Skin has a special place in psychiatry with its responsiveness to emotional stimuli and ability to express emotions such as anger, fear, shame and frustration, and by providing self-esteem, the skin plays an important role in the socialization process, which continues from childhood to adulthood. [1] The relationship between skin and the brain exists due to more than a fact, that the brain, as the center of psychological functions, and the skin, have the same ectodermal origin and are affected by the same hormones and neurotransmitters.[2] Psychodermatology describes an interaction between dermatology and psychiatry and psychology. The incidence of psychiatric disorders among dermatological patients is estimated at about 30 to 60%.[3] In the past era, dermatological conditions encountered high social criticism which led to stigmatization by subjects themselves and others that further took a toll on their mental health. Subjects that have psychiatric conditions such as catatonia, schizophrenia, and depression usually find it as challenging to maintain self-care owing to lack of contact with reality, loss of interest, and reduced energy. Further, these subjects can develop different dermatological conditions. Also, psychotropic drugs can lead to dermatological side effects including acne, and in a few cases, metabolic side-effects which can expose subjects to different dermatological disorders.[4] Co-occurrence of various psychiatric and dermatological conditions can be seen in different ways ranging from exacerbation of psychiatric symptoms owing to skin disorders to development of skin manifestations secondary to psychiatric conditions or from treatment of psychiatric conditions. Also, the psychosocial effect of various dermatological conditions such as eczema, psoriasis, and acne usually extends beyond physical symptoms causing impaired quality of life, social stigma, and emotional distress.[5] Despite the growing recognition of this intricate relationship, there remains a paucity of comprehensive studies exploring the prevalence, clinical characteristics, and management outcomes of dermatology patients with psychiatric comorbidities. Understanding the complex interplay between dermatological and psychiatric disorders is crucial for providing holistic care and improving treatment outcomes for these patients. Therefore, this study aims to fill this gap in knowledge by conducting a thorough investigation into the demographics, clinical profiles, prevalence of psychiatric comorbidities, and their correlation with socio-demographic factors among dermatology patients presenting at a tertiary care hospital

The present cross sectional study was conducted at dermatology outpatient department in collaboration with the psychiatry department of a tertiary care hospital for a period of one year. Ethical clearance for conducting the research was taken from institutional ethics committee of college and hospital before commencement of study. Patients relatives were asked to sign an informed consent form after explaining them about the study. Through convenience sampling a total of 230 patients who reported to ODP of dermatology and psychiatric department were selected for the study on the basis of selection criteria. Inclusion criteria- 1. Patients diagnosed with any dermatological disorder with a minimum duration of 4 weeks. 2. Patients with age between 18 to 60 years. 3. Patients willing to participate in research. Exclusion criteria- 1. Patients with serious or debilitating conditions, such as those with erythroderma, toxic epidermal necrolysis, and pemphigus. Data collection for this study included 230 patients with various dermatological complaints, and the recording of socio-demo graphic information for each patient was done. Subsequently, patients were referred to the psychiatry outpatient department for screening of depression, anxiety, and stress disorders using the DASS-21 scale. Statistical analysis of the gathered data was done using SPSS (Statistical Package for the Social Sciences) software version 25.0 (IBM Corp., Armonk. NY, USA) for assessment of descriptive measures, Student t-test, ANOVA (analysis of variance), and Chi-square test. The results were expressed as mean and standard deviation and frequency and percentages. The p-value of <0.05 was considered as statistically significant.

Table 1. Socio-demographic Profile of the Study Population (n = 230) Variable Category Frequency (n) Percentage (%) Age group (years) 18–30 72 31.3 31–40 65 28.3 41–50 54 23.5 51–60 39 17.0 Gender Male 124 53.9 Female 106 46.1 Marital status Married 142 61.7 Unmarried 88 38.3 Residence Urban 134 58.3 Rural 96 41.7 Duration of illness ≤ 6 months 89 38.6 > 6 months 141 61.4 Table 1 shows sociodemographic data of patients. The mean age of the study participants was 38.6 ± 11.2 years. Males constituted a slightly higher proportion of the sample (53.9%) compared to females (46.1%). Majority of the patients were married (61.7%) and belonged to urban areas (58.3%). Duration of illness was less than 6 months for 38.6% patients and greater than 6 months for 61.4% patients. Table 2. Distribution of Dermatological Diagnoses among Study Participants Dermatological condition Frequency (n) Percentage (%) Psoriasis 48 20.9 Acne vulgaris 44 19.1 Eczema 39 17.0 Chronic urticaria 31 13.5 Vitiligo 28 12.2 Fungal infections 22 9.6 Others 18 7.8 Table 2 shows Distribution of Dermatological Diagnoses among Study Participants. Psoriasis was the most commonly observed dermatological disorder (20.9%), followed by acne vulgaris (19.1%) and eczema (17.0%). Pigmentary disorders such as vitiligo accounted for 12.2% of cases. Table 3. Prevalence of Psychiatric Morbidity Based on DASS-21 Psychiatric condition Present n (%) Absent n (%) Depression 92 (40.0) 138 (60.0) Anxiety 108 (47.0) 122 (53.0) Stress 76 (33.0) 154 (67.0) Psychiatric morbidity 132 (57.4) 98 (42.6) Table 3 shows Prevalence of Psychiatric Morbidity Based on DASS-21. Overall psychiatric morbidity was detected in 57.4% of dermatology patients. Anxiety was the most prevalent condition (47.0%), followed by depression (40.0%) and stress (33.0%). Table 4. Severity Distribution of Psychiatric Disorders (DASS-21 Scores) Severity Depression n (%) Anxiety n (%) Stress n (%) Mild 34 (14.8) 41 (17.8) 29 (12.6) Moderate 38 (16.5) 46 (20.0) 31 (13.5) Severe 20 (8.7) 21 (9.1) 16 (7.0) Table 4 shows Severity Distribution of Psychiatric Disorders (DASS-21 Scores). Moderate severity levels were most frequently observed across all psychiatric domains. Severe depression, anxiety, and stress were present in 8.7%, 9.1%, and 7.0% of patients respectively. Table 5. Mean DASS-21 Scores among Study Participants Parameter Mean ± SD Depression score 13.8 ± 6.4 Anxiety score 15.6 ± 7.1 Stress score 14.2 ± 6.8 Table 5 shows mean DASS-21 Scores among Study Participants. The mean anxiety score (15.6 ± 7.1) was higher than depression and stress scores, indicating anxiety as the predominant psychiatric manifestation in the study population. Table 6. Association of Socio-demographic and Clinical Factors with Depression, Anxiety, and Stress among Study Subjects Variable Category Depression n (%) Anxiety n (%) Stress n (%) Age (years) ≤ 40 (n=137) 48 (35.0) 58 (42.3) 39 (28.5) > 40 (n=93) 44 (47.3) 50 (53.8) 37 (39.8) (p-value) (0.073) (0.089) (0.052) Gender Male (n=124) 42 (33.9) 50 (40.3) 32 (25.8) Female (n=106) 50 (47.2) 58 (54.7) 44 (41.5) (p-value) (0.032*) (0.023*) (0.009*) Marital status Married (n=142) 48 (33.8) 58 (40.8) 40 (28.2) Unmarried (n=88) 44 (50.0) 50 (56.8) 36 (40.9) (p-value) (0.013*) (0.015*) (0.028*) Residence Urban (n=134) 50 (37.3) 60 (44.8) 38 (28.4) Rural (n=96) 42 (43.8) 48 (50.0) 38 (39.6) (p-value) (0.290) (0.423) (0.060) Educational status ≤ Secondary (n=104) 50 (48.1) 58 (55.8) 44 (42.3) > Secondary (n=126) 42 (33.3) 50 (39.7) 32 (25.4) (p-value) (0.015*) (0.011*) (0.005*) Duration of dermatological illness ≤ 6 months (n=89) 26 (29.2) 32 (36.0) 21 (23.6) > 6 months (n=141) 66 (46.8) 76 (53.9) 55 (39.0) (p-value) (0.007*) (0.009*) (0.012*) Table 6 shows association of socio-demographic and clinical factors with depression, anxiety, and stress among study subjects. A statistically significant association was observed between longer duration of dermatological illness (>6 months) and the presence of depression, anxiety, and stress (p < 0.05). Patients with chronic skin conditions demonstrated higher psychiatric morbidity compared to those with shorter disease duration. Female gender, unmarried status, and lower educational level were also significantly associated with all three psychiatric outcomes. Age and place of residence did not show statistically significant associations, although higher prevalence rates were noted among older individuals and rural residents.

Our study demonstrated a large prevalence of psychiatric illnesses among dermatology patients, with a considerable percentage exhibiting signs of depression, anxiety, and stress. Overall psychiatric morbidity was detected in 57.4% of dermatology patients. Anxiety was the most prevalent condition (47.0%), followed by depression (40.0%) and stress (33.0%).These findings support prior studies indicating a significant frequency of psychiatric comorbidities among dermatological patients, highlighting the necessity for regular screening and therapy of mental health concerns in this demographic.[6,7] In our study the mean age of the study participants was 38.6 ± 11.2 years. Males constituted a slightly higher proportion of the sample (53.9%) compared to females (46.1%). Majority of the patients were married (61.7%) and belonged to urban areas (58.3%). Duration of illness was less than 6 months for 38.6% patients and greater than 6 months for 61.4% patients. These data were comparable to the previous studies of Halvorsen JA et al in 2014 and Dalgard FJ et al in 2015 where authors assessed subjects with dermatological and psychiatric disorders in their studies as in the present study. [8,9] Psoriasis was the most commonly observed dermatological disorder (20.9%), followed by acne vulgaris (19.1%) and eczema (17.0%). Pigmentary disorders such as vitiligo accounted for 12.2% of cases. In a study conducted by Vaibhav K et al it was found that the most common presenting complaint was itching in 60.09% (n=500) subjects followed by discoloration in 28.84% (n=240) subjects, rashes in 21.15% (n=176), scales in 9.13% (n=76), wheals and nodules in 8.17% (n=68), hair loss and pustules in 6.73% (n=56), erosions in 5.76% (n=48), comedons in 4.8% (n=40), papules in 4.32% (n=36), and fluid-filled lesions in 3.36% (n=28) study subjects respectively.[10] Similar results were found in the study conducted by Carniciu S et al in 2023 and Shenoi S et al in 2020 where the clinical profile of dermatological and psychiatric disorder subjects comparable to the present study was also reported by the authors in their respective studies.[11,12] The mean anxiety score (15.6 ± 7.1) was higher than depression and stress scores, indicating anxiety as the predominant psychiatric manifestation in the study population. Moderate severity levels were most frequently observed across all psychiatric domains. Severe depression, anxiety, and stress were present in 8.7%, 9.1%, and 7.0% of patients respectively. These findings were in agreement with the results of Raikhy S et al in 2017 and Bewley A et al in 2011 where the prevalence of stress, anxiety, and depression in dermatologic subjects reported by the authors in their studies was comparable to the results of the present study.[6,7] A statistically significant correlation (p < 0.05) was found between the presence of stress, anxiety, and depression with a longer duration of dermatological illness (>6 months). Compared to patients with shorter disease durations, individuals with chronic skin disorders showed increased psychiatric morbidity. All three mental outcomes were also substantially correlated with female gender, single status, and lower educational attainment. Higher prevalence rates were observed among older people and those living in rural areas, although there were no statistically significant correlations between age and place of residence. In a study conducted by Faizan MA et al explored the correlation between psychiatric symptoms and various demo graphic and clinical factors. Interestingly, we found a significant correlation between the duration of illness and depression scores, indicating a potential association between prolonged dermatological conditions and psychological distress. Addition ally, gender emerged as a significant factor, with females exhibiting higher mean scores of anxiety and stress compared to males. Depression’s complexity, influenced by genetic, environmental, and neurochemical factors, may not directly correlate with dermatological conditions as stress and anxiety do in females. This gender difference aligns with existing literature highlighting the differential psychological impact of dermatological conditions on men and women.[13,9] Study conducted by Vaibhav K et al correlation of sociodemographic data with stress, anxiety, and depression in study subjects, a statistically significant correlation was seen in family type to anxiety and depression with p=0.03 and 0.02 respectively. A significant association was also seen between socioeconomic status and depression with p=0.04. Gender also depicted a significant association with stress and anxiety with p=0.01 and 0.04 and illness duration to depression with 0.007. [10] Convenience sampling, which may introduce biases restricting generalisability, was utilised in our study to recruit individuals from an outpatient dermatology department at a tertiary care hospital. The cross-sectional design and the use of self-report measures for psychological evaluation are two other drawbacks. Further studies employing objective diagnostic criteria for psychiatric diseases and longitudinal techniques might shed more light on the interactions between psychiatry and dermatology.

The present investigation indicates a substantial burden of psychiatric comorbidity among patients attending the dermatology outpatient department at a tertiary care hospital. Depression, anxiety, and stress were regularly observed, with anxiety being the most prevalent psychiatric disorder. Female gender, unmarried status, lower educational level, and longer duration of dermatological illness indicated a statistically significant connection with psychiatric morbidity. Chronic dermatological disorders were related with a larger psychological burden compared to conditions of shorter duration. These findings underscore the complicated biopsychosocial link between skin disorders and mental health. Routine psychiatric assessment of dermatological patients, combined with a multidisciplinary approach involving dermatologists and mental health experts, is critical for holistic patient care and improved treatment outcomes.

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