|Year : 2020 | Volume
| Issue : 2 | Page : 140-147
Comparison of Anxiety and Depression Scores in Patients with Oral Lichen Planus and Normal Individuals
Darshan R Prasad Hiremutt1, Amit Anil Mhapuskar1, Priya Singh2, Nitin Gupta3
1 Department of Oral Medicine and Radiology, Bharati Vidyapeeth (Deemed to be University), Dental College and Hospital, Pune, Maharashtra, India
2 Department of Oral Medicine and Radiology, Babu Banarasidas College of Dental Sciences, Lucknow, Uttar Pradesh, India
3 Department of Public Health Dentistry, D. Y. Patil Dental College and Hospital, Pune, Maharashtra, India
|Date of Submission||25-Sep-2019|
|Date of Decision||05-Dec-2019|
|Date of Acceptance||06-Feb-2020|
|Date of Web Publication||14-Dec-2020|
Dr. Darshan R Prasad Hiremutt
Department of Oral Medicine and Radiology, Bharati Vidyapeeth (Deemed to be University), Dental College and Hospital, Katraj-Dhankawadi, Pune - 411 043, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: Oral lichen planus (OLP) is a common chronic inflammatory, psycho-mucocutaneous disease affecting about 1%–4% of the general population associated with psychoneuroendocrine and psychoimmunological comorbidities. Lichen planus although it is not an infectious disease, its cause is unknown, it is classified as an autoimmune disorder that may be precipitated or exacerbated by psychosocial stress. The Hospital Anxiety and Depression Scale (HADS) was originally developed to indicate the possible presence of anxiety and depressive states in the setting of a medical outpatient clinic and was found to perform well in assessing the anxiety disorders and depression in both somatic, psychiatric and primary care patients and in the general population. Aims: The aim of this study is to evaluate the levels of psychological status and the impact of treatment on psychological status in OLP individuals and compare it with normal individuals. Materials and Methods: Forty OLP patients along with the same number of age- and gender-matched healthy controls were included in the study. HADS questionnaire was administered to all 40 OLP (start of therapy) and 40 non-OLP individuals. In the OLP Group (40 participants): 20 were given “active” intervention with Cyclosporine Oral Solution (Group A), 20 were given “placebo” intervention (Group P). HADS questionnaire was given to all the twenty participants of Group A and all twenty participants of Group P at the end of therapy. The questionnaire consisted of 14 questions; 7 questions pertaining to anxiety and 7 pertaining to depression. Results: High level of anxiety (47.5%) and depression (85%) was observed in participants with OLP as compared to non-OLP (0%). After the active intervention, 14 participants were relieved of anxiety as compared to 8. Comparison of the prevalence of depression in OLP individuals before and after getting “active” intervention revealed that on getting active intervention the depression present in all 20; 1 (10%) mild and 9 (90%) frank came down to 1 (10%), and 4 (40%) mild. Five (50%) participants were completely relieved of depression. Conclusion: Lichen planus is to some extent a psychosomatic or somatopsychic disease or both. The present study results matches with the majority of the studies, showing a positive association between anxiety and depression levels in OLP patients, suggesting counseling along with traditional treatment can be effective in reducing the size of the lesions. Oral healthcare providers should pay attention to the emotional state of their patients. Emotional factors are important as evidenced by higher frequency of psychiatric symptoms, poor quality of life, higher level of anxiety, and neuroendocrine and immune dysregulations. Counseling may help in ameliorating symptoms, improving quality of life, and enhancing recovery.
Keywords: Anxiety, cyclosporine oral solution, depression, Hospital Anxiety and Depression Scale, oral lichen planus
|How to cite this article:|
Hiremutt DR, Mhapuskar AA, Singh P, Gupta N. Comparison of Anxiety and Depression Scores in Patients with Oral Lichen Planus and Normal Individuals. J Int Clin Dent Res Organ 2020;12:140-7
|How to cite this URL:|
Hiremutt DR, Mhapuskar AA, Singh P, Gupta N. Comparison of Anxiety and Depression Scores in Patients with Oral Lichen Planus and Normal Individuals. J Int Clin Dent Res Organ [serial online] 2020 [cited 2021 Apr 11];12:140-7. Available from: https://www.jicdro.org/text.asp?2020/12/2/140/303405
| Introduction|| |
Oral lichen planus (OLP) is a common chronic inflammatory, psycho-mucocutaneous disease affecting about 1%–4% of the general population associated with psychoneuroendocrine, psychoimmunological comorbidities. It occurs at any age (mean age of onset middle age), affecting both sexes with females being at higher risk for oral mucosal and genital involvement. It is an obstinate disorder baffling not only the patients but also the practitioner.,
Psychologically, the skin is an erogenous zone and channel for emotional discharge so that troubled skin could be a manifestation of unexpressed anger or an inner conflict due to external stress. Brig et al. suggested that there is a diversionary symbiosis between the skin and psyche. Psychological stress could have a negative impact on healthy skin, exacerbating or precipitating dermatological disorders suggesting the presence of interface between psychiatry and dermatology.
Lichen planus is not an infectious disease. The cause is unknown, but it is classified as an autoimmune disorder which may be precipitated or exacerbated by psychosocial stressors. Patients with lichen planus experience stressful events before the onset of the disease and also a higher level of anxiety along with high salivary cortisol levels.,
Andreasen was the first to point out in 1968 that OLP patients are found to be in conditions of stress leading to anxiety and depression. Colella et al. applying the Hamilton scale, found anxiety as well as depression in patients with OLP. McCartan, Jose L, Rojo-Moreno carried out trials to prove the same.
Hegarthy AM, Hodgson A suggested that OLP does affect the quality of life, and effective treatment improves patient well-being [Figure 1].
The Hospital Anxiety and Depression Scale (HADS) is a 14-item self-report screening scale that was originally developed to indicate the possible presence of anxiety and depressive states in the setting of a medical outpatient clinic (Zigmond and Snaith, 1983). It contains two seven-item scales: one for anxiety and one for depression, both with a score range of 0 ± 21. Validity of HADS was assessed by Ingvar Bjelland, Alv A Dahl et al. in 2001, and HADS was found to perform well in assessing the anxiety disorders and depression in both somatic, psychiatric, and primary care patients and in the general population.
Soto Araya et al. (2004) recently established a positive relationship between psychological alterations and OLP, considering the stress and anxiety levels in OLP patients as high [Figure 2]. According to these findings, it is possible to assume that psychological factors should be taken into account when maintaining oral health as such patients showed increased values on the Hamilton anxiety scale and Hamilton depression scale (Colella et al. 1993). There are reported differences in psychoimmune interactions between patients afflicted with nonerosive OLP lesions compared with those with erosive OLP lesions (Chiappelli et al. 1997). Andreasen (1968) reported that 49% of OLP patients had been subjected to strong stress in their lives, while others have reported stress-related history in OLP patients with the erosive form, as compared with reticular form (Lowental and Pisanti 1984).
Eisen et al. in 1990 recommended “Swish and Spit” method of use cyclosporine in patients with OLP. They conducted a randomized double-blind trial in 16 symptomatic OLP patients. All of the eight recipients of cyclosporine receiving 5 ml of medication (containing 100 mg/ml of cyclosporine per mL) three times daily showed significant improvement in signs and symptoms. When all the 16 were treated openly, 50% of the lesions were almost or completely clear after 8 weeks.
Pacor et al. in 1994 evaluated the efficacy of topical cyclosporine (5 ml of solution [500 mg]) used as a mouth rinse in swish and spit manner three times a day for 3 months in 14 OLP patients and found beneficial effects on signs and symptoms after only 1 month of therapy. They thus concluded that cyclosporine is useful in the treatment of OLP.
To begin to address this uncertainty and to explore the possibility of psychosomatization as a possible pathogenic mechanism of initiation and clinical expression of this oral disorder, we evaluated the levels of psychological status in OLP individuals and the impact of treatment in psychosocial status in OLP individuals.
- To evaluate the levels of psychological status in OLP individuals and compare the same in normal individuals
- To evaluate the impact of treatment in psychosocial status in OLP individuals and compare the same in normal individuals.
| Materials and Methods|| |
The study was conducted in the Department of oral medicine and radiology.
Patients coming in the OPD of the Department Of Oral Medicine & Radiology.
Inclusion criteria for oral lichen planus participants
- Self reporting individuals, 18 years and above, clinically and histologically proven OLP
- Burning sensation as one of the presenting symptoms.
Inclusion criteria for nonoral lichen planus participants
- Otherwise healthy individuals reporting with the dental complaint of short duration, age- and gender-matched to OLP participants.
The patients fulfilling the inclusion and exclusion criteria were explained the need and procedure of the trial. Informed consent was obtained.
The study design underwent the Institute Research Board and Ethical Board clearance and approval.
Forty OLP (Group OLP) and forty normal individuals (Group non-OLP) age- and gender-matched to OLP participants were enrolled in the study.
Hospital Anxiety and Depression Questionnaire was given to all forty OLP (start of therapy) and forty non-OLP individuals.
In the OLP Group (forty participants): Twenty were given “active” intervention (Group A) with Cyclosporine Oral Solution (Commercially available as PanimunBioral™ 100 mg/ml), twenty were given “placebo” intervention (Group P) [Figure 3] and [Figure 4].
The placebo was prepared at institute pharmacy similar in appearance and taste and contained only the vehicle, i.e., hydrogenated castor oil and labrafilm, minus the active ingredient, i.e., Cyclosporine.
Patients were given 150 ml (dispensed in three bottles of 50 ml each) of either the active drug or placebo. Patients in both the groups were instructed to use 5 ml of the solution in a “Swish and Spit” manner once a day in the morning after breakfast for 5 min for 30 days. Instructions for use were given to participants and a copy given in the English and/or vernacular language.
Randomization was done for both the active drug and placebo samples by generating a series of ten random numbers for both the groups. Participants were numbered serially as they entered the trial. Based on the two series, the participants got assigned either to the active group (Group A) or placebo group (Group P).
Concealment of Allocation and Binding: The principal investigator carried out the initial as well as the posttreatment evaluation of all the participants.
To minimize the bias, the investigator was unaware of intervention received during all stages of the trial. The intervention material (cyclosporine or placebo) were delivered to participants by another person unrelated to the trial.
The participants, too, were blinded by preparing the placebo similar in taste and color to cyclosporine preparation.
Hospital Anxiety and Depression Questionnaire was given to 20 (Group A) and 20 (Group P) at the end of the therapy.
Questionnaire consisted of 14 questions; 7 questions pertaining to anxiety and 7 pertaining to depression.
Each item had to be answered on a four point (0–3) response category.
- 0–7 = No anxiety/depression
- 8–10 = Mild anxiety/depression
- ≥11 = Frank anxiety/depression.
The patients were assessed at baseline (day 1) and at the end of the therapy period (30th day) and the patient were kept on follow-up for the next 6 months.
| Results|| |
Nineteen (47.5%) of the participants with OLP had “frank anxiety,” thirty-four (85%) of the participants had “frank depression” [Table 1].
|Table 1: Levels of psychological status in oral lichen planus individuals|
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None of the participants in the non-OLP group had anxiety, whereas only two participants had mild depression [Table 2].
Anxiety is more prevalent in OLP individuals (47.5%) as compared to non-OLP individuals (0%) [Table 3]a and [Graph 1].
Depression (85%) like anxiety too is more common in OLP as compared to non-OLP individuals (5%) [Table 3]b and [Graph 2].
Comparison of the prevalence of anxiety in OLP individuals before and after getting “active” intervention revealed that on receiving active intervention the anxiety scores in OLP individuals dropped from 12 participants having the combination of mild and frank anxiety to 6 participants. After active intervention, 14 participants were relieved of anxiety as compared to 8 [Table 4]a.
Comparison of the prevalence of depression in OLP individuals before and after getting “active” intervention revealed that on getting active intervention the depression present in all 20; 1 (10%) mild and 9 (90%) frank came down to 1 (10%) and 4 (40%) mild. Five (50%) participants were completely relieved of depression [Table 4]b.
Comparison of the prevalence of anxiety in OLP individuals before and after getting “placebo” intervention revealed that not much change in anxiety registered in group receiving passive intervention before and after the intervention [Table 5]a.
Comparison of the prevalence of depression in OLP individuals before and after getting “placebo” intervention revealed that there was no change in depression in OLP individuals before and after getting passive intervention [Table 5]b.
Comparison of anxiety in Group A and Group P after getting respective intervention [Table 6]a and [Graph 3].
Comparison of depression in Group A and Group P after getting respective intervention [Table 6]b and [Graph 4].
In our study, according to HADS scale, depression level in OLP patients was 85% compared to the control group (0%) and anxiety level in OLP patients was 47.5% compared to the control group 0%. The present study showed that there is significant increase in depression and anxiety in OLP patients than control groups.
| Discussion|| |
Dermatology shows a distinct relation with psychosomatics as the skin has strong psychological implications. The skin is made up of glands, blood vessels, nerves, and muscle elements, many of which are controlled by the autonomic nervous system and are influenced by psychological stimuli. These have the capacity to cause autonomic arousal and the capability of affecting the skin leading to the development of various skin disorders. Clinical studies have shown that psychological stress can cause suppression of killer T-cells and macrophages, both of which play important roles in skin-related immune reactions. Field described the skin as the “shock organ” for emotional stress, manifesting in the form of several skin diseases. Clinical observations have identified psychological stress as either precipitating, aggravating, or prolonging many skin diseases and the psychosomatic aspects of many disorders.
Brazzini et al. proposed the “an active neuro-immune-endocrine interface” or neuroendocrine organ, exhibiting multidirectional and local communication, which is made possible by the production in the skin of cytokines, hormones and neurotransmitters, and anatomical links between the central nervous system (CNS) and skin. In addition, circulating immune cells, recruited in the skin, express receptors for a variety of neuropeptides, cytokines, neurotransmitters, and hormones, identical to those expressed centrally, allowing the CNS to communicate with the skin. This means that systemic signals affecting the skin initiate a flow of information between this and other organs, leading to modulation of local immune activity, vascular functions, sensory reception, thermoregulation, exocrine secretion, and the maintenance of skin barrier integrity.
OLP is described as an adult disease. The typical age of presentation is between 30 and 60 years. Exact etiology of the LP is unknown, but a change in cell-mediated immune response has a significant role in the pathogenicity of the lesion. Factors such as stress and psychological problems, especially depression and anxiety, have been mentioned as etiologic factors in OLP. Exacerbations of OLP have been linked to periods of psychological stress and anxiety. Ivonavaski et al. proposed that prolonged emotive stress in OLP. Patients has been proposed to lead to psychosomatization which in turn may contribute to the initiation and clinical expression of OLP and also suggested that psychosocial and emotional stress is one possible factor that may precipitate reticular OLP to transform to the erosive form.
Different studies have been done for the evaluation of the relationship between OLP and psychiatric disorders. In 1961, Altman and Perry conducted a study on of 197 patients with LP, which revealed that “10% were aware of a precipitating stressful incident at the onset of their LP.” Andreasen pointed out in 1968 that patients with LP were found to be in conditions of stress, anxiety, and emotional changes. Colella et al. conducted a study in 1993 using different psychiatric tests such as “General Health Questionnaire,” “Hamilton Anxiety Scale,” “Melancholia scale, depression,” and “Hamilton Depression Scale” demonstrated that OLP patients had higher depression and anxiety score. McCartan noticed that out of fifty patients with OLP, tendency toward anxiety was in 50% of the cases, but depression scores were minimal and it could not be related to any specific clinical pattern of OLP.
Other study showed that 63.6% of LP patients had psychiatric symptoms with mixed anxiety and depression being the most frequent (15.7%), followed by social phobia (12.9%), panic symptoms (11.4%), obsessive-compulsive predominantly obsession thoughts and ruminations (10%), and dysthymia (5.7%) arranged in order. In one study, involved 100 patients with OLP and controls were subjected to the following psychometric tests to both groups: Spielberger State-Trait Anxiety Inventory, Cartel Personality Questionnaire 16PF, Hassanyeh Rating of Anxiety-Depression-Vulnerability, Beck Depression Inventory, Raskin Depression Screen, and Covi Anxiety Screen. Despite the higher anxiety scores observed in patients with OLP, it was not established that the observed psychological alterations constitute a direct etiologic factor of OLP, nor was it established that such alterations are a consequence of OLP and its lesions.
Chaudhary conducted an analytical age- and sex-matched double controlled study where the General Health Questionnaire-version 28 and the HADS were used to evaluate psychosocial stressors in terms of stress, anxiety, and depression, respectively. He found that significantly higher stress, anxiety, and depression levels were found in the OLP and positive control than the general population. These suggest that psychological stressors play an important role in the causation of OLP. It may be further hypothesized that these stressors form a starting point for the initiation of various autoimmune reactions, which have been shown to be contributory to the pathogenesis of OLP. Further longitudinal studies need to be done globally before definitive conclusions can be drawn.
Agha-Hosseini et al. conducted a study to detect the importance of psychological factors in OLP patients by means of psychological tests and make a meaningful comparison between the levels of anxiety and depression in OLP patients and the healthy population. He saw a significant difference in anxiety scores in two groups, but no statistically significant difference when the depression levels between the two groups were assessed. His results analysis did not appear to support the concept that lichen planus is a disease that is seen in persons who are more depressed than the normal population, but prolonged anxiety in many OLP patients may lead to psychsomatization and may contribute to exacerbation or recurrence of this disease. He concluded that a substantial number of patients might benefit from a mutual collaboration between psychiatrists and oral medicine specialists in OLP management.
Harpenau et al. in 1995 and Sieg et al. in 1995, independently in a controlled, randomized prospective trial, consisting of 14 and 13 patients confirm that topical cyclosporine as a rinse (500 mg 1–3 times daily for 5 min) is more effective than placebos but equivalent to topical steroid. No significant side effects were reported in either of the clinical trials. Hence in our trial, we found prescribing 500 mg of cyclosporine as a rinse one time a day gave almost good results.
| Conclusion|| |
Though there have been many studies conducted to evaluate the role of anxiety, stress, and depression in the etiopathogenesis of OLP, the results have been conflicting. The present study results matches with the majority of the studies, showing a positive association between anxiety and depression levels in OLP patients, suggesting counseling along with traditional treatment can be effective in reducing the size of the lesions. With regard to the discussion above, it seems logical to claim that psychiatric evaluation and appropriate treatment of the patients along with routine treatment of OLP lesions should be recommended. Lichen planus is to some extent apsychosomatic or somatopsychic disease or both. Oral healthcare providers should pay attention to the emotional state of their patients. Emotional factors are important as evidenced by higher frequency of psychiatric symptoms, poor quality of life, higher level of anxiety, and neuroendocrine and immune dysregulations. Counseling may help in ameliorating symptoms, improving quality of life, and enhancing recovery.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Tawil M, Sediki N, Hassan H. Psychobiological aspects of patients with lichen planus. Curr Psychiatr 2009;16:370-80.
Sugerman PB, Savage NW, Walsh LJ, Zhao ZZ, Zhou XJ, Khan A, et al
. The pathogenesis of oral lichen planus. Crit Rev Oral Biol Med 2002;13:350-65.
Mansur AT, Kilic Z, Atalay F. Psychological evaluation of patients with lichen planus. Dermatol Psychosom 2004;5:132-6.
Zouboulis CC, Böhm M. Neuroendocrine regulation of sebocytes – A pathogenetic link between stress and acne. Exp Dermatol 2004;13 Suppl 4:31-5.
Sharma YK, Sudarsanan S, Bhatnagar A. Skin and Psyche: Diversionary Symbiosis. Med J Armed Forces India 2005; 61:163-6.
Kimyai-Asadi A, Usman A. The role of psychological stress in skin disease. J Cutan Med Surg 2001;5:140-5.
Manolache L, Seceleanu-Petrescu D, Benea V. Lichen planus patients and stressful events. J Eur Acad Dermatol Venereol 2008;22:437-41.
Koray M, Dülger O, Ak G, Horasanli S, Uçok A, Tanyeri H, et al
. The evaluation of anxiety and salivary cortisol levels in patients with oral lichen planus. Oral Dis 2003;9:298-301.
Spinhoven P, Ormel J, Sloekers PP, Kempen GI, Speckens AE, Van Hemert AM. A validation study of the Hospital Anxiety and Depression Scale (HADS) in different groups of Dutch subjects. Psychol Med 1997;27:363-70.
Ivanovski K, Nakova M, Warburton G, Pesevska S, Filipovska A, Nares S, et al
. Psychological profile in oral lichen planus. J Clin Periodontol 2005;32:1034-40.
Eisen D, Ellis CN, Duell EA, Griffiths CE, Voorhees JJ. Effect of topical cyclosporine rinse on oral lichen planus. A double-blind analysis. N Engl J Med 1990;323:290-4.
Pacor ML, Biasi D, Urbani G, Lombardo G, Lunardi C. The efficacy of cyclosporin for topical use in oral lichen planus. Minerva Stomatol 1994;43:129-32.
Kalkur C, Sattur AP, Guttal KS. Role of depression, anxiety and stress in patients with oral lichen planus: A pilot study. Indian J Dermatol 2015;60:445-9.
] [Full text]
Brazzini B, Ghersetich I, Hercogova J, Lotti T. The neuro-immuno-cutaneous-endocrine network: Relationship between mind and skin. Dermatol Ther 2003;16:123-31.
Zhao ZZ, Savage NW, Sugerman PB, Walsh LJ. Mast cell/T cell interactions in oral lichen planus. J Oral Pathol Med 2002;31:189-95.
Ismail SB, Kumar SK, Zain RB. Oral lichen planus and lichenoid reactions: Etiopathogenesis, diagnosis, management and malignant transformation. J Oral Sci 2007;49:89-106.
Rojo-Moreno JL, Bagán JV, Rojo-Moreno J, Donat JS, Milián MA, Jiménez Y. Psychologic factors and oral lichen planus. A psychometric evaluation of 100 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;86:687-91.
Chaudhary S. Psychosocial stressors in oral lichen planus. Aust Dent J 2004;49:192-5.
Agha-Hosseini F, Moosavi M.S, Sadrzadeh Afshar MS, Sheykhbahaei N. Assessment of the Relationship Between Stress and Oral Lichen Planus: A Review of Literature. J Islam Dent Assoc Iran. 2016;28:78-85.
Harpenau LA, Plemons JM, Rees TD. Effectiveness of a low dose of cyclosporine in the management of patients with oral erosive lichen planus. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;80:161-7.
Sieg P, Von Domarus H, Von Zitzewitz V, Iven H, Färber L. Topical cyclosporin in oral lichen planus: A controlled, randomized, prospective trial. Br J Dermatol 1995;132:790-4.
Andreasen JO. Oral lichen planus. 1. A clinical evaluation of 115 cases. Oral Surg Oral Med Oral Pathol 1968;25:31-42.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]