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|Year : 2018
: 60 | Issue : 3 | Page
|Cross-sectional study of psychiatric morbidity in patients with melasma
Sharmishtha Shailesh Deshpande1, Swapna S Khatu2, Geeta S Pardeshi3, Neeta R Gokhale2
1 Department of Psychiatry, Smt. Kashibai Navale Medical College and General Hospital, Pune, Maharashtra, India
2 Department of Dermatology, Smt. Kashibai Navale Medical College and General Hospital, Pune, Maharashtra, India
3 Department of Community Medicine, Vardhaman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
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|Date of Web Publication||16-Oct-2018|
| Abstract|| |
Context: Patients with dermatological problems have higher prevalence of psychiatric illnesses than the general population. Melasma, hyperpigmentation of skin over sun-exposed areas, has bidirectional cause-effect relationship with depression and stress through psycho-neuro-endocrine pathways.
Aims: The aim of this study is to study the psychiatric morbidity and perceived stress in patients with melasma and statistically compare objective study parameters with those without melasma.
Settings and Design: This cross-sectional descriptive study was carried out in Tertiary hospital in urban setting, jointly by psychiatrist and dermatologist.
Methods and Materials: The study involved 50 consecutive patients with melasma and 30 relatives of patients coming to dermatology clinic not having any skin disorder. Cases were assessed by psychiatrist as per the International Classification of Diseases-10 Diagnostic Criteria for Research, Cohen's 4 item perceived stress scale, Disability Assessment Scale 2.0 by WHO and Hospital Anxiety Depression Scale (HADS) and Dermatologist calculated melasma area severity index score (MASI).
Results: Majority patients were females (88%) in the reproductive age group. The most common psychiatric morbidity seen in 42% cases was major depressive disorder. Adjustment disorder (26%) was the second most common diagnosis. Nonparametric analysis using Mann–Whitney U test revealed significantly more perceived stress (P = 0.001), more disability (P = 0.000) and anxiety-depression on HADS (P = 0.0 16) in cases than in their relatives.
Limitations: This was a hospital-based study and thus melasma patients in the community are not represented. Small sample size, less number of controls, lack of structured diagnostic interview are other limitations of this study.
Conclusions: There is high psychiatric comorbidity (76%) of depressive and stress disorders, higher functional disability and perceived stress in patients with melasma compared to controls.
Keywords: Depression, melasma and psychiatric morbidity, perceived stress in melasma, stress, and melasma
|How to cite this article:|
Deshpande SS, Khatu SS, Pardeshi GS, Gokhale NR. Cross-sectional study of psychiatric morbidity in patients with melasma. Indian J Psychiatry 2018;60:324-8
| Introduction|| |
Patients attending skin clinic are known to have more prevalence of psychiatric disorders than in the general population.,, About one-third of them suffer from various psychiatric disorders. Research about psychocutaneous disorders stresses on liaison between psychiatrist and dermatologist, for successful management of conditions such as depression, anxiety, and suicidal ideation in psoriasis, vitiligo, acne, etc., Pigmentary disorder melasma is also a cause of cosmetic handicap. However, it has not been considered as psychocutaneous disorder.
In melasma, symmetric, irregular brown patches of hyperpigmentation over photoexposed areas are seen more commonly in females although involvement in males is observed in 10% of cases. It is common cutaneous disorder accounting for 0.025%–4% of the patients seen in dermatology outpatient department (OPD) and it is most common pigment disorder among Indians. Its management is challenging because it is a chronic condition with common recurrences and is often difficult to treat,, provoking significant emotional and psychological effects in affected patients.
The exact etiology of melasma remains to be clearly defined, ultraviolet radiation, hormonal therapy, genetic background, pregnancy, thyroid dysfunction, cosmetics, and medications containing phototoxic agents are possible causes. Melanocytes per se are responsive to stress hormones. Locally excessive melanin pigment in the form of increased melanin granules in melanocytes is usually secondary to excessive melanocyte-stimulating hormones (MSH)/adrenocorticotropic hormone (ACTH) levels. Menstrual cycle changes are common in these patients, as estrogen and progesterone are implicated in melanogenesis as per earlier research.
Inter-relation between onset of melasma with stress is not studied, though in animal studies increased MSH secretion is described as local response to stress.
Aim of this study was to assess psychiatric morbidity and perceived stress in patients with melasma and study its impact on functioning of the individuals.
| Materials and Methods|| |
This was a liaison study with dermatology department conducted in a tertiary level hospital located in an urban area catering for patients from urban, semi-urban, and adjoining rural areas. Institutional Ethics Committee permission was obtained, and informed consent was taken from the patient.
The data were collected over a period of 9 months from pigmentary disorders clinic in dermatology OPD by the authors (SD, SK). The sample size was not predetermined. Fifty consecutive patients of melasma between the age group 18 and 65 years could be included in the study. Two patients with melasma were reluctant and did not participate. Those with vitiligo or any other visible skin condition were excluded. Those with a history of significant sun exposure/pregnancy/using of oral contraceptive pills were excluded as these could be confounding factors exacerbating melasma and/or depression.
Patients with clinically significant intellectual/cognitive impairment could not be included. In all, five patients were not included out of 55 as per these exclusion criteria.
Thirty individuals taken as controls were also interviewed during this study. Relatives of patients coming to dermatology clinic, not having melasma or any other skin condition were taken as controls in required age and gender proportion.
Semi-structured proforma along with Cohen's 4 item Perceived Stress Scale (PSS-4) and Hospital Anxiety Depression Scale (HADS), Disability Assessment Scale 2.0 by WHO (WHO DAS) were administered by psychiatrist. Dermatologist calculated melasma area severity index (MASI) score. The patients were interviewed by psychiatrist to establish clinical diagnosis as per International Statistical Classification of Diseases–10 mental and Behavioral disorders diagnostic criteria for research (WHO).
Perceived stress in the patient was assessed using PSS – 4 scale. This is 4-item interviewer-administered questionnaire with established reliability and validity. We assessed the extent of stress as perceived by the individual.
We assessed anxiety and depression in the patients and controls using HADS which is a well-known, reliable, and validated 12-item scale to assess the anxiety and depressive features in the clinical population.
The severity of facial melasma was estimated using the MASI score. It is the most used tool for assessing the severity of melasma., The score ranges from 0 to 48.
The background characteristics between cases and controls were compared using Fisher's exact test. As the scores did not follow a normal distribution, they were compared using Mann-Whitney U-test. Analysis was carried out using Statistical Package for the Social Sciences (SPSS) (IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0, IBM Corp., Armonk, NY, USA).
| Results|| |
A total of 50 consecutive patients with melasma were enrolled in the study. Most of them were females (88%), married (86%), belonged to the reproductive age group (21–40 years) (90%) and educated at least up to secondary school level (100%). There was no significant difference in cases and controls as regards to their age, gender, education or marital status [Table 1].
Although duration of melasma was variable, it was persistent for more than 6 months in 86%. In some patients, the hyperpigmentation was stable whereas, in others, it went on increasing in area or darkening.
WHO DAS, PSS, and HADS scores were significantly higher in cases than the controls indicating worse functioning, more perceived stress and higher levels of anxiety and depression in patients with melasma than those without it [Table 2].
|Table 2: Comparison of World Health Organization Disability Assessment Scale, Perceived stress scale and Hospital Anxiety and Depression Scale scores in cases and controls|
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Number of cases of depressive disorders were 21 (42%) among cases and 6 (20%) among controls. As perceived stress is significantly more in cases, which is reflected from score on PSS scale, number of patients with stress disorders is also much more in cases than controls [Table 3].
Major depressive disorder and adjustment disorder were significantly more prevalent in melasma patients compared to controls.
We tried to assess if deterioration of functioning in melasma patients as assessed by WHO DAS is due to presence of anxiety and depressive features measures by HADS. Thus, we statistically found correlation between these and confirmed that functional disability was due to mental health morbidity. Spearman's correlation coefficient 0.714 (P < 0.01) indicated positive correlation i.e., increasing functional impairment with increasing anxiety and depression [Figure 1].
|Figure 1: Correlation between WHO disability assessment scale and Hospital Anxiety Depression Scale scores|
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Patients may be emotionally affected when melasma is more severe as measured by MASI. However statistical analysis did not discover any such correlation [Figure 2].
|Figure 2: Correlation between melasma area severity index and hospital anxiety depression scale scores|
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There was no significant rise in anxiety-depression with increasing severity of melasma (MASI score) as seen in the second figure (Spearman's correlation coefficient 0.128 [P = 0.37]).
We studied psychiatric morbidity with duration of melasma. Melasma with more than 2 years duration was considered as chronic.
Depressive disorders seem more common in patients suffering melasma for more than 2 years. Stress disorders are more common with patients with melasma for <2 years.
| Discussion|| |
Melasma, local hyperpigmentation over the face, is upsetting for many individuals, which is often a reason for seeking treatment. Although melasma is not classified under the group of psychocutaneous disorders in various classifications by prominent researchers, overall approach to psychocutaneous disorders mentioned in the literature is useful in this disorder too. Recently, Bashir et al. 2010 and Shenoi et al. 2013 have mentioned the cases of melasma seen in psychodermatology clinic. In our setting, we had examined patients with melasma who often had Depressive disorders. Handel et al., have reported the frequent use of anxiolytics and antidepressants by these patients in their study involving 212 patients with melasma. Strong emotional impact on quality of life is also reported in literature. Recent Indian studies, report high prevalence of anxiety and depression as much as up to 84% of the patients in melasma.
In none of these studies, melasma patients were assessed clinically by psychiatrist for diagnosis of various psychiatric disorders, which is the strength of this study. Mental health morbidities were present in significantly high number of cases and led to functional impairment as well [Table 2], [Table 3] and [Figure 1], which were independent of melasma severity [Table 4] and [Figure 2].
Perceived stress and stress-related disorders in melasma
Melasma was seen commonly in women in reproductive age group in this study [Table 1]. Stress and depression raise cortisol and Pro-opiomelanocortin levels such as ACTH and MSH. These have melanogenic potential due to skin-stress – response system as mentioned in the literature. Precipitating stress causing or exacerbating melasma was reported by 54% of the patients in this study. Second, depressive disorders were more common in patients suffering from melasma for more than 2 years [Table 5] (30% vs. 12%, P = 0.02). Adjustment disorders were more common with patients with melasma for <2 years (22% vs. 4%, P = 0.01). Thus, based on these two results, persistent stress leading to depression seems common in melasma.
These observations would recommend further research to confirm the bidirectional relationship between melasma and adjustment disorder as well as major depressive disorder. Stressful events triggered melasma in 4%–7% cases and exacerbated melasma in 26% cases in an earlier recent research.
Functional disability in melasma
HADS scores had a positive correlation with WHO DAS scores (Spearman's correlation coefficient 0.612 [P < 0.01]) indicating the worsening of functioning with rising HADS score [Figure 1]. Unexplained functional impairment can suggest the treating dermatologist to consider the possibility of psychiatric comorbidity and not mere distress secondary to melasma.
Depressive disorders in melasma
The most common associated psychiatric morbidity (42%) was depressive disorders, major depressive episode or recurrent depressive disorder. Eight of them had dysthymic disorder indicating chronic emotional suffering associated with the condition.
Twenty-eight patients had HADS score more than 11 (indicating significant anxiety-depression), which was significantly more than controls (odds ratio – 2.19). Twelve of them had score more than 8 when objectively assessed by PSS-4. As melanocytes are reported to a part of local response to stress by the same hypothalamo-pituitary axis related to depressive disorders,,, these findings hint toward the biological stress-related origin of depression in melasma.
This was hospital-based study, and thus melasma patients in the community are not represented. Small sample size, less number of controls, and lack of structured diagnostic interview are other limitations of this study.
| Conclusions|| |
There was high psychiatric comorbidity (76%) in patients with melasma, most of the patients suffered from depressive disorders (42%). Significantly higher HADS scores were found in melasma patients than the comparable control group. There were significant impairments in functioning, which could be statistically correlated with mental health problems, but not with severity of melasma. Patients presenting with melasma should be therefore be assessed for disturbances in mood and impairment of functioning.
Future research in a bigger sample including cases in the community would confirm Neurobiological correlates and psychiatric morbidity in melasma. It would also be imperative to study impact of successful treatment of depression on the course of melasma.
Authors sincerely acknowledge the support of Dr. Vasudeo Paralikar and Dr Vidyadhar Watve in this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bashir K, Dar NR, Rao SU. Depression in adult dermatology outpatients. J Coll Physicians Surg Pak 2010;20:811-3.
Hughes JE, Barraclough BM, Hamblin LG, White JE. Psychiatric symptoms in dermatology patients. Br J Psychiatry 1983;143:51-4.
Picardi A, Amerio P, Baliva G, Barbieri C, Teofoli P, Bolli S, et al.
Recognition of depressive and anxiety disorders in dermatological outpatients. Acta Derm Venereol 2004;84:213-7.
Basavaraj KH, Navya MA, Rashmi R. Relevance of psychiatry in dermatology: Present concepts. Indian J Psychiatry 2010;52:270-5.
] [Full text]
Shenoi SD, Prabhu S, Nirmal B, Petrolwala S. Our experience in a psychodermatology liaison clinic at Manipal, India. Indian J Dermatol 2013;58:53-5.
] [Full text]
Katsambas AD, Stratigos AJ, Lotti TM. Melasma. In: Katsambas AD, Lotti TM, editors. European Handbook of Dermatological Treatments. 2nd
ed. Berlin: Springer; 2003. p. 336-41.
Achar A, Rathi SK. Melasma: A clinico-epidemiological study of 312 cases. Indian J Dermatol 2011;56:380-2.
] [Full text]
Sheth VM, Pandya AG. Melasma: A comprehensive update: Part I. J Am Acad Dermatol 2011;65:689-97.
Dominguez AR, Balkrishnan R, Ellzey AR, Pandya AG. Melasma in Latina patients: Cross-cultural adaptation and validation of a quality-of-life questionnaire in Spanish language. J Am Acad Dermatol 2006;55:59-66.
Handel AC, Lima PB, Tonolli VM, Miot LD, Miot HA. Risk factors for facial melasma in women: A case-control study. Br J Dermatol 2014;171:588-94.
Slominski AT, Botchkarev V, Choudhry M, Fazal N, Fechner K, Furkert J, et al.
Cutaneous expression of CRH and CRH-R. Is there a “skin stress response system?” Ann N Y Acad Sci 1999;885:287-311.
Tamega Ade A, Miot LD, Bonfietti C, Gige TC, Marques ME, Miot HA. Clinical patterns and epidemiological characteristics of facial melasma in Brazilian women. J Eur Acad Dermatol Venereol 2013;27:151-6.
Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav 1983;24:385-96.
Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983;67:361-70.
World Health Organization. The International Statistical Classification of Diseases and Related Health problems. Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. 10th
ed. Geneva: World Health Organization; 1992.
Herrmann C. International experiences with the hospital anxiety and depression scale – A review of validation data and clinical results. J Psychosom Res 1997;42:17-41.
Koo JY, Lee CS, editors. General approach to evaluating psychodermatological disorders. In: Psychocutaneous Medicine. New York: Marcel Dekker, Inc.; 2003. p. 1-29.
Handel AC, Miot LD, Miot HA. Melasma: A clinical and epidemiological review. An Bras Dermatol 2014;89:771-82.
Ikino JK, Nunes DH, Silva VP, Fröde TS, Sens MM. Melasma and assessment of the quality of life in Brazilian women. An Bras Dermatol 2015;90:196-200.
Kanish B, Goyal S, Thomas EA, Singla M, Kate P, Kamra D. Depression and anxiety in melasma: Prevalence and correlates in North India. Indian J Clin Exp Dermatol 2017;3:167-71.
Jaiswal SV, Nayak CS, Shah HR, Kamath RM, Kadri K. Comparison of quality of life, depression and self-esteem in patients of vitiligo and melasma. J Med Sci Clin Res 2016;4:13675-82.
Dr. Sharmishtha Shailesh Deshpande
Department of Psychiatry, Smt. Kashibai Navale Medical College and General Hospital, Narhe, Pune - 411 041, Maharashtra
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]