Alopecia Areata (AA) is a common, chronic, T-cell-mediated autoimmune disease that targets the hair follicle, leading to non-scarring hair loss [1]. It is characterized by well-circumscribed, usually round or oval patches of hair loss, most frequently on the scalp and beard area, but it can affect any hair-bearing surface of the body [2]. The clinical presentation of AA is highly variable, ranging from a single, small patch that may resolve spontaneously to complete loss of all scalp hair (Alopecia Totalis, AT) or all body hair (Alopecia Universalis, AU) [3]. The lifetime risk of developing AA is estimated to be around 2% globally, affecting both sexes equally and all age groups, with a peak incidence in the second and third decades of life [4,5]. The precise etiopathogenesis remains incompletely understood, but it involves a complex interplay of genetic predisposition, environmental triggers (such as infections, stress, or trauma), and a breakdown of the immune privilege of the hair follicle, leading to an inflammatory attack [6].

For decades, Alopecia Areata has been predominantly viewed and treated as a purely dermatological condition. However, this perspective is fundamentally incomplete. Hair holds significant psychological, social, and cultural importance, symbolizing individuality, health, attractiveness, and vitality [7]. The visible and often sudden nature of hair loss in AA can be a deeply distressing experience, leading to a cascade of negative psychological consequences. Patients frequently report feelings of loss of control, altered self-image, and a diminished sense of self-worth [8]. The unpredictable, relapsing-remitting course of the disease adds another layer of burden, creating a constant state of anxiety about future flares and further hair loss. The social stigma associated with hair loss, although not a physically disabling condition, can be immense, leading to social withdrawal, avoidance behaviours, and a significant impairment in social and occupational functioning [9].

A substantial body of evidence, primarily from Western countries, has established a strong link between AA and various psychiatric comorbidities. Major Depressive Disorder and Generalized Anxiety Disorder are the most frequently reported conditions, with prevalence rates significantly higher than in the general population [10,11]. A large-scale systematic review and meta-analysis found that patients with AA had a significantly increased risk of depression and anxiety compared to healthy controls [12]. Furthermore, studies have shown that the subjective psychosocial impact of AA is often a better predictor of quality of life impairment than objective clinical severity [13]. The chronic stress associated with living with a visible and unpredictable condition can also lead to more severe outcomes, including suicidal ideation and attempts. Research indicates that the prevalence of suicidal ideation is elevated in AA patients, reflecting the profound despair that can accompany the disease [14]. The psychological distress may also, in turn, exacerbate the disease itself, creating a vicious cycle of stress and hair loss [6].

In the Indian context, where cultural and societal norms place a high premium on physical appearance, especially regarding hair, the psychological impact of AA may be uniquely profound. Hair is deeply intertwined with concepts of beauty, marriage prospects, social status, and even spirituality in Indian society. The stigma attached to visible hair loss can be particularly severe, leading to significant distress for the patient and their family [15]. Despite this, research exploring the psychosocial burden of AA in the Indian population remains sparse. There is a critical need to understand the prevalence and correlates of psychological morbidity among Indian patients with AA to inform holistic and culturally sensitive patient care. This study aims to fill this gap by assessing the prevalence of depression, anxiety, and suicidal ideation in patients with AA attending a tertiary care hospital in Telangana, India.

OBJECTIVE

The primary objective of this study was to determine the prevalence of depression, anxiety, and suicidal ideation in a cohort of patients diagnosed with Alopecia Areata attending a tertiary care centre in Telangana, India. By quantifying the burden of these psychological comorbidities, the study aims to highlight the significant, yet often overlooked, mental health challenges faced by this patient population. This is a crucial step in advocating for the integration of psychological care into the standard dermatological management of AA.

The secondary objective was to investigate the relationship between the clinical severity of Alopecia Areata, as measured by the Severity of Alopecia Tool (SALT) score, and the severity of depression and anxiety, as measured by standardised psychometric tools. This analysis sought to determine if patients with more extensive hair loss are at a higher risk of experiencing severe psychological distress. Understanding this correlation is vital for identifying patients who may benefit most from targeted mental health screening and intervention, thereby enabling a more personalised and comprehensive treatment approach.

This was a cross-sectional, observational study conducted over a five-month period from September 2020 to January 2021. The study was carried out in the Dermatology Outpatient Department (OPD) of a tertiary care teaching hospital located in Telangana, India. The target population comprised all consecutive patients presenting to the Dermatology OPD with a clinical diagnosis of Alopecia Areata during the study period. The study protocol was reviewed and approved by the Institutional Ethics Committee prior to the commencement of data collection. The research adhered to the ethical principles outlined in the Declaration of Helsinki. The nature and purpose of the study were explained to all eligible patients, and written informed consent was obtained before their enrolment in the study. Patient confidentiality and anonymity were strictly maintained throughout the research process. Inclusion Criteria: Patients of both sexes, aged 18 years and above, with a confirmed clinical diagnosis of Alopecia Areata (including its subtypes Alopecia Totalis and Alopecia Universalis) were considered eligible for inclusion in the study. Only patients who were willing to participate and provided written informed consent were enrolled. The study included both newly diagnosed and previously diagnosed cases of Alopecia Areata. Exclusion Criteria: Patients with other forms of hair loss (e.g., androgenetic alopecia, telogen effluvium, cicatricial alopecia) were excluded. Individuals with a pre-existing, diagnosed psychiatric illness (such as major depressive disorder, bipolar disorder, or schizophrenia) or those currently on psychotropic medications (e.g., antidepressants, anxiolytics, antipsychotics) were also excluded to avoid confounding the assessment of psychological morbidity attributable to AA. Furthermore, patients with other significant chronic medical conditions (e.g., autoimmune diseases like systemic lupus erythematosus, uncontrolled thyroid disorders, or active malignancies) that could independently affect mental health were not included. Pregnant or lactating women were also excluded from the study. Data Collection Procedure: A semi-structured proforma was designed to collect data. The proforma was divided into two sections. The first section gathered socio-demographic information, including age, sex, marital status, education level, occupation, and residence. It also captured clinical details such as age at onset of AA, duration of the disease, family history of AA, and any history of previous treatments received. The clinical severity of AA was assessed by a dermatologist using the Severity of Alopecia Tool (SALT) score. The SALT score is a validated and widely used measure that quantifies the percentage of scalp hair loss, with a score of 0 (S0) indicating no hair loss and 100 (S5) indicating complete scalp hair loss. The second part of the assessment involved the administration of two standardised, self-report psychological questionnaires: the Hospital Anxiety and Depression Scale (HADS) and the Beck Scale for Suicide Ideation (BSSI). The HADS is a 14-item scale with two subscales: HADS-Anxiety (HADS-A) and HADS-Depression (HADS-D). Each subscale has seven items, scored from 0 to 3. A score of 0-7 on either subscale is considered 'normal', 8-10 is 'borderline', and 11-21 indicates a 'case' of anxiety or depression. For the purpose of this study, a score of ≥8 on a subscale was taken as a positive screen for clinically significant anxiety or depression. The BSSI is a 21-item instrument used to assess the current intensity of a patient's attitudes, behaviours, and plans to commit suicide. The first 19 items are scored, with a total score ranging from 0 to 38. Higher scores indicate a greater risk of suicide. A score of >0 is indicative of the presence of suicidal ideation. The questionnaires were administered in English or the local language (Telugu), and assistance was provided to patients who had difficulty reading or understanding the questions. Statistical Data Analysis: The collected data were entered into a Microsoft Excel spreadsheet and analysed using a standard statistical software package (e.g., SPSS version 21.0). Descriptive statistics, including means, standard deviations (SD), frequencies, and percentages, were calculated for socio-demographic and clinical variables. The prevalence of anxiety, depression, and suicidal ideation was reported as percentages. The relationship between the SALT score and HADS subscale scores was explored using Pearson's correlation coefficient for normally distributed continuous data, or Spearman's rank correlation for non-parametric data. A p-value of less than 0.05 was considered statistically significant for all analyses.

A total of 36 patients with a clinical diagnosis of Alopecia Areata were enrolled in the study during the five-month period. The socio-demographic and clinical profile of the study population is summarised in Table 1. The cohort comprised an equal number of males (n=18, 50%) and females (n=18, 50%). The mean age of the patients was 29.4 ± 8.2 years, with the majority falling in the 25-34 year age group (n=14, 38.9%). The mean age at the onset of AA was 26.1 ± 7.8 years. The duration of the disease was variable, with most patients (n=15, 41.7%) having the condition for 6-12 months. A positive family history of AA was reported by a small minority of patients (n=5, 13.9%). According to the SALT score, the majority of patients had mild disease (S1-S2, <50% scalp hair loss), accounting for 58.3% (n=21) of the sample. Moderate disease (S3) was observed in 9 patients (25%), and severe disease (S4-S5, >95% hair loss including AT/AU) was seen in 6 patients (16.7%).

Table 1: Socio-demographic and Clinical Characteristics of Patients (N=36)

The prevalence of psychological comorbidities, as determined by the HADS and BSSI, is presented in Table 2. Anxiety was the most common finding, with 16 patients (44.4%) scoring ≥8 on the HADS-Anxiety subscale, indicating a positive screen for clinically significant anxiety. Depression was identified in 14 patients (38.9%) based on a score of ≥8 on the HADS-Depression subscale. A significant proportion of patients (n=8, 22.2%) screened positive for both anxiety and depression. The mean HADS-Anxiety score was 7.6 (± 3.1) and the mean HADS-Depression score was 6.9 (± 3.4). Suicidal ideation, as indicated by a BSSI score greater than zero, was present in 5 out of 36 patients (13.9%). The mean BSSI score was 1.8 (± 2.6), with scores ranging from 0 to 15.

Table 2: Prevalence of Psychological Comorbidities (N=36)

An exploratory analysis was conducted to examine the relationship between the severity of Alopecia Areata (SALT score) and the severity of psychological distress (HADS scores). A significant positive correlation was found between the SALT score and the HADS-Depression score (r = 0.46, p = 0.005), suggesting that patients with more extensive hair loss reported more severe depressive symptoms. Similarly, there was a significant positive correlation between the SALT score and the HADS-Anxiety score (r = 0.39, p = 0.02). This indicates that the severity of anxiety also increased with the severity of alopecia. No statistically significant correlation was found between the duration of the disease and the HADS or BSSI scores.

This cross-sectional study from a tertiary care centre in Telangana, India, reveals a substantial burden of psychological morbidity among patients with Alopecia Areata. Our findings demonstrate that a significant proportion of patients experience clinically significant levels of anxiety (44.4%) and depression (38.9%). Furthermore, a concerningly high percentage of patients (13.9%) reported suicidal ideation. These results are consistent with a growing body of international literature that establishes AA as a condition with profound psychological consequences that extend far beyond its dermatological presentation [10-12]. The visible nature of hair loss, coupled with its unpredictable and chronic course, appears to be a major driver of this psychological distress. The prevalence rates of anxiety and depression found in our study are comparable to those reported in previous research. A large-scale US-based study using the National Health Interview Survey found that patients with AA had significantly higher odds of reporting anxiety and depression compared to those without the condition [11]. Similarly, a systematic review and meta-analysis by Okhovat et al. concluded that AA is significantly associated with an increased risk of both depression and anxiety [12]. Our rates are also similar to those from studies in other Asian populations. For example, a study from Taiwan reported elevated risks of depression and anxiety in AA patients [16]. The prevalence of suicidal ideation in our cohort (13.9%) is particularly alarming and aligns with findings from a US study which reported a higher prevalence of suicidal ideation in patients with AA (12.5%) compared to healthy controls [14]. The psychological impact may be magnified in the Indian socio-cultural context, where hair is closely linked to concepts of beauty, social acceptability, and marriage prospects. This cultural emphasis can lead to intense feelings of shame, stigma, and social isolation, thereby exacerbating emotional distress [15]. A key finding of our study is the statistically significant positive correlation between the clinical severity of AA (SALT score) and the severity of both anxiety and depression. This suggests that patients with more extensive hair loss are at a higher risk for severe psychological distress. This finding is logical, as a greater degree of visible hair loss is likely to result in a more profound alteration of body image, leading to greater social anxiety and depressive symptoms [8]. However, it is important to note that the literature is not entirely unanimous on this point, with some studies suggesting that the subjective perception of the disease's impact may be a stronger predictor of psychological outcome than objective severity [13]. A patient with a single, small patch in a highly visible area may experience as much distress as someone with more extensive but easily concealable hair loss. Nevertheless, our results support the notion that disease severity is a crucial clinical indicator for identifying patients who may need additional psychological support. This aligns with findings from studies on other dermatological conditions, where higher clinical severity is often linked to poorer mental health outcomes. The significant psychological morbidity observed in this and other studies underscores the critical need for a paradigm shift in the management of Alopecia Areata. The traditional, purely dermatological approach is insufficient to address the holistic needs of the patient. A multidisciplinary approach, integrating dermatology and psychiatry/psychology (often termed 'psychodermatology'), is essential [6,17]. Dermatologists should be trained to routinely screen for psychological distress using simple, validated tools like the HADS or the Patient Health Questionnaire-9 (PHQ-9) [17]. Early identification of patients at risk can facilitate timely referral to mental health professionals for appropriate interventions such as cognitive-behavioural therapy (CBT), which has been shown to be effective in managing the psychological impact of skin disease [18], or psychopharmacological treatment when indicated. Furthermore, patient support groups and psychoeducation can play a vital role in helping patients cope with the social and emotional challenges of living with AA. By addressing the psychological comorbidities alongside the dermatological symptoms, clinicians can significantly improve the overall quality of life and treatment outcomes for their patients. Limitations of the Study This study has several limitations that must be considered when interpreting the results. First and foremost, the small sample size (N=36) is a major limitation. It reduces the statistical power of the study and limits the generalizability of the findings to the broader population of patients with Alopecia Areata. A larger, multi-centre study would be necessary to validate these results and allow for more robust subgroup analyses. Second, the cross-sectional design of the study only allows for the identification of associations, not causal relationships. It is impossible to determine whether the psychological distress is a consequence of AA, a contributing factor to its onset or exacerbation, or both. A longitudinal study would be required to explore the temporal relationship between hair loss and mental health. Third, the study was conducted at a single tertiary care centre, which may introduce selection bias. Patients attending a tertiary care hospital might have more severe or treatment-resistant forms of AA, and the findings may not be applicable to patients seen in primary or community care settings. Fourth, the use of self-report questionnaires, while standardised, is subject to response bias. Patients may under-report or over-report their symptoms. A clinical interview by a psychiatrist would have been a more robust method for diagnosing anxiety and depressive disorders. Finally, while the BSSI assesses suicidal ideation, it does not capture the full spectrum of suicide risk, and patients with high scores would require a more detailed clinical risk assessment. Acknowledgement The authors would like to express their sincere gratitude to all the patients who participated in this study for their time and willingness to share their experiences. We also thank the staff of the Dermatology Outpatient Department for their support during the data collection phase. We are grateful to the administration and the Institutional Ethics Committee of the tertiary care hospital in Telangana for granting the necessary permissions to conduct this research. This study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

In conclusion, this study demonstrates a high prevalence of depression, anxiety, and suicidal ideation among patients with Alopecia Areata attending a tertiary care hospital in Telangana. The severity of psychological distress is closely linked to the clinical severity of the disease. These findings serve as a crucial reminder that Alopecia Areata is not merely a cosmetic condition; it is a psychologically significant disorder that can have a devastating impact on a patient's life. The presence of suicidal ideation in over a tenth of the patients is a call for urgent action and highlights the potentially life-threatening consequences of this condition.

Therefore, the management of Alopecia Areata must evolve to be more holistic and patient-centred. Dermatologists must routinely assess the psychological state of their patients and integrate mental health screening into their clinical practice. A collaborative, multidisciplinary model of care, involving dermatologists, psychiatrists, and psychologists, is essential to address both the physical and psychological aspects of the disease. Early identification of psychological distress and timely referral for evidence-based interventions like cognitive-behavioural therapy or pharmacotherapy can significantly alleviate suffering and improve long-term outcomes. By acknowledging and treating the 'invisible' burden of Alopecia Areata, healthcare providers can help patients regain not only their hair but also their self-esteem and quality of life.