CME Author: Zeena Nackerdien
Study Authors: Jeena K. Sandhu, Kevin K. Wu, et al.
Target Audience and Goal Statement: Dermatologists, internists, family physicians, and mental health professionals
The goal was to synthesize the available medical literature to evaluate the possible association between atopic dermatitis (AD) and suicidality.
Is there an increased risk of suicidality among patients with atopic dermatitis?
Synopsis and Perspective
Eczema, also known as atopic dermatitis (AD), is an incurable, chronic, common disease with periodic flare-ups. Symptoms vary from person to person and can include thickened, cracked, scaly skin and itching, which may be especially severe at night. In the U.S., approximately 18 million adults (7.2%) and 9.6 million children (13.0%) are known to have this inflammatory, familial condition of the skin.
Disruption of the skin barrier, a distinct inflammatory response to environmental allergens, and skin colonization with Staphylococcus aureus are among the numerous factors impacting the etiology of AD. People with AD also tend to develop other allergic conditions such as allergic rhinitis and asthma. Symptom control of this relapsing disease can be achieved with emollients, topical corticosteroids, and calcineurin inhibitors, but different strategies may be required for treatment-resistant disease.
Prior studies have highlighted the immense psychosocial burden of AD. For instance, adult AD sufferers performed worse at work and had fewer job opportunities compared with their healthy counterparts. People with AD also were found to suffer disproportionately from anxiety and depression. Current evidence, however, has been inconclusive regarding an association between AD and suicidality.
The systematic review and meta-analysis of relevant studies by April Armstrong, MD, MPH, of the University of Southern California Keck School of Medicine in Los Angeles, and colleagues addressed what they called a gap in the literature with respect to the association between AD and suicidality.
As described in the team’s study online in JAMA Dermatology, the researchers reviewed 15 studies conducted in Europe (n = 6), Africa (n = 1), North America (n = 1), and Asia (n = 7) published over the past 20 years, including a total of 4,770,767 participants. Among them, 310,681 were AD patients (52.7% female) and 4,460,086 served as controls (50.9% female).
All the studies were observational and examined suicidality in all its forms — i.e., suicidal ideation, suicide attempts, and completed suicides. Assessments were made via the Carroll Rating Scale for Depression, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition Questionnaire, the German Pöldinger Scale, the Beck Depression Inventory, and the Primary Care Evaluation of Mental Disorders, along with medical records, mortality records, and various other questionnaires; case series and case reports were excluded.
The investigators found that when compared with individuals who did not have AD, patients with the condition had a 36% greater chance of attempting suicide (pooled odds ratio 1.36, 95% CI 1.09-1.70), as well as 44% greater chance of having suicidal thoughts (pooled OR 1.44, 95% CI 1.25-1.65).
Data from the analysis showed inconsistencies when it came to completed suicides in patients with AD, the researchers noted. For example, one study showed that when compared with control participants, AD patients have a greater risk of completed suicide — relative risk of 1.4 (95% CI 1.1-1.8). Another study showed no significant risk for completed suicides, with point estimates for hazard ratios less than 1. Overall, the pooled data did not show a clear increase in risk for completed suicides.
Studies also showed varying results for suicidal thoughts and attempts, with some indicating significant risk associated with AD across the board, whiles others found increased risk only for certain subgroups such as female children. But the pooled data did indicate a significant risk for suicidal thoughts and attempts associated with the skin condition.
Because a large number of different instruments were used among a small number of studies in the current analysis, Armstrong and colleagues noted that it was not possible “to discern the amount of heterogeneity that resulted from the differences in study instrumentation and the amount of heterogeneity that resulted from true differences in individual study results.” Potential confounders included patients with other medical conditions in the control groups of some studies and the fact that few studies investigated the prevalence of completed suicides among patients with AD compared with controls.
Source Reference: JAMA Dermatology, December 12, 2018; doi:10.1001/jamadermatol.2018.4566
Study Highlights: Explanation of Findings
The systematic review and meta-analysis found that patients with AD had a 44% higher likelihood of suicidal ideation and a 36% higher likelihood of suicide attempts. Evidence from the literature regarding completed suicides has been inconsistent, Armstrong and co-authors noted, and suggested that future studies with larger sample sizes followed over longer periods may be needed to validate any detected differences in suicide rates between patients with and without AD.
The observed increased risk in suicidality in patients with AD may relate to physical and psychosocial factors, the researchers noted. For example, elevated pro-inflammatory cytokines in the central nervous system may alter serotonin metabolism, thereby disrupting the balance of neurotransmitters in the brain. Targeted treatments of cytokines such as interleukin 4 and interleukin 13, have been shown to decrease symptoms of depression and anxiety in patients with AD. But uncontrolled AD may lead to the clinical manifestation of debilitating symptoms such as pruritus, burning, and dermatological pain.
More severe disease such as aggravated pruritus can lead to higher depression and anxiety rates, which can all contribute to more suicidal ideation, the team added. Similarly, the associated stigmatization and shame and impairment of school or work performance may also contribute to the increased risk of suicidality in these individuals.
Armstrong and co-authors suggested that dermatologists should screen patients with AD for suicidality — for example, the following are some possible simple questions that clinicians could ask their patients:
- “Do you have any thoughts of killing yourself?” or “Do you currently have a plan to commit suicide?”
- “Over the past 2 weeks, how often have you been bothered by any of the following problems: little interest or pleasure in doing things, or feeling down, depressed, or hopeless?”
When a patient’s screening results point to suicidality, “the dermatology provider should send a referral to the patient’s primary care or mental health provider for follow-up care,” the investigators wrote. And when a patient admits to having a suicide plan, the patient should be “urgently referred to the emergency department for further assessment.”
Clinicians should also refer patients to resources such as suicide awareness brochures and the U.S. National Suicide Prevention Lifeline phone number (1-800-273-8255). This hotline provides emotional support to people in suicidal crises in nonemergent cases, the study authors noted.
Ashley Lyles wrote the original story for MedPage Today.