Depression and suicidal ideation in dermatology patientswith acne, alopecia areata, atopic dermatitis and psoriasis

M.A.GUPTA AND A.K.GUPTA*Department of Psychiatry, University of Western Ontario, London, Ontario, Canada*Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada

Accepted for publication 23 June 1998

Summary We examined the prevalence of depression (measured by the Carroll Rating Scale for Depression,CRSD), wishes to be dead and acute suicidal ideation among 480 patients with dermatologicaldisorders that may be cosmetically disfiguring, i.e. non-cystic facial acne (n ¼ 72; 5·6% suicidalideation), alopecia areata (n ¼ 45; 0% suicidal ideation), atopic dermatitis (n ¼ 146; 2·1%suicidal ideation) and psoriasis (79 outpatients, 2·5% suicidal ideation and 138 inpatients,7·2% suicidal ideation). Analysis of variance revealed that the severely affected psoriasisinpatients (mean 6 SD total body surface area affected: 52 6 23·4%) had the highest(P <0·05) CRSD score, followed by the patients with mild to moderate acne; both scores werein the range for clinical depression (CRSD score >10). The 5·6–7·2% prevalence of activesuicidal ideation among the psoriasis and acne patients was higher than the 2·4–3·3%prevalence reported among general medical patients. Our findings highlight the importance ofrecognizing psychiatric comorbidity, especially depression, among dermatology patients andindicate that in some instances even clinically mild to moderate disease such as non-cystic facialacne can be associated with significant depression and suicidal ideation.

In a recent report,1 Cotterill and Cunliffe described 16cases of completed suicide among dermatology patients.Seven of the 16 patients who had committed suicide hadacne.1 The impact of acne on body image was believedto be a major contributory factor for the depression andsuicide. The second subgroup of patients with primaryskin problems comprised those with chronic, disfiguringskin disorders such as psoriasis and eczema. Theremaining patients had primary body image problemssuch as body dysmorphic disorder (or dysmorphopho-bia) or a major psychiatric disorder. The authors1

stressed the importance of recognizing depression inthe dermatology patient and underlined the profoundimpact skin disorders can have on the body image ofsome patients. In an earlier paper, we reported a 9·7%prevalence of a death wish and a 5·5% prevalence ofsuicidal ideation among psoriasis patients with a widerange of psoriasis severity.2 As a follow-up to theimportant observations of Cotterill and Cunliffe,1 weexamined the prevalence of depression, wishes to bedead and suicidal ideation among patients with a rangeof dermatological disorders that that are typically

associated with cosmetic disfigurement and bodyimage problems.

Subjects and methods

In this study we merged the data from several largeexploratory studies2–6 involving patients with acne(n ¼ 72), alopecia areata (n ¼ 45), atopic dermatitis(n ¼ 146) and psoriasis (n ¼ 217), dermatological dis-orders that are all associated with some degree ofcosmetic disfigurement and psychosocial morbidity.7

The data from the psoriasis patients have been pub-lished previously,2 and were included in this study forthe purposes of comparison. In this study we examinedthe less severely affected psoriasis outpatients (n ¼ 79)and the more severely affected psoriasis inpatients(n ¼ 138) separately, because we had previouslyobserved that depression increases with psoriasis sever-ity.2 Informed consent was obtained from all thepatients and all studies were approved by the Institu-tional Review Board at the University of Michigan, AnnArbor, MI, U.S.A. The exploratory studies enquiredabout a wide range of demographic and psychosocialfactors including depression and suicidal ideation,which were all self-rated by the patients. In addition

British Journal of Dermatology 1998; 139: 846–850.

846 q 1998 British Association of Dermatologists

Correspondence: M.A.Gupta, 490 Wonderland Road South, Suite 6,London, Ontario N6K 1L6, Canada. E-mail: magupta@julian.uwo.ca

to clinical dermatological evaluations, the patients alsoself-rated the severity of their dermatological symptoms.The general demographic features of the patients aresummarized in Table 1.

Dermatological ratings

Some clinical characteristics of the four subgroups ofpatients are described. The acne patients (72 of 100patients initially recruited completed the study ques-tionnaire: a 72% response rate) and psoriasis patients(79 of 100 outpatients or 79% response rate and 138of 200 inpatients or 69% response rate) were given therating scales while they were in the hospital or clinic,and the alopecia areata patients (45 of 50 or 90%response rate) and atopic dermatitis patients (146 of200 or 73% response rate) were recruited over thetelephone from the clinic database and the studyquestionnaire mailed to them along with the returnpostage. All patients were unpaid volunteers. The 72acne patients had mild to moderate non-cystic acnevulgaris mainly affecting their facial region. Thepatients rated the severity of acne affecting individualbody regions on a 10-point scale where 0 denoted ‘notat all’ and 9 denoted ‘very markedly’. The mean 6 SDpatient-rated acne severity score for the face was4·7 6 2·1, which was consistent with mild to moder-ate acne. Of the 45 alopecia areata patients, 13 hadalopecia areata, four had alopecia totalis and 28 hadalopecia universalis at the time of the study. The 146atopic dermatitis patients had mild to moderate atopicdermatitis. The mean 6 SD pruritus rating was4·8 6 2·6 (based upon the response to the question‘How much does your rash usually itch?’ on a 10-point scale where 0 denoted ‘not at all’ and 9 denoted‘very markedly’). As pruritus is a central feature ofatopic dermatitis, these ratings were consistent with

mild to moderate disease. The 217 psoriasis patients2

represented 79 outpatients and 138 inpatients. Theoutpatients were recruited from a database of derma-tology outpatients who were documented as having# 30% of their total body surface area affected bypsoriasis. The psoriasis inpatients entered the psycho-social study within the first week of admission tohospital at the onset of treatment; their mean 6 SDtotal body surface area affected was 52 6 23·4%,which was consistent with extensive disease.

Ratings for depression and suicidal ideation

The patients completed the Carroll Rating Scale forDepression (CRSD), which is a 52-item self-ratedinstrument used to screen for the clinical depressivesyndrome.8,9 The CRSD includes ratings of a depressedmood, and various vegetative symptoms of depressionsuch as sleep difficulties, concentration difficulties,change in appetite and energy, feelings of hopelessnessand worthlessness and suicidal ideation. Each of the52 items of the CRSD are self-rated by the patient witha ‘Yes’ or ‘No’, and a global CRSD score >10 is used toscreen for the presence of clinical depression.8,9

Death-related ideation was assessed by examiningthe four items (described in Table 2) of the 52-itemCRSD that address wishes to be dead and suicidalideation.8,9

Statistical analysis

The total depression scores (as measured by the 52-item CRSD) between the five dermatological categories(Table 2) were examined using one-factor analysis ofvariance (ANOVA), and post-hoc comparisons were madeto examine the differences between each of the fivediagnostic groups after the omnibus F-test was found

DEPRESSION, SUICIDE AND SKIN DISEASE 847

q 1998 British Association of Dermatologists, British Journal of Dermatology, 139, 846–850

Table 1. Some demographic features of the study subjects

Demographic feature Acne Alopecia areata Atopic dermatitis Psoriasis

Age (mean 6 SD) (years) 23.7 6 6.8 44.7 6 11.6 42.0 6 15.6 47.8 6 16.2Sex 14 men, 11 men, 52 men, 111 men,

58 women 34 women 94 women 106 women (41 men and 38 womenoutpatients; 70 men and 68 womeninpatients)

Race 75% ‘white’ 98% ‘white’ 84% ‘white’ 97% ‘white’8% ‘black’ 2% ‘oriental’ 11% ‘black’ 2% ‘black’8% ‘oriental’ 2% Hispanic 1% ‘other’8% ‘other’ 2% ‘other’

to be significant. The frequency of the four dichoto-mously rated (‘Yes’ or ‘No’) items of the CRSD thataddressed a death wish or suicidal ideation werefurther examined and the differences between thefrequencies were examined using a x2-test (Table 2).

Results

Table 2 summarizes the depression scores and thefrequency of a death wish and suicidal ideationamong the five subgroups of dermatology patients.ANOVA using the CRSD scores as the dependent variablerevealed a significant difference between the diagnosticgroups (omnibus F4,445 ¼ 12·48, P<0·001; Table 2).All 52 items of the CRSD were considered when the totalCRSD score was calculated and cases with any missingvalues were not included. Of 480 patients studied, 450completed all the 52 items of the CRSD and hence onlythese patients were considered for the ANOVA. Post-hoctests revealed that the inpatient psoriasis patients whohad extensive disease had the highest depression (CRSD)scores (Table 2), followed by the patients with mild tomoderate non-cystic acne, who had significantly higherdepression scores (P<0·05) than the other diagnosticgroups, including the alopecia areata, atopic dermatitisand psoriasis outpatients.

Examination of the individual items of the CRSDaddressing wishes to be dead and suicidal ideation(Table 2) revealed that as a group, 4% of the dermatol-ogy patients expressed active suicidal ideation at thetime of the study (i.e. they responded with a ‘Yes’ to theitem ‘I have been thinking about trying to kill myself ’)and 7·3% of patients endorsed a wish to be dead (i.e.they responded with a ‘Yes’ to the item ‘I often wish Iwere dead’). Examination of the individual diagnosticcategories revealed that 7·2% of the inpatient psoriasispatients endorsed active suicidal ideation followed by5·6% of the acne patients (Table 2).

The depression (CRSD) scores between the men(n ¼ 188) vs. the women (n ¼ 292) were 10·3 6 7·7vs. 9·7 6 7·3, respectively, and were not significantlydifferent. The men and women did not differ signifi-cantly (at P <0·05 using the x2-test) with respect tothe frequency with which they endorsed active suici-dal ideation (response to item stating ‘I have beenthinking about trying to kill myself ’: 4·3% of men vs.3·9% of women endorsed a ‘Yes’) or a death wish(responses to items stating ‘Dying is the best solutionfor me’: 3·8% men vs. 2·1% women endorsed a ‘Yes’; ‘Ioften wish I were dead’: 6·4% of men vs. 8% of womenendorsed a ‘Yes’; and ‘I feel that life is still worth

848 M.A.GUPTA AND A.K.GUPTA

q 1998 British Association of Dermatologists, British Journal of Dermatology, 139, 846–850

Tabl

e2

.Dep

ress

ion

scor

esan

dde

ath

-rel

ated

idea

tion

amon

gm

en(M

)an

dw

omen

(F)

wit

hde

rmat

olog

ical

diso

rder

s(n

¼4

80

)

Tota

lCR

SDsc

ore

and

pati

ent

rati

ngs

(‘Y

es’v

s.‘N

o’re

spon

se)

onin

divi

dual

Acn

eA

lope

cia

area

taA

topi

cde

rmat

itis

Pso

rias

isou

tpat

ien

tsP

sori

asis

inpa

tien

tsP

-val

ue

ofdi

ffere

nce

deat

h-r

elat

edit

ems

ofth

eC

RSD

(n¼

72

)(n

¼4

5)

(n¼

14

6)

(n¼

79

)(n

¼1

38

)be

twee

ngr

oups

CR

SDsc

ore

(mea

n6

SD)

11

·26

6·8

7·5

67

·37

·66

6·2

8·6

66

·51

3·4

68

·0<

0·0

01

a

‘Dyi

ng

isth

ebe

stso

luti

onfo

rm

e’(Y

es)

0%

(0of

71

)2

·2%

(1of

45

)1

·4%

(2of

14

6)

5·2

%(4

of7

7)

4·4

%(6

of1

36

)N

Sb

Ove

rall

prev

alen

ce:2

·7%

(13

of4

75

)(1

F)(1

M,1

F)(3

M,1

F)(3

M,3

F)

‘Iof

ten

wis

hI

wer

ede

ad’(

Yes

)8

·3%

(6of

72

)9

·1%

(4of

44

)2

·7%

(4of

14

6)

8·9

%(7

of7

9)

10

·1%

(14

of1

38

)N

Sb

Ove

rall

prev

alen

ce:7

·3%

(35

of4

79

)(2

M,4

F)(1

M,3

F)(4

F)(3

M,4

F)(6

M,8

F)

‘Ife

elth

atlif

eis

still

wor

thliv

ing’

(No)

1·4

%(1

of7

2)

2·2

%(1

of4

5)

3·4

%(5

of1

46

)5

·1%

(4of

78

)1

0·3

%(1

4of

13

6)

0·0

3b

Ove

rall

prev

alen

ce:5

·2%

(25

of4

77

)(1

F)(1

F)(2

M,3

F)(3

M,1

F)(5

M,9

F)

‘Ih

ave

been

thin

kin

gab

out

tryi

ng

toki

llm

ysel

f’(Y

es)

5·6

%(4

of7

2)

0%

(0of

44

)2

·1%

(3of

14

3)

2·5

%(2

of7

9)

7·2

%(1

0of

13

8)

0·0

98

b

Ove

rall

prev

alen

ce:4

%(1

9of

47

6)

(1M

,3F)

(3F)

(2F)

(7M

,3F)

CR

SD,C

arro

llR

atin

gSc

ale

for

Dep

ress

ion

;8,9

NS,

not

sign

ifica

nt.

a An

alys

isof

vari

ance

;bx

2-t

est.

living’: 5·3% of men vs. 5·3% of women endorsed a‘No’ response).

Discussion

We examined the prevalence of depressive symptoms (asmeasured by the CRSD) and death-related ideationincluding suicidal ideation among several diagnosticgroups of dermatology patients who all had conditionsthat have been associated with cosmetic disfigurement,body image problems and psychosocial morbidity. Com-parison of the overall depression (CRSD) scores (Table 2)revealed that the psoriasis inpatients who had extensivedisease (mean 6 SD total body surface area affected:52 6 23·4%) had the highest depression scores, fol-lowed by the acne patients who had mild to moderatenon-cystic acne. The mean CRSD scores among boththe psoriasis inpatients and the acne patients were >10and therefore within the range that screens for clinicaldepression.8,9 The acne patients had higher (P<0·05)(Table 2) CRSD scores than alopecia areata, atopicdermatitis and outpatient psoriasis patients who had# 30% of their total body surface area affected. Thesefindings indicate that psoriasis and acne are associatedwith higher depression scores than alopecia areata andatopic dermatitis. The relatively high depression scoresamong the mildly to moderately affected non-cysticacne patients further underlines the profound impactof even mild to moderate acne on body image. The acnepatients in our study were mainly adolescents andyoung adults (Table 1) and our finding may be indica-tive of the fact that in this age group, which is typicallymore vulnerable to the development of depressive dis-ease, the cosmetic impact of even relatively mild tomoderate acne can result in a significant emotionalburden for the patient. This may act as a precipitatingfactor for depressive illness in this more vulnerablegroup of patients. In an earlier report we observedthat psoriasis had a greater adverse effect upon thequality of life in younger patients in comparison withtheir older counterparts.10 These findings suggest thatthe effect of a skin disorder on body image should beassessed in the context of the patients’ life and develop-mental stage, as adolescents and young adults may havegreater difficulty adjusting to the cosmetic problemsimposed by the skin disorder. Depressive disease is alsomore prevalent among women; however, the depressionscores were not significantly different between the menand women in our study, suggesting that gender did notplay a significant part in differences observed betweenthe diagnostic categories.

Examination of the individual item of the CRSD thataddressed active suicidal ideation (‘I have been thinkingabout trying to kill myself ’) (Table 2), revealed that7·2% of the inpatient psoriatics followed by 5·6% of theacne patients endorsed having acute suicidal thoughts.The overall prevalence of acute suicidal ideation inpsoriasis decreased to 5·5% when both the inpatientsand outpatients were combined into one group. Theseprevalence rates of acute suicidal ideation are higherthan the 3·3%,11 2·6%12 and 2·4%13 prevalence ratesof suicidal ideation reported in three other studies11–13

that examined the prevalence of suicidal ideation ingeneral medical patients. The atopic dermatitis and theless severely affected psoriasis outpatients reported aprevalence of acute suicidal ideation which was similarto the other medical outpatients,10–12 while none of thealopecia areata patients endorsed acute suicidal idea-tion. These findings suggest that the higher depressionscores among the acne and psoriasis patients are alsoassociated with a higher frequency of suicidal ideationamong these patients.

Our findings highlight the profound psychologicalmorbidity that may be associated with certain derma-tological disorders and confirm the importance of recog-nizing psychiatric comorbidity, especially depression,1

among dermatology patients. Our findings further indi-cate that even mild to moderate dermatological disease,especially facial acne, can be associated with significantdepression and suicidal ideation.

Acknowledgments

We thank Andrew M.Johnson, MA. for statistical assis-tance, and the Department of Dermatology, University ofMichigan, Ann Arbor, MI, U.S.A. for allowing us tostudy their patients.

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Dermatol 1997; 137: 246–50.2 Gupta MA, Schork NJ, Gupta AK et al. Suicidal ideation in

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10 Gupta MA, Gupta AK. Age and gender differences in the impact ofpsoriasis upon the quality of life. Int J Dermatol 1995; 34: 700–3.

11 Zimmerman M, Lish JD, Lush DT et al. Suicidal ideation amongurban medical outpatients. J Gen Int Med 1995; 10: 573–6.

12 Cooper-Patrick L, Crum RM, Ford DE. Identifying suicidal ideationin general medical patients. JAMA 1994; 272: 1757–62.

13 Olfson M, Weissman MM, Leon AC et al. Suicidal ideation inprimary care. J Gen Int Med 1996; 11: 447–53.

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