients with acne vulgaris.(ii) to evaluate the relationship between acne severity, anxiety, depression and disease specific quality of life in patients with acne vulgaris.
Design: Cross sectional study.
Place and duration of study: The study was conducted in the psychiatry outpatient department of a teaching medical institution in New Delhi, India during January to September 2006.
Subjects and Methods: Forty six patients of Acne vulgaris were studied in dermatology department of general hospital jointly by psychiatrists and dermatologists. Acne severity was graded by dermatologists using Global Acne Grading System, Psychiatric morbidity and Quality of life were assessed by psychiatrists. All patients were administered a General Health Questionnaire (GHQ) (12 item), a 17 item HAM-D Scale, a Hamilton Anxiety Rating Scale (HAM-A) and Dermatology specific quality of life (DSQL) Scale.
Results: Showed existence of clinically significant depression in 39.1% and anxiety in 4.35%. There were statistically significant differences between males and females with respect to GHQ but not with HAM-D and HAM-A. There was positive correlation between mean GHQ scores and perceived severity (r =0.327, p =0.02). We found no correlation between acne grading and HAM-D, HAM-A or DSQL.
Conclusion: The present study has clearly depicted higher psychiatric morbidity in patients with acne vulgaris. We found no correlation between disease severity, anxiety, depression and quality of life in patients with acne vulgaris. Patients’ perception of their disease might be important consideration in the evaluation and treatment of acne vulgaris.

INTRODUCTION

Acne vulgaris items is commonly referred to as acne, is a chronic inflammatory disorder of the pilosebaceous unit. Acne vulgaris affects atleast 85% of adolescents and young adults1,2. Acne can probably be exacerbated by psychological stress3. The influence of acne on body image is believed to be the main factor associated with psychological morbidity. As the face is almost always site of involvement by acne, its presence can alter one’s perception of body image.
Psychiatric disorders can develop secondary to acne vulgaris4-8. Clinical depression, social phobia and anxiety disorders have been associated with acne. Earlier studies have suggested that acne may be associated with decreased self - esteem / self - confidence, interpersonal difficulties, unemployment and increased prevalence of depression and anxiety. Cotterill and Cunliffe6 have described sixteen cases of completed suicide among dermatology patients, seven of whom had acne. The impact of acne upon the quality of life is a very important component of assuring its overall morbidity and often is the primary consideration in deciding whether or not to institute therapy. Mallon et al7 reported that acne patients reported levels of social, psychological and emotional problems that were as great as those reported by patients with bronchial asthma, epilepsy, diabetes, back pain or arthritis.

SUBJECTS AND METHODS

Sample: The cross-sectional study consisted of 46 new, consecutive patients of acne vulgaris reporting to the dermatology out patients department of a tertiary care teaching hospital. The acne severity was graded by Dermatologists using Global Acne Grading Systems (GAGS)8.
Inclusion Criteria:
(1) All patients of acne vulgaris from 14-30 years of age.
(2) Patients who gave informed consent.
Exclusion Criteria:
(1) All patients with comorbid skin conditions like Psoriasis, Lichen planus were excluded.
(2) All patients with chronic medical, surgical conditions were excluded from the study.
(3) All patients with organic brain syndrome, chronic mental illness were excluded from the study.

Informed consent was taken from the patient for their inclusion into the study. The sociodemographic profile of the sample was noted on the performa specially designed for the purpose of the study. Relevant case history including Psychiatric and dermatological history was also noted on the performa.

Assessment of Psychiatric morbidity

1. 12-item General Health Questionnaire (GHQ)9.
2. 17- item Hamilton Rating Scale for Depression (HAM-D)10.
3. Hamilton Rating Scale for Anxiety (HAM-A)11.

Assessment of Quality of Life

Dermatology – Specific Quality of Life (DSQL) Instrument12:
In this instrument, QOL items form 5 general groupings
(I) Physical symptoms and somatic complaints.
(II) Activities of daily living (including functional status, personal care and grooming).
(III) Social activities and functioning.
(IV) Experiences at work or school or both.
(V) Self-perception. DSQL is intended as a self administered QOL profile which can be completed in 15 minutes or less. It assesses bothersome symptoms, quality of life and perceived severity in patients of acne vulgaris on a global item scale from 1 to 10. The aims of this study were to assess psychiatric morbidity and quality of life in patients of acne vulgaris and also to evaluate the relationship between acne severity, anxiety, depression and disease specific quality of life in patients with acne vulgaris. Apart from Psychiatric morbidity and Quality of Life of patients, their Socio-Demographic Profile was also assessed.

Statistical Analysis

Data were analyzed by using a statistical package for the computer. Scores obtained from the scales were compared by using the t-Test, correlations were examined by Pearson’s Correlation Analysis.

RESULTS

The study group consisted of 26 males and 20 females. No patient dropped out from the study. 52% of patients had their age group in the range of 14-18 years which is representative the clinical population of acne vulgaris. 54% of total patients were students (Table1).



Mean GHQ of the study sample was 3.56. The number of patients with clinically significant depression was eighteen and mild, moderate and severe depression was noted in six patients each respectively, clinically significant anxiety symptoms were noted in two patients. A score of 14 has been suggested as threshold for clinically significant anxiety in Hamilton Rating Scale for Anxiety (HAM-A). A score of 8-13 for mild depression, 14-18 for moderate depression, >18 for severe depression has been suggested for 17- item Hamilton Rating Scale for Depression (HAM-D) (Table 2).



When the male and female patients of acne were grouped according to HAM-D, HAM-A scores and GHQ, statistically significant differences were observed between males and females with respect to GHQ, though no such differences were observed with respect to HAM-D and HAM-A (Table 3).



Quality of Life had negative correlation with GHQ (r=-0.412,p=0.004) and perceived severity (r=0.327, p=0.02). Positive correlation was found between mean GHQ scores and perceived severity (r=0.327, p=0.02). No relationship were found between acne Grading and HAM-D, HAM-A scores and DSQL items.(Bothersome symptoms, Quality of life and perceived severity).

DISCUSSION

Quality of life(QOL) has been defined as a useful measure which assesses the functioning, well-being, and life satisfaction of an individual. QOL refers to , not only the subjective sense of well-being but also objective indicators such as health status and external life situations.QOL is emerging as one of the recent trends in assessing treatment response from the patient’s point of view.
The present study has reiterated the fact that the patient’s perception of acne might be an important indicator for the treatment. Our study found out that patient’s perception of severity did correlate with psychiatric morbidity. Interestingly, we found no correlation was seen between clinician rated acne severity and perceived severity as noted on DSQL.
We reported no correlation between acne vulgaris severity, DSQL, HAM-D, HAM-A, GHQ . Similarly, the previous study by Aktan et al. of 2657 high-school students, also reported no correlation between acne severity and HAM-D or HAM-A scores13.
The patients’ perception of acne might include factors other than the size and number of lesions. Patients’ perception of their disease might be important consideration in the evaluation and treatment of acne because facial acne is highly visible and carries a certain degree of social negativity, it has been hypothesized that even mild acne can decrease a person’s self confidence, body image, willingness to be seen in public and social interactions14. Martin et al15 observed that quality of life scores correlated more strongly with patient reported severity than with physician reported severity.
Dermatology outpatients had a higher prevalence of psychiatric disorder than the general population. Our findings are similar to previous studies which also reported higher depression and anxiety scores in patients of acne. The previous studies also made comparisons with other dermatological conditions13,16-19.
Gupta and Gupta5 examined depression and suicidal ideation in dermatology patients and found that patients with mild to moderate clinical significant gender differences were seen on mean scores of GHQ. This was also reported by Hughes et al20 and Rubinow et al21 .We also found that female patients of acne had significantly higher mean scores of GHQ. We found no gender differences in HAM - D, HAM – A scores. Previous study by Yazici et al. also found no gender differences in acne quality of life scale and hospital anxiety and depression scale16.
The major strengths of the study is sound methodology including the use of a disease specific measure for the assessment of QOL of patients with acne vulgaris, collaborative work of psychiatrist and dermatologist in throwing light into this relatively recent area for research which has direct treatment implications.
The major limitation for the study were absence of a control group, larger sample size, longitudinal follow up of the study sample both before and after treatment, the use of a generic QOL instrument which makes comparison with other disease group easier.
Future work in the area needs to use a control group, bigger sample size and longitudinal follow up of acne vulgaris patients.

CONCLUSIONS

Some conclusions can be drawn from this study. First, patients with acne vulgaris has clearly depicted higher psychiatric morbidity and positive correlation between GHQ scores and perceived severity. Hence, treatment needs to be addressed both the primary skin condition and psychiatric manifestations. Second, acne negatively affects quality of life. We could not find any relationship between acne severity, anxiety, depression and disease specific quality of life in patients with acne vulgaris. Third, patient’s perception of the disease has emerged as an important factor which is associated with increase in anxiety and depressive symptoms.

REFERENCES

1. Weiss JS. Current opinions for the topical treatment of acne vulgaris. Paediatr Dermatol 1997;14;480-88.
2. Knowchuck RP. Managind acne in adolescents. Pediatr Clin N Am 2000; 47:841-57.
3. Lasek RJ, Chren MM. Acne Vulgaris and the quality of life of adult dermatology patients. Arch Dermatol 1998;134:454-8.
4. Kellet SC, Gawkrodger DJ. The Psychological and emotional impact of Acne and the effect of treatment with Isotretinoin. Br J Dermatol 1999;140:273-82.
5. Gupta MA, Gupta AK. Depression and suicidal ideation in dermatology patients with acne, alopecia areata, atopic dermatitis and psoriasis. Br J Dermatol 1998; 139:846-50.
6. Cotterill JA, Cunliffe WJ. Suicide in dermatological patients. Br J Dermatol 1997;137:246-50.
7. Mallon EM, Newton JN, Klassen A, Stewart-Brown SL, Ryan TJ, Finlay AY. The quality of life in acne: a comparison with general medical conditions using generic questionnaires. Br J Dermatol 1999;140:672-6.
8. Doshi A, Zaheer A, Stiller MJ. A Comparison of current acne grading systems and proposal of a novel system. Int J Dermatol 1997; 36: 416-8.
9. Goldberg DP. Rating Scale for General Health Questionnaire. (GHQ-12). Windsor: NFER-Nelson, 1992.
10. Hamilton M, Rating scale for Depression. J Neurol Neurosurg Psychiatr 1960; 23:56-62.
11. Hamilton M, Diagnosis and Rating of Anxiety. Studies of Anxiety, Br J Psychiatr Spec Publication 1969;3: 76-9. 12. Anderson RT, Rajgopalan U, Salem W. Development and Validation of a quality of life instrument for cutaneous disease. J Am Acad Dermatol 1997;37:41-50.
13. Aktan S, Ozman E, Sanli B. Anxiety, Depression and nature of acne vulgaris in adolescents. Int J Dermatol 2000 : 39 : 354-7.
14. Koo JY, Smith LL. Psychological Aspects of Acne. Pediatr Dermatol 1991;8:185-8.
15. Martin AR, Lookingbill DP, Botek A, Light J, Thiboutot D, Girman CJ. Health related quality of UJC among patients with facial ache-assessment of a new specific questionnaire. Clin Exp Dermatol 2001; 26; 380-5.
16. Yazici K, Baz K, Buturak V. Disease specific quality of life is associated with anxiety and depression in patients with acne. J Eur Acad Dermatol Venerol 2004; 18: 435-9.
17. Vander-Meren, Van der Schaar W W, Vander Hub CM. The Psychological impact of severe acne. Cutis 1985 ; 36: 84-6.
18. Wu SF, Kinder, BN, Trunnell TN, Pulton JE, Role of anxiety and anger in acne patients: a relationship with the severity of the disorder. J Am Acad Dermatol 1988 :18 : 325-32.
19. Koo JY. The psychosocial impact of acne : patients perceptions. Am Acad Dermatol 1995; 32: 26-30.
20. Hughes JE, Barrelough BM, Hamblin White JE, Psychiatric Symptoms in dermatology patients. Br J Psychiatry 1983;143:51-4.
21. Rubinow DR, Peck GL, Squillace KM, Gantt GG. Reduced anxiety and depression in cystic Acne and patients after successful treatment with oral Isotretinoin. J Am Acad Dermatol 1987;17:25-32.