A Systematic Review Of Anxiety Prevalence in Dermatology Patients
Overview
This study conducts a systematic review to analyze the prevalence and trends of anxiety among dermatology outpatients. This study also highlights the correlation between anxiety and patient demographics.
Anxiety is very common among individuals with medical conditions, especially dermatological ailments like psoriasis, and as such, affects the mental and physical well-being of the patient.
Considering this, it is vital for dermatologists to have a good understanding of how anxiety affects their patients, how to identify it, and ways to support them through treatment.
The primary objective of this review is to give an overview of the prevalence of anxiety and its trends among dermatology patients in outpatient settings.
Introduction
Anxiety is a term used to describe an emotion or feeling of excessive worry, fear, or stress. This emotion is normal and can be a temporary reaction to a certain event or thing. However, in some cases, this feeling could persist chronically, which then poses a risk to the individual’s overall well-being.
Anxiety disorder is a clinical spectrum lasting up to 6 months or more, usually presenting with fear, anxiety, and similar behavioral disturbances. These disorders are often associated with other mental and physical health abnormalities and can be very detrimental to a patient’s recovery and well-being.
Several prevalence studies on anxiety disorders were targeted at the general population which yielded variable results. These variabilities could occur as a result of an event or pandemic, geographical location, socioeconomic class, or the health status of subjects.
In a systematic review carried out globally, anxiety disorders were shown to vary before and after a pandemic occurred, with pre-pandemic prevalence at 3.8% and post-pandemic prevalence at 4.8%. This review shows a 1% increase in the prevalence of anxiety in the global population, also noting some significant variations with regard to socioeconomic status and geographical location.
Some other reviews have shown significant variations in the prevalence of anxiety disorders in the general public owing largely to varying demographic zones of the population. However, there has been no significant variation in the prevalence of anxiety disorders between developing and developed countries.
Anxiety rates have been shown to rise among individuals with chronic illnesses. In dermatology patients, several studies have shown that there are variations in the prevalence of anxiety. Some of these studies show prevalence ranges of 7% – 48% in patients with psoriasis, 0.49% – 6% in patients with hyperhidrosis, and 11.8% – 19.3% in patients with rosacea.
The severity and impact of a dermatologic condition on a patient’s life contribute significantly to the variation in the prevalence of anxiety among dermatology patients.
Most systematic reviews in dermatology focus on particular conditions, however, a recent study assessed dermatology patients more broadly rather than narrowing down to a particular condition. Drawbacks to this broad study were; patients were not grouped (into outpatient, inpatient, or primary health patients), prevalence statistics were not synthesized and general search strategies were utilized across all disease types which may lead to the omission of some important dermatology papers.
There is an increased tendency to combine outpatient groups with other groups of patients, which ultimately leads to an increase in variability, making the study less reliable to be applied to dermatologic outpatients.
To date, there is no systematic review that evaluates the prevalence of anxiety disorders among the entire adult dermatology outpatients.
Anxiety disorders usually present with other physical or mental comorbidities, which depending on their severity can affect an individual’s quality of life. Patients with anxiety may have varying presentations depending on comorbidities present for example; care seeking or avoidant patterns.
This meta-analysis, however, is to determine the prevalence of anxiety disorders among a specific population, which in this case are dermatology outpatients. The aim of this is to grant dermatologists a better understanding of anxiety trends among their outpatients.
Methods
This systematic review was carried out in accordance with the 2020 statement of the Preferred Reporting Items for Systematic
Reviews and Meta-Analyses (PRISMA) and registered with the International Prospective Register of Systematic Reviews (PROSPERO; CRD42021282416).
The databases used for this analysis include; Pubmed, Cochrane, EMBASE, and PsycINFO, with a final search carried out on the 7th of September 2022.
The studies used for this review were initially carried out to assess the prevalence of anxiety among outpatients cutting across five major specialties. These specialties include; dermatology, gastroenterology, endocrinology, cardiology, and respiratory medicine.
However, due to the large number of results, the researchers then resolved to record outcomes for each specialty separately so as to allow for a more detailed analysis of the study results. This change led to the amendment of its PROSPERO protocol which was further reflected in the screening and extraction processes employed.
Screening and extraction were carried out via the use of a covidence systematic review software. Two reviewers were in charge of independently screening abstracts, titles and completed full-text review, data extraction and risk of bias quality assessment. A third reviewer was present to resolve any conflicts arising during the process.
Studies used for this review were to contain adequate data to ease calculation. Authors were contacted in cases where the full text of the studies were not available. If there was no response from the author after two weeks, the study is then excluded from the review.
The risk of bias or quality of the studies included were assessed using the Joanna Briggs Institute Checklist for Prevalence Studies (JBI). This tool includes 9 questions which have a scoring system of “yes” equaling 1 mark and “no” or “unsure” or “not applicable” equaling 0.
This goes to say that the lower the JBI score of a study, the lesser the quality and the higher the risk of bias.
Inclusion Criteria
The analysis included studies that have a JBI score of not less than 6. Also, studies involving dermatology outpatients were included.
Exclusion Criteria
Studies that were removed from the analysis included those that involved only female and geriatric patients. Also, outlier studies with the prevalence of anxiety being 100% were excluded from the study.
Outcome Variables
The principal outcome of this review is to estimate the prevalence or trends of anxiety or symptoms of anxiety as quantified by a clinical diagnosis or anxiety rating scale.
The secondary outcome of this review is to evaluate the variability of the prevalence of anxiety with regard to the method of diagnosis, the dermatologic condition present, and the country where the study is carried out.
Statistical Analysis
Comprehensive Meta Analysis version 4.0 (CMA 4) was used to conduct the meta-analysis of the studies. X² and I² statistics were used to evaluate the proportion of the study variance.
Possible sources of heterogeneity were determined using the random-effect subgroup analysis. Also, publication bias was evaluated using the funnel plot and Egger’s regression intercept.
Results
- 32 out of the 5,423 studies obtained for this review passed the inclusion criteria, as they involved dermatology outpatients. These approved studies had a total of 12,812 participants.
- All 32 studies passed the JBI score inclusion criteria. 9 out of the 32 studies reached a JBI score of 9, 18 out of the 32 studies reached a JBI score of 8, 2 out of the 32 studies reached a JBI score of 7, while 3 out of the 32 studies reached a JBI score of 6.
- This review included case-control studies (n = 3), cross-sectional studies (n = 19) and prevalence studies (n = 10).
- Most of the studies used for this review were carried out in Europe, while others were conducted in the Middle East, Asia, South America, North America and Africa.
- Patient records, self-reports and diagnostic interviews were used to assess anxiety in these studies.
Overall Anxiety Prevalence
The prevalence of anxiety and its symptoms in the meta-analysis of 29 studies varied significantly, ranging from 2.9% to 67.8%. The overall prevalence of anxiety and its symptoms across 29 studies had a mean prevalence of 26.7%, 95% confidence interval of 22.4 to 31.4 and a 95% prediction interval of 9.6 to 55.4.
Analysis was carried out with regard to diagnosis method, country of study, and dermatologic condition involved. This showed significant heterogeneity between the studies. No publication bias was noted on the funnel plot and Egger’s test.
Prevalence of Anxiety With Respect to the Method of Diagnosis
The prevalence of anxiety varied significantly in subgroups of patients who were diagnosed via different methods. The highest anxiety prevalence of 34.3% was reported in subgroups that were diagnosed using the Hospital Anxiety and Depression Scale (HADS-A), also noting a 95% confidence interval of 27.8 to 41.6 and a 95% prediction interval of 12.2 to 66.2.
Closely following this method of diagnosis is the self-report method, marking a prevalence of 27.5%, a 95% confidence interval of 20.5 to 35.7 and a 95% prediction interval of 7.4 to 64.2.
Studies involving a diagnostic interview and patient records as a method of diagnosis marked an anxiety prevalence of 14.8%, a 95% confidence interval of 8.9 to 23.6 and a 95% prediction interval of 2.1 to 58.0.
Prevalence of Anxiety With Respect to Dermatologic Conditions
Among the included studies, psoriasis was the only dermatologic condition with an adequate sample size sufficient for this meta-analysis. Patients with psoriasis were noted to have a high anxiety prevalence of 33.9%, also noting a 95% confidence interval of 28.8 to 39.5 and a 95% prediction interval of 18.6 to 53.6.
This data was then compared to the anxiety prevalence among the general dermatology outpatients which was marked at 27.0%, with a 95% confidence interval of 20.8 to 34.2 and 95% prediction interval of 8.6 to 59.1.
Prevalence of Anxiety With Respect to Country of Study
In this analysis, countries were categorized into developing and developed using the United Nations Human Development Index guidelines.
Two studies were excluded from this analysis, as they included reports from multiple countries without a specific prevalence report on each country.
There was no notable difference in the prevalence rates of the developed and developing countries.
The developed countries had an anxiety prevalence rate of 26.8%, plus a 95% confidence interval of 20.9 to 33.6 and a 95% prediction interval of 8.2 to 60.
The developing countries had an anxiety prevalence rate of 28.5%, with a 95% confidence interval of 23.4 to 34.3 and a 95% prediction interval of 13.7 to 15.1.
Limitations
Issues encountered with this study include; anxiety prevalence being reported as a mean value rather than its actual value, calculations being unclear, unclear exclusion criteria and reported response rates were omitted.
Additionally, due to the limited number of included studies, subgroup analyses which properly assessed the prevalence of anxiety were not adequately conducted. This was seen with the inability to compare the anxiety prevalence rate in psoriasis with other specified dermatologic conditions.
Discussion
Psychodermatology is an area of dermatology that focuses on the link between the skin and the mental health of a person. This meta-analysis is the first to study the prevalence of anxiety among all dermatology outpatients.
Irrespective of the significant variations noted in the course of this analysis, an average anxiety prevalence rate of 26.7% was noted among all dermatology outpatients.
It was also noted that the anxiety prevalence among dermatology outpatients is higher than the prevalence in the general population.
Data from this study showed a higher anxiety prevalence among dermatology outpatients who were diagnosed using a standard screening tool (Hospital Anxiety and Depression Scale) compared to other methods of diagnosis.
Furthermore, a higher anxiety prevalence was seen in patients with psoriasis (33.9%) compared to the prevalence obtained among the general dermatology outpatient population (27.0%).
Additionally, there was no significant difference in the anxiety prevalence rate of developing and developed countries.
Final Thoughts
This systematic review is a good resource that provides insight into the rates at which dermatology outpatients come down with anxiety. This study also helps identify the dermatology outpatients that are more at risk or prone to anxiety and support them.
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