Prevalence and correlates of suicidal ideation

among patients with skin disease

Angelo Picardi, MD, Eva Mazzotti, DPsych, and Paolo Pasquini, MD, MPH
Rome, Italy

Background: Concerns have been raised about the potential of deliberate self-harm and suicide among
patients with dermatologic conditions.

Objective: We sought to estimate the prevalence of suicidal ideation among patients with dermatologic
conditions, and to identify demographic, clinical, and psychosocial correlates.

Methods: Two samples of outpatients with dermatologic conditions (N = 294) and inpatients (N = 172)
completed the 12-item General Health Questionnaire, the Skindex-29, and the Patient Health
Questionnaire.

Results: Forty patients (8.6%) reported suicidal ideation during the previous 2 weeks. In univariate
analysis, the presence of suicidal ideation was associated with female sex, inpatient status, presence of a
depressive or anxiety disorder, and higher 12-item General Health Questionnaire and Skindex-29 scores.
The size of the diagnostic groups allowed reasonable prevalence estimates only for psoriasis (10%) and
acne (7.1%). In multivariate analysis, only emotional distress (12-item General Health Questionnaire) and
impaired social functioning (Skindex-29) were independently associated with suicidal ideation.

Limitations: We lacked an observer-rated evaluation of skin condition and could rely only on the Skindex-
29 symptoms subscale as a measure of disease severity. In addition, the measurement of suicidal ideation
was limited as a result of the use of only one question to assess it. Furthermore, the cross-sectional design
prevented causal inferences.

Conclusion: Suicidal ideation is not rare among patients with dermatologic conditions. Assessing suici-
dality would be warranted in dermatologic practice among patients at particular risk such as women with
high psychologic distress and impaired social functioning. The development of psychiatric consultation-
liaison services is mandatory to provide effective treatment and careful follow-up of patients who are
suicidal. ( J Am Acad Dermatol 2006;54:420-6.)

I n recent years, there has been increasing

awareness of the high prevalence of psychiatric
disorders among patients with dermatologic
conditions.1-4 In addition, concerns have been raised
Abbreviations used:
CI:

PHQ:
confidence interval
GHQ-12: 12-item General Health Questionnaire
Patient Health Questionnaire
about the potential for deliberate self-harm among
patients with skin diseases. Indeed, several cases
of patients with dermatologic conditions who
From the Clinical Epidemiology Unit, Dermopathic Institute of the completed suicide have been reported.5,6 In a survey
Immaculate IDI-IRCCS. of 341 consultant dermatologists in the United
Funding sources: Pfizer Italy kindly provided the official Italian Kingdom, participants reported that they knew of
version of the PHQ and is thanked by the authors.
Conflicts of interest: None identified.
178 and 28 patients who had either attempted or
Accepted for publication November 30, 2005. completed suicide, respectively.7 Some reports sug-
Reprint requests: Angelo Picardi, MD, Clinical Epidemiology Unit, gested that suicidal ideation and behavior can occur
Dermopathic Institute of the Immaculate IDI-IRCCS, Via dei among patients with mild skin lesions8 or no objec-
Monti di Creta, 104-00167 Rome, Italy. E-mail: [email protected]. tive signs of skin disease.9
Published online January 17, 2006.
0190-9622/$32.00
Suicide can be regarded as a process extending
ª 2006 by the American Academy of Dermatology, Inc. over time. Different types of suicidal expression,
doi:10.1016/j.jaad.2005.11.1103 such as life weariness, death wishes, suicidal

420
J AM ACAD DERMATOL Picardi, Mazzotti, and Pasquini 421
VOLUME 54, NUMBER 3

ideation, suicidal plans, and suicidal attempts, con- a sealed envelope to their dermatologist during the
stitute a possible continuous sequence of phenom- visit.
ena,10 although there may be exceptions to this In the second study, all adult patients admitted
pattern.11 Although unplanned suicide attempts to 5 inpatient wards on predetermined days were
are seldom preventable, planned attempts might contacted by a research dermatologist. All partici-
be. Given that suicidal ideation is associated with a pants signed an informed consent form and com-
markedly increased probability of planned suicidal pleted several self-report instruments.
behavior,12 any intervention aimed at early detection
and treatment of patients at risk might carry consid- Assessment instruments
erable benefit. As only a minority of suicidal indi- In both studies, patients completed, among
viduals overtly seeks professional help for mental other self-report instruments, the Patient Health
health reasons,13 the dermatologic consultation Questionnaire (PHQ), the 12-item version of the
might be a precious opportunity to recognize and General Health Questionnaire (GHQ-12), and the
treat depression associated with suicidal ideation in Skindex-29.
these patients. The PHQ is a fully self-administered version of
To date, only two studies have systematically the Primary Care Evaluation of Mental Disorders.
assessed the prevalence and correlates of suicidal PHQ diagnoses are strongly associated with indices
ideation among patients with dermatologic condi- of functional impairment and health care services
tions.14,15 Although both studies included an assess- use. The PHQ has also been tested against indepen-
ment of psychologic distress, only one included an dent diagnoses made by mental health professionals.18
evaluation of quality of life,15 and no study included It consists of several sections, each focused on spe-
an assessment of depression according to operation- cific psychiatric conditions. Each PHQ section can be
alized psychiatric diagnostic criteria. used independently. In both studies, we adminis-
The current study aimed at inquiring further tered the section on anxiety disorders and the 9-item
about the prevalence of suicidal ideation among pa- section on depressive disorders. The latter is closely
tients with dermatologic conditions, and at identify- worded after the Diagnostic and Statistical Manual
ing demographic, clinical, and psychosocial factors of Mental Disorders, Fourth Edition19 summary cri-
associated with suicidal ideation. To this purpose, terion for each symptom, and includes one item
we performed a new and specific analysis of the assessing the presence and severity of suicidal ide-
information collected in two recent studies where a ation, which is worded as follows: ‘‘over the last
standardized assessment of suicidal ideation, health- two weeks, how often have you been bothered
related quality of life, emotional distress, and de- by thoughts that you would be better off dead or
pressive and anxiety disorders had been performed. of hurting yourself in some way?’’ The possible
answers are ‘‘not at all,’’ ‘‘several days,’’ ‘‘more than
half the days,’’ and ‘‘nearly every day.’’ We used the
METHODS official Italian version of the PHQ.
Participants and procedure The GHQ-1220 is a widely used self-administered
The data were drawn from previous studies on questionnaire to measure psychologic distress. The
the recognition of depressive and anxiety disorders Italian translation has established validity and relia-
in outpatients with dermatologic conditions16 and on bility21 in patients with skin diseases.22,23 Higher
the performance of 3 depression screeners in inpa- scores indicate greater psychologic distress.
tients with dermatologic conditions.17 Both investi- The Skindex-29 is a self-administered question-
gations were performed at our facility, which is the naire to measure the effects of skin disease on
largest dermatologic institution in Italy. It serves the patients’ quality of life. It consists of 3 scales, asses-
entire population of Rome and its province (approx- sing burden of symptoms, social functioning, and
imately 3,800,000 people, of whom 3,200,000 are emotional state, respectively. Several studies pro-
aged $ 18 years). In addition, several patients come vided evidence of reliability and validity for this
from central and southern Italy. The institutional instrument.24-26 We used the validated Italian ver-
ethical committee reviewed and approved the pro- sion.26 Higher scores indicate greater negative im-
tocols of both studies. pact of skin disease on quality of life.
In the first study, all adult outpatients seen by 4
dermatologists on predetermined days were appro- Data reduction and statistical analysis
ached in the waiting room by a research assistant. All The PHQ scoring algorithm was used to generate
participants signed an informed consent form, com- the diagnoses of major depressive disorder and other
pleted self-report instruments, and returned them in depressive disorder. Skindex-29 was scored as
422 Picardi, Mazzotti, and Pasquini J AM ACAD DERMATOL
MARCH 2006

recommended.24 The GHQ-12 was scored with the 7.6) for having a PHQ diagnosis of anxiety disorder.
Likert scoring method, which assigns separate scores No significant association was found with age, mar-
to each response category. ital status, and education (all P [.15).
First, a descriptive analysis was performed. Exact To better understand what aspects of emotional
binomial 95% confidence intervals (CI) for propor- distress and impaired quality of life were related to
tions were calculated. Then, the x2 test (with Yates’ suicidal ideation, we repeated the comparison be-
correction for 2 3 2 tables) and the t test were used as tween patients with and without suicidal ideation at
appropriate to analyze differences between patients the item level, and we calculated the effect size for
with and without suicidal ideation. To provide a each item. In all, 5 GHQ-12 items and 8 Skindex-29
common metric to gauge the magnitude of effect items had an effect size greater than 0.90, indicating a
across items of different questionnaires, the effect very strong association with suicidal ideation. These
size was calculated for each GHQ-12 and Skindex-29 GHQ-12 items cover problems related to depression,
item by dividing mean differences between groups ie, ‘‘Not playing a useful part,’’ ‘‘Could not make
with the pooled SD. Finally, multiple logistic regres- decisions,’’ ‘‘Could not overcome difficulties,’’
sion was used to identify factors independently ‘‘Unhappy and depressed,’’ ‘‘Felt worthless.’’ These
associated with suicidal ideation. Statistical analyses Skindex-29 items cover painful feelings of frustration
were run under software (SPSS, Version 9.0 for and humiliation, and difficulties in close relation-
Windows, SPSS Inc., Chicago, Ill). ships, ie, ‘‘Skin condition affects closeness with loved
ones,’’ ‘‘Skin condition makes showing affection
RESULTS difficult,’’ ‘‘Skin condition affects interactions with
In the first investigation,16 4 of 317 eligible others,’’ ‘‘Skin condition is a problem for loved
outpatients returned a blank questionnaire, and 9 people,’’ ‘‘Skin condition makes me feel frustrated,’’
did not answer the PHQ. We also excluded another 10 ‘‘Skin condition affects desire to be with people,’’
patients who answered incompletely the PHQ section ‘‘Skin condition makes me feel humiliated,’’ ‘‘Skin
on depressive disorders. Hence, 294 patients (92.7% condition interferes with sex life.’’
of eligible patients) were included in the analysis. The relationship between dermatologic diagnosis
In the second investigation,17 145 inpatients and suicidal ideation was examined in those diag-
returned a complete PHQ (81.5% of eligible pa- nostic groups with more than 10 people each,
tients). We also included in the analysis a further allowing for reasonable although tentative preva-
27 inpatients who had not been involved in the study lence estimates. Although suicidal ideation was
on depression screeners but nevertheless had com- absent among patients with minor skin conditions
pleted the PHQ, Skindex-29, and GHQ-12 according such as nevi (N = 33), mycosis (N = 11), and
to the same procedure. androgenetic alopecia (N = 15), it was frequent
Of 466 patients included in the analysis, 40 (8.6%; among patients with seborrheic dermatitis (N = 19;
95% CI 6.2-11.5) reported suicidal ideation during prevalence 5.3%; 95% CI 0.1-26.0), bacterial infec-
the last 2 weeks. It had been present ‘‘several days’’ in tions (N = 15; prevalence 6.7%; 95% CI 0.2-31.2),
29 patients (6%), ‘‘more than half the days’’ in 8 benign skin neoplasms (N = 28; prevalence 7.1%;
patients (1.6%), and ‘‘nearly every day’’ in 3 patients 95% CI 0.8-23.5), acne (N = 42; prevalence 7.1%; 95%
(0.6%). Only 7 patients with suicidal ideation (17.5%) CI 1.5-19.5), skin tumors (N = 12; prevalence 8.3%;
reported that they were taking medication for 95% CI 0.2-38.4), various forms of dermatitis (N = 57;
‘‘anxiety, depression, or stress.’’ prevalence 8.8%; 95% CI 2.9-19.3), and particularly
A detailed comparison of patients with and with- frequent among patients with psoriasis (N = 80;
out suicidal ideation on demographic and clinical prevalence 10%; 95% CI 4.4-18.7) and urticaria
variables is presented in Table I. (N = 16; prevalence 18.8%; 95% CI 4.0-45.6).
In univariate analysis, suicidal ideation was asso- Finally, multiple logistic regression analysis was
ciated with female sex (P = .02), inpatient status performed to identify factors independently associ-
(P # .001), PHQ diagnosis of major depressive dis- ated with suicidal ideation. Given that the dependent
order or another depressive syndrome (P \ .001), variable was derived from a PHQ item, GHQ-12
PHQ diagnosis of anxiety disorder (P = .01), and scores were preferred to PHQ diagnoses as measure
higher scores on the GHQ-12 and on the Skindex-29 of psychologic distress, to avoid any overlap be-
symptoms, functioning, and emotions scales (all P \ tween predictors and dependent variable. When
.001). The odds ratio, a close approximation to analyzing data from paper-and-pencil instruments,
relative risk, was 2.6 (95% CI 1.2-5.6) for being it is prudent to consider the possible influence of age
female, 12.8 (95% CI 6.3-26.1) for having a PHQ and education. Therefore, although these variables
diagnosis of depressive disorder, and 3.2 (95% CI 1.4- were not associated with suicidal ideation in
J AM ACAD DERMATOL Picardi, Mazzotti, and Pasquini 423
VOLUME 54, NUMBER 3

Table I. Characteristics of patients with suicidal ideation compared with patients without suicidal ideation
Presence of Absence of
suicidal ideation suicidal ideation
(n = 40) (n = 426)
Age, y (%)
18-29 46.2 42.3
30-39 10.3 23.9
40-49 17.9 15.1
50-59 10.3 11.3
$ 60 15.4 7.3
Sex*
Male 23.1 43.7
Female 76.9 56.3
Marital status
Unmarried 48.7 49.5
Married 43.6 46.4
Separated or divorced 7.7 4.1
Education
0-8 y 30.8 25.5
High school 59.0 59.6
University 10.3 14.9
Inpatient/outpatient statusz
Inpatients 15.1 84.9
Outpatients 4.8 95.2
Psychologic distress
GHQ-12 score (mean 6 SD)z 18.7 6 7.1 11.5 6 5.5
Health-related quality of life
Skindex-29 functioning (mean 6 SD)z 44.3 6 29.1 18.6 6 20.1
Skindex-29 emotions (mean 6 SD)z 49.6 6 26.0 30.6 6 21.2
Skindex-29 symptoms (mean 6 SD)z 49.5 6 24.3 32.1 6 24.0
PHQ diagnosis
Any depressive disorderz 56.4 9.2
Any anxiety disordery 20.5 7.4

GHQ-12, 12-Item General Health Questionnaire; PHQ, Patient Health Questionnaire.

*P # 05.
y
P # .01.
z
P # .001.

univariate analysis, they were nevertheless entered prevalence in a large, heterogeneous sample of
in the regression model. Sex, age, education, inpa- patients with dermatologic conditions was as high
tient or outpatient status, GHQ-12, and Skindex-29 as 8.6%, with a lower confidence limit of 6.2%. As
scales were entered as independent variables, expected based on previous work,15 suicidal idea-
whereas suicidal ideation was entered as dependent tion was more common among inpatients than
variable. A test of this model versus a constant-only outpatients. However, even in outpatients only, the
model was highly significant (P # .0001). The prevalence was still about 5%. Given that recent
Nagelkerke R2 was 24.5%, and 91.1% of participants population-based studies reported 1-year preva-
were correctly classified. Only higher scores on the lence rates of suicidal ideation of 2.4% in Finland,27
GHQ-12 (P = .003) and the Skindex-29 functioning 3.4% in Australia,28 5.6% in the United States,29 and
scale (P = .04) were found to be independently 6.9% in Denmark,30 the point prevalence of 8.6% that
associated with suicidal ideation. we found among patients with dermatologic condi-
tions is really high. Recent studies assessing suicidal
DISCUSSION ideation with the PHQ in general practice settings
Our main finding is that suicidal ideation is reported similar or lower prevalence rates. For in-
common among patients with dermatologic condi- stance, the prevalence was 9% in 8 general practice
tions. Although the size of the diagnostic groups settings across the United States,31 whereas in an
allowed reasonably robust prevalence estimates only urban general practice setting in New York, NY,
for psoriasis (10%) and acne (7.1%), the overall serving a low-income population the prevalence of
424 Picardi, Mazzotti, and Pasquini J AM ACAD DERMATOL
MARCH 2006

suicidal ideation was only 3.7% among patients with item of the Skindex-29 symptoms scale showed a
no current psychotic symptoms.32 marked association with suicidal ideation. Similarly,
Our findings are consistent with the few studies a recent study found that the Dermatology Life
performed so far. Among 480 patients with psoriasis, Quality Index item more strongly associated with
mild-to-moderate facial acne, atopic dermatitis, or suicidal ideation was item 8: ‘‘How much has your
alopecia areata who completed the Carroll Rating skin created problems with your partner or any of
Scale for Depression, suicidal ideation and death your close friends and relatives?’’15 In addition, a
wishes were present among 4% and 7.3% of patients, relationship between emotional distress and poor
respectively. The highest prevalence was found perceived support by family and friends has recently
among inpatients with psoriasis (7.2%) and patients been underscored in patients with psoriasis or atopic
with acne (5.6%), whereas no patient with alopecia dermatitis.40 Results such as these suggest that it is
areata and only some outpatients with psoriasis not only the skin disease itself, but also its impact on
(2.5%) and patients with atopic dermatitis (2.1%) daily activities and especially on close relationships
reported suicidal ideation.14 In another study, sui- that is associated with emotional distress and the
cidal ideation as measured by the relevant Beck development of suicidal ideation. Indeed, a study on
Depression Inventory item was quite common patients with psoriasis showed that physical, psy-
among patients with psoriasis (21%) and atopic chologic, and social features of skin disease interact
dermatitis (19%). A bit surprisingly, patients with to create a negative impact on patients, and that
eczema (6%) and urticaria (6%) did not differ from suicidal ideation is more strongly linked to psycho-
healthy control subjects (7%).15 A Pakistani study logic distress and psychosocial disability than to
found a prevalence of suicidal ideation of 8% among disease severity.41
patients with acne.33 Furthermore, some patients Our study has several limitations. We lacked
with acne scars have been reported to have become an observer-rated evaluation of skin condition and
suicidal even after successful dermabrasion.34 These could rely only on the Skindex-29 symptoms scale as
findings suggest that considering acne merely a a measure of disease severity. In addition, only one
cosmetic problem and neglecting psychosocial as- PHQ item inquires about suicidal ideation. Future
pects can be dangerous.35,36 studies might profitably use more sophisticated
Consistently with a previous study,15 inpatient measures of suicidal ideation including several ques-
status was associated with suicidal ideation in uni- tions. Using a self-report measure to assess suicidal
variate analysis. Although several recent population ideation might be regarded as a further limitation,
studies did not report an association between female although it might be easier to give sincere answers to
sex and self-reported suicidal ideation,27,29,30 we an anonymous questionnaire than during a personal
found that suicidal ideation was more common in interview. Furthermore, the cross-sectional design
women. For instance, of 8 patients with psoriasis prevented causal inferences, and we could not
reporting suicidal ideation, 7 were female. However, determine the causal pathway accounting for the
multivariate analysis suggested that the association high prevalence of suicidal ideation in patients with
between suicidal ideation and both inpatient status dermatologic conditions. For instance, skin disease
and female sex is moderated by increased psycho- might trigger suicidal ideation, or an underlying
logic distress and psychosocial disability. Given their psychiatric condition might increase help-seeking
higher investment in appearance,37 women might behaviors such as visiting the doctor for a skin
be more vulnerable than men to the impact of skin problem. Likely, both pathways operate, depending
disease on their lives, as suggested also by the on the specific dermatologic condition and individ-
interaction between visibility of skin lesions and ual characteristics.
female sex in increasing the risk of psychiatric Despite these limitations, our results underscore
morbidity.38 the deep emotional suffering that can be associated
Psychologic distress and impaired quality of life in with skin diseases, and confirm the importance of a
the social functioning domain were the only inde- timely recognition of depression and psychosocial
pendent risk factors for suicidal ideation. Concerning disability among patients with dermatologic condi-
psychologic distress, the presence of a depressive tions. In the suicidal process, ideation precedes
or anxiety disorder was associated with suicidal ide- planning, which in turn may result in an attempt
ation. Consistently with the literature,39 the asso- leading to death.10 Therefore, early detection and
ciation with depression was particularly strong. treatment of patients with suicidal ideation is of
Regarding psychosocial disability, most Skindex-29 utmost importance. In our study, only 17.5% of
items strongly associated with suicidal ideation cov- patients with suicidal ideation reported that they
ered difficulties in close relationships, whereas no were taking medication for ‘‘anxiety, depression, or
J AM ACAD DERMATOL Picardi, Mazzotti, and Pasquini 425
VOLUME 54, NUMBER 3

stress.’’ Although some of the remaining patients of suicide. A sample question to start with might be
might have been receiving nonpharmacologic treat- ‘‘Do you ever think of hurting yourself or taking
ments such as psychotherapy, medication is the most your own life?’’ If the answer is yes, this should
common treatment for psychiatric disorders in Italy be followed by questions such as ‘‘Do you currently
and, thus, it seems quite likely that most patients with have a plan?’’ and possibly ‘‘What is your plan?’’ If
suicidal ideation were not receiving treatment for suicidal ideation is detected, the dermatologist can
emotional distress. Given that the Italian health care refer the patient to mental health services and pos-
system requires patients to be referred by their sibly alert patient’s close relatives to the danger and
primary care physician to the dermatologist, and the need of treatment. However, if the patient is
that inpatients with dermatologic conditions are unsure of being able to resist suicidal urges, or if the
usually seen as outpatients before hospitalization, dermatologist fears that the patient may not seek
this finding raises concern and corroborates reports help before committing self-harm, emergency psy-
of frequent underrecognition of depression both in chiatric evaluation is mandatory.46,49
primary care42 and dermatology.16,43 Although the dermatologist has a key role in
Our findings and those of other studies14,15 sug- preventing fatal self-harm in patients with suicidal
gest that assessing suicidality might be warranted in ideation, he or she also needs support from mental
patients with dermatologic conditions at higher risk, health professionals to treat these patients most
such as emotionally distressed women with inflam- effectively. Unfortunately, such support is not always
matory skin conditions or patients with other known available, and several dermatologists complain about
risk factors for suicidal behavior such as alcoholism, the scarcity of local clinical psychology or psychiatric
unemployment, and recent divorce or bereavement. liaison services.7 The development of consultation-
Given the strong association between depression liaison services50,51 and the implementation of qual-
and suicidal ideation, validated brief depression ity improvement programs52 are mandatory to
screeners such as the PHQ18 or Primary Care provide effective treatment and careful follow-up of
Screener for Affective Disorders17,44 might be helpful patients with dermatologic conditions and suicidal
to identify patients at increased risk. If screening is ideation or other mental health needs.
not feasible, 3 simple questions to identify patients at
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