Major depressive disorder (American Psychiatric Association, 1994) is one of the most commonly encountered psychiatric disorders in dermatology (Gupta &
Gupta, 1996; Woodruff et al., 1997). Major depressive disorder (Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition (DSM-IV)) (American Psychiatric Association, 1994) is characterised by one or more major depressive episodes. Depression is a recurrent disorder and 50-60% of patients who have experienced one major depressive episode are expected to have a second episode. In about two-thirds of cases the major depressive episode remits completely, and in one-third of the syndrome remits only partially or not at all. Chronic medical conditions (such as chronic recurrent skin disorders) are a known risk factor for more persistent episodes of depression.
A major depressive episode (American Psychiatric Association, 1994) is associated with at least 2 weeks of depressed mood, or loss of interest or pleasure in activities that the patient previously found pleasurable or interesting. In children the depression often manifests as dysphoria and irritability rather than frank depression, and in some adults the most prominent affect may be one of anxiety and agitation rather than sadness and depression. It is important not to misdiagnose these symptoms as being representative of a primary anxiety disorder. The mood changes in depression are accompanied by four or more symptoms that represent a change from the previous functioning of the patient including psychomotor agitation or retardation; difficulties with initiating and maintaining sleep or hypersomnia nearly every day; decrease or increase in appetite; fatigue or loss of energy; feelings of worthlessness, or excessive or inappropriate guilt; indecisiveness or decreased concentrating ability; and recurrent thoughts of death with or without suicidal ideation. Some of these symptoms such as sleep difficulties can complicate other dermatological symptoms like pruritus and difficulties with concentration may interfere with adherence to prescribed treatments. The psychomotor agitation experienced by some patients can be associated with hair pulling, rubbing, scratching or picking of the skin.
Depressive disease is a clinically important feature of psoriasis (Russo et al., 2004). Onset of psoriasis prior to age 40 years has been associated with greater difficulties with the expression of anger (Gupta et al., 1996), a personality trait which may predispose the patient to develop depression and be more vulnerable to psychosocial stressors. Psoriasis-related stress has been associated with greater psychiatric morbidity (Fortune et al., 1997) as patients who feel stigmatised in social situations have higher depression scores. Adult psoriasis patients who experienced greater deprivation of social touch as a result of their psoriasis had higher depression scores than patients who did not feel stigmatised (Gupta et al., 1998). Pruritus, which is reported to be one of the most bothersome features of psoriasis, has been associated with suicide. In psoriasis, severity of pruritus correlates directly with the severity of depressive symptoms (Gupta et al., 1988; Gupta et al., 1994). Improvement in pruritus has been associated with an improvement in depression scores among psoriasis patients (Gupta et al., 1988) and the severity of the skin disorder correlates directly with the severity of depression and frequency of suicidal ideation (Gupta et al., 1993). In a cross-sectional survey, a 2.5% prevalence of suicidal ideation was observed among less severely affected psoriasis outpatients in contrast to a 7.2% suicidal ideation among the more severely affected inpatients with psoriasis (Gupta & Gupta, 1998).
The psychiatric morbidity in acne (Gupta & Gupta, 2001b) is often the most important index of disease severity and often the most important factor in deciding whether or not to institute treatments for the acne, especially in the case of mild-to-moderate disease. The psychiatric morbidity in acne can be severe and comparable to the disability resulting from other chronic disorders such as diabetes and asthma (Mallon et al., 1999). In contrast to psoriasis, the severity of acne does not necessarily correlate with the severity of depression (Aktan et al., 2000; Yazici et al., 2004), as even mild-to-moderate acne has been associated with depression, suicidal ideation (Gupta & Gupta, 1998) and completed suicide (Cotterill & Cunliffe, 1997). Adolescent acne patients who experience problems at school or work and blame it mainly on their acne may be clinically depressed (Gupta et al., 1998). Treatment of both mild-to-moderate non-cystic acne (Gupta et al., 1990) and the treatment of cystic acne with isotretinoin have been associated with an improvement in psychiatric morbidity, including depression (Rubinow et al., 1987). In a cross-sectional survey, a 5.6% prevalence of suicidal ideation was observed among patients with mild-to-moderate non-cystic facial acne (Gupta & Gupta, 1998). The peak incidence of acne is during mid-adolescence, a life stage that is also associated with a high incidence of depressive disease, and body image disorders. This may be one reason why the prevalence of psychiatric morbidity, including depressive disease in even mild-to-moderate acne, is relatively high in some instances.
The association between acne and depression is further confounded by reports of a possible link between isotretinoin, depression, suicidal ideation, suicide attempts and suicide (Lamberg, 1998; Gupta & Gupta, 2001b; Hull & D'Arcy, 2003). A large-scale epidemiological study (Jick et al., 2000) that examined medical databases failed to demonstrate an increased prevalence of depression, suicide or other psychiatric disorders among acne patients who were using isotretinoin versus those who were using other antibiotics. However, in individual case studies, the relation between depression and isotretinoin was confirmed by re-challenging the patient with isotretinoin (Scheinman et al., 1990). A past history of depressive disease does not appear to increase the risk of developing depression when the patient is challenged with isotretinoin, and patients who develop depression with isotretinoin may have previously used the drug with no adverse psychiatric effects (Scheinman et al., 1990). The literature suggests that the association between depression and isotretinoin is a sporadic and idiosyncratic phenomenon.
Depression is encountered in a wide range of other dermatological disorders (Panconesi, 1984; Gupta & Gupta, 1996; Woodruff et al., 1997; Picardi et al., 2000; Gupta & Gupta, 2003; Picardi et al., 2004; Sampogna et al., 2004). Depression may modulate pruritus perception in other pruritic skin disorders such as atopic dermatitis and chronic idiopathic urticaria in addition to psoriasis (Gupta et al., 1994). Higher anxiety and depressive symptoms (Ullman et al., 1977; Hashiro & Okumura, 1998; Kiebert et al., 2002; Zachariae et al., 2004) have been reported in patients with atopic dermatitis. The anxiety may be the feature of an underlying depressive illness in some of these patients. Chronic intractable eczema during childhood may be a sign of a disturbed parent/child relationship (Koblenzer & Koblenzer, 1988); however, a major depressive disorder should be ruled out before a disturbance in the family dynamics is implicated (Allen, 1989). Chronic idiopathic urticaria has been associated with a wide range of psychopathology (Rees, 1957; Czubalski & Rudzki, 1977; Juhlin, 1981; Sheehan-Dare, 1990; Badoux & Levy, 1994) and frequently associated with difficulties with the expression of anger and increased hostility, personality traits which may both predispose the patient to develop depression. Alopecia areata has been associated with depressive disease; however, this association is not a consistent finding across studies. In a survey of 294 alopecia areata patients, the prevalence of major depression was 8.8% (Koo et al., 1994). Another survey of 31 patients with alopecia areata reported a 74% lifetime prevalence of one or more psychiatric disorders with 39% prevalence of major depression (Colon et al., 1991). A study of 32 patients with alopecia areata reported a 66% prevalence of psychiatric comorbidity including generalised anxiety disorder, adjustment disorder and major depressive episodes (Ruiz-Doblado et al., 2003). However, a study of 52 patients with alopecia areata found no significant difference in psychological morbidity between patients and non-clinical controls with no alopecia (Gulec et al., 2004). In this study, the patients with stress-reactive alopecia areata had experienced more major life events (Gulec et al., 2004), supporting the possible role of stress. In another study, patients whose alopecia areata was more reactive to stress also had higher depression scores, suggesting that comorbid depression may render the condition more stress reactive (Gupta et al., 1997).
Some depressed patients may complain of cutaneous dysaesthesias such as pain and burning sensations, for which no physical basis can be identified. These symptoms may represent 'masked depression' or 'depressive equivalents' as some patients lack psychological insight and may deny an underlying depressive disorder (Gupta & Gupta, 1996). Some other patients with primary depressive disease may become preoccupied with relatively minor dermatological problems such as minimal hair loss. More severe depressive disease (American Psychiatric Association, 1994) can present with mood-congruent delusions; for example, of having an incurable skin disease or delusions that their skin is rotting or emitting a foul odour.
The vegetative disturbances associated with depressive disease are a central feature of the syndrome (American Psychiatric Association, 1994). It is well recognised that depressive disorder is accompanied by measurable alterations of circadian rhythms for example, cortisol secretion and the sleep-wake cycle. A commonly encountered clinical feature of circadian rhythm disturbance is the worsening of mood, energy and psychomotor activity early in the day with an improvement during the latter part of the day. Another disturbance of biological rhythm encountered in mood disorders is seasonal worsening of depressive symptoms in some patients, especially during the fall and winter months. The depression-related somatic concerns related to the integumentary system, or symptoms which are related to depression such as pruritus can therefore also manifest a diurnal or seasonal pattern.
Suicide, defined as intentional self-inflicted death, is a central feature of depressive disease and 50% of all persons who commit suicide are depressed (Sadock & Sadock, 2001); 15% of depressed individuals eventually kill themselves and the suicide rate in the USA is 12 per 100,000 (Sadock & Sadock, 2001). Among men the suicide rate peaks after age 45 years and among women after age 65 years (Sadock & Sadock, 2001). After age 75 years, the suicide rate rises in both sexes. Women attempt suicide four times more frequently than men; however, men commit suicide three times more often than women. Currently, there is a rapid rise in suicide rates among males between 15 and 24 years (Sadock & Sadock, 2001). Suicidal behaviour in the adolescent acne patient therefore may not be solely due to the psychosocial impact of the acne.
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