Advertisement

Suicidal ideation associated with vitiligo - A systematic review of prevalence and assessment

Open AccessPublished:September 11, 2022DOI:https://doi.org/10.1016/j.cegh.2022.101140

      Abstract

      Background

      Vitiligo is a chronic dermatological condition associated with an increased risk of psychiatric disorders, including Suicidal Ideation (SI). Therefore, understanding of SI in patients with vitiligo is critically important. This systematic review aimed to investigate the assessment, and prevalence of SI in vitiligo patients.

      Method

      This systematic review was prepared according to the PRISMA statement. We searched PubMed, Scopus, Google Scholar, and additional sources to find out relevant articles. Study selection, data extraction, and quality assessment were carried out independently by two reviewers. We used the Joanna Briggs Institute critical appraisal checklist tool to assess the methodological quality of the included study.

      Findings

      Six studies involving 516 vitiligo patients were included in the analyses. The prevalence of suicidal ideation ranged from 6% to 25%. Two studies relied on 28 items General Health Questionnaire (GHQ) and the remaining studies used the Hamilton Rating Scale for Depression (HDRS), Beck Depression Inventory (BDI), Quick Inventory of Depressive Symptomatology- Self Report-16 (QIDS-SR-16) and Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

      Conclusion

      Clinicians should aware that a significant proportion of vitiligo patients are exposed to the risk of suicide. Therefore, it is recommended that vitiligo patients should be screened for suicidal ideation and make appropriate referrals to treat their psychiatric morbidities.

      Keywords

      1. Introduction

      Vitiligo is a complex disease with underlying immune destruction of epidermal melanocytes and characteristic hypopigmented or depigmented macular and patchy skin lesions.
      • Spritz R.A.
      • Santorico S.A.
      The genetic basis of vitiligo.
      The lesions have well-demarcated white or depigmented macules or patches that are oval, round, or linear in shape with convex borders measuring from a few millimeters to centimeters and enlarge centrifugally.
      • Ahmed jan N.
      • Masood S.
      Vitiligo.
      The global prevalence of vitiligo has been estimated to be between 0.1 and 8%.
      • Krüger C.
      • Schallreuter K.U.
      A review of the world wide prevalence of vitiligo in children/adolescents and adults.
      Knowledge on the etiopathogenesis of vitiligo is evolving; multiple mechanisms are thought to be involved, including genetic predisposition, environmental triggers, neural mechanisms, metabolic/physiological stress, and altered inflammatory and autoimmune responses.
      • Said-Fernandez S.L.
      • Sanchez-Domínguez C.N.
      • Salinas-Santander M.A.
      • et al.
      Novel immunological and genetic factors associated with vitiligo: a review.
      ,
      • Tang L.
      • Li F.
      • Xu F.
      • et al.
      Prevalence of vitiligo and associated comorbidities in adults in Shanghai, China: a community-based, cross-sectional survey.
      Environmental factors such as ultraviolet rays and chemicals may worsen vitiligo by causing gene damage or melanocyte stress.5According to the neural hypothesis, the release of neurogenic factors in response to a stressful event has an impact on melanocytes survival.
      • Manolache L.
      • Benea V.
      Stress in patients with alopecia areata and vitiligo.
      The loss of melanocytes was also reported to be caused by an autoimmune reaction.
      • van den Wijngaard R.
      • Wankowicz-Kalinska A.
      • Pals S.
      • Weening J.
      • Das P.
      Autoimmune melanocyte destruction in vitiligo.
      According to the ROS model, faulty oxygen metabolism leads to an excess of reactive oxygen species (ROS), which causes melanocyte destruction.
      • Malhotra N.
      • Dytoc M.
      The pathogenesis of vitiligo.
      Vitiligo has a significant impact on the personal and social life of the affected individual due to cosmetic disfigurement.
      • Grimes P.E.
      • Miller M.M.
      Vitiligo: patient stories, self-esteem, and the psychological burden of disease.
      The patient may suffer from embarrassment, discomfort, depression, and social isolation, and may go into hiding especially when the lesion appears on the exposed part of the body. This may ultimately impact the relationship with friends and relatives. Some people are embarrassed, ashamed, depressed, worried about how others will react,
      • Frisoli M.L.
      • Essien K.
      • Harris J.E.
      Vitiligo: mechanisms of pathogenesis and treatment.
      ,
      • Bidaki R.
      • Majidi N.
      • Moghadam Ahmadi A.
      • et al.
      Vitiligo and social acceptance.
      and fear of their 'disease spreading.
      • Salzes C.
      • Abadie S.
      • Seneschal J.
      • et al.
      The vitiligo impact patient scale (VIPs): development and validation of a vitiligo burden assessment tool.
      Depression is a common mental illness that affects a patient's health-related quality of life and satisfaction with medical care.
      • Wang J.
      • Wu X.
      • Lai W.
      • et al.
      Prevalence of depression and depressive symptoms among outpatients: a systematic review and meta-analysis.
      ,
      • Sorour F.
      • Abdelmoaty A.
      • Bahary M.H.
      • El Birqdar B.
      Psychiatric disorders associated with some chronic dermatologic diseases among a group of Egyptian dermatology outpatient clinic attendants.
      Female sex, lesion location in visible areas, younger age, and extensive body area involvement were all significantly associated with higher psychosocial or overall QoL burden.
      • Ezzedine K.
      • Eleftheriadou V.
      • Jones H.
      • et al.
      Psychosocial effects of vitiligo: a systematic literature review.
      Longer disease duration (>5 years), unmarried and/or single relationship status, progressive disease, lower education status, non-segmental vitiligo, a positive family history of vitiligo, and a higher socioeconomic level were found to be associated with an increased psychosocial burden.
      • Ezzedine K.
      • Eleftheriadou V.
      • Jones H.
      • et al.
      Psychosocial effects of vitiligo: a systematic literature review.
      ,
      • Bassiouny D.
      • Hegazy R.
      • Esmat S.
      • et al.
      Cosmetic camouflage as an adjuvant to vitiligo therapies: effect on quality of life.
      To the best of our knowledge, no systematic review on SI in vitiligo was done. Therefore, we planned to summarize the prevalence and assessment of SI in patients with vitiligo.

      2. Methods

      2.1 Literature search methods

      We performed a systematic review of observational studies on the suicidal ideation associated with vitiligo, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We systematically search the following databases PubMed, Scopus, and Google Scholar. The search was limited to peer-reviewed articles published in English language. To achieve the maximum sensitivity of the search strategy, we combined the terms: “vitiligo” AND (“suicidal ideation” OR “suicide” OR “suicidality” OR “self-harm ideation” OR “suicidal behavior” OR “suicidal risk assessment” OR “suicidal ideation assessment” OR “suicidal prevalence”). Studies published from inception to September 20, 2021, were included in this review. Subsequently, we assessed the abstracts of all potentially relevant articles to see if they met the eligibility criteria. Finally, we screened the bibliography lists of all the selected articles to identify additional relevant studies.

      2.2 Eligibility criteria

      We included all the cross-sectional, case-control, or cohort studies that evaluated the prevalence of SI in patients with vitiligo using validated tools. Case reports, case series, review articles, letters to the editor, and psychometric studies were excluded.

      2.3 Selection of studies and data extraction

      To select potential studies, the titles and abstracts were reviewed, followed by a full-text review by the two authors independently. The following data were collected using a standardized reporting form created in Microsoft Excel: First author, publication year, country, setting, sample size, study design, the prevalence of SI, eligibility criteria, and assessment tools.

      2.4 Quality assessment

      The methodological quality of the included articles were independently assessed by two reviewers using a critical appraisal checklist prepared by the Joanna Briggs Institute (JBI). In case of discrepancy arose between reviewers, consultation of a third investigator was taken to reach a consensus. JBI critical appraisal checklist consisted of 9 questions (Q1- Q9) related to sampling frame, sampling methods, sample size, study subjects, and statistical analysis. The total scores ranged from 0 to 9. Studies that scored more than 5 for ‘Yes’ ratings were included in this review. The details of the quality assessment are shown in Table 2.

      3. Results

      A total of 6 articles that meet study illegibility criteria were included (Fig. 1). Included studies were conducted in Egypt (n = 2), Iran (n = 1), and India (n = 3). The majority of studies were from India and recruited patients from dermatology settings. Most of the included studies were cross-sectional (n = 5, 83.3%), followed by case-control (n = 1, 16.6%).

      3.1 Methodological quality

      All the included studies scored between 6 and 9 and were considered an acceptable quality for inclusion in this review. A total of three studies did not mention the sampling procedure and carry the unclear risk of bias.
      • Sorour F.
      • Abdelmoaty A.
      • Bahary M.H.
      • El Birqdar B.
      Psychiatric disorders associated with some chronic dermatologic diseases among a group of Egyptian dermatology outpatient clinic attendants.
      ,
      • Saleh H.M.
      • Salem S.A.
      • El-Sheshetawy R.S.
      • El-Samei A.M.
      Comparative study of psychiatric morbidity and quality of life in psoriasis, vitiligo and alopecia areata.
      ,
      • Layegh P.
      • Arshadi H.
      • Shahriari S.
      • Pezeshkpour F.
      • Nahidi Y.
      A comparative study on the prevalence of depression and suicidal ideation in dermatology patients suffering from psoriasis, acne, alopecia areata and vitiligo.
      Similarly, five different studies had smaller sample size hence, carries the risk of bias related to the precision of results.
      • Sorour F.
      • Abdelmoaty A.
      • Bahary M.H.
      • El Birqdar B.
      Psychiatric disorders associated with some chronic dermatologic diseases among a group of Egyptian dermatology outpatient clinic attendants.
      ,
      • Saleh H.M.
      • Salem S.A.
      • El-Sheshetawy R.S.
      • El-Samei A.M.
      Comparative study of psychiatric morbidity and quality of life in psoriasis, vitiligo and alopecia areata.
      • Layegh P.
      • Arshadi H.
      • Shahriari S.
      • Pezeshkpour F.
      • Nahidi Y.
      A comparative study on the prevalence of depression and suicidal ideation in dermatology patients suffering from psoriasis, acne, alopecia areata and vitiligo.
      • Sangma L.N.
      • Nath J.
      • Bhagabati D.
      Quality of life and psychological morbidity in vitiligo patients: a study in a teaching hospital from north-East India.
      • Sharma N.
      • Koranne R.V.
      • Singh R.K.
      Psychiatric morbidity in psoriasis and vitiligo: a comparative study.
      All the studies were free from coverage and measurement bias. One study had missing or unclear information related to the sample size, study subjects, and study settings, and thus scored less than 6 were excluded from this review.
      • Ramakrishna P.
      • Rajni T.
      Psychiatric morbidity and quality of life in vitiligo patients.
      The results of the methodological quality assessment are presented in Table 1.
      Table 1JBI Critical Appraisal Checklist for included studies.
      AuthorQ1Q2Q3Q4Q5Q6Q7Q8Q9Total scores
      Sorour et al. [
      • Sorour F.
      • Abdelmoaty A.
      • Bahary M.H.
      • El Birqdar B.
      Psychiatric disorders associated with some chronic dermatologic diseases among a group of Egyptian dermatology outpatient clinic attendants.
      ]
      YesUNoYesYesYesYesYesYes7
      Saleh et al. [
      • Saleh H.M.
      • Salem S.A.
      • El-Sheshetawy R.S.
      • El-Samei A.M.
      Comparative study of psychiatric morbidity and quality of life in psoriasis, vitiligo and alopecia areata.
      ]
      YesUNoYesYesYesYesYesYes7
      Layegh et al. [
      • Layegh P.
      • Arshadi H.
      • Shahriari S.
      • Pezeshkpour F.
      • Nahidi Y.
      A comparative study on the prevalence of depression and suicidal ideation in dermatology patients suffering from psoriasis, acne, alopecia areata and vitiligo.
      ]
      YesUNoYesYesYesYesYesYes7
      Sangma et al. [
      • Sangma L.N.
      • Nath J.
      • Bhagabati D.
      Quality of life and psychological morbidity in vitiligo patients: a study in a teaching hospital from north-East India.
      ]
      YesYesNoYesYesYesYesYesYes8
      Sharma et al. [
      • Sharma N.
      • Koranne R.V.
      • Singh R.K.
      Psychiatric morbidity in psoriasis and vitiligo: a comparative study.
      ]
      YesYesNoYesYesYesYesYesYes8
      Kota et al. [
      • Kota R.S.
      • Vora R.V.
      • Varma J.R.
      • Kota S.K.
      • Patel T.M.
      • Ganjiwale J.
      Study on assessment of quality of life and depression in patients of vitiligo.
      ]
      YesYesYesYesYesYesYesYesYes9
      Q1 Was the sample frame suitable for the target population? Q2 Were study subjects sampled appropriately? Q3 Was the sample size appropriate? Q4 Were the study subjects and the setting discussed in detail? Q5 Was the data analysis carried out with adequate coverage of the identified sample? Q6 Were objective, standard criteria used to identify the condition? Q7 Was the condition measured reliably? Q8 Was appropriate statistical analysis performed? Q9 Was the response rate sufficient, and if not, was the low response rate managed properly. U: unclear.

      3.2 Prevalence of suicidal ideation

      The prevalence rate of SI varied substantially across studies. Prevalence of SI ranged from as low as 6%, using a general health questionnaire (GHQ), in a sample of adults (18–65years) diagnosed with vitiligo
      • Saleh H.M.
      • Salem S.A.
      • El-Sheshetawy R.S.
      • El-Samei A.M.
      Comparative study of psychiatric morbidity and quality of life in psoriasis, vitiligo and alopecia areata.
      to as high as 25%, using a DSM-5 in a sample of 109 patients.
      • Sorour F.
      • Abdelmoaty A.
      • Bahary M.H.
      • El Birqdar B.
      Psychiatric disorders associated with some chronic dermatologic diseases among a group of Egyptian dermatology outpatient clinic attendants.
      The detailed prevalence data are shown in Table 2.
      Table 2Summary of collected data included in this review.
      First Author Year,CountrySample SizePurposeStudy population and Study settingStudy designCriteria of eligible populationPrevalence of SIMeasurement of SIRef.
      Kota RS et al.(2019), India150To observe the difference in quality of life and depression levels in vitiligo patientsBoth genders aged ≥18,Dermatology department of a tertiary care hospitalCross-Sectional StudyPatients of both genders, aged ≥18 years with clinical diagnosis of vitiligo were included Depigmentation caused by factors other than vitiligo and those with previously diagnosed psychiatric conditions were excluded23.3%Question 12 (Thoughts of Death or Suicide) of QIDS-SR 16[
      • Kota R.S.
      • Vora R.V.
      • Varma J.R.
      • Kota S.K.
      • Patel T.M.
      • Ganjiwale J.
      Study on assessment of quality of life and depression in patients of vitiligo.
      ]
      Sorour F et al.(2017), Egypt108Evaluation of psychiatric co-morbidities in chronic dermatological diseases in Egyptian patientsBoth genders, aged between 17 and 60 years,Outpatient clinics of 3 major hospitalsCross-Sectional studyPatients of both genders, aged between 17 and 60 years and suffering from vitiligo for 6 months were included

      Patients with psychiatric disorders, chronic systemic diseases, and receiving treatment with corticosteroid or isotretinoin were excluded
      25%Question 6 (Thoughts of death or hurting yourself) of DSM-5 questionnaire[
      • Sorour F.
      • Abdelmoaty A.
      • Bahary M.H.
      • El Birqdar B.
      Psychiatric disorders associated with some chronic dermatologic diseases among a group of Egyptian dermatology outpatient clinic attendants.
      ]
      Sangma LN et al.(2015), India100To assess the quality of life, as well as psychological morbidity like depression in a vitiligo patientBoth genders aged between 18 and 40 years,Outpatient Department of dermatology and Venereology of a tertiary care hospitalCase-Control studyPatients of both genders, aged between 18 and 40 years and willing to participate in the study were included.

      Patients with personal or familial mental illness, substance abuse, or any other apparent causes of depression were excluded
      8%Question 3 (Suicide) of HRSD[
      • Sangma L.N.
      • Nath J.
      • Bhagabati D.
      Quality of life and psychological morbidity in vitiligo patients: a study in a teaching hospital from north-East India.
      ]
      Layegh P et al.(2010), Iran78Evaluating the depression and suicidal ideation in psoriasis (n = 62), acne vulgaris (n = 78), alopecia areata (n = 73), and vitiligo (n = 87)Both genders, a Mean (±SD) age of 26.5 (±10.8) years HospitalCross-Sectional studyMale and female patients of both genders, without a history of psychiatric or cognitive disorders, brain damage, or epilepsy, and did not take alcohol or narcotic drugs for at least one month prior to participating in the study were included

      Patients who were unable to completely fill the BDI questionnaire were excluded
      18.4%Question 9 (Suicidal thoughts or wishes) of BDI[
      • Layegh P.
      • Arshadi H.
      • Shahriari S.
      • Pezeshkpour F.
      • Nahidi Y.
      A comparative study on the prevalence of depression and suicidal ideation in dermatology patients suffering from psoriasis, acne, alopecia areata and vitiligo.
      ]
      Saleh HM et al.(2008), Egypt50To assess the psychiatric morbidity and quality of life in patients with vitiligo, psoriasis, and alopecia areataBoth genders, aged between 18 and 65 years,Dermatology department of hospitalCross-Sectional StudyPatients of both genders, aged between 18 and 65 years and the disease duration of 1–26 years were included

      Patients with chronic debilitating diseases, pregnant or lactating women, and patients receiving antipsychotic drugs were excluded
      6%Four questions on the GHQ-28 usually ask about suicidal thoughts or SI as follows:

      1. Do you feel that life isn't worth living?

      2. Do you think of the possibility that you might do away with yourself?

      3. Do you find yourself wishing you were dead and away from it all?

      4. Do you find that the idea of taking your own life kept coming into your mind?
      [
      • Saleh H.M.
      • Salem S.A.
      • El-Sheshetawy R.S.
      • El-Samei A.M.
      Comparative study of psychiatric morbidity and quality of life in psoriasis, vitiligo and alopecia areata.
      ]

      [
      • Sharma N.
      • Koranne R.V.
      • Singh R.K.
      Psychiatric morbidity in psoriasis and vitiligo: a comparative study.
      ]
      Sharma N et al.(2001), India30To assess the psychiatric morbidity related to vitiligo and psoriasisBoth genders aged between 18 and 60 years,Dermatology department of hospitalCross-Sectional studyNewly diagnosed, treatment naïve vitiligo patients of both genders, aged between 18 and 60 years were included10%
      QIDS-SR 16- Quick Inventory of Depressive Symptomatology- Self Report-16, DSM 5- Diagnostic and Statistical Manual of Mental Disorders, HRSD-Hamilton Rating Scale for Depression, BDI- Beck Depression Inventory, GHQ-General Health Questionnaire, I- Inclusion, E− Exclusion, NM- Not mentioned, Ref- Reference.

      3.3 Assessment of suicidal ideation

      Different tools were used for the measurement of SI across the studies. Two different studies used 28 items general Health Questionnaire (GHQ) (n = 2)18, 21, and the remaining studies relied on item 3 from the Hamilton Rating Scale for Depression (HRDS) (n = 1)20, item 9 from the Beck Depression Inventory (BDI) (n = 1)19, item 12 from Quick Inventory of Depressive Symptomatology- Self Report 16 (QIDS-SR 16) (n = 1)
      • Kota R.S.
      • Vora R.V.
      • Varma J.R.
      • Kota S.K.
      • Patel T.M.
      • Ganjiwale J.
      Study on assessment of quality of life and depression in patients of vitiligo.
      scale and Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (n = 1).
      • Sorour F.
      • Abdelmoaty A.
      • Bahary M.H.
      • El Birqdar B.
      Psychiatric disorders associated with some chronic dermatologic diseases among a group of Egyptian dermatology outpatient clinic attendants.

      4. Discussion

      The skin plays a crucial role in socialization. Cosmetically disfiguring skin diseases, mainly those appearing on exposed areas of the body, and face may lead to significant feelings of social isolation, thereby increasing the risk of suicidality.
      • Gupta M.A.
      • Pur D.R.
      • Vujcic B.
      • Gupta A.K.
      Suicidal behaviors in the dermatology patient.
      In contrast to many other organs in the body, the human epidermis reacts immediately to psychological stress, so several authors aimed to prove the brain-skin connection.
      • Mento C.
      • Rizzo A.
      • Muscatello M.R.A.
      • Zoccali R.A.
      • Bruno A.
      Negative emotions in skin disorders: a systematic review.
      The effect of visible skin disorders extended beyond physical symptoms to psychosocial problems.
      • Germain N.
      • Augustin M.
      • François C.
      • et al.
      Stigma in visible skin diseases - a literature review and development of a conceptual model.
      Aslam et al. concluded that skin diseases such as acne, pruritus, urticaria, vitiligo, and alopecia areata have a high prevalence of psychiatric diseases.
      • Aslam R.
      • Qadir A.
      • Asad F.
      Psychiatric morbidity in dermatological outpatients: an issue to be recognized.
      Silvan et al. emphasized that up to 80% of dermatology patients have psychiatric symptoms.
      • Silvan M.
      The psychological aspects of vitiligo.
      Chronic skin diseases can lead to depression, which in turn increases the risk of SI, attempted suicide, or suicide.
      • Pronizius E.
      • Voracek M.
      Dermatologists' perceptions of suicidality in dermatological practice: a survey of prevalence estimates and attitudes in Austria.
      The purpose of this study was to assess the prevalence of SI in vitiligo patients based on previous studies that looked at suicidal behavior in this population.
      Vitiligo is usually very frustrating for patients due to its chronic nature, long treatment course, lack of uniform curative management, and unpredictable course.
      • Karbakhsh M.
      • Hedayat K.
      • Goodarzi A.
      • Ghiasi M.
      • Ghandi N.
      Social participation in vitiligo patients and its association with quality of life.
      Patients may also suffer from low self-esteem, embarrassment, sorrow, and social exclusion as a result of lesions in exposed parts of the body. Although vitiligo patients have no symptoms other than discolored patches of skin, this pathology is associated with a wide variety of psychological problems including anxiety, depression, and even SI.
      • Bergqvist C.
      • Ezzedine K.
      Vitiligo: a review.
      A recently published meta-analysis by Kussainova et al. reported that a significant proportion of vitiligo patients have anxiety symptoms, with the prevalence of anxiety ranging from 4.76% to 60.0%.
      • Kussainova A.
      • Kassym L.
      • Akhmetova A.
      • et al.
      Vitiligo and anxiety: a systematic review and meta-analysis.
      The prevalence of SI in the included studies ranged from 6% to 25%. The difference in prevalence rate could be due to the variation in tools used in studies, skin type, and severity of the condition. In addition, the cultural background of the patients might also play a role in the variation in prevalence. The prevalence of SI in other dermatological diseases was found to be 1.2%, 5.4%, and 2.6% in acne vulgaris, psoriasis, and alopecia respectively.
      • Jagtiani A.
      • Nishal P.
      • Jangid P.
      • Sethi S.
      • Dayal S.
      • Kapoor A.
      Depression and suicidal ideation in patients with acne, psoriasis, and alopecia areata.
      A study conducted by Dieris-Hirche et al.in which the prevalence rate of SI was16% in atopic dermatitis.
      • Dieris-Hirche J.
      • Gieler U.
      • Kupfer J.P.
      • Milch W.E.
      Suicidal ideation, anxiety and depression in adult patients with atopic dermatitis.
      In another study, SI was found to be 18.5% of patients with chronic pruritus and 11.8% of those with atopic dermatitis.
      • Hawro T.
      • Przybyłowicz K.
      • Spindler M.
      • et al.
      The characteristics and impact of pruritus in adult dermatology patients: a prospective, cross-sectional study.
      Limited studies on suicidal ideation in vitiligo patients are available and all the eligible studies were from developing countries hence, more studies need to be conducted throughout the globe to get a clear prevalence of suicidal ideation.
      There is no specific questionnaire for assessing suicidal ideation in vitiligo. The method of assessment of SI varied significantly depending on the instruments used. All studies measured SI as a part of the assessment of psychiatric disorders in vitiligo patients. One or a few items of the questionnaires were used for the assessment of SI. Four questions of the GHQ-28 questionnaire containing questions related to death or suicide were used by two different studies. Item 3 of HRSD, item 6 of DSM-5, item 9 of BDI, and item12 of QIDS-SR-16 questionnaires containing questions about suicidal thoughts or behavior were used for the measurement of SI.
      Different instruments were used for assessing SIin vitiligo patients. Two different studies in our review relied on the GHQ questionnaire to assess the psychological morbidities in vitiligo patients. GHQ is a self-administered instrument designed for screening and assessing psychological morbidities.
      • Goldberg D.P.
      • Hillier V.F.
      A scaled version of the general health questionnaire.
      It is a well-validated instrument translated into many different languages. Different versions of GHQ are available consisting of 12, 28, 30, and 60 questions. Both the scales have also been widely used for assessing SI in many other dermatological disorders.
      • Golpour M.
      • Hosseini S.H.
      • Khademloo M.
      • Mokhmi H.
      Mental health and suicidal ideation in patients with dermatologic disorders.
      ,
      • Rehn L.M.
      • Meririnne E.
      • Höök‐Nikanne J.
      • Isometsä E.
      • Henriksson M.
      Depressive symptoms, suicidal ideation and acne: a study of male Finnish conscripts.
      Hamilton Rating Scale for Depression (HDRS) was another popular tool used for suicidal ideation. The 17-item version of the HDRSis the most widely used scale for controlled clinical studies on depression.
      • Karia S.
      • Sousa A.D.
      • Shah N.
      • Sonavane S.
      • Bharati A.
      Psychological morbidity in vitiligo-A case control study.
      The HDRS is also used in other skin conditions like psoriasis, and allergic disorders to assess psychiatric disorders.
      • Pompili M.
      • Innamorati M.
      • Forte A.
      • et al.
      Psychiatric comorbidity and suicidal ideation in psoriasis, melanoma and allergic disorders.
      This scale has 17 items, nine of which are scored on a 5-point range (0–4) and the other eight on a 3-point scale (0–2); higher scores indicate greater depression. Scores reflect symptoms that are (0) absent; (1) doubtful or trivial; (2) mild; (3) moderate; or (4) severe for 5-point items, whereas, for 3-point items, scores reflect symptoms that are (0) absent; (1) doubtful, trivial, or mild; and (2) severe.
      • Cole J.C.
      • Motivala S.J.
      • Dang J.
      • et al.
      Structural validation of the Hamilton depression rating scale.
      Another tool used for SI measurement was the Beck Depression Inventory (BDI). This scale has also been widely used in different health care studies.
      • Teismann T.
      • Forkmann T.
      • Glaesmer H.
      • Egeri L.
      • Margraf J.
      Remission of suicidal thoughts: findings from a longitudinal epidemiological study.
      The BDI is a 21-questions, self-report inventory that is one of the most widely used tools for assessing the severity of depression. The BDI consists of 21 questions, each of which is rated on a scale of 0–3. Questions 1–13 measure psychological symptoms while 14–21 measure physical symptoms.
      • Jagtiani A.
      • Nishal P.
      • Jangid P.
      • Sethi S.
      • Dayal S.
      • Kapoor A.
      Depression and suicidal ideation in patients with acne, psoriasis, and alopecia areata.
      Cronbach alpha reliability coefficient of this scale was 0.92.
      • Beck A.T.
      • Steer R.A.
      • Ball R.
      • Ranieri W.
      Comparison of Beck depression inventories -ia and -ii in psychiatric outpatients.
      This scale was also applied to many other dermatological diseases like acne vulgaris,
      • Kang L.
      • Liu J.
      • An R.
      • Huang J.
      • Huang H.
      • Yi Q.
      [Depression in patients with facial acne vulgaris and the influential factors].
      psoriasis,
      • Taner E.
      • Coşar B.
      • Burhanoğlu S.
      • Calikoğlu E.
      • Onder M.
      • Arikan Z.
      Depression and anxiety in patients with Behçet's disease compared with that in patients with psoriasis.
      and atopic dermatitis.
      • Chrostowska-Plak D.
      • Reich A.
      • Szepietowski J.C.
      Relationship between itch and psychological status of patients with atopic dermatitis.
      QIDS-SR 16 and DSM-5weresome other tools used in the measurement of SI. The QIDS-SR is a brief self-report rating scale derived from the 30-item Inventory of Depressive Symptomatology.
      • Trivedi M.H.
      • Rush A.J.
      • Ibrahim H.M.
      • et al.
      The inventory of depressive Symptomatology, clinician rating (IDS-C) and self-report (IDS-SR), and the Quick inventory of depressive Symptomatology, clinician rating (QIDS-C) and self-report (QIDS-SR) in public sector patients with mood disorders: a psychometric evaluation.
      It consists of 16 items arranged in nine domains, sixth domain is related to thoughts of death or suicide.
      • Zhang W.Y.
      • Zhao Y.J.
      • Zhang Y.
      • et al.
      Psychometric properties of the Quick inventory of depressive symptomatology-self-report (QIDS-SR) in depressed adolescents.
      It has strong psychometric properties and is sensitive to treatment changes.
      • Brown E.S.
      • Murray M.
      • Carmody T.J.
      • et al.
      The Quick Inventory of Depressive Symptomatology-Self-report: a psychometric evaluation in patients with asthma and major depressive disorder.
      DSM-5 was developed by the American Psychiatric Association and provides a list of criteria for the diagnosis of mental health disorders. The different psychiatric illnesses that can be measured by DSM-5 are depression, anxiety, suicide ideation, suicide attempt, sleep disorders, obsessive-compulsive diseases, and sexual problems.
      • GroschwitzRC
      • Kaess M.
      • Fischer G.
      • et al.
      The association of non-suicidal self-injury and suicidal behavior according to DSM-5 in adolescent psychiatric inpatients.
      Most of the studies used a single item for the assessment of suicidality. The use of a single item for the assessment of SI is sometimes problematic because it may fail to report the episodic nature of SI.
      • Zhou E.S.
      • Hu J.C.
      • Kantoff P.W.
      • Recklitis C.J.
      Identifying suicidal symptoms in prostate cancer survivors using brief self-report.
      However, Desseilles et al. demonstrated that using a single item from an instrument for the measurement of SI could be a valid approach.
      • Desseilles M.
      • Perroud N.
      • Guillaume S.
      • et al.
      Is it valid to measure suicidal ideation by depression rating scales?.

      5. Study limitations

      The data was obtained from a variety of studies with different designs and screening instruments. The prevalence of suicidal ideation in vitiligo may vary because the studies were heterogeneous in terms of screening tools, sampling methods, disease severity, and socioeconomic status of patients. Studies were conducted in India, Egypt, and Iran, making the generalizability of findings limited. Only English language studies were included and thus, non-English language studies were missed, and also the possibility of recall bias in the assessment of SI could not be excluded. A multi-center study using a single validated tool would give a more precise result of the prevalence of SI in vitiligo patients.

      6. Conclusion

      Suicidal ideation is common in patients with vitiligo. With the prevalence of vitiligo, the need for increased screening for suicidal ideation is also essential. Physicians should actively screen SI in patients with vitiligo and may take appropriate interventions to reduce the risk of suicide. A future systematic review of risk factors associated with suicidal ideation and behavior in vitiligo patients is recommended.

      Funding support

      Nil.

      Ethical approval

      It is not applicable.

      Author's contributions

      B.P, S.K, & K.M contributed to the conception of work, manuscript revising, editing and approval of manuscript final; S.P & K.P contributed to methodology, data collection, and writing review, R.K & N.A.S contributed to visualization, data analysis and interpretation.

      Declaration of competing interest

      The authors state that they do not have any competing interests.

      References

        • Spritz R.A.
        • Santorico S.A.
        The genetic basis of vitiligo.
        J Invest Dermatol. 2021; 141: 265-273
        • Ahmed jan N.
        • Masood S.
        Vitiligo.
        in: StatPearls [Internet]. Stat Pearls Publishing, Treasure Island (FL)Jan 2021 (Available from: https://www.ncbi.nlm.nih.gov/books/NBK559149/)
        Date accessed: November 22, 2022
        • Krüger C.
        • Schallreuter K.U.
        A review of the world wide prevalence of vitiligo in children/adolescents and adults.
        Int J Dermatol. 2012; 51: 1206-1212
        • Said-Fernandez S.L.
        • Sanchez-Domínguez C.N.
        • Salinas-Santander M.A.
        • et al.
        Novel immunological and genetic factors associated with vitiligo: a review.
        Exp Ther Med. 2021; 21: 312
        • Tang L.
        • Li F.
        • Xu F.
        • et al.
        Prevalence of vitiligo and associated comorbidities in adults in Shanghai, China: a community-based, cross-sectional survey.
        Ann Palliat Med. 2021; 10: 8103-8111
        • Manolache L.
        • Benea V.
        Stress in patients with alopecia areata and vitiligo.
        Eur Acad Dermatol Venereol. 2007; 21: 921-928
        • van den Wijngaard R.
        • Wankowicz-Kalinska A.
        • Pals S.
        • Weening J.
        • Das P.
        Autoimmune melanocyte destruction in vitiligo.
        Lab Invest. 2001; 81: 1061-1067
        • Malhotra N.
        • Dytoc M.
        The pathogenesis of vitiligo.
        J Cutan Med Surg. 2013; 17: 153-172
        • Grimes P.E.
        • Miller M.M.
        Vitiligo: patient stories, self-esteem, and the psychological burden of disease.
        Int J Womens Dermatol. 2018; 4: 32-37
        • Frisoli M.L.
        • Essien K.
        • Harris J.E.
        Vitiligo: mechanisms of pathogenesis and treatment.
        Annu Rev Immunol. 2020; 38: 621-648
        • Bidaki R.
        • Majidi N.
        • Moghadam Ahmadi A.
        • et al.
        Vitiligo and social acceptance.
        Clin CosmetInvestig Dermatol. 2018; 11: 383-386
        • Salzes C.
        • Abadie S.
        • Seneschal J.
        • et al.
        The vitiligo impact patient scale (VIPs): development and validation of a vitiligo burden assessment tool.
        J Invest Dermatol. 2016; 136: 52-58
        • Wang J.
        • Wu X.
        • Lai W.
        • et al.
        Prevalence of depression and depressive symptoms among outpatients: a systematic review and meta-analysis.
        BMJ Open. 2017; 7e017173
        • Sorour F.
        • Abdelmoaty A.
        • Bahary M.H.
        • El Birqdar B.
        Psychiatric disorders associated with some chronic dermatologic diseases among a group of Egyptian dermatology outpatient clinic attendants.
        JEgyptwomen dermatol soc. 2017; 14: 31-36
        • Ezzedine K.
        • Eleftheriadou V.
        • Jones H.
        • et al.
        Psychosocial effects of vitiligo: a systematic literature review.
        Am J Clin Dermatol. 2021; 22: 757-774
        • Bassiouny D.
        • Hegazy R.
        • Esmat S.
        • et al.
        Cosmetic camouflage as an adjuvant to vitiligo therapies: effect on quality of life.
        J Cosmet Dermatol. 2021; 20: 159-165
        • Institute JB
        (The Joanna Briggs Institute Critical Appraisal tools for usein JBI Systematic Reviews: Checklist for Prevalence Studies. 2017, Available from:)
        • Saleh H.M.
        • Salem S.A.
        • El-Sheshetawy R.S.
        • El-Samei A.M.
        Comparative study of psychiatric morbidity and quality of life in psoriasis, vitiligo and alopecia areata.
        Egypt Dermatol Online J. 2008; 4: 2
        • Layegh P.
        • Arshadi H.
        • Shahriari S.
        • Pezeshkpour F.
        • Nahidi Y.
        A comparative study on the prevalence of depression and suicidal ideation in dermatology patients suffering from psoriasis, acne, alopecia areata and vitiligo.
        Iran J Dermatol. 2010; 13: 106-111
        • Sangma L.N.
        • Nath J.
        • Bhagabati D.
        Quality of life and psychological morbidity in vitiligo patients: a study in a teaching hospital from north-East India.
        Indian J Dermatol. 2015; 60: 142-146
        • Sharma N.
        • Koranne R.V.
        • Singh R.K.
        Psychiatric morbidity in psoriasis and vitiligo: a comparative study.
        J Dermatol. 2001; 28: 419-423
        • Ramakrishna P.
        • Rajni T.
        Psychiatric morbidity and quality of life in vitiligo patients.
        Indian J Psychol Med. 2014; 36: 302-303
        • Kota R.S.
        • Vora R.V.
        • Varma J.R.
        • Kota S.K.
        • Patel T.M.
        • Ganjiwale J.
        Study on assessment of quality of life and depression in patients of vitiligo.
        Indian Dermatol Online J. 2019; 10: 153-157
        • Gupta M.A.
        • Pur D.R.
        • Vujcic B.
        • Gupta A.K.
        Suicidal behaviors in the dermatology patient.
        Clin Dermatol. 2017; 35: 302-311
        • Mento C.
        • Rizzo A.
        • Muscatello M.R.A.
        • Zoccali R.A.
        • Bruno A.
        Negative emotions in skin disorders: a systematic review.
        Int J Psychol Res. 2020; 13: 71-86
        • Germain N.
        • Augustin M.
        • François C.
        • et al.
        Stigma in visible skin diseases - a literature review and development of a conceptual model.
        J EurAcad Dermatol Venereol. 2021; 35: 1493-1504
        • Aslam R.
        • Qadir A.
        • Asad F.
        Psychiatric morbidity in dermatological outpatients: an issue to be recognized.
        J Pak Assoc Dermatol. 2007; 17: 235-239
        • Silvan M.
        The psychological aspects of vitiligo.
        Cutis. 2004; 73: 163-167
        • Pronizius E.
        • Voracek M.
        Dermatologists' perceptions of suicidality in dermatological practice: a survey of prevalence estimates and attitudes in Austria.
        BMC Dermatol. 2020; 20: 10
        • Karbakhsh M.
        • Hedayat K.
        • Goodarzi A.
        • Ghiasi M.
        • Ghandi N.
        Social participation in vitiligo patients and its association with quality of life.
        Iran J Dermatol. 2021; 24: 6-10
        • Bergqvist C.
        • Ezzedine K.
        Vitiligo: a review.
        Dermatology. 2020; 236: 571-592
        • Kussainova A.
        • Kassym L.
        • Akhmetova A.
        • et al.
        Vitiligo and anxiety: a systematic review and meta-analysis.
        PLoS One. 2020; 15e0241445
        • Jagtiani A.
        • Nishal P.
        • Jangid P.
        • Sethi S.
        • Dayal S.
        • Kapoor A.
        Depression and suicidal ideation in patients with acne, psoriasis, and alopecia areata.
        J Mental Health and Hum Behav. 2017; 22: 50
        • Dieris-Hirche J.
        • Gieler U.
        • Kupfer J.P.
        • Milch W.E.
        Suicidal ideation, anxiety and depression in adult patients with atopic dermatitis.
        Hautarzt. 2009; 60: 641-646
        • Hawro T.
        • Przybyłowicz K.
        • Spindler M.
        • et al.
        The characteristics and impact of pruritus in adult dermatology patients: a prospective, cross-sectional study.
        J Am Acad Dermatol. 2021; 84: 691-700
        • Goldberg D.P.
        • Hillier V.F.
        A scaled version of the general health questionnaire.
        Psychol Med. 1979; 9: 139-145
        • Golpour M.
        • Hosseini S.H.
        • Khademloo M.
        • Mokhmi H.
        Mental health and suicidal ideation in patients with dermatologic disorders.
        World Appl Sci J. 2010; 11: 573-577
        • Rehn L.M.
        • Meririnne E.
        • Höök‐Nikanne J.
        • Isometsä E.
        • Henriksson M.
        Depressive symptoms, suicidal ideation and acne: a study of male Finnish conscripts.
        J EurAcad Dermatol Venereol. 2008; 22: 561-567
        • Karia S.
        • Sousa A.D.
        • Shah N.
        • Sonavane S.
        • Bharati A.
        Psychological morbidity in vitiligo-A case control study.
        J Pigment Disord. 2015; 2: 2376
        • Pompili M.
        • Innamorati M.
        • Forte A.
        • et al.
        Psychiatric comorbidity and suicidal ideation in psoriasis, melanoma and allergic disorders.
        Int J Psychiatr Clin Pract. 2017; 21: 209-214
        • Cole J.C.
        • Motivala S.J.
        • Dang J.
        • et al.
        Structural validation of the Hamilton depression rating scale.
        J Psychopathol Behav Assess. 2004; 26: 241-254
        • Teismann T.
        • Forkmann T.
        • Glaesmer H.
        • Egeri L.
        • Margraf J.
        Remission of suicidal thoughts: findings from a longitudinal epidemiological study.
        J Affect Disord. 2016; 190: 723-725
        • Beck A.T.
        • Steer R.A.
        • Ball R.
        • Ranieri W.
        Comparison of Beck depression inventories -ia and -ii in psychiatric outpatients.
        J Pers Assess. 1996; 67: 588-597
        • Kang L.
        • Liu J.
        • An R.
        • Huang J.
        • Huang H.
        • Yi Q.
        [Depression in patients with facial acne vulgaris and the influential factors].
        Zhong Nan Da XueXue Bao Yi Xue Ban. 2015; 40: 1115-1120
        • Taner E.
        • Coşar B.
        • Burhanoğlu S.
        • Calikoğlu E.
        • Onder M.
        • Arikan Z.
        Depression and anxiety in patients with Behçet's disease compared with that in patients with psoriasis.
        Int J Dermatol. 2007; 46: 1118-1124
        • Chrostowska-Plak D.
        • Reich A.
        • Szepietowski J.C.
        Relationship between itch and psychological status of patients with atopic dermatitis.
        J EurAcad Dermatol Venereol. 2013; 27: e239-e242
        • Trivedi M.H.
        • Rush A.J.
        • Ibrahim H.M.
        • et al.
        The inventory of depressive Symptomatology, clinician rating (IDS-C) and self-report (IDS-SR), and the Quick inventory of depressive Symptomatology, clinician rating (QIDS-C) and self-report (QIDS-SR) in public sector patients with mood disorders: a psychometric evaluation.
        Psychol Med. 2004; 34: 73-82
        • Zhang W.Y.
        • Zhao Y.J.
        • Zhang Y.
        • et al.
        Psychometric properties of the Quick inventory of depressive symptomatology-self-report (QIDS-SR) in depressed adolescents.
        Front Psychiatr. 2020; 11: 1354
        • Brown E.S.
        • Murray M.
        • Carmody T.J.
        • et al.
        The Quick Inventory of Depressive Symptomatology-Self-report: a psychometric evaluation in patients with asthma and major depressive disorder.
        Ann Allergy Asthma Immunol. 2008; 100: 433-438
        • GroschwitzRC
        • Kaess M.
        • Fischer G.
        • et al.
        The association of non-suicidal self-injury and suicidal behavior according to DSM-5 in adolescent psychiatric inpatients.
        Psychiatr Res. 2015; 228: 454-461
        • Zhou E.S.
        • Hu J.C.
        • Kantoff P.W.
        • Recklitis C.J.
        Identifying suicidal symptoms in prostate cancer survivors using brief self-report.
        J Cancer Surviv. 2015; 9: 59-67
        • Desseilles M.
        • Perroud N.
        • Guillaume S.
        • et al.
        Is it valid to measure suicidal ideation by depression rating scales?.
        J Affect Disord. 2012; 136: 398-404