Treatment outcome and incidence of psychiatric disorders in dermatological out-patients

OBJECTIVE: Epidemiological studies have shown that the prevalence of psychiatric disorders among dermatological patients is high. We aimed at estimating the short-term incidence of psychiatric disorders among patients with skin disease. METHODS: The 12-item General Health Questionnaire (GHQ-12) was used to identify subjects free from psychiatric morbidity at their first dermatological visit. The GHQ-12 was administered again after 1 month during a computer-assisted telephone interview. RESULTS: A total of 277 subjects was included in the study. At the follow-up interview, 21 (7.6%) were found to have significant psychiatric morbidity. Only lack of improvement was associated with increased incidence of psychiatric morbidity (13.6%), with an odds ratio of 3.1 (95% confidence interval 1.2-7.8), after adjustment for gender, age, educational level and clinical severity. CONCLUSIONS: Physicians should devote special attention to the risk of psychiatric complications in patients who have not improved with treatment.     

Increased psychiatric morbidity in female outpatients with skin lesions on visible parts of the body

Psychiatric disorders are frequent among patients with skin diseases. We aimed at identifying factors associated with psychiatric morbidity in dermatological outpatients. All adults attending the outpatient clinics of a dermatological hospital on predetermined days were given the 12-item General Health Questionnaire. The dermatologists indicated the diagnosis and location of skin lesions and rated the disease severity. A total of 1389 patients were asked to take part in the study. Of the 722 who accepted, 389 had a complete set of data and were included in the analysis. To verify the representativeness of our sample, we used the administrative registries to compare participants with the total population of patients who attended the clinics during the same period, and we examined the distribution of missing data. There was a tendency towards a younger age in the sample studied, but no evidence of substantial selection bias. The prevalence of psychiatric morbidity was 20.6%. We found higher probability of psychiatric disorders in women, controlling for age, clinical severity and localization of lesions. In women, but not in men, the prevalence of psychiatric morbidity was higher in patients with lesions on the face or hands. Given that the identification and appropriate management of psychiatric morbidity are important, it seems that the dermatologist should be particularly alert to the possibility of a concurrent psychiatric disorder in women with lesions on the face or hands.     

Mental health in patients with pemphigus: an issue to worth consideration

Background:

There exists a high prevalence of psychiatric disorders in dermatological patients. Although, investigators have evaluated psychiatric aspects of the patients suffering from skin diseases; there are rare studies concerning mental health in pemphigus patients. The objective of this study was to evaluate mental health status and quality of life of newly diagnosed pemphigus patients.

Materials and Methods:

Between April 2007 and June 2008, all newly diagnosed pemphigus patients attending the outpatient clinic of a dermatological hospital were given a questionnaire comprising the GHQ-28 and DLQI to fill out.

Results:

Of 283 patients, 212 complete forms were returned. The bimodal score of GHQ ranged from 0 to 26 (Mean = 9.4) and the Likert score of GHQ ranged from 6 to 68 (Mean = 31.9). The DLQI score ranged between 0 and 30 (Mean of 13.8). A total of 157 patients (73.7%) were yielded to be possible cases of mental disorder considering GHQ-28 bimodal scores. Significant correlation was detected between the DLQI score and bimodal and Likert scoring of GHQ-28.

Conclusion:

Our study has depicted high prevalence of psychiatric comorbidity in pemphigus patients. It underlines the fact that physicians, who are in-charge of care for these patients, are in an exceptional position to distinguish the psychiatric comorbidity and to take appropriate measures.     

Screening for depressive disorders in patients with skin diseases: a comparison of three screeners

Despite being common, depression often goes undetected in patients with skin diseases. Our aim was to examine and compare the performance of three depression screeners. We studied dermatological inpatients aged 18-65 years. They completed the questionnaires Primary Care Screener for Affective Disorders (PC-SAD), Patient Health Questionnaire (PHQ) and General Health Questionnaire (GHQ-12) and were administered a standardized psychiatric interview (SCID-I) by a mental health professional, who was unaware of the questionnaire answers. The analysis was performed on 141 patients with complete data (79% of all eligible patients, 89% of all patients who agreed to participate). The prevalence of the main forms of depression, major depressive disorder and dysthymic disorder, was 8.4% and 6.3%, respectively. For major depressive disorder, the sensitivity and specificity of the questionnaires were as follows: PC-SAD, 73% and 88%; PHQ, 55% and 91%; GHQ-12, 73% and 78%. For dysthymic disorder, the sensitivity and specificity were as follows: PC-SAD, 56% and 95%; PHQ, 44% and 90%; GHQ-12, 56% and 76%. The small sample size suggests caution in drawing conclusions about the relative merits of these screeners. Although both the GHQ and the PHQ are short and easily hand scored, the first is a generic screener for psychiatric morbidity that is not specific for depression, while the second displayed modest sensitivity. The PC-SAD, with short average administration time, acceptable sensitivity and high specificity, might be particularly useful in settings where the technology for computer automated scoring is available. Although screening programmes might be useful, they should be supplemented by quality improvement programmes and by the development of consultation-liaison services.     

Psychiatric morbidity in vitiligo: prevalence and correlates in India

BACKGROUND: Vitiligo, a common pigmentary disorder, is recognized to be associated with a high psychiatric morbidity, yet compared to other dermatological disorders like leprosy, psoriasis, etc., it has not been subjected to detailed evaluation of its psychological consequences. The data from the developing countries on this aspect in particular is meager. METHODS: One hundred and thirteen cases with vitiligo were evaluated along with 55 healthy controls comparable for sociodemographic profile and matched on attitude to appearance scale. Clinical details, impact of illness, associated dysfunction and psychological morbidity were additionally assessed. RESULTS: Twenty-eight patients with vitiligo were found to have psychiatric morbidity, a clinic prevalence rate of 25% (95% confidence interval 20.3-29.3%). The majority of the cases had a diagnosis of adjustment disorder. Psychiatric morbidity was significantly correlated with dysfunction arising out of illness. CONCLUSIONS: Vitiligo is associated with high psychiatric morbidity. There is a need to develop cross-cultural database on psychosocial aspects and psychiatric morbidity associated with vitiligo.     

Recognition of depressive and anxiety disorders in dermatological outpatients

Although mental disorders are frequent among dermatological patients, little is known about their recognition by dermatologists. This study aimed to assess dermatologists' ability to recognize depressive and anxiety disorders. All adult outpatients who visited four dermatologists on predetermined days (n=317) completed the 12-item General Health Questionnaire (GHQ-12) and the section on depressive and anxiety disorders of the Patient Health Questionnaire (PHQ). Dermatologists, masked to GHQ-12 and PHQ scores, rated patients' mental health status. The analysis was performed on 277 patients (87%) with complete data. With the PHQ as criterion standard, the dermatologists' assessment sensitivity was 33%, while specificity was 76%. In most cases of disagreement between the dermatologists and the PHQ, the GHQ-12 corroborated the PHQ classification. Anxiety disorders tended to be recognized better than depressive disorders. Among patients with a PHQ diagnosis, male gender tended to be associated with misclassification by dermatologists. Although limitations inherent in self-report psychiatric assessment should be considered, this study suggests that mental disorders often go unrecognized in dermatological patients. This issue might be addressed by implementing specific training programmes, using validated screening questionnaires for depression and anxiety, and developing rational consultation-liaison services.     

Screening for mental disorders in leprosy patients: comparing the internal consistency and screening properties of HADS and GHQ-12

OBJECTIVE: The aim of the study was to investigate the internal consistency and screening properties of the General Health Questionnaire-12 (GHQ-12) and the Hospital Anxiety and Depression Scale (HADS) in Turkish patients with leprosy. METHODS: The two screening instruments and a fully structured diagnostic interview (CIDI) were administered to 65 people drawn from all leprosy inpatient units in Turkey between March and June of 2001. The scales were evaluated using Cronbach's alpha and Receiver Operating Characteristics (ROC) analyses. For each scale, criterion validity was assessed for any psychiatric disorder, depressive disorder and anxiety disorder. RESULTS: The Cronbach alpha coefficients for the GHQ-12 and HADS were 0.84 and 0.81 respectively. For detecting any psychiatric disorder, the optimal cut-off for the GHQ-12 was 4/5 (sensitivity 0.82, specificity 0.62). The optimal cut-off for the HADS total score was 12/13 (sensitivity 0.80, specificity 0.77). CONCLUSION: The results indicate that the General Health Questionnaire-12 and Hospital Anxiety and Depression Scale have satisfactory internal consistency, and performed well to a similar extent for detecting psychiatric disorders in leprosy patients.     

The impact of skin diseases on patients: comparing dermatologists' opinions with research data collected on their patients

BACKGROUND: Research data suggest that the detection of psychiatric disorders by dermatologists is not completely satisfactory, and that patients and dermatologists often assess patients' quality of life differently. Given that expectations influence perception and cognitia, these discrepancies might at least in part descend from conceptual models of skin disease that are prevalent among dermatologists. OBJECTIVES: We explored to what degree dermatologists' opinions about quality of life and prevalence of psychiatric disorders in several dermatological conditions corresponded to the actual data collected on their patients. METHODS: All dermatologists working in a large institution were asked to express on a five-point scale their opinion about the quality of life and the prevalence of depressive and anxiety disorders in different skin conditions. Physicians' opinions were then compared with the results of a large research project on quality of life and psychological well-being in dermatological out-patients performed in their institution some months before. RESULTS: Forty-six dermatologists (82%) agreed to participate and completed the research questionnaire. We observed a fairly good concordance between dermatologists' opinion about the impact of the various skin conditions on patients' lives and survey data on quality of life impairment. With regard to psychiatric morbidity, we found that dermatologists believe that psychiatric disorders are substantially less frequent than they actually are in many skin conditions. CONCLUSIONS: The belief that psychiatric morbidity is rare in patients with certain skin conditions might hamper, at least in part, the recognition of psychiatric disorders in these patients. Dermatologists probably should be more alert to the question of psychiatric morbidity in their patients. Allocating more space to this issue in training programmes for dermatologists might favour a shift in their conceptual models of skin disease.     

Assessing psychological distress in patients with skin diseases: reliability, validity and factor structure of the GHQ-12

OBJECTIVE: We studied reliability, validity and factor structure of the 12-item General Health Questionnaire (GHQ-12) in dermatological patients. METHOD: Subjects attending a dermatological outpatient clinic were administered the GHQ-12 and the Skindex-29. A random subsample was mailed another copy of the questionnaires to be completed within 1 week. RESULTS: A total of 2,579 subjects completed the GHQ-12. The internal consistency of the GHQ-12 was high (Cronbach's alpha = 0.88). Test-retest reliability on 137 subjects was also fairly satisfactory (intraclass correlation coefficient = 0.72), notwithstanding a re-test artefact probably related to reassurance from the physician. Evidence of construct validity was provided by the pattern of correlation between scores on the GHQ-12 and on the scales of Skindex-29, which were as hypothesized. Also, GHQ-12 scores of patients in different clinical groups varied as hypothesized, with patients affected by inflammatory skin diseases scoring significantly higher than patients with isolated skin lesions. We obtained both a two-factor and a three-factor solution: the latter seemed theoretically more appropriate, although the first may have practical advantages. A 'social dysfunction' factor emerged in both analyses, while the other items loaded on a 'general dysphoria' factor or on two separate factors interpreted as 'anxiety' and 'loss of self-esteem'. CONCLUSIONS: The GHQ-12 is a reliable and valid instrument with a factor structure that is quite stable across different samples as well as across diverse cultures. Its brevity and easiness of completion make it a useful tool to assess psychological distress in dermatological patients.     

Prevalence and factors associated with body dysmorphic disorder in women under dermatological care at a Brazilian public institution

BackgroundBody dysmorphic disorder consists of excessive concern with minimal appearance defects, which causes functional impairment. Its prevalence is estimated to range from 5% to 35% of dermatological patients, especially adult women with esthetic complaints.ObjectivesTo investigate the prevalence and factors associated with dysmorphic disorder in female dermatological patients, in a public institution in Brazil.MethodsThis was a cross-sectional study involving adult women attended at a public dermatological service in Brazil. Participants underwent a demographic survey, in addition to a screening form for body dysmorphic disorder (Body Dysmorphic Disorder Examination [BDDE]). The presence of dysmorphic disorder (BDDE > 66 points) was assessed among the participants according to demographic covariates and psychological problems, through logistic regression.ResultsA total of 223 women were evaluated. The BDDE showed high internal consistency (Cronbach’s α = 0.90). It is noteworthy the high prevalence of psychological problems and the fact that over one-third (38%) of the sample presented a high degree of dissatisfaction with their image. The prevalence of dysmorphic disorder was 48% among women with esthetic complaints and 30% among the others (p < 0.01). Lower family income (OR = 2.97), history of domestic violence (OR = 3.23), search for dermatological care due to an esthetic complaint (OR = 2.05), and suicidal ideation (OR = 4.22) were independently associated with the occurrence of body dysmorphic disorder.Study limitationsThis was a single-center study of a non-randomized sample from public service.ConclusionsBody dysmorphic disorder is prevalent among female dermatological patients; it is associated with traumatic psychological experiences, lower income, affective disorders, and demand for esthetic care. It is essential to recognize the diagnosis in order to treat such patients and refer them for appropriate psychiatric treatment instead of trying to satisfy their esthetic demands.     

The impact of changes in clinical severity on psychiatric morbidity in patients with psoriasis: a follow-up study

BACKGROUND: Psoriasis has a strong impact on quality of life and is correlated to psychopathological states. It is important to investigate the effect of clinical changes on psychological status. OBJECTIVES: To analyse the extent of clinical change and its effect on the presence of psychiatric morbidity in a group of patients with psoriasis. METHODS: All eligible adults hospitalized with psoriasis in a dermatological hospital (February 2000-February 2002) were given the self-administered Psoriasis Area and Severity Index (SAPASI) to assess clinical severity, the 12-item General Health Questionnaire (GHQ-12) to detect patients with psychological problems (defined as 'cases') and the Skindex-29 to evaluate symptoms. The same questionnaires were completed by the patients a month after hospital discharge. RESULTS: In our population of 414 patients, the incidence of GHQ cases becoming noncases was correlated with the SAPASI percentage improvement, ranging from 17.6% in patients with SAPASI worsened or unchanged at follow-up, to 68.2% in patients with clearance of psoriasis. Also, the proportion of patients who became GHQ noncases was much higher in patients with improvement of >/= 50% in symptoms, compared with patients with no improvement or worsening (70% vs. 32%, respectively). In a multivariate model the possible determinants of the passage from GHQ case to noncase were: SAPASI improvement, symptom improvement, no localization on the face, and gender (i.e. women were less likely to improve psychologically). CONCLUSIONS: The improvement in clinical severity and symptoms was associated with a decreased frequency of psychiatric disturbance. However, dermatologists should be aware that even in the presence of vast clinical improvement patients may still substantially suffer psychologically.     

Correlates of psychiatric morbidity in patients with leprosy

The relationship between psychiatric morbidity in 30 leprosy patients under treatment as assessed by the General Health Questionnaire (GHQ-12) and certain variables of their illness and psychosocial factors is examined in this paper. Physical disability and duration of illness were the illness variables considered; knowledge and adjustment were the psychosocial variables included. Bell's Adjustment Inventory (BAI) measured the latter, psychiatric morbidity was positively correlated with physical disability (p < 0.05), knowledge about the disease (p < 0.01) and social, emotional and health maladjustment (p < 0.01), but not with duration of illness (p > 0.05). The importance of appropriate knowledge, social stigma and physical disability in leprosy is discussed in addressing the psychiatric morbidity of leprosy patients.     

Screening for depression in adult acne vulgaris patients: tools for the dermatologist

Summary Background Adult dermatological out patients have a 40% prevalence of psychiatric co‐morbidity. If psychiatric co‐morbidity is unrecognized, undetected and untreated, the consequences may be fatal. Acne is the most common skin disorder of the second and third decades of life. Acne and its treatments may cause depression. Aims To identify a screening tool to identify depression in adult acne patients. Methods The literature was reviewed to identify validated screening instruments for depressive disorders. Questionnaires studied included the Hospital Anxiety and Depression Scale (HAD), the Brief Patient Health Questionnaire (B‐PHQ), the General Health Questionnaire‐12 item version (GHQ‐12), and the World Health Organization‐5 Well Being Index (WHO‐5). Results WHO‐5 performed best in terms of sensitivity (0.93 for a cut‐off score of 13) as well as taking least time to complete (2–5 min) and evaluate (0.5–2 min). Conclusions WHO‐5 can be recommended as part of a two‐step screening process for depression in acne patients. Step 1 is the WHO‐5. In the case of a positive score, step 2 is a detailed psychosocial assessment.     

Effects of patient satisfaction with care on health-related quality of life: a prospective study

OBJECTIVES: To evaluate the effect of patient satisfaction on health-related quality of life among dermatological outpatients, independently of patients' sociodemographic, and clinical characteristics. DESIGN: Prospective cohort study. Satisfaction was evaluated with a standardized questionnaire three days after the visit by telephone interview. Quality of life and psychiatric disorders were measured with validated instruments (Skindex-29 and Ghq-12) before the dermatological visit and after four weeks. At the four week interview also self-reported medication adherence was assessed. SETTING: Outpatient clinics of a large dermatological hospital in Rome, Italy. PATIENTS: A consecutive sample of 1389 outpatients was approached, and 52% agreed to participate. Inclusion criteria were met by 424 patients, and 396 (93%) of them completed the study. MAIN OUTCOME MEASURES: Improvement in health related quality of life. RESULTS: At multivariate analysis satisfied patients have approximately twice the odds for an improved quality of life on the emotions scale (OR = 1.99; 95%CI 1.1 to 3.7; P = 0.03) and on the functioning scale (OR = 2.2; 95%CI 1.1 to 4.7; P = 0.03). Patients with psychiatric disorders at baseline were less likely to have an improved quality of life on the functioning scale (OR = 0.3; 95%CI 0.2 to 0.8; P = 0.01). CONCLUSIONS: This is the first prospective study showing that patient satisfaction and psychiatric disorders have a significant effect on quality of life improvement among dermatological patients, independently of patient characteristics. Particular attention should be devoted to improving physicians' interpersonal skills, the major component of patient satisfaction.     

Skin disorders in chronic psychiatric illness

Background Chronic psychiatric patients are prone to develop skin diseases. However, epidemiological data are scarce. Objective To describe the prevalence of skin complaints and dermatological disorders in residential psychiatric patients. Methods Ninety‐one randomly chosen patients of the residential wards of a general psychiatric hospital completed a short, structured interview concerning skin disease and underwent a physical examination of the skin. Results Of the examined patients, 69% reported symptoms of skin disease in the month prior to the interview and 77% had skin disorders at physical examination. In 34 (37%) patients, skin disorders were diagnosed, which were not mentioned in the interview. Patients with diabetes had infectious skin disease more often than their fellow patients [odds ratio (OR) 10.9; 95% confidence interval (CI): 2.40–49.75]. Moreover, overweight patients had infectious skin disease more often (OR 7.4; 95% CI: 1.38–39.3). Women reported more skin complaints (OR 6.4: 95% CI: 1.67–24.2), and also had skin problems other than infection, tumours or dermatitis more frequently (OR 3.7; 95% CI: 1.34–10.14). Clozapine use was associated with benign neoplasms of the skin. The nature of this association remains unclear and merits further investigation. Conclusions Many chronic psychiatric patients have skin problems. Clinical examination of the skin is important to discover these problems. Patients with diabetes mellitus are particularly at risk for skin infections. Because of their relationship with overweight and diabetes mellitus, atypical antipsychotics may be partly responsible for these serious complications. Only a few other relationships between psychiatric medication and specific skin problems were found.     

Psychiatric treatments in dermatology: an update

There is a considerable degree of connection between psychiatry and dermatology. This connection is relevant both for diagnosis and management of dermatological pathology. This article summarises common psychiatric conditions seen in patients with skin disease, both primary psychiatric disorders and psychiatric disorders secondary to dermatological pathology. Diagnosis of relevant psychiatric conditions such as anxiety, depression, obsessive–compulsive disorder, delusional parasitosis and dermatitis artefacta, and psychiatric treatments are discussed. It gives an update of psychopharmacology relevant to the dermatologist including important interactions between psychotropic and dermatological agents.     

Substantial skin disorders in psychiatric illness coincide with diabetes and addiction

Background Dermatological diseases in psychiatric patients are common; however, epidemiological data on this subject are scarce and to our knowledge integral studies of dermatological disease in psychiatric inpatients are not available yet. Aim The aim of this study was to describe the incidence of dermatological problems in psychiatric inpatients. Method This study evaluates the consultations for new dermatological problems by inpatients of a general psychiatric hospital of over 700 beds during a 6‐month period. Results A total of 255 patients consulted their physician because of a new dermatological problem. Diagnoses (n = 360) included skin infections (32%), accidents (7%), decubitus ulcers (7%), complications of medical treatment (3%), auto mutilation (1%) and neoplasms of the skin (1%). Patients with skin infections were likely to have diabetes [odds ratio (OR) = 3.6; 95% confidence interval (CI): 1.56–8.40]. Patients with decubitus ulcers were likely to have an addiction problem (OR = 6.4; 95% CI: 1.46–28.00). Dermatitis was associated with affective disorder (OR = 2.5; 95% CI: 1.12–5.43) but not with psychosis (OR = 0.5; 95% CI: 0.23–0.90). Only a poor correlation existed between the length of hospital stay and skin problems. Conclusions Dermatological problems are common in hospitalized psychiatric patients. Patients with diabetes mellitus are at high risk for skin infections. There are significant relationships between the psychiatric and the dermatological diagnoses. The length of the admission to a psychiatric hospital does not seem to play a major role in skin diseases.     

Psychiatric morbidity and skin disease: what dermatologists think they see

It has been suggested that skin disease and psychological disturbance may be linked. Recent work has focused on the fatal outcome associated with some dermatological disorders as a result of suicide. The impressions of dermatologists about how much psychological or psychiatric morbidity they see related to dermatological disease has not been addressed. The survey reported here revealed that most dermatologists recognized the relationship and demonstrated the perceived need for clinical psychology and psychiatric services for patients with dermatological disorders. It confirmed the impression that in a small number of cases, skin complaints are associated with attempted or completed suicide.     

Assessment of psychiatric morbidity in patients attending a colposcopy clinic situated in a genitourinary medicine clinic.

OBJECTIVE--To determine the adverse psychological implications of referral for colposcopic screening within a genitourinary medicine clinic. DESIGN--Cross sectional survey. SETTING--A colposcopy clinic held within a genitourinary medicine clinic. SUBJECTS--160 consecutive women referred to the clinic were assessed for psychiatric morbidity using the General Health Questionnaire (GHQ-28). Women were referred to the colposcopy clinic because of one or more of the following: abnormal cervical cytology, condylomata acuminata, HIV antibody positivity. A history of prior local ablative therapy to the cervix was also included in the analysis. RESULTS--There was no difference in psychiatric morbidity, as detected by the GHQ-28, in women referred to the clinic because of abnormal cervical cytology or condylomata acuminata. The total GHQ-28 scores indicated a significant increase in psychiatric morbidity, with increased sub-scores indicating social dysfunction, anxiety and somatic symptoms, in women who had had prior laser therapy to the cervix. Women with HIV infection attending the clinic were noted to have an increase in GHQ-28 sub-scores indicating social dysfunction and depression. CONCLUSIONS--Women who have undergone laser therapy to the cervix may benefit from psychological evaluation and supportive measures if they develop further genital lesions which require colposcopic evaluation. Women with HIV infection need further psychological evaluation prior to planning intervention and preventative strategies.     

The use of antidepressant drugs in dermatology

This paper provides an updated review of the use of antidepressant drugs in dermatology. Some of the psychiatric disorders that are usually comorbid with dermatological disorders and respond to antidepressants include major depressive disorder, obsessive compulsive disorder, body dysmorphic disorder, social phobia and post-traumatic stress disorder usually secondary to trauma and abuse during early life. Cutaneous symptoms may be the feature of a primary psychiatric disorder, e.g. cutaneous body image problems, dermatitis artefacta, neurotic excoriations and trichotillomania, or psychiatric syndromes may be comorbid with a primary dermatological disorder such as the association of major depressive disorder or social phobia with psoriasis and obsessive compulsive disorder with acne excoriee. Some of the salient pharmacological properties of the tricyclic antidepressants (TCAs) and the selective serotonin reuptake inhibitor (SSRI) antidepressants are reviewed. The review indicates that the SSRI antidepressants are potentially beneficial in the management of all the major psychiatric syndromes that are encountered in dermatological disorders. The generally more favourable side-effect profile of the SSRIs, such as lower cardiotoxicity in contrast to the TCAs, has made them the first-line agents for the treatment of depression. Furthermore, some of the pharmacological properties of the antidepressant agents that are not related to their antidepressant activity, such as the histamine H1 blocking effect of TCAs, such as doxepin, amitriptyline and trimipramine, are of benefit in dermatological conditions such as urticaria and pruritus. This paper reviews the general guidelines for use of antidepressants and salient drug-drug interactions resulting mainly from the inhibition of the cytochrome P450 (CYP) 2D6 and 3A3/4 isoenzymes by some of the SSRI antidepressants. Before prescribing an antidepressant agent, the specific guidelines, side-effect profile, drug-drug interactions and most current indications should always be obtained.