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JEADV (2002) 16, 573– 578

OR I G I N AL AR T I C LE

Psychiatric morbidity in vitiligo: prevalence and correlates in India Blackwell Science, Ltd

SK Mattoo,†* S Handa,‡ I Kaur,‡ N Gupta,† R Malhotra† †Departments of Psychiatry and ‡Dermatology, Venereology and Leprosy, Postgraduate Institute of Medical Education and Research, Chandigarh, India. *Corresponding author, Department of Psychiatry, Postgraduate Institute of Medical Education & Research, Chandigarh – 160 012, India. Tel. +91 172 713390 (R); fax +91 172 744401; E-mail: [email protected]

ABSTRAC T Background Vitiligo, a common pigmentary disorder, is recognized to be associated with a high psychiatric

morbidity, yet compared to other dermatological disorders like leprosy, psoriasis, etc., it has not been subjected to detailed evaluation of its psychological consequences. The data from the developing countries on this aspect in particular is meager. Methods One hundred and thirteen cases with vitiligo were evaluated along with 55 healthy controls comparable for sociodemographic profile and matched on attitude to appearance scale. Clinical details, impact of illness, associated dysfunction and psychological morbidity were additionally assessed. Results Twenty-eight patients with vitiligo were found to have psychiatric morbidity, a clinic prevalence rate of 25% (95% confidence interval 20.3–29.3%). The majority of the cases had a diagnosis of adjustment disorder. Psychiatric morbidity was significantly correlated with dysfunction arising out of illness. Conclusions Vitiligo is associated with high psychiatric morbidity. There is a need to develop cross-cultural database on psychosocial aspects and psychiatric morbidity associated with vitiligo. Key words: vitiligo, psychiatric diagnosis, psychological Received: 2 November 2001, accepted 27 March 2002

Introduction Vitiligo, a chronic dermatological disorder, is characterized by hypopigmentation or depigmentation of skin and mucosa. Its onset is often correlated with certain personality characteristics,1,2 stress, illness and personal crisis.3 The disfiguring nature often leads to social and sexual embarrassment, or perceived or actual discrimination or rejection. 2,4–9 This has been reported to have a profound psychological effect, resulting in up to two-thirds of subjects under-achieving their potential.6,10 A few studies have reported on more specific aspects in vitiligo like self-esteem, coping, perceived support from doctors, social support, quality of life and psychiatric disorders.4–7,9,11 A careful review of dermatological research shows that most of the relatively comprehensive studies on psychological morbidity have been carried out on psoriasis, leprosy or all dermatological disorders considered together, and have been reported mostly from the developed countries.12,13 Considering that vitiligo is a common disorder affecting 1– 2% of the general population,14 the psychosocial research on © 2002 European Academy of Dermatology and Venereology

vitiligo is meager and mostly of western origin. The psychosocial milieu of the developing countries being different from that of the developed countries, the stigma associated with hypo- or de-pigmentation is possibly more severe in coloured races inhabiting most of the developing world. As no previous psychosocial research on vitiligo is available from India, the present study was carried out as part of a prospective crosssectional study of psychosocial profile of vitiligo and psoriasis patients in India.15 The objectives of the study were to assess treatment-seeking patients of vitiligo for: (i) the prevalence of psychiatric morbidity; (ii) the psychological and psychopathological profile and (iii) the psychological and social correlates of psychiatric morbidity.

Materials and methods Setting The study was carried out at the Postgraduate Institute of Medical Education and Research, Chandigarh, a tertiary care referral hospital providing services to a major area of north 573


574 Mattoo et al.

India and catering to approximately 40 million people. The study was carried out from March 1998 to September 1999.

Sample The sample comprised two groups: (1) Patient group (n = 113), comprised subjects attending the Vitiligo Clinic of the dermatology outpatient department of the Institute. They were of either sex, aged at least 14 years, with diagnosed vitiligo and not on psoralens or systemic steroids. (2) Healthy control group (n = 55), comprised subjects recruited from the attendants/ relatives of the patients attending the dermatology outpatient (excluding specialty clinics like psoriasis, vitiligo and leprosy) of the Institute. They were group-matched with the patient group for sex, age and education, and were to be free from any major physical or psychiatric illness; the psychiatric morbidity being determined by administration of General Health Questionnaire-12 Item (GHQ-12)16,17 as explained in the subsequent section. All the subjects were recruited on the basis of an informed consent assuring confidentiality and freedom of choice of participation.

Assessment A cross-sectional assessment of dermatological profile, and psychosocial and psychiatric aspects was made using the following instruments: 1 Sociodemographic proforma: A proforma, specially designed for this study, was used to record the relevant sociodemographic data. 2 Clinical profile sheet: A proforma specifically constructed for this study was used to get clinical details of vitiligo, e.g. duration of illness, type of vitiligo, percent body area affected (covered/ uncovered), etc. 3 General Health Questionnaire-12 items (GHQ-12): A screening instrument for assessing psychiatric morbidity, the GHQ-1216 has been validated in Indian population.18 For the present study the twelve items were taken from the Hindi translation of the 60-item GHQ that has been validated in India.17 This Hindi version of the GHQ-12 was used after establishing its face validity and carrying out a reliability exercise with back translation on five vitiligo patients. Any person scoring ≥ 5 was defined as a case with psychiatric morbidity.19 4 Attitude to Appearance scale (ATT): Wessley and Lewis20 developed this scale to measure attitudes to appearance, using semantic differentials based on the dysfunctional attitude scale of Beck.21 In this five-item yes/no response scale the possible scores range from 0 to 5, a higher score indicating a more perfectionist attitude. 5 Impact of Skin Disease Scale (IMPACT): Wessley and Lewis20 developed this scale to measure the effect of skin disease on certain areas of the subject’s life. In this eight-item two point scale the possible score ranges from 0 to 8, the

scoring pattern being such that any change in behaviour after onset of illness, is scored as positive. In the present study the subjects were asked to rate change occurring since the onset of vitiligo. 6 Dysfunction Analysis Questionnaire (DAQ): Developed at our centre, this questionnaire22 is designed to assess the dysfunction in terms of the current level of functioning in comparison with the level of functioning before any illness. In this 50-item five-point questionnaire the possible score ranges from 50 to 250. The percentage dysfunction is assessed across five areas – social, vocational, personal, family and cognitive. This questionnaire has been widely used in India on different clinical populations. It has proven reliability and validity, and provides norms for the local population. 7 Comprehensive Psychopathological Rating Scale (CPRS): This scale23 assesses full range of psychopathology with a high degree of reliability. An explicit description of each of the 65 items is provided. The items are scored 0–3; each scale step being operationally defined on the basis of intensity, frequency and duration of the symptoms. The CPRS has two subscales to assess the severity of depression and anxiety, respectively: Montgomery Asberg Depression Rating Scale (MADRS) and Anxiety Severity Index (ASI), comprising 10 and seven items each with a maximum possible score of 60 and 21, respectively.

Procedure The patients of vitiligo meeting the inclusion criteria were administered all the above listed instruments (selection of consecutive patients was attempted but was not always possible). Assessment was carried out on the same day, over a maximum of three sessions. The initial recruitment and assessment of the cases was carried out by the consultant dermatologist (SH). Thereafter, the psychologist (RM) administered instruments 3–6. Those with GHQ score ≥ 5 were assessed using CPRS and were subjected to a detailed interview for determining presence of the psychiatric illness as per the International Classification of Diseases-10th Revision (ICD10).24 A consultant psychiatrist (NG) completed this. Controls were administered instruments 1 and 4 by the psychologist (RM), after satisfying the inclusion criteria.

Statistical analysis Non-parametric variables were subjected to Pearson’s Chi-square analysis while parametric variables were analysed using student’s t-test. Spearman’s correlation analysis was carried out for select variables. Due to the large number of correlations carried out, Bonferroni correction was applied; significance level being kept at P < 0.01 instead of P < 0.05. Confidence interval was calculated using the SPSS statistical package.25

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Psychiatric morbidity in vitiligo 575

Table 1 Comparison of vitiligo and healthy control groups

Variable Age in years (mean ± SD) Sex (N): Educational years (mean ± SD) Marital status (N): Religion (N): Locality (N):

Male Female Unmarried Married Hindu Sikh Rural Urban

ATT Score (mean ± SD)

Vitiligo cases (N = 113)

Healthy controls (N = 55)

30.11 ± 12.49 62 51 10.98 ± 4.19 53 60 97 16 49 64 4.09 ± 0.65

31.62 ± 9.57 35 20 11.02 ± 3.72 20 35 38 17 25 30 4.01 ± 0.81

2

X /t value 0.867 1.155 0.059 1.672 6.58* 0.019 0.653

*P < 0.05.

Table 2 Comparison of the GHQ Positive and GHQ Negative vitiligo cases on demographic and psychological parameters

Variable GHQ score (mean ± SD) Age in years (mean ± SD) Sex (N): Educational years (mean ± SD) Marital Status (N): Religion (N): Locality (N):

Male Female Unmarried Married Hindu Sikh Rural Urban

Duration of Illness in years (mean ± SD) Percent Body Area Affected (mean ± SD) ATT score (mean ± SD) IMPACT score (mean ± SD) DAQ score (mean ± SD)

GHQ positive cases (N = 28)

GHQ negative cases (N = 85)

7.57 ± 2.38 27.75 ± 11.43 12 16 9.61 ± 3.67 16 12 25 3 13 15 6.79 ± 5.31 10.89 ± 12.15 4.23 ± 0.36 4.00 ± 1.72 56.00 ± 15.86

1.08 ± 1.20 30.88 ± 12.78 50 35 11.44 ± 4.27 37 48 72 13 36 49 8.32 ± 8.33 10.38 ± 15.49 4.06 ± 0.72 1.98 ± 1.88 42.92 ± 7.24

2

X /t value 13.86* 1.22 2.17 2.19 1.67 0.57 0.03 1.14 0.18 1.67 5.27* 4.22**

*P < 0.01, ** P < 0.001.

Results During the course of the study no subject refused to participate at the time of initial intake (informed consent and administration of instruments 1–7, as applicable). The vitiligo patients (n = 113) and healthy control subjects (n = 55) had a comparable profile on ATT scores and all sociodemographic variables except that the patient group had a higher representation of Hindu subjects (Table 1). The GHQ-12 assessment of the vitiligo group led to the generation of two subgroups: GHQ Negative (i.e. GHQ score ≤ 4 i.e. those without psychiatric morbidity, N = 85) and GHQ Positive (i.e. GHQ score ≥ 5, i.e. those suffering from psychiatric morbidity, N = 28). This gave a prevalence rate of GHQ positive psychiatric morbidity at 24.78% (95% confidence interval of 20.3%−29.3%).

The two subgroups were comparable on sociodemographic and clinical parameters and ATT scores, however, the GHQ positive subgroup demonstrated significantly higher IMPACT and DAQ scores (Table 2). Out of 28 GHQ positive cases the diagnostic assessment of the psychiatric morbidity as per the ICD-10 diagnostic criteria could be not be carried out in 12 cases, for reasons such as refusal, no follow-up, etc. (the reasons for refusal or no followup, etc. were not enquired). For 16 cases assessed completely, the diagnostic break-down was as follows: adjustment disorder12 cases, depressive episode-3 cases and dysthymia-1 case (Table 3). For these 16 cases, the mean ± SD scores on CPRS were: Total CPRS, 15.13 ± 8.6; MADRS, 16.7 ± 8.9; and ASI, 4.2 ± 3.9. An attempt to determine the correlates of psychiatric morbidity in these 16 GHQ positive cases revealed that the only

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576 Mattoo et al.

The comparability of the vitiligo subjects given a diagnostic assessment and those who could not be given a diagnostic assessment on select demographic and duration of illness profile, established the representative nature of the subjects given a diagnostic assessment (Table 6).

Table 3 Diagnostic break-up of GHQ positive vitiligo cases Total cases Cases not assessed Cases assessed (psychiatric disorder) Adjustment disorder Depressive episode Dysthymia

28 12 16 12 3 1

Discussion

Table 4 Correlation between the scores of various psychopathological variables in diagnostically assessed GHQ positive vitiligo cases (N = 16) Variable

Duration of illness

GHQ

DAQ

AT T

IMPACT

GHQ CPRS DAQ ATT IMPACT

0.132 −0.268 −0.019 −0.203 0.023

0.408 0.390 0.149 0.398

0.825*

0.208

0.125

0.197 0.376

0.317

*P < 0.01. Table 5 Comparison of vitiligo clinic population and study sample

Variable Age in years (mean ± SD) Sex (N): Male Female Locality (N): Urban Rural Duration of illness in years (mean ± SD)

Vitiligo clinic population (N = 199)

Vitiligo study sample (N = 113)

32.56 ± 12.65 92 107 111 88

30.11 ± 12.49 62 51 64 49

1.66

8.07 ± 7.81

0.94

9.01 ± 9.63

2

X /t value

2.05 0.02

significant correlation was of DAQ score with CPRS score (Table 4). The comparability of the vitiligo sample and the whole population of the vitiligo clinic seen during the study period on select demographic and duration of illness profile, established the representative nature of the sample (Table 5).

Variables Age in years (mean ± SD) Education in years (mean ± SD) Sex (N): Male Female Locality (N): Urban Rural Marital status (N): Married Unmarried Duration of illness in years (mean ± SD)

Based on the similarities between vitiligo sample vs. vitiligo clinic population and subjects given a diagnostic assessment vs. subjects that were not given a diagnostic assessment, the findings may be safely generalized to the clinical population of vitiligo but not to the subjects with vitiligo in general population, as no relevant data for comparison is available in India. The vitiligo and healthy control groups being comparable across ATT scores and all sociodemographic variables (except religion), implies that psychiatric morbidity is not a simple function of these variables. The GHQ assessed psychiatric morbidity of 25% is slightly less compared to the GHQ assessed psychiatric morbidity reported for other outpatient studies ranging from 30% to 47.6% of outpatient subjects with all dermatological disorders considered together, but excluding vitiligo.20,26 –28 This morbidity rate however, is identical to that obtained by Picardi et al.19 in their study on dermatological outpatients, including vitiligo, using the Italian version of GHQ-12. No comparable data on vitiligo is available, however, 65% of vitiligo outpatient subjects have been reported to be ‘worried’ about their illness.7 These rates of psychiatric morbidity are slightly higher than those reported for medical and surgical outpatients and inpatients at around 30% and 33%, respectively.29,30 The GHQ positive and negative groups were comparable across all sociodemographic variables (ATT scores, duration of illness and percent of body area affected) except IMPACT and DAQ scores. The higher IMPACT and DAQ scores in GHQ positive group suggest a significant change in vitiligo related social behaviour and psychosocial dysfunction. The present study was

Assessed cases (N = 16)

Not assessed cases (N = 12)

27.75 ± 11.67 8.81 ± 4.42 7 9 6 10 10 6

27.75 ± 11.63 10.67 ± 2.06 5 7 7 5 7 5

0.000 1.478

5.83 ± 4.11

0.863

7.50 ± 6.10

2

X /t value

Table 6 Comparison of vitiligo cases assessed and not assessed for psychiatric diagnosis

0.012 1.192 0.005



Psychiatric morbidity in vitiligo 577

not designed to establish the cause and effect relationship between behaviour change and dysfunction. Hence, except saying that it did not find attitude to appearance contributing to vitiligo related behaviour change and psychosocial dysfunction, it cannot add to the speculation that dysfunction or psychiatric morbidity is due to environmental variables, e.g. social attitudes/reactions or social support or due to personality variables, i.e. anxiety traits, poor coping skills.1 The 25% rate of psychiatric disorder is lower than 67% reported by Attah Johnson and Mostaghimi31 and 37% reported by Weiss et al.32 in vitiligo outpatients, however, this is in contrast to 9% reported by Pulimood et al.33 in dermatological inpatients and 50% and 8%, respectively, reported by Weiss et al.32 in leprosy and tinea versicolor outpatients. Picardi et al.19 had reported presence of psychiatric morbidity in 25% of their subjects with vitiligo. Findings, including those obtained in this study, support the notion that psychiatric disorders are fairly common in vitiligo.4 The profile of psychiatric diagnoses obtained in the present study (75% adjustment disorder, 18% depressive episode and 7% dysthymia) was somewhat, but not exactly, comparable to that of other studies reporting 50% neurotic depression and 20% anxiety neurosis in vitiligo outpatients;31 34% depressive episode, 29% adjustment disorder and 7% organic manic disorder in mixed dermatological inpatients,33 and depression, anxiety and somatoform disorders in decreasing frequency in leprosy, vitiligo and tinea versicolor outpatients.32 This profile of neurotic-reactive-adjustment disorders with anxiety and depression predominating, coupled with the high rates of 65% of ‘worried’ vitiligo subjects reported by Porter et al.7 supports the hypotheses of ‘worried well’20 or cognitive errors underlying the psychiatric morbidity in dermatological – including vitiligo – patients. Accordingly, Wessely and Lewis20 argued in favour of the physicians and dermatologists acquiring skills for early identification and proper management of psychiatric morbidity. This recommendation is supported by the fact that counseling, supportive psychotherapy, cognitive-behaviour therapy and low-dose antidepressants have been shown to help alleviate such disorders.34–36 In terms of correlates of psychiatric morbidity the only positive and significant correlation emerging between CPRS and DAQ suggests that psychopathology is associated with dysfunction but not with other measures of psychopathology or behaviour change. The exact cause and effect relationship between psychiatric morbidity, dysfunction and behaviour change on one hand and the personality and environmental factors on the other hand was not elucidated by the cross-sectional nature of the present study that focused only on the coexistence of these variables. Thus, the cause and effect relationship between these various variables remains open to speculation and further investigation using a longitudinal method of assessment. With the limitations of a small outpatient tertiary care hospital sample, high drop-out, lack of specific measurement of

other variables (vitiligo specific stressors, coping, quality of life, etc.), non-use of a standardized interview for assessing psychiatric morbidity (leading to possible exclusion of comorbid disorders), exclusion of patients on steroids (leading to recording of a lower psychiatric morbidity) and a cross sectional design, the present study – the first of its kind from India – reports a high prevalence of psychiatric morbidity and its correlates in vitiligo, and highlights the need to develop a cross-cultural psychosocial database on this common but less studied disorder with significant psychiatric morbidity.

Acknowledgements The Institute Research Fund of PGIMER, Chandigarh funded this research.

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