Is Bad Skin Driving Some Patients to Suicide?
The incidence of psychiatric disorders among dermatology patients is high, with estimates ranging between 30 to 40 percent.1 Psychiatric conditions include depression, anxiety, obsessive compulsive disorder (OCD), post traumatic stress disorder (PTSD), body dysmorphic disorder (BDD), and sometimes dissociative amnesia.2
The relationship between dermatological and psychiatric disorders is complex, but the most widely accepted classification distinguishes between three types of "psychocutaneous disorders," which increase suicide risk in affected patients:3
- Dermatosis of primary psychological/psychiatric nature, responsible for self-induced dermatologic disorders (eg, trichotillomania)
- Dermatosis of multifactorial basis (eg, psoriasis, atopic dermatitis, acne), the course of which is subject to emotional influences
- Psychiatric disorders secondary to serious or disfiguring dermatosis (eg, adjustment disorders with depression or anxiety in conditions such as alopecia areata or vitiligo)
The connection between skin and psychiatric disorders has only recently begun to garner research attention, as dermatologic conditions have been popularly regarded as a relatively benign, in terms of mortality risk. In their article "Suicide Risk in Skin Disorders,"4 Picardi and colleagues review the risk and management of suicidality in patients with dermatologic conditions.
What Increases Risk?
Studies comparing dermatologic diseases to each other have yielded mixed results in terms of which disease (psoriasis, atopic dermatitis, acne vulgaris, and urticaria) carries the highest risk. Several studies have found psoriasis to carry the highest risk of suicidal ideation, compared to acne, alopecia areata, atopic dermatitis, eczema, and urticaria, but acne also is associated with suicide attempts, which "underscore the danger inherent in neglecting psychosocial aspects... especially in those suffering from the disease after adolescence."
Isotretinoin, an agent used to treat cystic acne, carries a documented risk factor for suicidality,5 but the authors note that the disorder itself carries an independent risk for suicidality.
Most studies have found that higher suicide risk is mediated by concerns of appearance and embarrassment, though some suggested a significant role of impaired quality of life (QOL) as an important mediating factor. This includes changes in body image (eg, skin lesions on exposed body parts) and difficulties in interpersonal relationships and impaired daily activities. In general, clinical disease severity is less associated psychological distress than is the impact of skin disease on QOL and social relationships.
Additional risk factors include male gender, marital status (unmarried, widowed, or divorced), age (adolescent and young adult, and geriatric), personal or family history of mood disorders or other severe psychiatric illness, history of childhood abuse, current or past alcohol abuse, family history of suicide, suicidal ideation, feelings of hopelessness, impulsivity, aggression, severe or chronic physical illness, recent bereavement, lack of social support, unemployment, and access to firearms or other lethal means.
Assessment and Treatment of Suicide Risk
The authors outline an array of assessment tools for potentially suicidal patients in dermatology practice, including the use of brief depression screening questionnaires that have been validated in dermatologic settings (eg, the PHQ-9)6 and a general evaluation of suicidality usable in any setting (eg, the evaluation laid out in the American Psychiatric Guidelines for Assessment of Patients with Suicidal Behaviors).7 A companion article by Gupta and Gupta2 provides an algorithm for assessing depression that is specific to patients with dermatologic disorders.