Understanding the relationship between objective disease severity, psoriatic symptoms, illness-related stress, health-related quality of life and depressive symptoms in patients with psoriasis — a structural equations modeling approach

doi:10.1016/j.genhosppsych.2006.12.004

General Hospital Psychiatry

Volume 29, Issue 2, March–April 2007, Pages 134-140

https://doi.org/10.1016/j.genhosppsych.2006.12.004 Get rights and content

Abstract

Objectives

The aim of this study was to assess associations between objective disease severity, psoriasis symptoms, illness-related stress (IRS), health-related quality of life (HRQL) and depressive symptoms in patients with psoriasis.

Method

Cross-sectional study conducted between January and May 2005. Recruitment of 265 adult patients with psoriasis through Internet advertisements. Analysis of the validity of different measurement models and the fit of hypothesized structural models using a structural equations modeling approach.

Results

Thirty-two percent of the participants screened positive for depression. Because of poor discriminant validity (correlation: 0.919), IRS and HRQL were considered as one factor. The final measurement model had adequate validity and fit. A significant proportion of the variance of depressive symptoms was explained by HRQL (standardized direct effect: 0.916; P<.001). After adjustment for HRQL, objective severity of psoriasis was inversely related to depressive symptoms (standardized direct effect: −0.250; P=.094).

Conclusion

In psoriasis — a condition without direct brain involvement — specific disease-related problems in everyday life seem to cause depression in a significant proportion of patients. It is therefore critically important to regularly assess and work to maximize HRQL in psoriasis patients. Patients with high HRQL impairment despite objectively mild psoriasis should be screened for depression.

Introduction

Psoriasis is a chronic inflammatory, systemic disease that primarily affects the skin. Currently incurable, psoriasis can occur at any age and is equally distributed between men and women [1]. With a prevalence of 2–3% in the general population and estimated annual direct medical cost per patient between US$650 and 800, the socioeconomic impact of psoriasis is considerable [2], [3]. The typical thickened, red, scaly plaques are often disfiguring and may cause substantial problems in everyday life [4].

Being almost exclusively discussed in the dermatological literature for several years, the introduction of biological medications recently evoked some broader notice of psoriasis [5], [6], [7], [8], [9]. The fact that most biological medications are approved exclusively for moderate-to-severe psoriasis led to a controversial discussion about the definition of severity in psoriasis [10]. Clinically, the severity of psoriasis is described by the intensity and extent of the psoriatic lesions [11], [12]. From the patient's perspective, however, the impact psoriasis has on their everyday physical, social and psychological-emotional functioning is most important. Illness-related stress (IRS) is a particular problem for many patients with psoriasis. IRS mainly results from the anticipation of others' reactions to psoriasis and adversely affects interpersonal activities [13]. The growing number of studies that include health-related quality of life (HRQL) as an outcome reflects the current broadening of the conceptualization of psoriasis [14].

A recent Italian study suggested that depression plays a considerable role in the overall morbidity of psoriasis patients [15]. Demoralization and dissatisfaction with treatment of psoriasis may contribute to depression. Depression affects treatment adherence and also modifies the perception of pruritus, a typical symptom of psoriasis [16], [17].

Although considerable research on individual aspects of the overall morbidity in psoriasis patients (e.g., extent and intensity of psoriatic lesions, psoriatic symptoms like pruritus and pain, HRQL and IRS) has been conducted, few researchers have focused on the strength of association between these factors. A comprehensive analysis of both the strength and the directionality of causal relationships between the different aspects of morbidity in psoriasis has not been conducted. The directionality and strength of association between disease severity of psoriasis, HRQL and depressive symptoms seem particularly important for developing an effective and efficient care plan for patients with psoriasis.

We used a structural equations modeling (SEM) approach to test the fit and validity of different comprehensive measurement models and analyzed the strength and directionality of associations in different hypothesized structural models including psoriatic signs and symptoms, IRS, HRQL and depression in adult psoriasis patients from the US population.

Section snippets

Setting and study population

Adults (age 18 years or older) with a self-reported diagnosis of psoriasis, who accessed the Internet from the United States were eligible in this cross-sectional study. Restriction to participants from the United States was technically enabled through registration of the Internet protocol address of the user.

Participants were recruited between January and May 2005. Recruitment included an advertisement at Google that appeared on the screen when “psoriasis” or related search terms were entered

Results

The study questionnaire was started by 359 participants and completed by 267 (74%). Two participants (0.7%) were excluded because they indicated that they did not answer all questions honestly. There were no statistically significant differences between participants who completed the study and those who did not with respect to age, sex, socioeconomic status, disease characteristics of psoriasis, personal history and current treatment of depression. Whites were more likely to complete the study

Discussion

The present study extends previous research by quantitatively describing the complex relationship between objective severity and symptoms of psoriasis, HRQL, IRS and depressive symptoms. SEM appears to be a useful technique for the causal model of psoriasis and its psychosocial effects. Because temporality cannot be established based on cross-sectional data, our findings should be interpreted with caution before they are confirmed in a longitudinal study and/or replicated from another

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The most studied associations are between affected genital areas and sexual dysfunction, and palmoplantar psoriasis and quality of life [13–16]. The assessment of the severity and the psychosocial impact of the disease are of fundamental importance to better understand psoriasis and are indicators supporting the careful selection of the treatment to be carried out [17–23]. Severity is the most common index used by Food and Drug Administration (FDA) to the approval process of new medicines, particularly biologics [24].
The psychosocial impact of psoriasis is well documented. However, the contributing role of clinical disease characteristics is not satisfactorily explored. This study aimed to validate the Self-administered Psoriasis Area and Severity Index (SAPASI) to a Portuguese population (SAPASI-PT) and to perform its cross-validation, assessing how the results will generalize to an independent data set, with the Psoriasis Area and Severity Index (PASI), in order to assess the influence of psoriasis' severity on psychosocial disability and psychopathology.
A cross-sectional study with 228 patients with psoriasis was carried out. Data was collected through a sociodemographic and clinical questionnaire, SAPASI-PT, the Psoriasis Disability Index (PDI) and the Brief Symptoms Inventory (BSI). The cultural and linguistic adaptation of SAPASI to a Portuguese version and the cross validation with PASI was carried out. Multiple associations between psychosocial disability, psychopathology and severity, discomfort and location of lesions were investigated through logistic regression models.
A good adjustment model for SAPASI-PT is found. Also, associations between psychosocial disability, psychopathology and the psoriasis severity and discomfort are found. The existence of lesions is positively associated with the severity of the disease. Patients with lesions in hands or genitals are those reporting a greater discomfort. The presence of lesions in hands is positively associated with PDI, i.e., with leisure and with treatment, marginally. Additionally, patients scoring higher in the personal dimension are found to have a significantly greater percentage of lesions in the genitals.
The psoriasis severity and location of lesions are important determinants of patients´ quality of life. Lesions on face, hands and genitals are associated with a higher impact on psychosocial wellbeing of patients. Psychological counselling should be considered within psoriasis treatment context in patients with the described disease manifestations.
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According to clinical trials, several factors increase the risk of psychological disorders in psoriasis patients. For instance, female gender, damaged appearance and lack of emotional/social support are reported as contributing to high risk of depression in psoriasis patients [11]. Also, a psychological study indicates that female gender, large affected surface area, self-distraction, behavioral disengagement and lack of emotional support all constitute risk factors for psychological distress in psoriasis patients [10].
The purpose of this study was to explore the correlation of anxiety and depression with therapeutic response to etanercept in psoriasis patients.
One hundred and thirty-three patients with moderate-to-severe plaque psoriasis undergoing etanercept treatment were consecutively enrolled in this prospective cohort study, with all patients receiving etanercept treatment for 6 months. Psoriasis Area and Severity Index (PASI) score was evaluated at baseline (M0) and at month 1 (M1), M3 and M6 after treatment, and PASI 75/90 responses were calculated. The Hospital Anxiety and Depression Scale-Anxiety (HADS-A) score and the HADS-Depression (HADS-D) score were used to evaluate patients’ anxiety and depression at M0, M1, M3 and M6. Sustained anxiety/depression were defined as HADS-A/D score ≥ 8 points both at M0 and M1.
Female gender and higher PASI score were associated with high risk of anxiety, while female gender, higher PASI score and longer disease duration were correlated with increased depression risk. After 6 months of etanercept treatment, 65.4% and 36.1% patients achieved PASI 75 and PASI 90 responses respectively, and both HADS-A and HADS-D scores were decreased. Most importantly, no correlation of baseline anxiety and depression with PASI 75 or PASI 90 response after 6 months of treatment was noted, while sustained depression, though not sustained anxiety, was observed to be correlated with decreased PASI 75 and PASI 90 responses.
Etanercept reduces anxiety and depression in psoriasis patients, and sustained depression correlates with reduced therapeutic response to etanercept.
Le but de ce travail était d’étudier la relation entre la réponse à l’étanercept et les niveaux d’anxiété et de dépression des patients atteints de psoriasis.
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Le sexe féminin et un score PASI plus élevé étaient associés à une plus grande anxiété ; les mêmes facteurs plus la durée d’évolution de la maladie étaient associés à un score de dépression plus élevé. Après 6 mois d’étanercept, le PASI 75 et le PASI 90 étaient atteints par respectivement 65,4% et 36,1 % des patients, tandis que les scores HADS-A et HADS-D diminuaient tous les deux. Le point le plus important est qu’il n’est apparu aucune corrélation les niveaux d’anxiété et de dépression à M0 et les réponses PASI 75 ou PASI 90 à M6 ; en revanche, la dépression persistante, mais non l’anxiété persistante, était associée à une moins bonne réponse au traitement en termes de PASI 75 et de PASI 90.
L’étanercept réduit les niveaux d’anxiété et de dépression des patients atteints de psoriasis. Une dépression persistante est associée à une moins bonne réponse au traitement.
Prevalence of psoriatic arthritis in patients with psoriasis: A systematic review and meta-analysis of observational and clinical studies
2019, Journal of the American Academy of Dermatology
Wide-ranging prevalence estimates of psoriatic arthritis (PsA) in patients with psoriasis have been reported.
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Two authors independently searched 3 databases for studies reporting on the prevalence or incidence of PsA in patients with psoriasis. A proportion meta-analysis was performed to calculate the pooled proportion estimates of PsA in patients with psoriasis.
A total of 266 studies examining 976,408 patients with psoriasis were included. Overall, the pooled proportion (95% confidence interval [CI]) of PsA among patients with psoriasis was 19.7% (95% CI, 18.5%-20.9%). In children and adolescents (<18 years of age), the pooled prevalence was 3.3% (95% CI, 2.1%-4.9%). The PsA prevalence was 22.7% (95% CI, 20.6%-25.0%) in European patients with psoriasis, 21.5% (95% CI, 15.4%-28.2%) in South American patients with psoriasis, 19.5% (95% CI, 17.1%-22.1%) in North American patients with psoriasis, 15.5% (95% CI, 0.009%-51.5%) in African patients with psoriasis, and 14.0% (95% CI, 95% CI, 11.7%-16.3%) in Asian patients with psoriasis. The prevalence of PsA was 23.8% (95% CI, 20.1%-27.6%) in studies in which the Classification Criteria for Psoriatic Arthritis were applied. The incidence of PsA among patients with psoriasis ranged from 0.27 to 2.7 per 100 person-years.
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Based on random population-based sampling, 2000 male residents in Hong Kong were interviewed. Levels of masculine role discrepancy, discrepancy stress, self-esteem, social anxiety, and depressive symptoms were assessed by using validated scales.
Results of structural equation modeling analysis indicated that the proposed model fit the sample well. (χ²(118) = 832.34, p < .05, CFI = 0.94, NNFI = 0.91, RMSEA = 0.06). Those who were young, single and less educated were vulnerable to masculine role discrepancy, discrepancy stress, and emotional/mental health problems. We found that discrepancy stress significantly mediated the association between masculine role discrepancy and social anxiety, while self-esteem significantly mediated the associations between masculine role discrepancy and both social anxiety and depression.
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Psoriasis is frequently associated with several comorbidities (e.g., cardiovascular disease, diabetes, obesity, and the metabolic syndrome), including psychological conditions (e.g., depression and anxiety) [9–11] which are frequently associated with worse health-related quality of life [6,12] and adherence to treatment regimens [13]. For example, depression may affect between 10% and 62% of psoriasis patients [10,14], even in patients with less severe psoriasis [14,15]. Kurd et al. [16] analyzed data from a population-based cohort study of 146,042 patients with mild psoriasis, 3956 patients with severe psoriasis, and 766,950 patients without psoriasis.
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Psoriasis is characterized by poor HRQoL and the presence of difficulties in understanding and regulating inner states and emotions. In patients with psoriasis the possible influence of food craving on abnormal eating habits should be carefully assessed.
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La psoriasis es un proceso inflamatorio crónico y sistémico con múltiples comorbilidades. Entre las más frecuentes se encuentran las enfermedades mentales y en especial la depresión, con la que interrelacionan negativamente llegando a producir un peligroso círculo vicioso. Clásicamente se ha explicado la depresión de los pacientes con psoriasis como reactiva a factores psicosociales y el deterioro en la calidad de vida. Sin embargo, la asociación de estas dos patologías a través del proceso inflamatorio crónico ofrece una nueva hipótesis para su comprensión y tratamiento. Este enfoque incide en nuevos fármacos y la importancia del estilo de vida.
Psoriasis is a chronic, systemic inflammatory disorder with multiple comorbidities.
The most common comorbidities are mental disorders, especially depression, which can interact negatively with psoriasis to produce a dangerous vicious circle. Depression in psoriasis has traditionally been explained as a response to psychosocial factors and impaired quality of life.
However, a new hypothesis linking depression and psoriasis through chronic inflammation offers insights that should help to understand and treat these diseases. In this approach, new drugs and lifestyle have an important role.

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Psychiatric–Medical ComorbidityUnderstanding the relationship between objective disease severity, psoriatic symptoms, illness-related stress, health-related quality of life and depressive symptoms in patients with psoriasis — a structural equations modeling approach

Abstract

Objectives

Method

Results

Conclusion

Introduction

Section snippets

Setting and study population

Results

Discussion

J Am Acad Dermatol

J Investig Dermatol Symp Proc

J Investig Dermatol Symp Proc

Lancet

J Am Acad Dermatol

J Investig Dermatol Symp Proc

J Psychosom Res

J Invest Dermatol

J Invest Dermatol

Lancet

Epidemiology of psoriasis

Curr Drug Targets Inflamm Allergy

Treatment of chronic plaque psoriasis by selective targeting of memory effector T lymphocytes

N Engl J Med

Efalizumab for patients with moderate to severe plaque psoriasis: a randomized controlled trial

JAMA

Etanercept as monotherapy in patients with psoriasis

N Engl J Med

A promising step forward in psoriasis therapy

JAMA

Quality of life and prevalence of arthritis reported by 5,795 members of the Nordic Psoriasis Associations. Data from the Nordic Quality of Life Study

Acta Derm Venereol

Adverse effects with long-term cyclosporin for severe psoriasis

Clin Exp Dermatol

Quality of life in patients with psoriasis: the contribution of clinical variables and psoriasis-specific stress

Br J Dermatol

The promise and challenge of new biological treatments for psoriasis: how do they impact quality of life?

Dermatol Ther

Association between poorer quality of life and psychiatric morbidity in patients with different dermatological conditions

Psychosom Med

Depression modulates pruritus perception: a study of pruritus in psoriasis, atopic dermatitis, and chronic idiopathic urticaria

Psychosom Med

Association of dissatisfaction with care and psychiatric morbidity with poor treatment compliance

Arch Dermatol

Dermatology Life Quality Index (DLQI) — a simple practical measure for routine clinical use

Clin Exp Dermatol

Clinical meaning of change in Dermatology Life Quality Index Scores

Br J Dermatol

The Psoriasis Life Stress Inventory: a preliminary index of psoriasis-related stress

Acta Derm Venereol

Psychiatric–Medical Comorbidity
Understanding the relationship between objective disease severity, psoriatic symptoms, illness-related stress, health-related quality of life and depressive symptoms in patients with psoriasis — a structural equations modeling approach