From the Journals

Atopic dermatitis associated with increased suicidality



Patients with atopic dermatitis might face up to a 44% increased risk of suicidal ideation and are 36% more likely to attempt suicide than those without the disorder, a large meta-analysis has determined.

atopic dermatitis on the neck aniaostudio/

The analysis, which included data from studies published as far back as 1945, also found some correlation of increased suicide risk and increasing disease severity, although the numbers were small, Jeena K. Sandhu and her colleagues reported in JAMA Dermatology.

Both physical and psychological factors could be involved in the link, wrote Ms. Sandhu, a medical student at the University of Missouri–Kansas City, and her coauthors.

“Atopic dermatitis is associated with multiple physical comorbidities, such as asthma, allergic rhinitis, metabolic syndrome, and sleep disturbances, which all contribute to the overall physical burden of the disease. Many patients also have a profound psychosocial burden. Because of the visibility of the disease, patients may experience shame, embarrassment, and stigmatization,” they wrote.

But the disease also is associated with high levels of proinflammatory cytokines, and those proteins have been isolated in the cerebrospinal fluid of patients who have attempted suicide, the investigators noted. “Treatments targeting cytokines, such as interleukin-4 and interleukin-13, have been shown to decrease symptoms of depression and anxiety in patients with atopic dermatitis.”

The investigators plumbed several databases of medical literature, searching for studies that mentioned both atopic dermatitis (AD) and suicide, suicidal ideation, or suicidal behavior. They found 15 studies, published from 1945 to May 2018. Most (13) were cross sectional; the remainder were cohort studies. Together, they comprised a total of 4.7 million subjects, 310,681 of whom had AD. The analysis looked at risks in three areas: suicidal ideation, suicide attempts, and completed suicides.

Of the studies, 11 investigated suicidal ideation. Pooled data determined that patients with AD were a significant 44% more likely to experience suicidal ideation than those without the disease.

Three studies mentioned suicide attempts and had complete data for pooling. Taken together, they showed a significant 36% increased risk of attempted suicide among patients with AD, compared with those without the disorder.

Two studies investigated the prevalence of completed suicides among patients. One did report a significantly increased risk of 40%, compared with the control group, but it failed to report the number of suicides in the control group. The other study found no increased risk of completed suicides in patients with either mild or moderate to severe disease, compared with controls.

Two studies involved only pediatric patients. One, conducted in Korea, found a significant 23% increased risk of suicidal ideation and a 31% increased risk of attempted suicide. The other failed to find any increased risks in the overall analysis, but did find small increases in the risks of ideation and attempt in girls with AD, compared with healthy controls.

“Monitoring for suicidality in patients with atopic dermatitis is crucial to improving patient outcomes,” the team concluded. “Dermatology providers may use several tools to screen patients for suicidality. Asking patients about suicidal ideation with a question may be integrated into a patient visit. If a patient screens positive for suicidality, the dermatology provider should send a referral to the patient’s primary care or mental health provider for follow-up care. If the patient reports an orchestrated plan to commit suicide, this patient should be urgently referred to the emergency department for further assessment.”

Ms. Sandhu reported no financial disclosures.

SOURCE: Sandhu JK et al. JAMA Dermatol. 2018 Dec 12. doi: 10.1001/jamadermatol.2018.4566.

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