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Association Between Atopic Dermatitis and SuicidalityA Systematic Review and Meta-analysis

Educational Objective
To recognize the increased risk of suicidal ideation and suicidal attempts in patients with atopic dermatitis (AD).
1 Credit CME
Key Points

Question  Is there an increased risk of suicidality among patients with atopic dermatitis?

Findings  In this systematic review and meta-analysis of 15 studies and 310 681 patients with atopic dermatitis, patients with atopic dermatitis had a 44% increased odds of suicidal ideation and a 36% increased odds of suicide attempts compared with patients without atopic dermatitis.

Meaning  According to the results of this study, patients with atopic dermatitis are at significantly greater risk of suicidal ideation and suicide attempts. It is important for dermatology providers to be aware of this increased risk in patients with atopic dermatitis, monitor for suicidality, and make appropriate referrals to mental health professionals.

Abstract

Importance  Atopic dermatitis (AD) is a chronic inflammatory skin disease associated with numerous psychiatric comorbidities. However, the association between AD and suicidality has not been well established.

Objective  To synthesize the available literature to evaluate the association between AD and suicidality.

Data Source  The protocol was prospectively registered in the PROSPERO database (CRD42018105291).

Study Selection  Per PRISMA guidelines, PubMed, Embase, PsycINFO, and Cochrane databases were systematically searched for relevant articles published from 1946 to May 25, 2018. The search criteria for PubMed were as follows: (dermatitis, atopic [MeSH] OR eczema [MeSH]) AND (suicidal ideation [MeSH] OR suicide, attempted [MeSH] OR suicide [MeSH] OR suicidality OR suicidal behavior). The search criteria for Embase, PsycINFO, and Cochrane were as follows: (atopic dermatitis OR eczema) AND (suicidal ideation OR suicide attempt OR suicide OR suicidality OR suicidal behavior).

Data Extraction and Synthesis  This systematic review and meta-analysis performed in an academic medical setting included observational studies that evaluated suicidal ideation, suicide attempts, and completed suicide among patients with AD.

Main Outcome and Measure  The quality of included studies was assessed using the Newcastle-Ottawa Scale for observational studies.

Results  The analysis identified 15 studies with a total of 4 770 767 participants, of whom 310 681 were patients with AD (52.7% female) and 4 460 086 served as controls (50.9% female). In the meta-analyses, patients with AD were 44% more likely to exhibit suicidal ideation (pooled odds ratio, 1.44; 95% CI, 1.25-1.65) and 36% more likely to attempt suicide (pooled odds ratio, 1.36; 95% CI, 1.09-1.70) compared with patients without AD. Studies investigating completed suicides in patients with AD had inconsistent results.

Conclusions and Relevance  Results of this study suggest that patients with AD are at significantly increased risk of suicidal ideation and suicide attempts. It is important for dermatology providers to be aware of this risk, screen for suicidality in patients with AD, and make mental health referrals when necessary.

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Article Information

Accepted for Publication: October 14, 2018.

Corresponding Author: April W. Armstrong, MD, MPH, Department of Dermatology, University of Southern California Keck School of Medicine, 1975 Zonal Ave, Keith Administration Room 510, Mail Code 9034, Los Angeles, CA 90089 (aprilarmstrong@post.harvard.edu).

Published Online: December 12, 2018. doi:10.1001/jamadermatol.2018.4566

Author Contributions: Ms Sandhu and Mr Wu contributed equally to this article and are co–first authors. Ms Sandhu and Mr Wu had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Sandhu, Wu, Armstrong.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Sandhu, Wu, Armstrong.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: All authors.

Obtained funding: Armstrong.

Administrative, technical, or material support: Wu, Armstrong.

Supervision: Armstrong.

Conflict of Interest Disclosures: Dr Armstrong reported serving as investigator and advisor to AbbVie, Janssen, Lilly, Pfizer, UCB, Dermira, Ortho Dermatologics, Sanofi, Regeneron, Science 37, and Modernizing Medicine. No other disclosures were reported.

Funding/Support: The data analysis in this study was partially funded by the Southern California Clinical and Translational Science Institute with grants UL1TR001855 and UL1TR000130 from the National Center for Advancing Translational Science of the National Institutes of Health (Dr Armstrong).

Role of the Funder/Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimers: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Dr Armstrong is an Associate Editor of JAMA Dermatology but was not involved in any of the decisions regarding review of the manuscript or its acceptance.

Additional Contributions: Wendy Mack, PhD, Department of Preventive Medicine, University of Southern California Keck School of Medicine, Los Angeles, assisted with and guided the statistical design of our study. No compensation was received.

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