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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 4  |  Issue : 2  |  Page : 159-163

Comorbidity of unipolar depression in patients of vitiligo attending tertiary care hospital


1 Department of Psychiatry, Fakhruddin Ali Ahmed Medical College and Hospital, Barpeta, Assam, India
2 Department of Psychiatry, Central Institute of Psychiatry, Ranchi, Jharkhand, India

Date of Submission29-Feb-2020
Date of Decision11-Apr-2020
Date of Acceptance19-Apr-2020
Date of Web Publication24-Sep-2020

Correspondence Address:
Dr. Pranjal Dey
Central Institute of Psychiatry, Kanke, Ranchi - 834 006, Jharkhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aip.aip_9_20

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  Abstract 


Background: Vitiligo is one of the most common dermatological illnesses with localized depigmentation leading to cosmetic impairment. This also causes impairment of physical, psychological, social functioning of individual which in turn leads to psychiatric morbidities such as anxiety and depression. Aims and Objective: The present hospital based study was carried out to evaluate the presence of depression in patients of vitiligo patients in their different socio demographic variables. In addition, attempts were made to measure the severity of depression in those patients. Material and Methods: This was a hospital based cross-sectional study. Eighty patients of vitiligo with lesions in the exposed body parts were enrolled for the study after their informed consent with purposive sampling method from the Department of Dermatology, in a tertiary care hospital in north eastern part of India and compared them with those of healthy control. Those patients were evaluated by using ICD-10 research criteria and 17 item Hamilton rating scale of depression to diagnose and grade the degree of depression. Data were collected and “Chi Square Test” or “Fisher Exact t Test” was used. Mean value and standard deviation were calculated. All analysis were done using SPSS version 20.0. Results: Co morbidity of depression was significantly higher in vitiligo group (23.75%) in comparison to control group (6.25%). Among the depressed patients 68.43% had mild depression and 31.57% had moderate depression. Depression was inversely proportional to the years of education. Conclusions: These findings indicate the need of early recognition of depression among these patients and their early intervention, which will improve the primary disease process positively.

Keywords: Comorbidity, depression, dermatological illness, vitiligo


How to cite this article:
Baidya S, Dey P, Mohanty R. Comorbidity of unipolar depression in patients of vitiligo attending tertiary care hospital. Ann Indian Psychiatry 2020;4:159-63

How to cite this URL:
Baidya S, Dey P, Mohanty R. Comorbidity of unipolar depression in patients of vitiligo attending tertiary care hospital. Ann Indian Psychiatry [serial online] 2020 [cited 2021 Apr 20];4:159-63. Available from: https://www.anip.co.in/text.asp?2020/4/2/159/295910




  Introduction Top


Vitiligo, a chronic dermatological disorder, is characterized by hypopigmentation or depigmentation of the skin and mucosa. It is an acquired condition resulting from the progressive loss of melanocytes. It is characterized by milky-white sharply demarcated macules. Its prevalence reaches 0.5%–2%, worldwide. Vitiligo equally affects males and females as well as all the different races worldwide.[1],[2] Vitiligo has a varied age of onset, distribution pattern, and progression course. The mean age of onset is about 20 years, and 95% of cases are under the age of 40.[3]

Depigmenting dermatosis, of which vitiligo is one, draws unusual attention to the patient especially when in visible areas of the body. This cosmetic impairment often leads to social and sexual embarrassment, which often perceived as discrimination or rejection.[4] The bewildered person already psychologically disturbed by his skin changes finds himself an object of unnecessary public focus because of this impairment. Vitiligo, as a result of its visibility and chronicity, may cause a significant burden on patients' health-related quality of life leading to many psychiatric disorders such as anxiety and depression. Multiple observational studies have suggested an epidemiological link between vitiligo and psychiatric morbidity such as depression.[5],[6]

The complex interrelationship between mind and skin has been investigated at both molecular and cellular levels. It has been recorded that patients with chronic illness suffer more often from a major depressive illness and vice versa.[7],[8],[9] When it comes to the association between vitiligo and depression, a bidirectional relationship is seen. The neuro-immuno-cutaneous-endocrine model was proposed by O'Sullivan et al. to explain the mind and body relationship. It forms the basis of many inflammatory cutaneous dermatoses like vitiligo that are triggered or exacerbated by psychological factors.[10] Genetic studies have supported the correlation between emotional stress and autoimmune markers in vitiligo patients.[11] Increased levels of heat shock protein 70, which is a stress protein, have found to be increased many autoimmune diseases like vitiligo.[12]

Previous workers evaluated psychiatric symptoms such as depression, anxiety, and alcoholism in patients with vitiligo and had documented a higher prevalence of depression in those patients.[13],[14] Another study in India showed that the prevalence of depression in vitiligo was 20%.[15]

In India and particularly in the northeastern part, a limited number of studies were done regarding this subject. Hence, an attempt has been taken to find the prevalence and severity of unipolar depression in vitiligo patients from this specific sociocultural and geographical background as well as its association with the different sociodemographic variables of these patients.

Aims and objectives

The aim of the study was to assess the prevalence and severity of unipolar depression in patients with vitiligo and also to assess the association of depression with the different sociodemographic variables in these patients.


  Subject and Methods Top


This was a hospital-based cross-sectional study. The sample was drawn with a purposive sampling method from the outpatient department (OPD) of dermatology of a tertiary care hospital, in the northeastern part of India from July 2019 to November 2019.

Mode of selection of cases

Sampling procedure

After obtaining informed consent, eighty vitiligo patients of the age group of 18–60 years of both sexes were included. Only patients affected in their exposed parts of the body were selected for the study. Patients with present or past history of any major physical or dermatological illness other than vitiligo were excluded from the study. Patients with present psychiatric disorder other than unipolar depression and a history of any psychiatric disorder before the onset of vitiligo were also excluded from the study. Patients with bipolar depression and with a family history of any type of bipolar disorder were too excluded from the study. Pregnant and lactating women were excluded as depression is commonly seen in pregnancy and the postpartum period.[16] Patients on systemic steroid, retinoids (isotretinoin, and acitretin), and on substance dependence were excluded from the study.[17]

Operational procedure

After obtaining institutional ethics committee approval, clinically diagnosed vitiligo patients were selected from dermatology OPD with a purposive sampling method as per inclusion and exclusion criteria. After obtaining informed consent, the mental status examination was done. Then the International Classification of Mental and Behavioral Disorders (ICD-10) research criteria[18] along with 17-item Hamilton Rating Scale of Depression (HAM-D)[19] were applied to diagnose the presence of depression and grading them as mild, moderated, severe, and very severe.

Mode of selection of controls

The control group comprised eighty attendants of patients attending dermatology OPD and indoor without any dermatological illness with same exclusion criteria. They were demographically matched with the study group. Controls were subjected to the same tools.

Description of tools

  1. Specially designed pro forma was used to record the sociodemographic data, which included present, family, medical, and drug histories; and also physical examination, as designed by the researchers
  2. Depression was diagnosed and assessed by the International classification of mental and behavioral disorders (ICD-10) tenth revision Research criteria[18]
  3. 17-item HAM-D[19] assessed the severity of depression. Items are scored between 0 and 4 points. A score of <7 has no depression (0-7); mild depression (8-16); moderate depression (17-23); and severe depression (≥24).


Analysis of data

Data were tabulated showing sociodemographic distribution between depressed and nondepressed patients. Chi-square test was administered to compare between the groups. Student's t-test was done to compare the mean values. All the statistical analyses were performed using Microsoft Excel software and the Statistical Package for the Social Sciences (SPSS for Windows, version 20.0. SPSS Inc., Chicago, IL, USA). P < 0.05 was taken as statistically significant in all aspects.


  Results Top


In our study, 23.75% of the patients of vitiligo were depressed, whereas only 6.25% in the control group were depressed (P < 0.004) [Table 1]. The sociodemographic profiles of both depressed and nondepressed patients were compared. Depression was significantly prominent among the school dropout group means up to high school studied people (P = 0.034 i.e. <0.05), whereas other items in sociodemographic profile did not have statistically significant difference [Table 2].
Table 1: Assessment of depression using the International Classification of Disease-10 research criteria in the study and control groups

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Table 2: Association of depression with different sociodemographic variables

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On applying HAM-D in cases fulfilling the ICD-10 criteria for depression, it was found that 68.42% had mild depression, whereas 31.57% had moderate depression [Table 3]. Furthermore, the mean depression score (HAM-D) in cases was significantly higher (8.20 ± 3.99) than the control group (3.26 ± 1.91) (P < 0.0001) [Table 4]. Mild depression was more in case of males (53.84%), whereas moderate depression was more in females (83.33%) [Table 5]. The mean HAM-D score in females (8.60 ± 3.73) was found to be higher than that of the males (7.50 ± 2.72).
Table 3: Distribution of severity of depression among cases and controls

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Table 4: Distribution of mean Hamilton Depression Rating Scale score between the study and control groups

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Table 5: Gender-wise distribution of severity of depression in the study group

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  Discussion Top


In our study, the prevalence of depression diagnosed as per ICD-10 research criteria in vitiligo patients and the control group was 23.75% and 6.25%, respectively, which was statistically significant (P < 0.05). The higher rate of depression in vitiligo as in our study was similar to the previous studies.[14],[20] The reason for a higher rate of depression in vitiligo patients could be due to low self-esteem, embarrassment for self and family, and fear of social rejection which leads to impairment in vocational and social function. This disability resulted from stress (disease-related stress), cosmetic impairment, and social stigma.[15]

Out of the eighty patients with vitiligo, majority of patients (38.8%) were in the age group of 18–27 years. The mean age in the study group was 33.3 years, and in the control group, it was 36 years. This was in concordance with the earlier study.[21] Regarding gender, we found that there is a high incidence of vitiligo cases in females. In our study, 60% of the cases are female [Table 2] and 40% were male. Our study was in concordance with other studies.[14],[21],[22] While comparing the prevalence of depression between genders, it was found that 57.89% of females and 42.10% of males were depressed. Hence, the females were more depressed compared to males. The mean HAM-D score in females (8.60 ± 3.73) was found to be higher than that of males (7.50 ± 2.72). Our findings were in accordance with previous studies.[13],[14],[22]

In our study, we have found that highest percentage of our patients were married, i.e. 71.25%, and they were more depressed (63.42%) compared to the single patients (36.57%). Married patients, particularly females, might face more stigmatization and poor social support. Furthermore, discrimination toward females might be the reason for higher depression, however difference in our study was not statistically significant.[13],[14]

Our study showed that 16 out of 19 depressed patients were either illiterate or studied up to high school level, i.e. school dropout who studied up to high school level and illiterate patients. Only 3 out of 19 patients had studied up to higher secondary or graduate level. We found a significant association between educational status and depression (P < 0.05). Thus, it was found that depression had an inverse relationship with the number of years of education. Our study was in accordance with previous studies.[13],[21] This might be due to the fact that with increasing education level, people can understand the nature of the disease and can cope better with the stress and anxiety and also can react in a more mature way to the social stigmatization.[13] Regarding occupation, we found that housewives were suffering more from depression (31.57%) compared to any other groups. This was also in accordance with our earlier finding that married females with vitiligo suffer more from depression.[13]

After applying HAM-D on these 19 patients who were depressed as per ICD 10 criteria, we found that 13 cases (68.42%) were having mild depression, whereas 6 patients (31.57%) had moderate depression. No patient was having severe depression [Table 3]. In the control group, only five participants who were depressed were having mild depression. Hence, we found that the severity of depression was also more in vitiligo patients than healthy controls. Furthermore, the mean depression score (HAM-D) in the study group was significantly higher than (8.20 ± 3.99) the control group (3.26 ± 1.91). Our finding was in accordance with previous studies [Table 4].[13],[21],[23] When comparing the severity of depression between males and females, it was found that 83.33% of females had moderate depression compared to 16.66% of males. Hence, the severity of depression was also more in females compared to males [Table 5].[14]

The limitations of the study were small sample size, and the patients were evaluated only once. Larger sample size and further evaluation would have been helpful to elicit the presence of depression in the course of illness. In addition, the study did not include the duration of vitiligo and their association with depression. Furthermore, this study did not take measurement of area involved in the body as only patients with vitiligo in their exposed body parts were included.


  Conclusion Top


Depression was found to be associated with vitiligo at a significant rate and with mild-to-moderate grades of severity. Depression was more common in younger age, female gender, married patients, housewives, and people with lower education level. Thus, this association of depression with vitiligo needs early diagnosis and intervention which will help in better treatment of the vitiligo patients. This will improve the prognosis and quality of life of these patients.

Thus, vitiligo patients should be assessed with more holistic approach. We should account both physical and psychological aspects of these patients, and there should be good collaboration between dermatologists and psychiatrists to treat such patients for better prognosis of the patients.

Acknowledgment

The author would like to thank all doctors of the Department of Dermatology, Fakhruddin Ali Ahmed Medical College and Hospital, Assam.

Ethical statement

This study was approved by the institutional ethical committee with reference number FAAMC&H/IEC/498/2019/4663 obtained on July 26, 2019.

Declaration of patient consent

The patient consent statement was obtained from each patient as per the institutional ethics committee approval along with consent obtained for participation in the study and publication of the scientific results/clinical information without revealing their identity, name, or initials. The patient was aware that though confidentiality would be maintained anonymity cannot be guaranteed

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Olasode OA. Psychosocial problems in patients with vitiligo in Nigeria. Sudan J Dermatol 2007;5:51-8.  Back to cited text no. 1
    
2.
Silverberg NB. The epidemiology of vitiligo. Curr Derm Rep 2015;4:36-43.  Back to cited text no. 2
    
3.
Lilly E, Lu PD, Borovicka JH, Victorson D, Kwasny MJ, West DP, et al. Development and validation of a vitiligo-specific quality-of-life instrument (VitiQoL). J Am Acad Dermatol 2013;69:e11-8.  Back to cited text no. 3
    
4.
Salzer BA, Schallreuter KU. Investigation of the personality structure in patients with vitiligo and a possible association with impaired catecholamine metabolism. Dermatology 1995;190:109-15.  Back to cited text no. 4
    
5.
Kent G, al-Abadie M. Factors affecting responses on dermatology life quality index items among vitiligo sufferers. Clin Exp Dermatol 1996;21:330-3.  Back to cited text no. 5
    
6.
Picardi A, Abeni D, Melchi CF, Puddu P, Pasquini P. Psychiatric morbidity in dermatological outpatients: An issue to be recognized. Br J Dermatol 2000;143:983-91.  Back to cited text no. 6
    
7.
Papadopoulos L, Bor R, Legg C, Hawk JL. Impact of life events on the onset of vitiligo in adults: Preliminary evidence for a psychological dimension in aetiology. Clin Exp Dermatol 1998;23:243-8.  Back to cited text no. 7
    
8.
Katon WJ. Epidemiology and treatment of depression in patients with chronic medical illness. Dialogues Clin Neurosci 2011;13:7-23.  Back to cited text no. 8
    
9.
Johnson TJ, Basu S, Pisani BA, Avery EF, Mendez JC, Calvin JE Jr., et al. Depression predicts repeated heart failure hospitalizations. J Card Fail 2012;18:246-52.  Back to cited text no. 9
    
10.
O'Sullivan RL, Lipper G, Lerner EA. The neuro-immuno-cutaneous-endocrine network: Relationship of mind and skin. Arch Dermatol 1998;134:1431-5.  Back to cited text no. 10
    
11.
Jin Y, Birlea SA, Fain PR, Gowan K, Riccardi SL, Holland PJ, et al. Variant of TYR and autoimmunity susceptibility loci in generalized vitiligo. N Engl J Med 2010;362:1686-97.  Back to cited text no. 11
    
12.
Doss RW, El-Rifaie AA, Abdel-Wahab AM, Gohary YM, Rashed LA. Heat shock protein-70 expression in vitiligo and its relation to the disease activity. Indian J Dermatol 2016;61:408-12.  Back to cited text no. 12
[PUBMED]  [Full text]  
13.
Saleki M, Yazdanfar A. Prevalence and frequency of depression in patients with vitiligo. Int J Curr Microbiol Appl Sci 2015;4:437-45.  Back to cited text no. 13
    
14.
Sangma LN, Nath J, Bhagabati D. Quality of life and psychological morbidity in vitiligo patients: A study in a teaching hospital from North-East India. Indian J Dermatol 2015;60:142-6.  Back to cited text no. 14
[PUBMED]  [Full text]  
15.
Mattoo SK, Handa S, Kaur I, Gupta N, Malhotra R. Psychiatric morbidity in vitiligo and psoriasis: A comparative study from India. J Dermatol 2001;28:424-32.  Back to cited text no. 15
    
16.
Meltzer-Brody S. New insights into perinatal depression: Pathogenesis and treatment during pregnancy and postpartum. Dialogues Clin Neurosci 2011;13:89-100.  Back to cited text no. 16
    
17.
Duke EE, Guenther L. Psychiatric reactions to retinoids. Can J Dermatol 1993;5:467.  Back to cited text no. 17
    
18.
World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. Geneva: World Health Organization; 1992.  Back to cited text no. 18
    
19.
Zimmerman M, Martinez JH, Young D, Chelminski I, Dalrymple K. Severity classification on the Hamilton Depression Rating Scale. J Affect Disord 2013;150:384-8.  Back to cited text no. 19
    
20.
Ramakrishna P, Rajni T. Psychiatric morbidity and quality of life in vitiligo patients. Indian J Psychol Med 2014;36:302-3.  Back to cited text no. 20
[PUBMED]  [Full text]  
21.
Karia S, Sousa AD, Shah N, Sonavane S, Bharati A. Psychological morbidity in vitiligo-a case control study. Pigment Dis 2015;2:170.  Back to cited text no. 21
    
22.
Kota RS, Vora RV, Varma JR, Kota SK, Patel TM, Ganjiwale J. Study on assessment of quality of life and depression in patients of vitiligo. Indian Dermatol Online J 2019;10:153-7.  Back to cited text no. 22
[PUBMED]  [Full text]  
23.
Cupertino F, Niemeyer-Corbellini JP, Ramos ES. Psychosomatic aspects of vitiligo. Clin Dermatol 2017;35:292-7.  Back to cited text no. 23
    



 
 
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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