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Fırat Tıp Dergisi
2019, Cilt 24, Sayı 1, Sayfa(lar) 031-036
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Prevalence of Dermatological and Psychiatric Diseases Related to Stress in Syrian Refugees and Local People: A Cross-sectional Study in Southeastern Anatolia, Turkey
Asude KARA1, Ümit Sertan ÇÖPOĞLU2, Yavuz YEŞİLOVA3, Emine Tuğba ALATAŞ4, Aslı AKIN BELLİ1, Metin PIÇAKÇIEFE5
1Muğla Sıtkı Koçman Üniversitesi Eğitim ve Araştırma Hastanesi, Deri ve Zührevi Hastalıklar Kliniği, Muğla, Türkiye
2Mustafa Kemal Üniversitesi Tıp Fakültesi, Psikiyatri Anabilim Dalı, Hatay, Türkiye
3Özel Lokman Hekim Hastanesi, Deri ve Zührevi Hastalıklar Kliniği, Van, Türkiye
4Muğla Sıtkı Koçman Üniversitesi Tıp Fakültesi, Deri ve Zührevi Hastalıklar Anabilim Dalı, Muğla, Türkiye
5Muğla Sıtkı Koçman Üniversitesi Tıp Fakültesi, Halk Sağlığı Anabilim Dalı, Muğla, Türkiye
Keywords: Epidemiyoloji, Psikiyatrik Hastalıklar, Mülteci, Deri Hastalıkları, Güneydoğu Anadolu, Epidemiology, Psychiatric Diseases, Refugee, Skin Diseases, Southeastern Anatolia
Summary
Objective: Although a large number of Syrian refugees have been living in Turkey, the studies demonstrating dermatological problems of Syrian refugees are scarce. We sought to investigate stress-related dermatological diseases and psychiatric disorders of Syrian refugees and local people in the dermatology clinic on the border of Syria.

Material and Method: A cross-sectional study was conducted on 48 Syrian refugees and 118 local people diagnosed as acne vulgaris, alopecia areata, psoriasis, pruritus, seborrheic dermatitis and urticaria between May and August 2013. Socio-demographic and clinical characteristics of the participants were recorded. All patients were examined by a single psychiatrist.

Results:Of 166 participants, 72 had acne vulgaris, 27 had psoriasis, 24 had pruritus, 18 had seborrheic dermatitis, 14 had alopecia areata, and 11 had urticaria. Of them, 47% had at least one psychiatric disorder; 31.3% had anxiety disorder, 7.2% had mood disorder, and 8.4% had both of anxiety and mood disorders. Whereas the prevalence of general psychiatric disorders and major depression was not significantly different between refugees and local people, the prevalence of post-traumatic stress disorder was significantly higher in refugees.

Conclusion: The frequency of psychiatric disorders and skin diseases related to stress were quite high in refugees and local people.

  • Top
  • Summary
  • Introduction
  • Methods
  • Results
  • Disscussion
  • Conclusion
  • References
  • Introduction
    Sanliurfa is the seventh largest province of Turkey located in the south-eastern Anatolia, which has the longest border with Syria. Ceylanpinar, one of the districts of Sanliurfa, has a particular geographical and political importance because of the localization at the zero point of Syrian borders. Ceylanpinar has quite large and flat lands suitable for agriculture. Majority of the local people are in the agriculture and animal husbandry industries as temporary or permanent workers 1.

    Turkey started to accept refugees from Syria after the civil war onset of Syria in March 2011. And then, several accommodation centers for Syrian refugees were constructed in Turkey 2,3. According to 2013 data of the Disaster and Emergency Management Authority (AFAD), the population of Syrian refugees was 188 421 and the number of Syrian refugees in Ceylanpinar was 42 043 in accommodation centers. Sanliurfa has the highest number of refugees (~97 000) in Turkey and has been followed by Ceylanpinar 4. As reported by Statista, Turkey is one of the countries hosting a large number of refugees in the world 5.

    Because of poor living conditions, health care deficiencies, and low socioeconomic status, both of physical health and mental status are adversely affected in refugees 6. Anxiety, depression, sleep disorders, suicidal tendency, post-traumatic stress disorder syndrome, marriage and interpersonal problems, domestic and street violence, alcoholism, and drug abuse are frequently reported problems in refugees 7. Psychological factors play an important role in the development of dermatological diseases that one third of dermatological diseases have been associated with psychological factors 8,9. Emotional stress can initiate or aggravate the majority of dermatological diseases. Dermatological diseases such as acne vulgaris (AV), alopecia areata (AA), psoriasis, pruritus, seborrheic dermatitis (SD), and urticaria are considered to be stress-induced dermatological diseases 8,10-12.

    Emotional stress is an important trigger of dermatological diseases and to our knowledge there is no study about the stress-related dermatological diseases and psychiatric disorders in Syrian refugees. We aimed to investigate the prevalence of stress-related dermatological diseases and psychiatric disorders of Syrian refugees and local people in the Dermatology Department of Sanliurfa Ceylanpinar State Hospital.

  • Top
  • Summary
  • Introduction
  • Methods
  • Results
  • Disscussion
  • Conclusion
  • References
  • Methods
    This study was a crosssectional study conducted in the Dermatology Outpatient Clinic of Sanliurfa Ceylanpinar State Hospital between May and August 2013. In this period, 186 Syrian refugees and 2968 local people were admitted to the hospital. Among these patients, 48 Syrian refugees and 118 local people were enrolled in the study. The patients with diagnoses of AV, AA, psoriasis, pruritus, SD and urticaria were included in the study. Four interpreters of AFAD translated phrases of the refugees who do not speak in Turkish. The participants were asked to answer a survey containing some socio-demographic variables and clinical data. No patients refused to participate in the study. All patients were referred to psychiatry department, evaluated by a single psychiatrist, and diagnosed based on the The Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV-TR) scale.

    Socio-demographic characteristics of the participants including gender, age, education status, marital status, parenting, duration of refugee status, refugees’ residencies (tent cities, guest, or rental house), smoking, and alcohol consumption were recorded. Clinical characteristics of the participants including diagnosis and duration of the dermatological disease (AV, AA, psoriasis, pruritus, SD, and urticaria), accompanying psychiatric disease (if present), and medical history were evaluated.

    Ethics Committee Approval was obtained from Harran University Faculty of Medicine Ethics Committee Department prior to the study. Informed consent forms of the participants were taken before the examinations.

    Statistical analysis
    "SPSS 20.0 software" was used to analysis of the study. Kolmogorov-Smirnov and Lilliefors tests were used to check normality of the data distribution. Two independent samples t test (t test) and one-way variance analysis (ANOVA) were used to analysis of the quantitative data. Fisher’s exact test, Pearson’s Chi-Square test, and logistic regression analysis were used to analysis of the qualitative data. P values <0.05 were accepted as significant.

  • Top
  • Summary
  • Introduction
  • Methods
  • Results
  • Disscussion
  • Conclusion
  • References
  • Results
    Socio-demographic characteristics of the participants
    A cross-sectional study was conducted on 166 patients who referred to the Dermatology Outpatient Clinic of our hospital between May and August 2013. Of 166 patients, 48 (28.9%) were refugees (29 female and 19 male) and 118 (71.1%) were local people (70 female and 48 male). Socio-demographic characteristics of the participants were shown in Table 1. The duration of refugee status were ranging from 1 month to 8 months.


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    Table 1: Socio-demographic characteristics of the participants.

    Clinical characteristics of the participants
    Among dermatological diseases; 19 (10.2%) of the refugees had AV, 10 (5.3%) had psoriasis, 4 (2.1%) had pruritus, 8 (4.3%) had SD, 5 (2.6%) had AA, and 2 (1.0%) had urticaria; 53 (1.7%) of the locals had AV, 17 (0.5%) had psoriasis, 20 (0.6%) had pruritus, 10 (0.3%) had SD, 9 (0.3%) had AA, and 9 (0.3%) had urticaria (Table 2).


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    Table 2: The prevalence rates of the dermatologic diseases of the participants.

    Of the participants, 78 (47%) had at least one psychiatric disorder; 52 (31.3%) had anxiety disorder, 12 (7.2%) had mood disorder, and 14 (8.4%) had both of anxiety and mood disorders. The rates of psychiatric disorders and major depression (MD) were not significantly different between refugees and local people (p = 0.24 and p = 0.93, respectively). But the rate of post-traumatic stress disorder (PTSD) was significantly higher in refugees than in local people (p < 0.001) (Table 3).


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    Table 3: The prevalence rates of psychiatric disorders, post-traumatic stress disorder, and major depression of the participants.

    There were no significant difference between the refugees with or without PTSD according to age, gender, marital status, and educational status (pwq > 0.05).

    In the medical history of the participants, 71.1% of them had a dermatologic disease, 9.6% had a psychiatric disorder, 7.8% had a chronic disease, 4.2% had a suicide attempt, and 17.5% had a history of trauma previously.

    Of the participants, 60.8% stated that their dermatologic disease had a relation with emotional stress, 32.5% stated that there was no relation between their dermatologic disease and emotional stress, and 6.6% had no idea about this topic.

  • Top
  • Summary
  • Introduction
  • Methods
  • Results
  • Disscussion
  • Conclusion
  • References
  • Discussion
    War is one of the preventable reasons of the life-threatening diseases causing disability and deaths. Wars have continued in the different regions of the world since the onset of history of the mankind 13,14. People have had to emigrate from their own countries to other countries because of the wars. Migrants or refugees are usually called to the people who leave their own country for economic and cultural reasons and settle in the other country with the expectation of a better life 15.

    A large number of refugees came to Turkey because of the civil war of Syria started in March 2011. Erdogan et al. reported that more than 1.6 million Syrian refugees have been in Turkey for 3.5 years that 13% of them are living in refugee camps and the others in different cities of Turkey 2.

    There are various studies about refugees in the world. Even though health problems of the refugees are particularly associated with traumatic events, there are a few studies about dermatological diseases observed in refugees 16,17. Pavodese et al. have noted the dermatological diseases as the most common disease group in their study conducted on the refugees 18. However, studies demonstrating dermatological problems of Syrian refugees in Turkey are scarce. Most of these studies are about leishmaniasis in the refugees 19-21. Turan et al. compared the socio-demographic and clinic features of Syrian refugees and local people with leishmaniasis. The duration and number of cutaneous leishmaniasis lesions were higher in Syrian refugees than in local people 21.

    In the present study, we evaluated the stress-related dermatological diseases such as AV, AA, psoriasis, pruritus, SD and urticaria in the refugees and local people. AV is an inflammatory disease of pilosebaceous unit. Corticotropin-releasing hormone (CRH), the stress hormone, has been shown to increase the lipid synthesis in the sebaceous glands as in vitro and therefore, has been proposed to induce of acne and seborrhea 9. In a study including 304 farmers, Quandt et al. found the acne prevalence of 48.4% in North Carolina 22. Krejci-Manwaring et al. 23 reported the acne prevalence of 24.1% among Latin immigrant farmers.

    In our study, the prevalence rates of AV were 1.7% and 10.2% in local people and refugees, respectively.

    AA is a cutaneous disease characterized by round, well demarcated bald patches resulting fromrapid loss of hair. AA influences the patients negative psychologically because of cosmetic concerns, even though it does not lead to any physical problems. The rates of psychiatric diseases, especially anxiety disorder, depression, and adjustment disorders, have been found high in the patients with AA 24. Albares et al. reported the AA prevalence of local people and refugees in Spain as 1.2% and 1.4%, respectively 25. In our study, the prevalence of AA was 2.6% in refugees and 0.3% in local people.

    Psoriasis is a chronic inflammatory skin disease that is considered to be a psychosomatic disorder. Stress and psychosocial factors play an important role in the onset, as well as exacerbation of psoriasis 26. In the present study, prevalence of the psoriasis was 5.3% in refugees and 0.5% in locals.

    Although the pathogenic mechanism of stress on itching is not clear, suppression of hypothalamic-pituitary-adrenal pathway have been proposed to induce itching mediators such as endogenous opioids 10. Albares et al. 25 reported the pruritus prevalence of the refugees and local people in Spain as 1.7% and 1.2%, respectively. In our study, pruritus prevalence was 2.1% in refugees and 0.6% in locals.

    SD is a chronic, recurrent, and inflammatory dermatosis affecting especially the sebum rich areas such as eyebrows, scalp, and nasolabial region characterized by yellowish scaly plaques. The vast majority of SD flares are usually seen in the periods of emotional stress and depression 27. In a multicenter study comprising 2159 patients with SD, depression, stress, and fatigue were triggers for SD 28. Misery et al. 29 have noted the stress as the main promoting factor of SD in their study population. In our study, the SD prevalence of refugees (4.3%) was significantly higher than local people (0.3%).

    Urticaria is an itchy disease characterized by erythematous, edematous papules, and plaques 30. Emotional stress is a well-known triggering factor of urticaria. Staubach et al. 31 have detected at least one psychosomatic disorder in 48% of the patients with chronic spontaneous urticaria (CSU). Among these disorders, the most common one was anxiety disorder, and it was followed by depression and somatoform disorders. In a study conducted on 30 patients with CSU, 30 patients with AA, and 39 controls, the anxiety and depression scores were significantly higher in the patients with CSU than in the controls 32. Albares et al. 25 found the prevalence of urticaria as 1.3% and 0.7% in the refugees and locals, respectively. In our study, the prevalence of urticaria was 1.0% in the refugees and 0.3% in the locals.

    Psychological trauma includes man-performed traumatic events such as wars, terrorist attacks, torture, and sexual assault other than unintentional traumatic events such as natural disasters 33. Gammouh et al. 6 have reported that 35% of the refugees with chronic diseases had depression. The prevalence rates of depression in the refugees have been varied from 22% to 68% in the different studies 34-36. TSSD is a condition including emotional, mental, behavioral, and social impairments that develops in everyone after unusual human experiments 37. Traumatic stress disorders have been known to cause of disability and loss of function. In a study performed by Fazel et al. 38, 9% of the refugees were diagnosed as PTSD and 5% as MD. Alpak et al. 39 found the PTSD prevalence of 33.5% in Syrian refugees. Nora Alghothani et al. noted that several psychiatric diseases such as somatoform disorders, depression, anxiety, PTSD, and smoking was quite common in Syrian refugees 40. In our study, 78 (47%) of the refugees had at least one psychiatric disease. Among these patients, 27 (16%) had MD and 19 (11%) had PTSD. The prevalence of PTSD was significantly higher in refugees (37.5%) than in local people (0.8%). The prevalence rates of MD were almost equal in refugees and locals (16.7% vs. 16.1%).

    The limitation of the study was the small number of the participants due to the poor life conditions of the researchers that bullets and shrapnel parts of bombs targeted the hospital for many times.

  • Top
  • Summary
  • Introduction
  • Methods
  • Results
  • Discussion
  • Conclusion
  • References
  • Conclusion
    Consequently, we evaluated dermatologic and psychiatric diseases of Syrian refugees and local people in the southeastern region of Turkey. In the literature, there are a few studies about the health status of refugees in Turkey and the most of the studies are about infection diseases. In our study, the frequency of psychiatric disorders and skin diseases related to emotional stress were quite high. There is a need of psychosocial support and training programs of chronic diseases for the refugees in our country, as well as in the other countries.

    Conflict of interest: The authors declare no conflict of interest.

  • Top
  • Summary
  • Introduction
  • Methods
  • Results
  • Discussion
  • Conclusion
  • References
  • References

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  • Top
  • Summary
  • Introduction
  • Methods
  • Results
  • Discussion
  • Conclusion
  • References
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