This study included responses from dermatology clinic patients within the King Hussein Medical Center in Amman, Jordan over a 3 month period between November of 2023 and February of 2024. There was a total of 134 responses registered (89 Females and 45 Males). With an age range of 15-76 (Mean age of 34 years).
onsenting Dermatology clinic patients were asked to complete a questionnaire containing information about age, gender, presence of pruritis and its severity, and presence of depression and its severity. This study was approved by the institutional review board at the King Hussein Medical Center and was performed in accordance with the relevant regulations.
All patients were asked to answer whether pruritis was present or not. In patients with pruritis they were then asked to complete the 12-Item Pruritis Severity Scale (12-PSS) which contains 12 items to assess the severity of pruritis, with scores ranging from 3 to 22. According to the 12- PSS score, pruritis can be classified into 3 severities (Mild, Moderate, Severe). A score range of (3-6) constituted mild pruritis, A score range of (7-11) constituted Moderate pruritis, and a score range of (12-22) constituted severe pruritis. The figure below shows the 12- Item Pruritis Severity Scale. Fig (1)
All patients were asked to complete the Patient Health Questionnaire-9 (PHQ-9) which is a 9 item score used to assess for the presence of depression and its severity asking questions about symptoms over the last 2 weeks. It has a score range of 0-27 and according to the PHQ-9 score there can be 5 categories of patients. Patients with a score range of (0-4) are considered to have "No Depression", Those with a score range of (5-9) are considered to have "Mild Depression", Those with a score range of (10-14) are considered to have "ModerateDepression". Those with a score range between (15-19) are considered to have "Moderately Severe Depression", And those with score ranges between (20- 27) are considered to have "Severe Depression".
Statistical analysis was performed using SPSS. Groups were compared with t-test or with ANOVA or chi square test. We considered a p-value less than <0.05 to be significant.
A total of 134 patients were included in the study, with a median age of 32.0 (15- 76). The majority of patients were females (n=89, 66%), while 45 (34%) were males. Pruritis was seen in 69 (51%) of samples, and 65 (49%) did not have pruritis. The median pruritis score was 11.0 (3.0, 21.0), with 10 (14.5%) of patients having mild pruritis, 26 (37.7%) having moderate pruritis, and 33 (47.8%) having severe pruritis. Median depression score was 7.0 (0.0, 24.0), with 90 (67%) of patients experiencing depression, and 44 (33%) with no depression. Severity of depression was mild in 41 (31%) of patients, moderate in 31 (23%) of patients, moderately severe in 13 (9.7%) of patients, and severe in 5 (3.7%) of patients.
When comparing patients with and without pruritis, there was a significant difference in age showing that patients with pruritis had a significantly higher age compared to those without pruritis JOURNAL OF THE ROYAL MEDICAL SERVICES Vol. 33 No. 2 August 2025 4 (median: 37.0 vs. 26.0, p-value=0.008) as shown in Table 2. Inaddition, 40 (58%) of patients with pruritis were females (pvalue=0.033). There was no significant difference between the presence of pruritis and depression. We have found no statistically significant difference in depression scores between patients with pruritis and others without pruritis (median depression score: 7.0 vs 7.0, p = 0.2). Association between pruritus severity and depression When comparing pruritis severity, patients with severe pruritis (n=33) showed a significantly higher depression score compared to those with mild and moderate pruritis (median: 10.0 vs. 5.0 vs. 5.0, p-value=0.037) as shown in Figure 1. In addition, 94% of patients with severe pruritis had depression (p-value<0.001), of which 14 (42%) had mild depression, 11 (33%) had moderate depression, 4 (12%) had moderately severe depression, and 2 (6.2%) had severe depression (pvalue=0.002), while 13 (50%) of patients with moderate pruritis, and 5 (50%) of patients with mild pruritis had depression as shown in Table 3. There was a significant relation between the presence of depression and pruritis severity on chisquare test X² (2, N=69) = 16.149, p-value = 0.0003. Patients with severe pruritus were more likely to have depression.
Table 2: Comparison in demographic and depression score between pruritis groups.
|
Characteristic
|
Pruritis
69 1)
|
No Pruritis (N = 651)
|
P-value2
|
|
Age (Years)
Gender
Female
Male
Depression score
Presence of depression
Depression
No depression
Depression severity
No depression
Mild
Moderate Moderately severe
Severe
|
37 (15, 76)
40 (58%)
29 (42%)
7.0 (0.0,24.0)
49 (71%)
20 (29%)
20 (29%)
20 (29%) 16 (23%) 8 (12%) 5 (7.2%)
|
26 (15, 62)
49 (75%)
16 (25%)
7.0 (0.0, 18.0)
41 (63%)
24 (37%)
24 (37%)
21 (32%) 15 (23%)
5 (7.7%)
|
0.008
0.033
0.2
0.3
0.2
|
I Median (Minimum, Maximum); n (%)
Mild Moderate Severe 2 Characteristic 261 N = 331 P-value
Table 3: Comparison between depression and pruritis severity
|
Age (Years)
Gender
|
31 (15, 64)
|
41 (15, 65)
|
36 (16,76)
|
0.9
0.9
|
|
Female
|
6 (60%)
|
16 (62%)
|
18 (55%)
|
|
|
Male
|
4 (40%)
|
10 (38%)
|
15 (45%)
|
|
|
Depression score
Presence of depression
|
5 (0, 16)
|
5 (0, 21)
|
10 (3,24)
|
0.037
<0.001
|
|
Depression
|
5 (50%)
|
13 (50%)
|
31 (94%)
|
|
|
No depression
Depression severity
|
5 (50%)
|
13 (50%)
|
|
0.002
|
|
No depression
|
5 (50%)
|
13 (50%)
|
|
|
|
Mild
|
2 (20%)
|
4 (15%)
|
14 (42%)
|
|
|
Moderate
|
1 (10%)
|
4 (15%)
|
11 (33%)
|
|
|
Moderately severe
|
2 (20%)
|
2 (7.7%)
|
4 (12%)
|
|
3 (12%) 2 (6.1%)
I Median (Minimum, Maximum); n (%)
Kruskal-Wallis rank sum test; Fisher's exact test
DISCUSSION
Pruritis is an uncomfortable sensation that causes itchiness, it is a common symptom in many dermatological diseases and even in the general public with the prevalence of acute pruritis (<6 weeks) among the general public reported at 8.4% and chronic pruritis (>6 weeks) at 13.5% [1]. A large survey in dermatological outpatient clinics was conducted in 13 European countries assessing the distribution of skin. conditions among dermatological patients. In this sample of 4,994 adult participants, the prevalence of itch among dermatological patients was 54.4%, and among controls it was 8% [2]. This is close to the results we got in our study among dermatology patients in Jordan. Where 51.4% of our patients suffered from pruritis. Interestingly while pruritis is generally more common in females, in our study pruritis was more common in males with an OR of 2.2 (95% CI 1.05-4.6). The majority of patients with pruritis had Severe pruritis with 47.82% of patients having severe pruritis according to 12-PSS. The majority of patients had severe pruritis (47.82% according to 12-PSS). This reflects the effect of severe disease on the mental health and the psychological aspect of patients. However, these results need to be interpreted carefully, as our data comes from a single-center tertiary hospital. As for depression, the results we had with the PHQ-9 screening were more than that reported in other studies with 67.2% of our dermatology patients suffering from depression according to PHQ-9 screening. Studies on depression prevalence estimated it to be 3.8% among the general public [3]. A meta-analysis of 83 cross-sectional studies assessing the presence of depression among outpatient clinics of different specialties showed a prevalence of 27% of depression among outpatient clinic patients. The highest depression/depressive symptom prevalence estimates occurred in studies of outpatients from otolaryngology clinics (53.0%), followed by dermatology clinics (39.0%) and neurology clinics (35.0%) [4]. The higher prevalence of depression among dermatology clinic patients in Jordan as compared to other countries remains unexplained, and it could be due to differences in screening tests used, differences in standards of life, and possible higher prevalence of depression among the Jordanian public [5]. Further data collection is needed to reinforce this finding and to find possible explanations. While there was no link in our study between the presence of pruritis as reported by patients with the presence of depression according to PHQ-9 screening, our limited sample size might have played a role in that finding. Patients with more severe pruritis were more likely to have moderately severe and severe depression, and this might explain the burden of severe pruritis on dermatology patients and possibly contributing to the development of depression in these patients. Additionally, both pruritis and depression are disorders of the nervous system. With many cases of pruritis being psychogenic and presenting with psychiatric symptoms, there might be a molecular explanation of their possible association [6]. It has been shown that the persistence of chronic stress in atopic dermatitis, with pruritus as a significant contributing factor, can perpetuate neuroendocrine dysfunction triggered by allergic inflammation. This, in turn, exacerbates the condition, creating a detrimental cycle of disease aggravation [7].
he cycle of itching and scratching eventually leads to a vicious circle, which can be interpreted as a loss of control and feelings of helplessness. Often, this is accompanied by a sense of despair and guilt [8]. Many studies have reported on a possible association between pruritus and depression, anxiety, insomnia, and quality of life [9]. But this is the first study done using the 12-PSS score to assess severity of pruritus and linking it to PHQ-9 screening for depression. It's also the first study to report on pruritis and depression among Jordanian dermatology patients. Such high rates of pruritis and depression among dermatology patients' population is very alarming, and it raises the importance of tackling these problems as dermatologists. Screening for psychological impacts including depression among all dermatology patients is of vital importance, as a lot of the time it can go unnoticed [10]. And so is screening for pruritis, while actively trying to relieve the sensation of itch, especially in those with severe pruritis who are more likely to have severe depression [11]. A previous study conducted on dermatology inpatients with itch as the primary symptom unveiled that among 109 patients, 70% were diagnosed with up to 6 psychiatric or psychosomatic conditions. Additionally, psychiatric or psychotherapeutic intervention was deemed necessary for 62% of all patients [12]. While in another investigation involving dermatology, outpatients found that one-third of those experiencing pruritus had concurrent psychiatric disorders. This elevated prevalence of comorbid psychiatric conditions is similarly observed in pruritic skin diseases like urticaria [13]. Moreover, the high prevalence rates of both conditions might intersect and contribute to the overall burden on dermatology patients. These factors among dermatology patients can have a large impact on the quality of life of patients and further research exploring potential causal relationships between pruritis and depression is needed.
LIMITATIONS
This study provides several strengths. The study utilized well-established assessment tools such as the 12-Item Pruritus Severity Scale (12-PSS) and the Patient Health Questionnaire-9 (PHQ-9) to evaluate the severity of pruritus and depression, respectively. This enhances the validity and reliability of the findings. However, the findings should be interpreted carefully due to several limitations. First, the study was conducted at a single dermatology clinic within the King Hussein Medical Center in Amman, Jordan. This limits the generalizability of the findings to a broader population, as the results may not be representative of other geographical locations or healthcare settings. The study utilized a cross-sectional design, which provides a snapshot of data at a single point in time. Longitudinal studies may offer insights into the temporal relationship between pruritus and depression and provide a better understanding of causality. The data collected relied on self-reported measures from patients, including the presence and severity of pruritus and depression. This introduces the possibility of response bias or misreporting, which could affect the accuracy of the results. Another major limitation of this study is the small size of patients which can produce false-positive results, or they over-estimate the magnitude of an association.
CONCLUSION
symptoms in our dermatology patient population, with over two thirds of patients suffering from depression and over half suffering from pruritis. Psychodermatology field is trending, and dermatologists are the sentinel for early detection of symptoms and should have a low threshold for psychiatric referral. Screening of Both conditions in dermatology patients is a must and further Improvements in therapeutics and patient care is required in order to improve patient's quality of life. Future studies should focus on investigating the association between depression and other skin diseases.
References
1. E. Weisshaar, "Epidemiology of Itch," Curr Probl Dermatol, vol. 50, pp. 5- 10, 2016, doi: 10.1159/000446010.
2. J. A. Halvorsen, J. Kupfer, and F. Dalgard, "The prevalence and intensity of itch among dermatological patients in 13 European countries," in acta dermatovenereologica, tradgardsgatan 14, uppsala, SE-753 09, SWEDEN, 2013, pp. 620-621.
3. "VizHub - GBD Results." Accessed: Mar. 18. 2024. [Online]. Available: https://vizhub.healthdata.org/gbd-results/
4. J. Wang et al., "Prevalence of depression and depressive symptoms among outpatients: a systematic review and meta-analysis," BMJ Open, vol. 7, no. 8, 2017, doi: 10.1136/BMJOPEN-2017- 017173.
5. N. T. Mleeh, H. M. Alshamrani, R. N. Basyouni, K. A. Alshehri, M. R. Algethami, and M. G. Sehlo, "Prevalence and predictors of depression among dermatology clinic patients in a teaching hospital, Jeddah, Saudi Arabia," J Family Med Prim Care, vol. 8, no. 7, p. 2496, 2019, doi: 10.4103/JFMPC.JFMPC_399_19.
6. H. L. Tey, J. Wallengren, and G. Yosipovitch, "Psychosomatic factors in pruritus," Clin Dermatol, vol. 31, no. 1, p. 31, Jan. 2013, doi: 10.1016/J.CLINDERMATOL.2011.11.004.
7. C. M. Moriguchi Jeckel et al., "Neuroendocrine and immunological correlates of chronic stress in 'strictly healthy' populations," Neuroimmunomodulation, vol. 17, no. 1, pp. 9-18, Oct. 2010, 10.1159/000243080.
8. J. C. Schneider et al., "Pruritus in Pediatric Burn Survivors: Defining the Clinical Course," Journal of Burn Care & Research, vol. 36, no. 1, pp. 151–158, Jan. 2015, doi: 10.1097/BCR.0000000000000145.
9. S. P. Sinikumpu, J. Jokelainen, K. Tasanen, M. Timonen, and L. Huilaja, "Association between Pruritus and Psychosocial Well-being: A Populationbased Study among 6,809 Subjects," Acta Derm Venereol, vol. 103, 2023, doi: 10.2340/ACTADV.V103.2922.
10. A. Kumar, K. Kumar, P. Swarup, S. Goel, and A. S. Tomar, "A study to find depression in patients attending dermatological OPD in a teaching hospital," J Family Med Prim Care, vol. 5, no. 2, p. 449, 2016, doi: 10.4103/2249- 4863.192317.
11. M. Rajagopalan et al., "Diagnosis and Management of Chronic Pruritus: An Expert Consensus Review," IndianJ Dermatol, vol. 62, no. 1, p. 7, 2017, doi: 10.4103/0019-5154.198036.
12. G. Schneider, G. Driesch, G. Heuft, S. Evers, T. A. Luger, and S. Ständer, "Psychosomatic cofactors and psychiatric comorbidity in patients with chronic itch," Clin Exp Dermatol, vol. 31, no. 6, pp. 762-767, Nov. 2006, doi: 10.1111/J.1365- 2230.2006.02211.X.
13. A. Picardi, D. Abeni, C. F. Melchi, P. Puddu, and P. Pasquini, "Psychiatric morbidity in dermatological outpatients: an issue to be recognized," Br J Dermatol, vol. 143, no. 5, pp. 983-991, 2000, doi: 10.1046/J.1365-2133.2000.03831.X.