Depression and Quality of Life among Saudi Patients with Vitiligo: A Descriptive Quantitative Review

1. INTRODUCTION

Vitiligo vulgaris is a widely common disfiguring skin disease and has an estimated prevalence of 0.5 to 2% worldwide [1, 2]. It is a multifactorial disorder characterized by depigmentation of the skin and mucosa due to deficiency or inactivation of melanocytes in the basal layer of the epidermis [1-3]. Its exact etiology is not entirely known. It occurs when there is a dysfunction or death of melanocyte cells due to auto-immune disease. The exact triggering factors of vitiligo's immune complex are unknown. However, contemporary evidence suggests a convergence theory as a comprehensive overview of vitiligo vulgaris etiology [4]. The current evidence emphasizes the pivotal involvement of immune cells and their mediators in the pathogenesis of vitiligo vulgaris. Prominent immune cell players encompass T cells, regularity and resident memory T cells, dendritic cells, natural killer cells, and activation of the type 1-IFN pathway [5]. Because vitiligo's appearance greatly impacts body image, it is unsurprising that the psychosocial well-being of patients suffering from it can be greatly impacted [6]. Vitiligo vulgaris is associated with low self-esteem, a tendency to social isolation, self-consciousness, psychological stigmatization, and social discrimination [7-9]. Vitiligo vulgaris patients are vulnerable to depression, anxiety, and social phobia [9, 10]. A growing body of evidence suggests a bidirectional association between depression and vitiligo vulgaris, which can be psychologically devastating [11]. This depression may affect vitiligo vulgaris patients' employment and restrict their social activities. These emotional effects have been reported in several systematic reviews [12, 13]. As sufferers from a chronic and often disfiguring disease, patients with vitiligo vulgaris are also associated with a poor quality of life (QoL) that is especially observed among the Asian and dark-skinned populations, married women, and in patients where vitiligo vulgaris appears on exposed sites [7, 14-16]. Furthermore, since depression and stress can increase systemic inflammation, the interplay between the burden of psychosocial stress and vitiligo vulgaris can worsen disease activity [3]. For these reasons, a conceptualization and management of the psychosocial aspect of vitiligo vulgaris is worth addressing.

In the Kingdom of Saudi Arabia, the prevalence of vitiligo vulgaris varies from 0.5 to 3.5% [17, 18]. Vitiligo vulgaris is found to demoralize the lives of affected patients and their families [11-13]. Considering these somatic morbidities, the psychosocial aspects of vitiligo vulgaris warrant further discussion. Two conceptions are considered in this review. Firstly, the relationship between depression and vitiligo vulgaris among Saudi patients is studied. Secondly, QoL and its effect on vitiligo vulgaris patients is evaluated. Although several studies on the psychosocial well-being of Saudi vitiligo vulgaris patients have been published before, there is no comprehensive understanding of this subject. Therefore, given the clinical importance of this topic, this descriptive quantitative review was carried out to provide a critical reappraisal based on a summary of the results of existing knowledge on depression among vitiligo vulgaris patients in Saudi Arabia. Furthermore, an identification and evaluation of the psychosocial impact of vitiligo vulgaris in a sub-group of Saudi patients tested using different domains of QoL measurements, and an offer of the best evidence of the psychological process for planning therapy for these patients was performed.

2. MATERIALS AND METHODS

3. RESULTS

The initial database generated a preliminary 124 articles on patients with vitiligo vulgaris. After screening the title and abstract, 96 articles were discarded as they were review articles and were not done in Saudi Arabia. Therefore, 28 articles were found eligible. Finally, 13 articles were found to fulfil the inclusion criteria. Two other studies were also discarded because of insufficient data. The remaining (n = 11) articles fulfilled the inclusion criteria and were included in the final analysis. (Fig. 1) All the included studies were cross-sectional. Of the included studies, 5 examined the association between vitiligo vulgaris and depression (Table 1) [21-25], while 6 studies examined the association between vitiligo vulgaris and QoL (Table 2) [15, 16, 21, 26, 27] Inter-rater agreement between the 2 researchers was 96%. There was considerable methodological variability, and the data extracted from different studies was heterogeneous. Most of the studies used BDI and HADS scales to assess depression.

3.2. Factors associated with Depression in Vitiligo Vulgaris Patients

The results of the studies showed that vitiligo vulgaris patients in a lower age group (<30 years old) are more prone to depression than vitiligo vulgaris patients in older age groups [23-25]. Furthermore, depression is more prevalent among females than it is among males [22, 24]. When we probed the results of the articles reviewed, we found patients perceive hands and exposed areas as the most impactful part of the body: they had an OR of 3.9 (1.1–14.2) and a p-value of 0.035 [25]. Depression was associated with a duration of disease of less than 5 years in different studies (P value = 0.001) [24, 25]. Also, Alharbi et al. [23], Shatla et al. [25], and Alsawaf [24] reported that the association of depression with marital status was significantly high among single patients (p = 0.006, p < 0.035, and p < 0.001), respectively, while others found no significant difference between single and married patients [22]. Most of the articles suggest that vitiligo vulgaris patients with high education are likely to have depression (P < 0.001, p = 0.037) [22, 24]. Alharbi et al. [23] reported that depression is high among patients with a low educational level (p < 0.001). The employment status of vitiligo vulgaris patients has no significant association with being depressed [22, 24, 25]. Pooled odds ratios could not be arrived at due to the lack of this outcome measure across the studies for any factors associated with depression in vitiligo vulgaris patients.

Table 3.

Study/Refs.	Sample size	Proportion (%)	95% CI	Weight (%)
				Fixed	Random
Alhetheli et al. [21]	173	53.757	46.030 to 61.354	19.12	20.37
Almomani et al. [22]	234	27.350	21.745 to 33.539	25.82	20.75
Alharbi [23]	308	54.545	48.801 to 60.201	33.96	21.02
Alsawaf et al [24]	58	58.621	44.927 to 71.404	6.48	17.91
Shatla et al. [25]	132	37.121	28.877 to 45.957	14.62	19.94
Total (fixed effects)	905	44.885	41.620 to 48.184	100.00	100.00
Total (random effects)	905	45.812	33.503 to 58.386	100.00	100.00

4. DISCUSSION

This review was conducted to understand the adverse effect of vitiligo vulgaris on the psychological well-being of Saudi patients. Despite not being life-threatening, the uncertainty of the clinical course of the disease and a lack of effective therapy causes vitiligo vulgaris to have a profound effect on the psychosocial being of patients. Therefore, we aimed to update and expand previous reports on the subject and quantify the level of depression and QoL among these patients. The outcome was inconsistent among studies owing to substantial variability of the results. This review suggests that Saudi patients with vitiligo vulgaris experience a significant disease-related burden and self-perceived depression. In the present study, the pooled data showed that the prevalence of depression is higher among Saudi patients with vitiligo vulgaris compared with average reported data on depression in the general population but is consistent with many international reports [13, 29, 30]. Several systematic reviews and a meta-analysis of the prevalence of depression among vitiligo vulgaris patients yielded divergent results: 12.2% to 59% [13, 31-33]. This variation is attributed to diverse ethnic backgrounds, geographical locations, and different assessment tools. In the current review, a young age (<30 yrs), female sex, and a short duration of the disease (less than 5 yrs) were found to be associated with perceived depression. In addition, marital status and low educational levels also offer protection, while the presence of vitiligo vulgaris in an exposed area often has an additional impact on depression. These results are in concurrence with previous reports [12, 32]. Depression is a significant impact factor in the long-term health of patients with chronic diseases, including vitiligo vulgaris, and recent data indicates that there is an increased risk of mortality among patients with depression [32-34]. Moreover, vitiligo vulgaris may increase depression, and, in turn, depression could exacerbate vitiligo [3]. The pathogenesis of depression in vitiligo vulgaris patients is unknown. However, the increased activity of hypothalamic–pituitary access with an increased level of catecholamines during chronic stress activates α receptors in skin arterioles, causing vasoconstriction and leading to microcirculation disturbance and epidermal and dermal hypoxia. As a result, the generation of oxidative stress results in cellular stress and the eventual destruction of melanocytes [35, 36]. Furthermore, there is an assumption that H₂O₂-mediated oxidation of acetylcholine esterase causes substantial oxidative stress in vitiligo vulgaris [37]. This assumption may underlie the theory behind the prevalence of depression among vitiligo vulgaris patients. Changes in neurotransmitters have been postulated as the reason behind using antidepressant agents such as amitriptyline, which has significant anticholinergic action and mild norepinephrine reuptake blockage in patients with vitiligo vulgaris and depression [38].

Data from different studies, including ours, show an impairment of the QoL among vitiligo vulgaris patients with gender differences, and the QoL score among vitiligo vulgaris patients is generally lower among females than among males [39-43]. This may be because females are vulnerable to experiencing negative emotions regarding their aesthetics, including anxiety, depression, and embarrassment from the stigma of feeling different because of great societal pressures on the female physical appearance [8, 43, 44].

The young are particularly psychologically affected by vitiligo vulgaris and have an overall great impairment of QoL since their age group is especially conscious of physical appearances and social acceptance. The young may view this disease as detrimental to their self-esteem and hindering their chance of finding a life partner [45, 46]. The findings of this review are also consistent with previous studies from Iran and Korea, which showed that QoL is poor among young age groups [42, 47]. Although this review showed that being married resulted in a higher QoL score compared to being single, there are conflicting results between married males and married females. Moreover, the effect of vitiligo vulgaris on the QoL of the married subjects is not as profound in the long run as it is in a single person with vitiligo vulgaris. Marriage is thought to profoundly affect the overall well-being of a vitiligo vulgaris patient as their significant other can offer emotional, physical, and financial support [48]. Unlike singles, the psychological burden of the disease is intense, as having vitiligo vulgaris decreases the chances of intimate relationships and marriage [49].

The impact of the affected body parts- especially exposed areas such as the face, hands, and feet and lesions on a large part of the body- significantly affects the patient's QoL. The result from this review can be compared to previous studies by Bae et al. [50] and Benny et al. [41]. Vitiligo vulgaris patients may view themselves as flawed and hideous, which may negatively affect their psychological condition as well as their social and professional relationships. Furthermore, this negative perception about oneself can be either a driving force to seek treatment or to hide the visible areas affected using makeup or clothing [32, 39, 51]

5. LIMITATION OF THE STUDY

Our study has methodological shortcomings. Firstly, the reviewed papers were cross-sectional research, which can impede a strong conclusion due to their inherent flaws. Secondly, there may be selection bias as all subjects were recruited from dermatology clinics; this may be misleading because patients who suffer from few psychological complaints are less likely to seek medical advice. Finally, because different instruments were used to quantify depression in different study groups, comparing these studies is imprecise.

CONCLUSION

This review provides a comprehensive overview of existing quantitative data on the impact of vitiligo vulgaris on the mental health of Saudi patients. Vitiligo vulgaris has a substantial negative effect on the QoL of these patients. It is, therefore, important that depressive illness in patients with vitiligo vulgaris is addressed by dermatologists. Screening these patients for depression may help treatment outcomes. Future research should concentrate on high-risk groups in need of psychiatric referral. Owing to the heterogeneity of the results, the data should be interpreted with caution.

REFERENCES